End-of-life nursing encompasses many aspects of care such as: pain and symptom management, culturally sensitive

practices, assisting patients and their families through the death and dying process, and ethical decision making.

Advocacy has been identified as a key core competency for the professional nurse, yet the literature reveals relevant

barriers to acquiring this skill. Nurses have sought ways to improve the quality of life for individuals, families, and

communities during every phase of life's journey. Advocacy is a common thread of quality end-of-life (EOL)

nursing cares, encompassing pain and symptom management, ethical decision making, competent culturally

sensitive care, and assistance through the death and dying process. The foundation of advocacy is the nurse-patient

relationship. Advocacy has 2 parts: information and support. The nurse experiences the patient as uniquely human,

with individual strengths and beliefs, and uses this understanding to intervene on the patient's behalf. Patients exhibit

the following traits when in need of advocacy: powerlessness, helplessness, dependency, vulnerability, inability to

speak, and loss of self-control. Trigger situations, including illness, hospitalization, or change in diagnosis, require

decision making and action; thus, the act of advocacy begins. The nurse's ability to represent the patient and

communicate on the patient's behalf is a core behavior at the EOL (The Nurse Advocate in End-of-Life Care, 2011)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241064/.

CNA’s Ethics in Practice series paper, titled “Futility Presents Many Challenges for Nurses” (2001) states, “the

resulting tension can create difficult ethical situations for the nurses”. It suggests that to deal with the tension, nurses

are encouraged to keep lines of communication open and find ways and means such as: calling a patient conference

or involving a clinical ethics committee, or to have rational dialogue.

In situations that involve these types of disagreements (patient in coma in ICU as mentioned in the scenario), nurses

often suffer moral distress. Moral distress occurs “when constraints interfere with acting in the way one believes to

be right” (CNA, 2001). Nurses experience moral distress because they perceive their inability to provide appropriate

care for the person and for his or her family. They perceive that they are causing harm because they know that a

prolonged life on artificial support leads to great suffering, medically induced by being forced to live (Schafer,

2013). Nurses’ moral distress, therefore, is far more than their concern about treatments that will not help. The moral

distress they experience is knowing that they are part of the team prolonging suffering and treating the person as a

body, not a sentient being. This leads to a deep sense of anguish and despair (CAN, 2015).
Family members are an important consideration in patient care. The CNA code of ethics (2008) acknowledges this

importance, affirming that a nurse’s care is to also include the health and well-being of a patient’s family. The code

provides the guidance that nurses need to work with families “to take into account their unique values, customs and

spiritual beliefs, as well as their social and Page 12 of 37 economic circumstances” (CNA, 2008, D3, p. 13). It is

through recognizing the intrinsic worth of each person that nurses can support and communicate with families, even

when disagreeing with them. At the same time, nurses must “advocate for persons in their care if they believe that

the health of those persons is being compromised by . . . the decision-making of others” (CNA, 2008, C6, p. 11).

According to the CNO guideline “decision about End-Of-Life care, 2009,” nurses are expected to practise in

accordance with the College’s practice documents as well as relevant legislation. To make safe and ethical decisions

when providing end-of-life care, it is important for nurses to

know and understand current legislation that is relevant to treatment(s) and end-of-life care such as the Health Care

Consent Act, 1996 and Substitute Decisions Act, 1992.

The code ethic is one of the important elements in the professionalism of nursing; it is a foundation for nurses’

ethical practice. Furthermore, the code provides the guidance for ethical relationships, behaviours and decision-

making, and it is to be used in conjunction with the professional standards, laws and regulations that guide practice.

The Code is used by many nursing regulatory bodies in Canada to define ethical nursing standards. Nurses recognize

the privilege of being part of a self-regulating profession and have a responsibility to merit this privilege. The Code

informs other health-care professionals as well as members of the public, scientific bodies, and governments about

the ethical commitments of nurses and the responsibilities nurses accept as being part of a self-regulating profession

(CAN, code ethic for the nurse, 2016).

One of important elements in the code ethic for the nurses is Promoting and Respecting Informed Decision-Making.

If a person receiving care is clearly incapable of consent, the nurse respects the law on capacity assessment and

substitutes decision-making in the nurse’s jurisdiction (Canadian Nurses Protective Society [CNPS], 2004). 11.

Nurses, along with other health-care professionals and with substitute decision-makers, consider and respect the best
interests of the person receiving care and any previously known wishes or advance care planning that applies in the

situation (CNPS, 2004). Referring to the above scenario, where the patient is in a coma and is not able to make a

decision, a nurse should must respect the family’s decision, which is doing everything for the patient to keep her

alive (CAN, code ethic for the nurse, 2016)

https://www.crnm.mb.ca/uploads/ck/files/CNA%20Code%20of%20Ethics%20for%20RNs%20and%20LPNs%20E

N%20Feb%2021%202017%20D.

As we go through the “MAPPING CODE OF CONDUCT TO CNO STANDARDS AND GUIDELINES,” There is

the summary of standard CNO Code of Conduct for nurses. Those guidelines are very important for us as nurses to

understand and have enough knowledge of. There are a few guidelines which have connections with the scenario:

1-Nurses treat patients with care and compassion. According to the CNO standard guideline, a nurse must

demonstrate respect and empathy for, and interest in clients (Professional Standards, Revised 2002). Furthermore,

nurses should listen to, understand and respect the client’s values, opinions, needs and ethnocultural beliefs and

integrate these elements into the care plan with the client’s help (Therapeutic Nurse-Client Relationship, Revised

2006).

2-Nursing care is not judgmental and is free of discrimination. According to the CNO code of ethic, the nurses need

to inform clients and their family, in a nonjudgmental manner. Furthermore, the nurse must acknowledge biases and

feelings that have developed through life experiences, and that these attitudes could affect the nurse-client

relationship (Therapeutic Nurse-Client Relationship, Revised 2006).

Referring to the scenario, as an RN, I will follow the CNO guideline regarding the code of conduct and ethic. I will

have a non-judgemental approach in my care for my patient and respect their wishes or family, in the case that the

patient is not able to speak out for herself. I will be open to any communication in order to help and guide my clients

or their family toward their wishes. I will take time to listen to them and provide them with the information that they

ask for or need.