Name
University of Phoenix
NSG/426 Integrity in Practice: Ethics and Legal Considerations
Prof. Name
Date
Ethical decision-making in nursing is a structured process that helps healthcare professionals resolve difficult clinical situations while protecting patient autonomy, dignity, safety, and well-being. Nurses can apply an ethical decision-making model by identifying the ethical problem, gathering relevant clinical and legal information, recognizing stakeholders, evaluating possible actions, applying ethical principles, consulting appropriate professionals, and documenting the final decision. This approach is particularly important in situations involving end-of-life care, informed consent, advance directives, patient confidentiality, treatment refusal, and conflicts between family preferences and patient wishes.
Ethical nursing practice requires more than following policies or making a clinical judgment. Nurses must consider professional standards, applicable laws, evidence-based practice, patient values, cultural considerations, and the potential benefits and harms of each option. A systematic approach helps nurses make defensible, patient-centered decisions even when there is disagreement among patients, families, clinicians, or healthcare organizations.
An ethical decision-making model is a systematic framework that nurses and other healthcare professionals use to analyze ethical dilemmas and determine the most appropriate course of action.
Rather than relying only on personal beliefs or intuition, nurses can use an ethical model to examine the situation from multiple perspectives. The process typically involves identifying the ethical issue, collecting relevant information, recognizing the people affected, considering available alternatives, applying ethical principles, evaluating the consequences, and selecting and implementing an appropriate action.
Ethical decision-making models can be especially useful when two or more legitimate values appear to conflict. For example, a patient’s right to autonomy may conflict with a family’s desire to pursue aggressive treatment, or an organizational policy may appear inconsistent with a patient’s individual needs.
Ethical decision-making is essential because nurses frequently encounter situations in which clinical, legal, professional, cultural, and personal considerations overlap. A treatment may be medically possible but inconsistent with the patient’s wishes. Similarly, a family may request an intervention that the healthcare team believes could cause unnecessary harm.
Applying an ethical framework helps nurses:
Protect patient autonomy and dignity.
Promote safe and compassionate care.
Reduce preventable harm.
Support informed decision-making.
Respect advance directives and documented preferences.
Address disagreements among patients, families, and healthcare professionals.
Maintain professional accountability.
Promote consistent and transparent decision-making.
Ethical practice also strengthens trust between patients and healthcare professionals. Patients are more likely to participate meaningfully in care when they understand that their values, preferences, rights, and concerns are being considered.
The most commonly applied ethical principles in nursing include autonomy, beneficence, nonmaleficence, justice, fidelity, and respect for human dignity.
Autonomy refers to a patient’s right to make informed decisions about their own healthcare when they have decision-making capacity. Nurses support autonomy by providing understandable information, answering questions, respecting informed choices, and avoiding coercion.
Beneficence means acting for the patient’s benefit. Nurses should consider interventions that promote health, relieve suffering, improve comfort, and support the patient’s overall well-being.
Nonmaleficence means avoiding or minimizing unnecessary harm. Nurses must consider whether an intervention could produce physical, psychological, emotional, or other forms of harm.
Justice involves treating patients fairly and distributing healthcare resources equitably. It requires nurses to avoid discrimination and provide care based on relevant clinical needs rather than personal preferences or bias.
Fidelity refers to keeping professional commitments and maintaining trust. Nurses demonstrate fidelity by acting responsibly, protecting confidentiality, communicating honestly, and fulfilling professional obligations.
The first step in ethical decision-making is recognizing what makes a situation ethically challenging. Nurses should distinguish between a routine clinical problem and a situation involving competing values, rights, responsibilities, or obligations.
An ethical problem may occur when:
A patient’s wishes conflict with family preferences.
Treatment decisions conflict with a patient’s advance directive.
A patient’s autonomy conflicts with concerns about safety.
Clinical recommendations conflict with organizational policies.
Available resources must be allocated among competing needs.
A healthcare professional faces a conflict of interest.
The benefits and potential harms of treatment are difficult to balance.
Identifying the specific ethical question prevents the healthcare team from focusing only on the medical aspects of the case.
End-of-life and hospice care can create particularly complex ethical situations because the goals of care may differ from those of traditional curative treatment.
Consider a patient with advanced multiple-organ cancer who is receiving hospice care. The patient has a documented Do Not Resuscitate (DNR) order and is receiving continuous medication for comfort. As the patient’s condition deteriorates, family members ask the healthcare team to change the patient’s status from DNR to Full Code.
