Volume 2, Issue 11 - January 2000

End-of-Life Decision-Making: Is There a Role for "Gut Reactions"?

It was early on a Wednesday morning and I was working the night shift on a medical floor in a tertiary acute care hospital. All was quiet as the other nurses working on the floor and I began our hourly rounds. A few minutes later, a call for assistance came from the nurse on the west wing. I was next to arrive.

What I saw before me was a frail, emaciated, elderly woman lying in her bed, unresponsive, not breathing, and without a pulse. As per our hospital's policy at the time for patients without a written do-not-resuscitate (DNR) order, I began CPR by doing artificial breathing--the patient's lips by this time were already cool and clammy.

The code team arrived shortly thereafter and over the next 20 to 30 minutes this elderly woman lay on the bed, nude and inert, while she was pricked with large bore needles, bombarded with electricity, and battered with chest compressions by a roomful of strangers--all to no avail. It was only after her death had been pronounced and her family arrived at the hospital that I learned some of the details about the patient's life including her diagnosis and prognosis.

She was a terminally ill, 78-year-old woman with cancer, who had been deteriorating during her hospitalization over the proceeding few weeks. She and her family members were aware of the poor prognosis and the primary goal of her care was comfort. For a variety of reasons, a DNR order was never written.

In my nursing practice, I have witnessed a number of deaths and participated in many code situations. This one, however, stands out clearly. I remember my stomach churning as the resuscitation process continued. Later that morning, and over the next few days, as I painstakingly replayed in my mind the details of the scene, I had become physically sick to my stomach. I rinsed my mouth out with mouthwash to try and wash away what I had done. I would awake from deep sleep with my heart racing. My "gut reaction' to this situation was powerful and could not be ignored. It forced me to seriously reflect upon the situation and after much contemplation, I concluded that we had failed to provide the best care possible for this patient and thus, had behaved unethically. It was my physical response, rather than an appeal to a set of principles or comparison of this case with a paradigm case, that first convinced me that I had participated in something that was fundamentally wrong. In the following discussion, I want to briefly consider the relevance of gut reactions in the end-of-life decision making process.

Gut reaction defined

My quest for a definition of gut reaction in the literature was not particularly fruitful. The only direct reference to this phrase appeared in articles on gastrointestinal diseases--another type of gut reaction for sure, but not the kind I was interested in. I did, however, come across some ideas that reflect a similar notion. These included a description of affect as a method of making decisions independent of cognition (Silverman, 1997) and Pascal's dictum that "the heart has its reasons, which reason does not know" (cited in Radey, 1992, p. 41). The concept of moral sense put forth in the 18th century by Hutcheson (cited in Lutzen, da Silva, & Nordin, 1995) as "a form of intuitionism that holds that the perception of certain situations arouses distinctive feelings of pleasure or discomfort that serve to distinguish a right action from a wrong action" (p. 58) seemed particularly relevant. Central to all of these concepts is the assumption that a gut reaction precedes or is independent of cognition.

Benefits of attending to gut reactions

There is a growing body of experts that strongly endorse incorporating feelings, emotions, and intuition into the ethical decision-making process at the end-of-life (Carson, 1994; Lutzen et al., 1995; Nelson, 1998; Redelmeir, Rozin, & Kahneman, 1993). Unfortunately, these authors have not been able to clearly articulate the reasons why we should pay attention to our gut reactions.

For me, the most powerful support for attending to gut reactions stems from my own experiences with and observations of individuals whose actions have been positively guided by their gut reactions. For instance, I once cared for a young man who had experienced several recurrences of leukemia. On his last admission to hospital, based on what he described as "a feeling in his gut", he made the decision not to undergo any further chemotherapy treatment should his leukemia relapse again. After making this decision, he described feeling that his mind and body were quiet and at peace. Although his physician thought he might benefit from further treatment, he was comfortable with his decision and he convinced me that it was the right decision for him. I heard later from his family that he lived out the remainder of his life living every day to the fullest and that he had died, as he wished, at home in his own bed.

A gut reaction can also be a source of motivation; it can stimulate an individual to action. The experience I described in the opening of this article was instrumental in my decision to become actively involved with the committee revising DNR guidelines for the hospital in which I was working. And it was experiences such as that one that led me to graduate school to learn more about how we can provide the best and right care for patients.

The immediacy of gut reactions is another potential benefit. Their use does not require any special training, extensive literature searches, extended periods of deliberation, or investigative procedures. When they occur, they are readily available and can be used in decision-making at that moment.

