Ethical Case Paper: Advanced Practice Dilemma

Nurse practitioners must provide high-quality, compassionate, patient-centered, and evidence-based care and respect the patient's autonomy if the patient is mentally capable of making decisions. When delivering care, it is important to practice compassion and respect for every person's inherent dignity, worth, and unique attributes (American Nurses Association, 2015). There comes a situation when providing quality and compassionate care conflicts with the patient's autonomy — the right to deny treatment when patients are competent.

In this paper, I will examine Mr. D's current situation, his treatment options, and his desire to deny treatment. This paper will explore the area of concern regarding Mr. D's hesitance to undergo further testing, such as a CT scan or biopsy, and treatment, such as chemo or radiation, discuss relevant information, and identify key stakeholders involved in decision-making. I will also explore my potential biases that might influence this decision-making and the legal considerations. This paper will explore ethical and legal aspects, evaluate various treatment options with their risks and benefits, and ultimately make an informed choice.

Clarifying the Problem

Identify the Uncertainty

I, as his long-term nurse practitioner, am concerned about his refusal of treatment without knowing his diagnosis and alternative treatment options. While I am worried about his refusal and the possibility that the condition might be treatable, I want to understand his reasons for refusing treatment. Is it because of pain, or does he prefer to spend more time with family rather than undergoing extensive treatments, or is it his desire to spend his remaining days relaxing at home with family? I also want to provide him with all the relevant information so that he can make his own decision.

Analyze Your Biases

What I consider nursing is providing compassionate, quality care to all patients, regardless of their background, race, color, sex, language, religion, politics, property, birth, or other factors — this is essentially the golden rule of nursing (United Nations, n.d.). As an advanced practice nurse, I provide evidence-based practices, educate patients, and provide patient-oriented, evidence-based treatment options based on patient's needs.

I am more biased toward the ethical principle of beneficence. In this case, even though the principle of autonomy would require me to respect the patient's decision to refuse the treatment, I must consider the principle of beneficence and advocate for the treatment because it is in the best interest of the patient's health. Overriding a person's autonomy is serious, but serving the patient's best interests is sometimes necessary (Grace, 2023a). To address this ethical dilemma, I would educate Mr. D and his family about the benefits and risks of the treatment and alternative options and include them in the decision-making process while respecting Mr. D's autonomy. Additionally, I would encourage open communication between Mr. D and his family members to ensure that any decision made would benefit Mr. D.

Clarify the Question

Mr. D is adamant that he does not want to undergo chemo or radiation treatment again. The primary concern is how to provide Mr. D with the best possible care while respecting his right to refuse further chemo and radiation. As an advanced practice nurse, I need to understand Mr. D's reasoning behind his refusal of these treatments and explore alternative options he may be willing to consider.

To better understand Mr. D's decision, it is important to find information about his reasons for refusing treatment — which might be because of pain and a desire to spend more time with family at home rather than in hospitalization. It is important to provide Mr. D with all relevant information to help him make an informed decision about his care, as well as alternative treatment options that are less invasive.

List the Major Stakeholders

Regarding making a sound decision about Mr. D's care, Mr. D — who is mentally capable of making his own decisions — holds the ultimate decision-making power regarding his care. His daughters, who are worried about him and want him to consider treatment options, also have a role in decision-making. Healthcare providers, including his long-term nurse practitioner, should have a role in shared decision-making by providing information about treatment options, their risks and benefits, and other alternative options.

Describe the Ethical Considerations

Ethical Principles to Consider

In Mr. D's scenario, the ethical principles of beneficence, autonomy, and virtue ethics come into play. The ethical principle of beneficence is always acting in the patient's best interest while minimizing harm and maximizing potential benefits (Grace, 2023a). Applying beneficence might help get Mr. D better and address his daughters' emotional well-being and concerns. However, it will take away his right to autonomy — the right to deny his medical treatment.

The ethical principle of autonomy is to respect the patient's right to self-determination — to provide clear, understandable information about their condition and treatment options to empower them to make informed decisions about their care (Grace, 2023a). It will empower Mr. D to make a better decision, respect his dignity, and respect his right to deny treatment, but it might negatively impact his daughters' emotional well-being and Mr. D's health condition in the future.

