Advocacy is one of the most important concepts in nursing practice. It means the support of an individual to promote their well-being as they understand it, preserving human dignity and equality of all patients. Nurses have the responsibility to recognize and identify ethical issues that affect both staff and patients (Ethical practice: NCLEX-RN, n.d.). The purpose of this paper is to review an ethical dilemma faced by nurses in a residential medical respite care facility and analyze it using the Bioethical Decision-Making Model
Mr. D was a man in his 60s admitted to the hospital with severe lung problems after living on the street for nine years. He was diagnosed with emphysema and, after receiving the initial treatment, was referred to recuperative care unit to a residential medical respite care program that provided short-term housing for people with acute medical needs. Mr. D displayed cognitive problems and refused to take some of his medications, despite being given all explanations about them being an essential part of effective management of lung problems. His care providers did what they could to arrange his treatment within these limitations, but his decisions significantly limited therapeutic options. After being referred to the medical care respite program, Mr. D started to display symptoms of depression and expressed a wish to return to the place where he lived. He refused to be treated for mental health conditions or depression and insisted that all he wanted was to be discharged from the hospital.
Bioethical Decision-Making Model
- Dilemma: Mr. D’s health care providers faced the question of whether he was mentally capable of making a decision that would likely lead to his death.
- Medical facts: Mr. D had severe emphysema and displayed the symptoms of depression and cognitive problems. Given his condition, the prognosis was that his continuing to live on the street without proper treatment would likely result in his death.
- Non-medical facts: Mr. D was homeless and had no known relatives; before hospitalization, he lived on the street for nine years, receiving a regular disability check.
- External influences: The external influences on the nurse’s decision included the Code of Ethics for Nurses developed by the American Nurses Association, and the relevant state and hospital guidelines on ethical decision-making.
- Items that need clarification: It was unclear and could not be established whether Mr. D had any mental health conditions that prevented him from making his own healthcare decisions.
- Decision-makers: The patient was an adult able to make his own choices; however, his actual capacity to make adequate decisions was questioned.
- Underlying ethical principles:
- Autonomy, which is the underlying concept for advocacy in nursing. It is upheld when the nurse accepts that a patient is a unique person who has the innate right to have their own opinions, perspectives, values, and beliefs (Ethical practice: NCLEX-RN, n.d.). In Mr. D’s case, nurses had to choose whether they need to advocate for his right to promote his well-being as he understands it, or act in his interests as they understand them.
- Beneficence, which means doing good and the right things for the patient. In Mr. D’s case, deciding to do the right thing for him would mean contradicting the principle of autonomy and acting contrary to the patient’s own will.
- Accountability, which implies accepting responsibility for professional and personal consequences resulting from the nurse’s actions. In Mr. D’s case, the nurses’ choice would have its consequences in either case, and the nurses would have to accept responsibility for them.
- Alternatives: The nurses treating Mr. D had to choose between two options. The first was to accept his wish to be discharged from the hospital and return to the street. The second was to conclude that his mental state did not allow him to make his own decisions and keep him at the hospital to receive treatment for depression. The benefits of the first option were adherence to the principles of autonomy and respect for the patient’s wishes. The consequences were allowing the patient to make a decision that could negatively affect his health or even lead to death. The benefits of the second option were the adherence to the principle of beneficence to save the patient’s life and ensure that he received good care for both physical and mental problems. The negative consequences were connected with neglecting his wishes and defying the principle of autonomy.
- Follow-up: If the first option was chosen, the nurses would have to supply Mr. D with all the necessary medication and healthcare instructions before discharging him from the hospital, as he wished. They would also have to encourage him to come back to respite whenever he felt it necessary. If the second option was chosen, they would have to inform him that a necessary procedure had to be conducted to evaluate his mental state and decide whether he was capable of making his own decisions.
Nursing Advocacy in the Clinical Setting
In the clinical setting, nurses are often faced with situations that require them to choose between ethically ambiguous options. The situation covered in this paper raises several important questions. The first is at what point people lose the capacity to make their own decisions and how providers can accurately assess their capacity. The second is connected with the patient having a mental health issue interfering with his decision-making process, such as depression. The third issue is the question of the patient’s beliefs and the actions of the care provider in case the patient’s beliefs conflict with the provider’s recommendations. The fourth is how the nurse should respond if the patient’s goals and wishes are not in their best interest. When making a choice, the nurses had to address these questions and choose the most beneficial option.
In end-of-life care and the nursing practice targeted at the homeless and underserved, several principles need to be observed. According to Reed et al. (2018), nurses as advocates need to practice holistic assessment, communication, empowering, and supporting people in the end stages of life, with support being especially crucial for the vulnerable groups of the population. When caring for the homeless, psychiatric needs often come to the foreground (Porter-O’Grady, 2018). With acute and chronic physical health issues being the predominant route of accessing mentally ill homeless people, their psychiatric health issues can be subsequently identified and addressed (Porter-O’Grady, 2018). Nurses often have to find a compromise between doing what is right for the patient and what the patient’s goals are.
Nurses often have to make difficult choices in their practice. When the patient wishes to make a decision that will likely lead to a negative outcome, nurses are faced with the ethical dilemma of letting them die or treating them against their own will. In such cases, the principles of autonomy and beneficence come into conflict, and the nurse should carefully evaluate all possible options and be ready to take responsibility for the consequences.
Ethical practice: NCLEX-RN. (n.d.). Registered Nursing.
Porter-O’Grady, T. (2018). Leadership advocacy: bringing nursing to the homeless and underserved. Nursing Administration Quarterly, 42(2), 115–122.
Reed, F., Fitzgerald, L., & Bish, M. (2018). A practice model for rural district nursing success in end-of-life advocacy care. Scandinavian Journal of Caring Sciences, 32, 746–755.