This paper examines the ethical and legal challenges that arise in end-of-life health care, with a focus on patients' rights, advance directives, and the role of nurses as patient advocates. Using a clinical case scenario involving conflicting family wishes and a documented advance directive, the paper applies Purtillo's six-step ethical decision-making model to guide conflict resolution. It also discusses the Patient Self-Determination Act, the ANA Code of Ethics, health care proxies, and the practical benefits of advance directives. The paper emphasizes that nurses must balance professional duties, personal beliefs, and patient autonomy to facilitate compassionate, legally and ethically sound end-of-life care.
The paper demonstrates effective use of a structured ethical framework as an organizing principle. Rather than simply asserting that nurses should respect patient wishes, the author walks through each step of Purtillo's decision-making model, showing how abstract ethical theory translates into concrete clinical action. This technique — applying a named framework step by step — is a hallmark of strong applied-ethics writing in health professions courses.
The paper opens with a clinical vignette, then establishes legal and ethical context before applying Purtillo's six-step model in detail. It then shifts to a practical discussion of advance directives, health care proxies, and the nurse's advocacy role, closing with a forward-looking conclusion. This structure moves from problem to framework to practice to conclusion, a pattern well suited to applied ethics papers at the undergraduate nursing level.
Consider the following scenario: a patient has end-stage heart failure, coronary artery disease, peripheral artery disease, chronic obstructive pulmonary disease, and sleep apnea. She has refused any invasive treatments for many years, ignoring potential consequences, and has opted for medical management. She has an advance directive stating her preference for no cardiopulmonary resuscitation, no artificial hydration or nutrition, and only desires comfort measures to allow for a pain-free and natural death. This patient has developed shortness of breath, leg edema, and chest pain, and is rushed to the emergency room. Upon admission, she is diagnosed with pulmonary edema and renal failure. Medications are administered to treat the pulmonary edema, but she does not respond and begins to decompensate. The patient states that she does not want dialysis or a respirator. Her family is informed of her critical status and that her chances of survival are minimal. The family insists on multiple treatments the doctor has recommended, and wants her placed on a respirator and given dialysis. Only one sibling holds medical durable power of attorney and has a copy of the advance directive; this sibling informs the family of the patient's wishes as documented. The family disregards the advance directive, insisting on keeping the patient alive regardless of her wishes or the severe decline in her quality of life.
The above scenario is not uncommon today, since technologically advanced medical treatments can keep patients alive longer than ever before. This development has made end-of-life care one of the most controversial issues in health care. Medical advancements have set the stage for ethical and legal dilemmas not only about patients' and families' rights, but also about the roles of health care professionals.
In 1991, the U.S. Congress passed the Patient Self-Determination Act (PSDA). The purpose of this law is to inform patients of their rights regarding their medical care, including the right to accept or refuse treatment and the right to make an advance directive, and to ensure that these rights are communicated by health care providers, especially when a patient becomes incapacitated (Duke et al., 2009). The dilemma surfaces as a result of conflicting desires between the patient and his or her family. The nurse's challenge is to fully support the patient's wishes while helping the family do the same. The nurse serves as the advocate for the patient, educator of the family, and liaison to the interdisciplinary team.
The ANA Code of Ethics requires nurses to respect the autonomy of each patient and his or her right to choose health care options based on religious views, socio-cultural values, and personal desires for end-of-life care (ANA Code of Ethics, 2001). Nurses are also obligated to advocate for the patient to avoid unnecessary treatment if the patient does not want treatments that doctors and/or family members may be pushing for (ANA Code of Ethics, 2001). Nurses must be familiar with the end-of-life wishes of their patients; otherwise, the patient loses a valuable advocate for achieving his or her goals for end-of-life care. Nurses must also recognize their own personal values and beliefs surrounding end-of-life care in order to advocate adequately for their patients. They cannot be judgmental or biased, but must follow the wishes of the patient and ensure that everyone involved in the case does the same.
