DNP850 Module 5 assignment: ethics analysis rooted in the student's setting, a full sample

No One to Ask: An Ethics Analysis of Treatment Decisions for an Unrepresented Older Adult on a Medical Unit

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP850: Nursing Practice, Professionalism, and Scholarship

Instructor Name

Month Day, Year

No One to Ask: An Ethics Analysis of Treatment Decisions for an Unrepresented Older Adult on a Medical Unit

Most ethical discussions about end-of-life decisions assume that someone can speak for the patient: the patient, an advance directive, or a surrogate. For some older adults, none exists. This paper analyzes one such situation from a composite hospital medical unit, identifies the ethical principles and professional obligations at stake, applies a published professional position on decision-making for these patients, and proposes a process for the hospital.

The Situation

Mr. E., 79, has advanced dementia and has been a long-stay nursing home resident for six years. He has no spouse, children, or known relatives, no advance directive, and no guardian. He has been admitted four times in the past year with aspiration pneumonia. He cannot state preferences, but nursing home staff describe him as a man who enjoyed music and disliked being restrained. On this admission, he is full code by default. Night physicians have twice discussed whether to transfer him to intensive care; one ordered it, and another, a week later, decided against it for a similar episode. A nurse noted that his code status seemed to depend on who was on call.

The Ethical Problem

The American Geriatrics Society defines unbefriended older adults as patients who lack capacity to make the medical decision at hand, have no advance directive that addresses it and cannot make one, and lack family, friends, or a legally authorized surrogate (Farrell et al., 2017). Mr. E. meets all three conditions. The ethical problem is not only which treatment to choose but who has the authority to choose and by what process. When no one speaks for the patient, the risk is not that the wrong person decides, but that decisions are made without anyone being accountable for them.

Principles in Tension

Autonomy cannot be exercised directly, but respect for persons still requires that decisions reflect what is known of Mr. E.'s values rather than defaults (Beauchamp & Childress, 2019). Beneficence and nonmaleficence require weighing the likely benefit of intensive care, mechanical ventilation, and resuscitation against their burdens for a man with advanced dementia and recurrent aspiration, whose underlying condition will not improve. Justice requires that unrepresented patients receive the same careful, consistent decision-making as those with families, and that they are neither overtreated because no one objects nor undertreated because no one advocates.

The current practice fails on justice most clearly. Leaving decisions to whichever physician is on call produces inconsistent care that depends on chance. Default full-code status may impose burdensome treatments that nobody who knew him would have chosen, while a unilateral decision to withhold treatment by one physician lacks transparency.

Professional Obligations

The Code of Ethics makes advocacy part of the nurse's basic duty, and that duty weighs more heavily when a patient has no voice of their own (American Nurses Association, 2015). Nurses are often the professionals who know unrepresented patients best, through daily care and conversations with nursing home staff. The nurse who noticed the inconsistency in Mr. E.'s care was exercising this obligation; the question is what the organization gives her to act on it.

A Fair Process

The AGS position statement recommends that decisions for unbefriended older adults follow standards of procedural fairness, including a capacity assessment, a diligent search for potential surrogates, including nontraditional ones such as close friends or long-time caregivers, and a team-based effort to determine the patient's preferences by synthesizing all available evidence (Farrell et al., 2017). It also calls for national efforts to reduce the number of unbefriended older adults through earlier advance care planning.

For Mr. E., this means documenting his lack of capacity; searching for surrogates, including asking nursing home staff whether any friend or long-time aide knew him well; gathering evidence of his values, such as his dislike of restraints and his enjoyment of music; and convening a team of the attending physician, nurse, social worker, chaplain, and a member of the ethics committee to recommend a plan of care. Given his recurrent aspiration and advanced dementia, the team might recommend a plan focused on comfort and treatment of reversible problems without intensive care or resuscitation, documented with its reasoning and reviewed if his condition changes.

Anticipating Objections

Some clinicians may object that a team review slows care. The process does not apply to emergencies, in which clinicians must act on their best judgment of the patient's interests, and a review scheduled within a day or two of admission prevents the emergency from arising unplanned. Others may argue that a court-appointed guardian is the proper decision-maker. Guardianship is sometimes appropriate, but it is slow, often assigns a stranger with no knowledge of the patient, and does not remove the need for clinicians to provide a clear recommendation. A third objection is that without a surrogate, choosing a comfort-focused plan risks devaluing a vulnerable patient's life. The answer is the process itself: a decision reached by a documented, multidisciplinary review of the patient's condition and known values is far less likely to reflect bias than a decision made at 3 a.m. by one physician, or a default of full treatment that no one chose.

Recommendations for the Organization

The hospital should adopt a policy for unrepresented patients that requires a team-based review, with ethics committee participation, before major decisions such as code status, intensive care admission, or surgery; prohibits single-physician decisions on these matters except in emergencies; requires documentation of the search for surrogates and of the evidence about the patient's values; and triggers a review whenever the patient's condition changes significantly. It should also work with local nursing homes to complete advance care planning with residents while they can still participate, which is the most effective way to prevent patients from becoming unrepresented.

Conclusion

Mr. E.'s care exposed an ethical gap: decisions made by chance for a man with no one to speak for him. Respect for the person, the duty to benefit him, fairness to unrepresented patients, the nurse's obligation to advocate, and a published professional position all point to the same remedy, a fair, team-based process that seeks his values, documents its reasoning, and holds the organization accountable. Building that process is an ethical responsibility that DNP-prepared nurses are well placed to lead.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Nursesbooks.org.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Farrell, T. W., Widera, E., Rosenberg, L., Rubin, C. D., Naik, A. D., Braun, U., Torke, A., Li, I., Vitale, C., Shega, J., & the Ethics, Clinical Practice and Models of Care, and Public Policy Committees of the American Geriatrics Society. (2017). AGS position statement: Making medical treatment decisions for unbefriended older adults. Journal of the American Geriatrics Society, 65(1), 14-15. https://doi.org/10.1111/jgs.14586