The family’s request may arise from grief, fear, hope, or difficulty accepting the patient’s prognosis. However, the healthcare team must determine whether the requested intervention is consistent with the patient’s wishes and goals of care.
For a terminally ill patient, CPR may cause injury, discomfort, or other burdens and may have little likelihood of achieving the patient’s desired outcome. The ethical challenge is therefore not simply whether CPR can technically be performed. The team must consider whether performing CPR would respect the patient’s known preferences and goals.
The nurse’s role includes supporting the patient, communicating accurately with the family, identifying concerns, advocating for the patient’s preferences, and collaborating with the interdisciplinary team.
An ethical decision should be based on accurate and comprehensive information. Nurses should first establish the clinical facts and then consider the patient’s preferences, legal documents, family circumstances, and professional obligations.
Important clinical information may include:
Diagnosis and current health status
Prognosis
Treatment options
Expected benefits and burdens
Pain and symptom severity
Decision-making capacity
Current goals of care
Existing advance directives
Code status
Previously expressed patient preferences
The healthcare team should verify documentation rather than relying on assumptions or incomplete information.
When a patient has decision-making capacity, the patient’s own preferences should be central to the decision. Nurses should explore what matters most to the patient, including quality of life, treatment goals, cultural values, personal beliefs, and acceptable levels of treatment burden.
When a patient lacks capacity, the healthcare team should determine whether an appropriate legally authorized representative or surrogate is available and use applicable laws and institutional policies to guide decision-making.
Families can provide important information about the patient’s values and previously expressed wishes. However, family preferences should not automatically replace the patient’s own decisions when the patient has expressed clear and legally recognized wishes.
Cultural, religious, and spiritual beliefs may also influence how patients and families understand illness, suffering, death, and medical treatment. Nurses should approach these considerations respectfully and avoid making assumptions based on cultural background.
Stakeholders are individuals or groups who are directly or indirectly affected by an ethical decision. Identifying stakeholders helps the healthcare team understand different perspectives without losing sight of the patient’s rights and interests.
Common stakeholders include:
The patient
Family members
Surrogate or legally authorized decision-makers
Nurses
Physicians and advanced practice clinicians
Social workers
Chaplains or spiritual care professionals
Palliative care specialists
Ethics consultants or ethics committees
Healthcare organizations
Park (2012) emphasizes the importance of considering multiple perspectives when nurses evaluate ethical problems. Although stakeholder input is valuable, the patient’s preferences and rights should remain central to patient-centered care.
After gathering information, nurses and healthcare teams should identify reasonable alternatives and compare their potential benefits, risks, ethical implications, and alignment with the patient’s goals.
For a hospice patient with a documented DNR order, for example, reasonable approaches may include continuing comfort-focused care while providing additional support to the family.
Comfort-focused interventions may include appropriate pain and symptom management, repositioning, skin care, oral care, emotional support, and other measures consistent with the patient’s goals of care.
Hospice and palliative care do not mean that healthcare professionals stop caring for the patient. Instead, the focus shifts toward comfort, quality of life, symptom relief, and support for the patient and family.
Family members may need additional explanations about the patient’s prognosis, the meaning of a DNR order, and the expected benefits and burdens of CPR.
Family meetings can provide an opportunity for clinicians to answer questions, address misconceptions, acknowledge emotions, and explain how the patient’s documented wishes guide the plan of care.
When appropriate, nurses can request assistance from:
Social workers
Chaplains or spiritual care professionals
Palliative care specialists
Ethics consultants
Mental health or grief-support professionals
These services can address emotional, psychosocial, spiritual, and ethical concerns that may not be resolved through medical treatment alone.
Ethical dilemmas rarely involve a single professional perspective. Interdisciplinary collaboration allows healthcare professionals to evaluate clinical facts, patient preferences, ethical considerations, psychosocial concerns, and applicable policies.
For example, a nurse may identify a conflict between a patient’s documented preferences and a family’s request. The nurse can communicate the concern to the physician or advanced practice clinician, involve social work or palliative care, and request an ethics consultation when appropriate.
Collaborative decision-making can reduce individual bias, improve communication, and provide a more comprehensive understanding of the patient’s needs.
An ethical decision should be supported by relevant facts, professional standards, ethical principles, patient preferences, applicable laws, and organizational policies.
A strong ethical rationale should explain why the selected action best protects the patient’s rights and welfare while minimizing avoidable harm.
For example, continuing comfort-focused care for a hospice patient with a documented DNR order may be ethically justified when the decision is consistent with the patient’s known wishes, clinical condition, goals of care, and applicable legal and professional standards.
