This reflective paper examines a firsthand clinical experience in which a patient with advanced diabetes-related complications chose to discontinue dialysis despite medical advice, ultimately resulting in her death. The author explores the ethical and professional dimensions of the nurse's role in supporting patient autonomy versus deferring to physician recommendations. Drawing on two studies about critical thinking development in nursing graduates, the paper argues that compassionate support for a patient's informed decision is appropriate nursing practice. It also highlights how experience and mentorship shape a nurse's capacity to navigate complex end-of-life scenarios effectively.
The paper demonstrates reflective practice writing — a core technique in nursing education — by moving systematically from observation and assumption, through analysis of the ethical dimensions involved, to a clearly stated professional position supported by evidence. This mirrors frameworks such as Gibbs' Reflective Cycle, even if not cited explicitly.
The paper opens with a detailed case narrative establishing the patient's medical history and the critical decision point. It then shifts to ethical reflection on whether the nurse's supportive response was appropriate, supported by two studies on critical thinking in nursing graduates. The paper closes with a practical recommendation — mentorship — as the best pedagogical approach for preparing nurses to handle similar situations. The structure moves naturally from experience, to analysis, to prescription.
I recently witnessed a medical decision that will weigh heavily upon my psyche for a long time. Having learned to critically ponder, analyze, and think about such scenarios carries no real weight until one actually undergoes a situation like the one just described. The experience involved a woman in her early 50s who spent the greater part of the last 18 months in the hospital. Her maladies stemmed from diabetes and included gastroparesis, uncontrolled blood sugar levels, high blood pressure, osteoporosis, a broken wrist, a broken hip, daily peritoneal dialysis (after a failed regimen of hemodialysis), heart attacks, blood clots, peritonitis, and a number of staph infections.
This lady was taken off all forms of dialysis due to the number of infections she had contracted. At that time, she was told that her kidneys appeared to have enough residual function to carry on for a while, but that her numbers would be monitored closely and that, if they began to deteriorate, she would once again be placed on dialysis. During the following month her numbers remained fairly steady, and she was allowed to go home. Shortly thereafter she slipped and fell, breaking her hip. After surgery to repair the hip, her numbers began to fall once again.
The nephrologist informed her and her family that she would have to begin dialysis treatments once again. After much discussion, she made the decision to forgo such treatments. Even after being told that she would likely die, she still refused the doctor's recommendations. After failing to change her decision, the doctor expedited her release from the hospital. Shortly thereafter, she passed away.
One recent study determined that graduates from Master's nursing programs "make statistically significant gains in critical thinking" (Drennan, 2010, p. 423), and I can hope that is true — because what I found was that one nurse working with the patient, after the doctor had left the room, told the woman that she had made the right choice, and that sometimes doctors were the last ones to let go. One statement she made captured the entire essence of the scenario: "Doctors are so sure that they can save lives; they don't like it when they are not given the chance to do so." In thinking about this, one could say that is true of most professionals. However, the question remains as to whether this was the correct decision — and, more importantly for this paper: was the nurse correct in attempting to reinforce the lady's choice? Should nurses be comforters — compassionate and caring — especially when a difficult scenario such as this one is present?
Initially, I assumed the patient's family might not agree with her decision, or that the doctor might order her back on dialysis against her wishes. I also assumed that the nurse I was observing would likely support the doctor and try to talk the patient into changing her mind. My assumptions were incorrect. Later, I took time to reflect upon my reaction to the situation.
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