Case Study


Ethical dilemmas are seen more nowadays by
nurses during their practice, particularly when they are taking care of a
patient who is at an end of life stage. The case study demonstrates an ethical
dilemma when nursing staff are taking care of an 80 year old lady who was
admitted onto the intensive care unit, for the purpose of this essay she will
be referred to as Mrs S, verbal consent was given by the family as it was
deemed that Mrs S did not have the capacity to give consent; this is to fully
comply with the Nursing and Midwifery Council (NMC) code of conduct (2015). There
will also be a brief explanation of the dilemma and also a discussion on
autonomy, beneficence, non-maleficence, justice, small conclusion about
the findings in this case study and It will also present the clinical case, identify
the ethical dilemma.


Mrs S was brought up to ICU from accident and
emergency after her condition deteriorated, she was originally brought into
A&E after being found on the floor; unconscious by her carers at home, she is
also found to have had significant weight loss over a short amount of time.
After further tests it was discovered that Mrs S had lung cancer with multiple
areas of metastases including brain, liver and bone. After this discovery there
was a discussion with the son who was the next of kin about a do not
resuscitate (DNAR) order being put in place. To which he agreed and said it was
what his mother wished for before she became ill; there was then a later discussion
with Mrs S’s daughter about the same situation to which she did not want the
DNAR order to be put in place. This is the ethical dilemma that will be
discussed in this case study; The daughter’s request for care conflicts with
the patient’s and next of kin’s wishes and places the staff in a complicated
position of either honouring the patient’s wishes or fulfilling the daughter’s


main framework for ethics that is used in healthcare is call ethical
principlism which is based on four principles; autonomy, beneficence,
non-maleficence and justice (Rich N.D). Nice Guidelines (2009) on DNAR decisions
states that unfortunately, when applied to an ethical dilemma, the four
principles often conflict with each other and so they only provide a framework for


The word autonomy is a derived from the Greek
‘autos’ (‘self’) and ‘nomos’ (‘rule, governance, or law’) (Beauchamp &
Childress, 2009, p. 99). In nursing practice autonomy is
known as the right of a competent adult to make an informed decision about their
own medical care (British Medical Association 2016). The ethical dilemma shown
in this case study is whether to respect the patient’s autonomy or ignoring her
wishes by giving in the demands of her daughter. In this circumstance the ICU
consultant was concerned about providing any additional medical treatment that
the patient may not have wanted.



The broad definition of beneficence is an act
of charity, mercy, and kindness. It connotes doing good to others and invokes a
large selection of moral obligation. Beneficent acts can be performed from a
position of obligation in what is owed and from a supererogatory perspective,
meaning more than what is owed, all professionals have the foundational moral
imperative of doing right (Kinsinger 2009). In the event of cardiac
arrest, the patient is in danger of dying within minutes. Any resuscitation
attempt aims at prevention of death (maleficence) and saving life
(beneficence). Resuscitative efforts are unsuccessful in the majority of cases.
In at least in 50% of cardiac arrests, the action of the heart cannot be
restored another 30% die in hospital after successful restoration of the circulation.
For these patients, resuscitation means an extension of the process of dying by
hours or days, often without regaining consciousness and accompanied by the concomitants
of intensive care treatment, such as tracheal intubation and artificial respiration.
This means considerable suffering for the patient and relatives, and is a heavy
burden for those involved, including the hospital staff. Of those who survive,
approximately 20–50% suffer from neurological disabilities, ranging from slight
disturbances of cognitive functions to the “ultimate tragedy” of resuscitation—severe
hypoxic brain damage (persistent vegetative state).


(2012) states that Non-malefinence is the injuction to ‘do no harm,” this is
often corresponding with beneficence; however there is a difference between the
two principles. Beneficence requires taking action to benefit others, whereas
non-maleficence involves refraining from action that might harm others.



The next principle is justice; Butts (2012) explains that the concept of justice
is quite broad in the field of ethics. Justice refers to the fair sharing of
benefits and burdens. In regards to principlism, justice most often refers to
the distribution of limited healthcare resources. The majority of the times,
complicated resource allocation decisions are based on attempts to answer
questions regarding who has a right to health care and who will pay for
healthcare costs. The use of this principle was not implemented
right at the start of this scenario. Failure to facilitate this ethical
principle has contributed to the conflict dilemma of this case. When Mrs S was admitted
to ICU the use of high technology equipment can often have the effect of
unrealistic expectations (by family members and visitors) of what should be
achieved at end-of life care. The respect for autonomy did not empower the
patient’s right at the start and this leads to a violation in the justice




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