Ethical Dilemma in Practice
While working on a cardiac unit, I experienced an ethical dilemma that continues to influence how I approach end of life discussions. One of my patients had a rapidly declining condition. As her health worsened, she became confused and eventually lost the capacity to make her own medical decisions. Before this decline, she had expressed that she did not want aggressive life prolonging measures and did not want to continue returning to the hospital as her condition progressed. Once she lost decision making capacity, however, her family insisted that she remain a full code and continue receiving all possible life saving treatments.
This situation created tension between respect for patient autonomy and the authority of surrogate decision makers. Ethically, patient autonomy requires honoring previously expressed wishes. In practice, once a patient no longer has decision making capacity and formal documentation is limited or unclear, families often assume control over medical decisions. In this case, the family requested continued hospitalization and aggressive interventions even as her condition declined further with each admission.
The care team attempted to have direct conversations with the family. We reviewed her prior statements and explained the likely progression of her disease. We discussed what aggressive measures would realistically involve and how they might impact her comfort and quality of life. Despite these discussions, the family continued to push for full treatment. The patient was repeatedly brought back to the hospital against what she had previously communicated she wanted.
This experience highlighted the emotional complexity that often accompanies surrogate decision making. (Childers, 2021) describe how family members may override a patients expressed wishes due to grief, denial, or fear. Their work emphasizes that surrogate decisions are frequently influenced by emotional distress rather than the patients previously stated preferences. That framework helped me better understand what we were seeing in this case. The familys insistence on aggressive care appeared rooted in difficulty accepting her decline rather than intentional disregard for her autonomy.
At the same time, the situation created moral distress within the team. (Hwu and Pai, 2025) found that nurses often experience ethical strain when they believe care being delivered does not align with what a patient would have chosen. That description matched how many of us felt. We were legally required to follow surrogate decision making authority, yet it felt inconsistent with the patients earlier wishes.
The situation was eventually managed through interdisciplinary involvement. Ethics consultation and palliative care were brought in to facilitate structured discussions. Eventually the focus shifted more toward comfort oriented measures, but it required repeated conversations rather than a single intervention. The resolution was gradual and emotionally complex for everyone involved.
This experience reinforced the importance of early advance care planning. As a registered nurse, I recognize that one of my responsibilities is to initiate clear conversations about goals of care before capacity is lost. Encouraging documentation of advance directives and discussing realistic disease trajectories may prevent similar conflicts. It also reminded me that ethical dilemmas in practice are rarely simple. They require balancing autonomy, beneficence, family dynamics, and legal standards while maintaining compassion for everyone involved.
References
Childers , J. (2021, June 9). shes not ready to give up yet!: When a family member overrides the patients medical decisions. Journal of pain and symptom management.
Hwu, L.-J., & Pai, H.-C. (2025, April 24). Exploring ethical dilemmas and coping strategies in nursing: A FOCUS Group Study of nurses and nursing students. Nursing & health sciences.
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