Conflicts during end-of-life care arise when there are differing opinions between the doctor, the family, and the patient about the care to be received. When faced with difficult ethical dilemmas, it is best to have a plan of action to assist in decision-making. A step-by-step approach often works best because it allows the decision-maker to break down a stressful choice into manageable parts. Purtillo identifies six steps for resolving ethical dilemmas: assessing the problem, identifying the ethical problem, analyzing the problem, exploring the options, implementing the action, and evaluating the outcome (Purtillo, 2005). Once the ethical conflict is addressed and/or resolved, nurses must not allow their personal feelings to interfere with professional decisions.
To begin assessing an ethical dilemma, the nurse needs to collect the medical, social, psychological, and legal facts pertaining to the case. In some situations, the nurse must also take into consideration the patient's psychological state, prognosis, knowledge of treatment options, and quality of life. It is equally important to evaluate the family's understanding of the patient's illness and wishes. The nurse must consider the patient's cultural and religious beliefs, the organizational policies of the healthcare institution, and other available resources that can aid in resolving the dilemma. Identifying ethical dilemmas can be challenging, and nurses may need guidance and support from professional resources such as patient advocates, risk management, palliative care teams, and the ethics committee, if available (Cohen & Erickson, 2006).
If a conflict emerges, it is important to determine whether the problem is truly an ethical one or whether the nurse's personal feelings are interfering with the ethical dilemma. When in doubt, the nurse should consult colleagues and other members of the care team. If personal moral issues interfere with the ethical situation, the nurse should ask a colleague to assume care of the patient. It is also important for nurses to consider relevant ethical theories to help identify solutions to the problem (Cohen & Erickson, 2006).
This step involves studying the problem to understand different perspectives — in particular, those of the patient, the family members, and the medical team. There are multiple theoretical methods that can help nurses analyze the dilemma. Ethical theories can be consequential, duty-based, rights-based, or grounded in communal and intimate relationships (Beauchamp & Childress, 2001). When dealing with ethical issues, nurses may tend to use either consequential or duty-based approaches to achieve the desired result. When using consequential theory, nurses emphasize telling patients the truth about their illness so that patients can make informed decisions about their care. When using a duty-based approach, health care professionals feel obligated to tell the truth even though it may cause patients mental stress and pain. Analysis may also involve interviewing each of the parties involved, researching similar cases, and communicating with various resource persons or organizations that could help advocate for the patient.
After analyzing the problem and confirming that the dilemma is an ethical one, the next step is to brainstorm possible solutions. It is helpful for nurses to work with colleagues at this stage in order to maximize creative thinking. In addition, nurses should try to anticipate the reactions of the parties involved in the conflict so that they are prepared with adequate responses.
When making ethical decisions, nurses may tend to rely on their personal morals and opinions for guidance. It is important to recognize that the perspectives of all team members matter, and that the values of the patient and family have priority in end-of-life decisions (ANA, 2001). When beginning to implement a plan of action, nurses should seek buy-in from all parties involved. Being prepared with adequate research and anticipating questions from the patient and family members will strengthen the implementation process.
After an attempt has been made to resolve the dilemma, all parties should evaluate the result and make any necessary revisions to the plan if possible. If the patient has passed away, an attempt should be made to interview the family members and medical team involved in the case to learn their perspectives on the outcome. This process can be difficult depending on the emotions of those involved, but explaining to the family that their reflections could potentially help future patients and their families may make it easier to engage them.
When providing support and guidance to patients and families at the end of life, one must understand how overwhelming and emotional the experience can be. If the patient or family member is struggling with end-of-life decisions, they should consult someone they trust to help them think through the implications of those decisions. Clergy members, counselors, and medical ethicists can help patients, family members, and caregivers consider end-of-life issues and answer questions about care. A grief and bereavement counselor can help individuals work through the emotional difficulties associated with these decisions. Doctors and health care providers can facilitate access to these resources.
Making end-of-life decisions is never easy — not for the patient, nor for the family members, nor for the medical staff involved. But since death is a fact of life and something that everyone will eventually face, it is important to be prepared, both as a patient and possibly as a family member, and to make the process as smooth as possible for oneself and one's loved ones. The best way to prepare for the possibility of terminal illness is to make preferences clear and to communicate openly with family members. Taking the step of writing an advance directive will help family members, nurses, and other medical staff honor the patient's wishes and help everyone involved cope more easily with the loss.
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