According to Thompson, Melia and Boyd (2000) ethical justice is the demand for universal fairness and that this can only come about through the respect for the rights of individuals. Tschudin (2003) argue that the complexity of justice or fairness makes it harder to exercise an individuals right and that in times of emergencies ethical decisions may be based on the information available and for the greater good, not for what is right for the person at that point in time.
Justice is about attempting to respect all people equally and to provide equal treatment; this is what is fair and just. According to the Code of Conduct (2004) nurses must understand the values that individuals have and respect them even if it goes against their personal beliefs and values. Being able to do this for individual patients would allow each one to receive the justice they deserve by delivering individualised health care, rather than treating each patient the same.
All patients are diverse they posses individual values and beliefs patients should be given choices as to how they want to be treated at the end of their life. Doctor and nurse may act using professional judgment and believe they are delivering equality of justice to their patients. Nevertheless nobody could truly state what an individual would choose, in a situation were they faced with the choice of life sustaining treatments but where incapacitated.
Patients should understand that the advanced directive must clearly state when and at what point they would want the doctors to implement their directive and state clearly what treatment the patient would or would not be given. What one individual finds acceptable treatment at the end of their life another may not. Therefore preference on such things like not to have food and hydration through a tube, although withdrawing feeding could be considered by some to be a cruel way to die of thirst, others would not want to prolong their death.
Being put on a ventilator at the end of life would be unacceptable is also another dilemma as some would rather be left to die. Ventilation is a problem because patients have come out of commas after many years and families might hold on to a glimmer of hope not wanting to let their loved one go without a fight, but what is written in the patients advanced directive should be held to be the doctors first priority. One problem that may arise out of making a living will is that a person could have changes in preference over time.
The directive may become inconsistent with the patients revised views about quality if life or other outcomes. BMA (2000) identify patients do not have the right to refuse basic nursing care such as provision for warmth, management of symptoms that distress the patient such as pain, vomiting and dyspnoea as well as personal hygiene needs. Nursing a patient for whom these symptoms were not sufficiently relieved, could inflict an intolerable load on nursing staff and people close to that patient, causing an unfair stressful situation.
The Nursing & Midwifery Council (2004) stipulate that nurses have a duty of care to patients within their professional role and that they are accountable for their own practice to treat patients as individuals. Therefore it is important for nurses to have guidance when dealing with advanced directives. When nurses work closely with patients and their families they develop trust and understanding and they can become aware of any fears and hopes the patient could have about future treatment.
The nurse can explore with the patient any concerns and correct misconceptions they may have. The nurse can provide the patient the opportunity to participate in their own care planning, by discussing advanced directives or by writing down expressed wishes in nursing notes. Nurses can become the patient's advocate giving them a voice and helping to avoid any interventions not acceptable to them. Respecting the patient choice is a part of justice in being allowed to have a dignified death without unnecessary medical intervention.
Nurses need to be aware that people may never truly appreciate how they will feel or desire to have medical treatment when the time comes. Nurses need to be conscious to ensure that people do not make an advanced directive because they feel a burden on their families, society and medical resources. It is important that a patient who wants to make an advanced directive do so with a professional fully able to help them understand what making the advanced directive implies. Patients need to know that the advanced directive can be withdrawn at any time (British Medical association 2000).