John (1995), states that the purpose of reflection is to promote desirable practice through the practitioners understanding and learning about his/her lived experiences (cited in Boud, 1998). Reflective writing provides us with the opportunity to document a previous experience, which we can then explore and discuss and learn from our findings.
To help structure my reflection I have chosen the model developed by Gibbs (1998), which is perceived as reflection on action. I have chosen this particular model as I feel the structure allows me the greatest opportunity to question my learning and develop it further. The structure of the model is cyclical and contains six main questions which will guide me, allowing me to discuss fully the issue concerned.
Permission from all those involved has been sought in order that I can use this issue for my assignment and all names of all involved have been changed so that confidentiality can be maintained in line with the NMC (2002).
Some of the most difficult moral dilemmas that we are likely to encounter concern human life, a good example of this kind of dilemma is one which occurred within my last placement.
Towards the end of my placement I was asked by my mentor to complete a mini mental state examination with a client, Bill. Bill was 78 years old; he lived alone and had been given a diagnosis of Alzheimer's. As I had managed to develop a good therapeutic relationship with Bill, it was felt by my mentor that I was able to complete the assessment without supervision. I explained to Bill that I was asking the questions to help me, in understanding his needs and as to how I could best support him. The first part of the assessment went without difficulty, though it soon became apparent that Bill was unable to answer the majority of the questions. Bill stated how he himself had realized that he could no longer remember certain things, and that his memory was deteriorating quite quickly. After giving several examples of how he was now struggling, Bill emotionally talked about how his life used to be. I felt that I had to ask Bill if he had ever contemplated taking his own life (which I did), the response that I received from Bill was the one which I had expected to hear. I then explained to Bill that I felt it necessary to pass on this information to the qualified staff (I felt that I had to be honest with him, as I did not want to jeopardise the trust the client had placed with me).
I returned to the ward manager's office, and explained to my mentor and the ward manager the outcomes of the assessment. It was the ward manager who then asked my opinion in what should be done next. I was concerned that it was a Friday afternoon, and I was aware that Bill lived alone. Respecting what Bill had said, and knowing that he had a lot of support through his community psychiatric nurse (CPN), I felt it would be the wrong decision to admit him. I felt that with extra support over the weekend from the out of hour's service, until his return to the unit on the Monday, Bill would be able to manage at home. The ward manager supported what I said and after a short discussion, asked me if I would contact his CPN, explain the situation and make the necessary arrangements, which I did.
I did get the chance to speak to Bill again that afternoon just before he left, and we discussed the decision that had been made about his care. He said he was grateful that I had taken the time to listen.
On reflection of the matter I felt that I had acted in the best interests of the client in line with the NMC (2002), whilst also respecting the client's wishes (which I feel, is important to do, as much as feasible). I had found myself, unanticipated, in a moral dilemma; one which I am aware is surrounded by many policies and ethical considerations. Not a very good time to realize that my knowledge on the subject was somewhat lacking.
As I began to think more about the matter I began asking myself does there not come a time when we can no longer justify treatment? Are we right to intervene against a patients wishes?
I tried to imagine how Bill may have felt, but I feel to know that, one would need to be there, in that situation. One thing that I can be reasonably sure of is how I would feel if my wishes surrounding my life were disregarded. I felt that because Bill had insight into his illness, he was making what he felt to the best decision with regards to his future.
The main priority in the situation was Bill's safety. Although Bill had made a rational decision to end his own life (if there is such a thing), it was a decision that as professionals we could not support. Whilst trying to respect bill's autonomy, there was also our professional responsibility which had to be adhered to.
I respected Bills wishes that he did not wish to be admitted to the ward (how could I justify taking away his freedom), but felt that I could not justify not intervening in some form, so although I decided to let Bill return home, extra support was put in place over the next 48 hours.
It meant a lot to me that the decision I made was supported by the qualified members of staff within the unit. My judgment was not questioned and the qualified staff treated me as a valued member of their team, which I feel gave me the greatest opportunity to develop my confidence (it really makes a difference when you're not just the student being sent on errands, but someone who is listened to).
This experience has also made me question my own values and beliefs, which I have had to balance against my professional responsibility.
But who should decide whether a life is worth living?
There are many different beliefs that surround suicide; it is a fundamental issue in ethics, as it can be seen to relate to such terms as the 'sanctity of life' and 'autonomy' (Robinson, 1999). So what is the right thing to do? Should life be preserved at all costs? Or should be respect the choice who an individual who wishes to end his own life? Dependent upon which ethical theory we choose to look at, we could justify both outcomes.
But what about, 'quality of life'? This is another tricky one, as how can anyone know for sure what 'quality of life' means to another person (Battin 1996). In Bill's case he was aware of his deteriorating quality of life (and also made me aware of it). The NMC Code of Professional Conduct (2002) states that "as a registered nurse you must respect the patient or client as an individual", and "...promote the interests and dignity of patients and clients..." Bill felt he was loosing his dignity (due to the nature of his illness), his independence, and he did not wish to continue until his body finally gave up. He wanted to end his own life while he still had some amount of dignity. What rights does any individual have to deny such rights to another? There is an argument from the point of view of ethical egoism, that should suicide be beneficial to the individual then it is justifiable (Thompson, 2000).
To stand back and not intervene and allow Bill to take his own life would have been inherently wrong from a deontological point of view; also as a nurse I would not have been acting in accordance with standards of professional practice which I am accountable. But should I have been left unsupervised in my role as a student?
It does concern me that if we were to keep an animal, that was in pain, and to which death was inevitable, wouldn't we be considered cruel? The animal would be put to sleep to prevent such cruelty. Yet this is what is professionally expected of us, to preserve life at all costs, our duty of care towards our clients (John, 1998)
Having further reflected on this experience, I still feel that the decision I made was the right one, under those circumstances. Bill did return to the unit the following week, I had succeeded in my role of 'preserving life', whilst respecting Bill's wishes to remain at home.
Although I feel I made the right decision (to intervene and preserve life), I still have to accept the longer term consequences are my actions. Bill will continue to attend the day unit, probably until he dies. I will probably see him loose control over his own actions and may one day have to feed him or perhaps change his incontinence pad. Knowing how he would be so ashamed if he was aware of what was happening.
Although this has been the first time that I had found myself having to make such a decision, I know that I will come across moral dilemmas similar to this again. I may find that whilst in a similar situation in the future that my actions this time will not be permissible. It will be then I will have to reflect on knowledge and experience gained in order to facilitate a decision.
I have found an area here that interests me greatly, one which I have already begun to look at in depth. I plan to continue reading literature relevant to the subject, so that in the future I am able to provide moral justification for my actions, not only to others but to myself (I have many questions of my own I need to find answers to).
For those people who would prefer to end their lives rather than loose their dignity and independence, do we really have the right to intervene against their final wishes? This leads us to the issue of informed consent, one which I have not discussed within this piece of work, which is an area that I plan to look at in relation to this topic.