Ethical justification should not be based solely on what the nurse, family, or healthcare organization personally prefers.
Patient autonomy is one of the most important considerations in ethical nursing practice. Competent adults generally have the right to accept or refuse recommended medical treatment after receiving appropriate information about the decision.
Nurses support autonomy by facilitating communication and helping patients understand their options. This includes recognizing that a patient may make a decision that healthcare professionals or family members would not personally choose.
When a patient lacks decision-making capacity, the healthcare team should follow applicable laws and institutional policies regarding surrogate decision-making and advance directives. The goal should be to honor the patient’s known values and preferences whenever possible.
Nurses have an important advocacy role in ethical decision-making because they often spend significant time with patients and families and may identify concerns that other members of the healthcare team have not recognized.
The nurse may be responsible for:
Identifying potential ethical concerns.
Advocating for patient preferences.
Providing patient and family education.
Communicating changes in patient condition.
Promoting informed decision-making.
Maintaining confidentiality.
Supporting shared decision-making.
Participating in interdisciplinary discussions.
Requesting ethics consultation when appropriate.
Documenting relevant assessments and communications.
The American Nurses Association (ANA) Code of Ethics provides a professional framework for nurses’ ethical responsibilities and emphasizes respect for human dignity, patient rights, and professional accountability.
Organizations can create an environment that supports ethical practice by providing nurses and other healthcare professionals with education, policies, consultation resources, and clear communication processes.
Healthcare professionals should apply recognized ethical principles together with professional codes of ethics, applicable laws, evidence-based practice, and organizational policies.
Clear communication among patients, families, nurses, physicians, and other professionals can prevent misunderstandings and identify ethical concerns early.
Documentation should accurately reflect relevant assessments, patient preferences, discussions, consultations, decisions, and changes in the plan of care. Good documentation promotes continuity, transparency, and accountability.
Some ethical cases cannot be resolved easily at the bedside. Ethics committees or consultants can provide structured analysis and help stakeholders understand competing ethical considerations.
Nurses should maintain appropriate professional boundaries and avoid relationships or financial arrangements that could interfere with objective clinical judgment.
For example, accepting a significant gift from a patient or family member may create concerns about professional boundaries or conflicts of interest even when the action is not necessarily illegal.
Ethical decisions can become particularly challenging in emergency settings when a patient arrives without readily available documentation of treatment preferences or code status.
When a patient’s wishes are unknown, clinicians generally follow applicable emergency-care laws, institutional policies, and professional standards while attempting to determine the patient’s preferences as quickly as possible. In many circumstances, emergency treatment may be initiated when there is no verified limitation on resuscitative efforts.
However, code-status requirements and emergency treatment laws vary by jurisdiction and circumstance. Nurses should therefore avoid assuming that one rule applies universally and should promptly verify available records, advance directives, prior documentation, and institutional procedures.
This approach balances the need to provide timely emergency care with the responsibility to respect patient autonomy when reliable information becomes available.
Ethical nursing practice also involves recognizing situations that could compromise professional judgment.
Examples include inappropriate gifts, financial relationships, dual relationships, preferential treatment, or personal relationships with patients. Nurses should evaluate whether an interaction could create a conflict of interest, exploit the nurse-patient relationship, or affect objective decision-making.
Professional boundaries protect both patients and healthcare professionals and help preserve trust in the nurse-patient relationship.
A practical approach to an ethical dilemma can be summarized as follows:
Identify the ethical issue. Clearly describe the conflict or question.
Gather relevant information. Review clinical facts, patient preferences, advance directives, code status, policies, and applicable legal requirements.
Identify stakeholders. Determine who is affected and whose perspectives need to be considered.
Determine the patient’s goals and values. Prioritize the patient’s expressed wishes whenever possible.
Apply ethical principles. Consider autonomy, beneficence, nonmaleficence, justice, fidelity, and human dignity.
Develop alternatives. Identify reasonable options and consider their potential benefits and harms.
Consult appropriate professionals. Involve the interdisciplinary team, ethics consultants, palliative care, social work, or spiritual care when appropriate.
Select and implement the most ethically appropriate option. Choose the action that best supports the patient’s rights, welfare, and goals of care.
Document the process. Record relevant assessments, discussions, consultations, decisions, and outcomes.
Evaluate the outcome. Reassess the patient’s condition and determine whether the decision continues to meet the patient’s needs.