Negatives of attending to gut reaction

The biggest drawback to using gut reactions to guide the decision-making process at the end-of-life is the legitimate concern that a gut reaction could lead to a wrong decision. Patients and health care providers may have had past experiences or hold irrational fears that would mistakenly influence their gut reaction to the present situation. Redelmeir and colleagues (1993) provide a thought-provoking illustration of this. They describe an experiment where college students were asked if they would drink a beverage if a cockroach had been dipped into it and removed. Overwhelmingly, they said no and supported their decision on the basis that cockroaches are dirty and may carry diseases--a rational and reasonable response. Then they were asked if they would drink a beverage if a cockroach, which had been sterilized so that it was clean and disease-free, had been dipped into it and removed. Their response was the same--absolutely not. Under these circumstances, however, they were unable to articulate any rational reasons for refusing the beverage. It was an emotional response based on their historical conception of cockroaches.

Closing thoughts

From gathering information about and reflecting upon the usefulness of gut reactions in making end-of-life decisions (perhaps any type of decision), I have come to believe that gut reactions should not be discounted, suppressed, or ignored. Instead, they should be embraced, explored, and investigated so that their use in the process of end-of-life decision-making can be enhanced and facilitated. Health care providers should remain open to the possibility that gut reactions (their own, their patients', or others') may be useful guides.

However, many unanswered questions remain. Are gut reactions more or less important than rational, cognitive approaches to end-of-life decision-making? Whose gut reactions count the most--the patient's? the family's? the doctor's? the nurse's? Is attending to gut reactions consistent with other well-established ethical approaches such as principlism? Until we have further explored all of these questions, this morally relevant element of a situation should at least be considered when the best decision in a given situation is sought.

References

• Carson, R. A. (1994). Sensibility and rationality in bioethics. Hastings Center Report, 24(3), 23-24.
• Lutzen, K., da Silva, A. B., & Nordin, C. (1995). An analysis of some dimensions of the concept of moral sensing exemplified in psychiatric care. Scholarly Inquiry for Nursing Practice: An International Journal, 9(1), 57-67.
• Nelson, J. L. (1998). Reasons and feelings, duty and dementia. The Journal of Clinical Ethics, 9(1), 58-65.
• Radey, C. (1992). Imagining ethics: Literature and the practice of ethics. The Journal of Clinical Ethics, 3(1), 38-45.
• Redelmeir, D. A., Rozin, P., & Kahneman, D. (1993). Understanding patients' decisions: Cognitive and emotional perspectives. Journal of the American Medical Association, 270(1), 72-76.
• Silverman, H. (1997). The role of emotions in decisional competence, standards of competency, and altruistic acts. The Journal of Clinical Ethics, 8(2), 171-175.

'Ethics at the End of Life' Conference

PHEN, in conjunction with the Palliative Care Association of Alberta and Grant MacEwan Community College, is pleased to announce an upcoming conference entitled, "The Fabric of Goodness: Weaving Ethical Practices into Decision-Making at the End of Life." The conference is to be held on March 24, 2000 at Grant MacEwan Community College in Edmonton (downtown campus).

Keynote speakers at the conference include Dr. Elizabeth Latimer, Dr. Laura Shanner, Dr. Michael Stingl and Dr. Rosalie Starzomski. For more information, please call (780) 497-5188 or email ethics.conference@gmcc.ab.ca.  

PHEN Membership Renewal

All PHEN Memberships expired as of December 31st, 1999. If you have not already done so, please mail your renewal form today! If you require an extra form, or have any questions about your membership, please contact Colette Mooney at info@phen.ab.ca, (780) 447-1180, or (800) 472-4066.

Thank you to all those members who have already renewed their memberships. We appreciate your continued support!  

Announcements

• Technical difficulties are being resolved, and conversations on PHEN's new internet discussion list will soon begin! All members are encouraged to sign up by contacting the Network's Research Assistant, Marika Warren, at warren@phen.ab.ca.

• The next deadline for PHEN User Fund applications has been moved from May 1, 2000, to April 1, 2000, to make it easier for members wishing to apply to the User Fund to facilitate attendance at PHEN's Annual Conference and General Meeting. The User Fund provides grants to PHEN members for ethics education initiatives.

• The summary report from the Long Term Care Review (Broda Report) Sessions has been completed and submitted to Alberta Health. A copy is available on the PHEN web site at http://www.phen.ab.ca/broda.html.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.