Nursing theory

Post # 1: Ashlyn

Wilkinson states that the method for determining defining attributes of a concept begins with a brainstorming technique, where one reviews literature to understand the multiple dimensions of a concept (1997). After literature review, a list of provisional criteria is created based on the topic, which in his case was autonomy. After identifying defining attributes of a concept, cases to support the concept are presented (Wilkinson, 1997). A model case of a concept is a real-life example which includes all the defining attributes- it is considered the purest example of a concept.  A borderline case is when an example only partially reflects the defining attributes of a concept- making it inconsistent with the concept’s full representation (Wilkinson, 1997). 

The patient case presented by Henig is about a woman named Margaret Bentley, who stated early in her life, before she became ill, that she wished to stop eating and drinking if she became completely disabled (2015). Later in her life she developed Alzheimer’s and was placed in a skilled nursing facility. At this facility she would sometimes express what appeared to be the desire to eat and drink, by responding when a spoon was close to her mouth (Henig, 2015). This patient case would be considered borderline because not all of the defining attributes of the concept are reflected. In her altered mental state, Ms. Bentley is inconsistent. This raises an ethical dilemma for the staff taking care of her and her family. The ethical dilemma here is: Do they respect her wishes from before she became ill, or do they respect her current responses to food- even though they may just be an ingrained response? This is called a “then-self/ now-self problem” (Steinbock & Menzel, 2018, p. 76). In a separate article, Menzel compares making the choice to stop eating and drinking to the choice to refuse lifesaving medications 2017. He states that patients that were previously competent and are no longer should be treated the same way as patients that have never been competent (Menzel, 2017). This is a highly debated topic- which “self” do we allow to make the decision? It would be simpler to follow what the patient has previously expressed as their wishes, since it is in writing. However, as a caregiver it would be very hard to refuse someone food and drink. Being an advocate for the person’s wishes is essential to patient care. A study that reviewed the human rights of intellectually disabled citizens in Ireland determined that very low rates of choice making and advocacy were seen in groups of mentally handicapped people (Mccausland, Mccallion, Brennan, & Mccarron, 2018).

In an article by Steinbock and Menzel about aid-in-dying laws, restrictions for advance directives are explained. By law, at the time of the lethal medication (or in Margaret’s case, the cessation of food and drink, the patient must be competent to make medical decisions (2018).  This would make Ms. Bentley’s previously stated wishes invalid. To be relevant in advanced cases where one loses cognitive function, the advance directives must be very specific about what kinds of care should be withheld and when (Steinbock & Menzel, 2018).

In a model case, the patient would not have dementia. She would have stated her wishes in an advanced directive and then become disabled in a way that did not leave her mentally impaired, so that her life ending decisions could be honored in a way that did not bring into question current wishes. Would it be that life were that simple. No matter where one works in healthcare ethical dilemmas like this arise that seem to have no “right” answer, regardless of how you look at it.

 
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