Ethical decision-making gives nurses a structured way to address difficult clinical situations without relying solely on personal beliefs or intuition. The process combines ethical principles with clinical evidence, patient preferences, professional responsibilities, and applicable legal requirements.
The most important points are:
Patient autonomy should remain central to ethical nursing practice.
Beneficence requires nurses to promote patient well-being.
Nonmaleficence requires healthcare professionals to minimize avoidable harm.
Justice supports fair and equitable treatment.
Advance directives and documented treatment preferences should be carefully reviewed and respected according to applicable law.
Hospice and palliative care emphasize comfort, symptom management, quality of life, and support rather than curative treatment when that reflects the patient’s goals.
Interdisciplinary collaboration can improve ethical analysis and reduce communication failures.
Ethics consultation can be valuable when disagreements or complex ethical conflicts cannot be resolved through routine communication.
Accurate documentation supports accountability and continuity of care.
An ethical decision-making model is a structured framework that helps nurses identify ethical problems, gather relevant information, consider patient preferences and stakeholder perspectives, evaluate alternatives, apply ethical principles, and select an appropriate course of action.
Ethical decision-making helps protect patient rights, promote safety, support informed choices, reduce unnecessary harm, resolve conflicts, and maintain professional accountability. It also helps healthcare teams provide care that is consistent with patient values and goals.
The primary ethical principles commonly applied in nursing are autonomy, beneficence, nonmaleficence, justice, and fidelity. Respect for human dignity is also a fundamental component of ethical nursing practice.
Stakeholders may include the patient, family members, legally authorized representatives, nurses, physicians, advanced practice clinicians, social workers, chaplains, palliative care professionals, ethics consultants, and healthcare organizations.
Nurses should first clarify the patient’s wishes and gather relevant clinical and legal information. The healthcare team should communicate respectfully with the family, explain the patient’s condition and goals of care, address questions and concerns, and involve appropriate interdisciplinary or ethics resources when necessary.
When the patient has decision-making capacity, the patient’s informed wishes should generally guide treatment decisions. If the patient lacks capacity, nurses should follow applicable laws and institutional policies concerning advance directives and legally authorized surrogate decision-makers while seeking to honor the patient’s known values and preferences.
Palliative care focuses on relieving physical and emotional suffering, managing symptoms, supporting quality of life, and helping patients and families navigate serious illness. It can provide valuable support when treatment decisions involve complex goals-of-care or end-of-life issues.
An ethics consultation may be appropriate when there is persistent disagreement about a patient’s care, uncertainty about ethical obligations, conflict between stakeholders, questions involving treatment goals or decision-making capacity, or difficulty interpreting competing ethical principles.
Patient autonomy means respecting a patient’s right to make informed healthcare decisions when the patient has decision-making capacity. Nurses promote autonomy by providing information, supporting informed consent, respecting treatment decisions, and advocating for the patient’s preferences.
Hospice generally focuses on comfort, symptom management, quality of life, and support for patients with terminal illness when the goals of care are no longer primarily curative. Curative treatment focuses on eliminating or controlling the underlying disease. The appropriate approach depends on the patient’s condition, preferences, prognosis, and goals of care.
Applying an ethical decision-making model in nursing helps healthcare professionals approach complex clinical situations systematically and compassionately. By identifying the ethical issue, gathering accurate information, recognizing stakeholders, respecting patient autonomy, evaluating potential benefits and harms, and consulting interdisciplinary resources, nurses can make decisions that support patient-centered care.
Ethical nursing practice is particularly important in hospice, palliative, emergency, and end-of-life settings, where disagreements about treatment goals can arise. Respecting documented patient preferences, communicating effectively with families, maintaining professional boundaries, and following applicable ethical, legal, and professional standards can help nurses protect patient dignity while reducing unnecessary suffering.
Ultimately, ethical decision-making is not simply about choosing the medically appropriate intervention. It is about determining how healthcare can best respect the patient’s rights, values, goals, safety, and dignity while meeting professional responsibilities.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/coe-view-only
American Nurses Association. (2025). The nurse’s role in addressing ethical issues. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press. https://global.oup.com/academic/product/principles-of-biomedical-ethics-9780190640873
National Institute on Aging. (2024). What are palliative care and hospice care? National Institutes of Health. https://www.nia.nih.gov/health/palliative-care-and-hospice-care
Park, E. J. (2012). An integrated ethical decision-making model for nurses. Nursing Ethics, 19(1), 139–159. https://doi.org/10.1177/0969733011413491
World Health Organization. (2020). Palliative care. https://www.who.int/news-room/fact-sheets/detail/palliative-care