Virtue ethics focuses on developing good character traits for a flourishing life rather than following strict rules (Encyclopaedia Britannica, 2024). The virtuous medical professional will care for their patient's health with practical wisdom, integrity, compassion, and self-effacement, placing the patient's interests above their own with trust and caring (Vizcarrondo, 2012). Virtue ethics would be ideal in this case, as it would respect Mr. D's autonomy and place the patient's interest above all.

Legal Issues to Consider

According to Annas (1983), patients have the right to self-determination, which means they have the right to decide what will or will not be done to their bodies. Recent court rulings have also affirmed that common law and the United States Constitution protect individuals' right to refuse medical treatment (Annas, 1983). The Patient Self Determination Act of 1990 protects patients' right to self-determination regarding deciding on their care, including refusing any medical treatment they believe is unnecessary or do not want.

Thus, as Mr. D's long-term nurse practitioner, my role is to provide unbiased and required information to him so that he can make informed decisions about his care. I am not allowed to make the final decision on his care.

Choosing a Solution

Risks, Benefits and Rank of Options

Mr. D has the option to undergo treatment with targeted radiation therapy. Given Mr. D's concerns and hesitancy about chemotherapy and radiation, targeted radiation therapy could be beneficial for him. This treatment option has the benefit of killing a large proportion of cancer cells within the entire tumor, and radiation alone may be sufficient to cure them at times (CancerQuest, n.d.). However, there are risks of damaging surrounding tissues, such as the lungs and heart, depending on how close the area of interest is located to the tumor. This treatment option is also effective for elders, making it the best first-choice option if Mr. D is eligible.

My second preference is palliative care for Mr. D, which focuses on his severe illness and enhances his current care by focusing on quality of life for him and his family (National Institute on Aging, 2021). Mr. D, who spends more time at home and enjoys talking to family members, would benefit from a palliative care team to address his breathing difficulties, pain, and other symptoms related to the lung mass, improving his comfort and well-being.

The third option is to refrain from further treatment. Mr. D is prepared to accept whatever comes his way and does not wish to undergo more testing and treatment. This choice may not be the best for his well-being or his daughters' emotional well-being. However, it is what Mr. D wants for his remaining days — to live at home rather than spend time in treatment and hospitals. This is my last preference, but it is our responsibility to honor whatever option Mr. D ultimately chooses.

Make a Choice and Justify It

I have utilized Dunsford's ethical decision-making model to navigate the complex ethical dilemma of Mr. D and determine the best course of action. Using this model, I first identified the uncertainty, analyzed biases, clarified the question, and listed the significant stakeholders. Then, I considered ethical considerations such as clinical issues, context, risks and consequences, applicable rules and duties, and moral principles.

The decision should be collaborative between the healthcare provider, Mr. D, and his daughters. I believe the best decision would be the combination of my first choice — targeted radiation therapy — and the second choice — palliative care, which can provide him the best of both worlds: clinical benefits and the option of receiving palliative care, improving his comfort and well-being.

With targeted radiation therapy, there is potential to cure Mr. D by killing a large proportion of cancer cells; radiation alone may be sufficient to cure them at times, and it is effective for elders. With palliative care, Mr. D gets to spend more time at home doing things that he likes; the treatment is less invasive and focuses on his comfort and well-being. This decision would benefit Mr. D and is based on a patient-centered plan, evidence-based care, and ethical choices and processes — while acknowledging that Mr. D holds the ultimate decision-making power.

Conclusion

Nurse practitioners often face ethical dilemmas between providing compassionate care and respecting patient autonomy. Mr. D's case emphasizes the conflict between providing high-quality, compassionate care and respecting patients' autonomy — the right to deny treatment when patients are competent. As nurse practitioners, we are responsible for balancing his rights and his well-being: a balance between treatment and the right to deny treatment.

This paper aimed to balance Mr. D's well-being and right to refuse treatment by gathering more information about his decision, involving relevant stakeholders, promoting open and honest communication, exploring alternative treatment options, and outlining the risks and benefits to empower him to make an informed decision. Ethical decision-making models guide nurse practitioners to make sound decisions daily using knowledge, experience, and skill, focusing on complex scenarios (Grace, 2023b). This paper used Dunsford's ethical decision-making model to guide Mr. D's complex moral decision-making and provide him with informed decisions and the best course of action while respecting his ultimate right to autonomy.