Nurses are increasingly faced with situations in practice regarding the prolongation of life and withdrawal of treatment. They play a central role in the care of dying people, yet they may find themselves disempowered by medical paternalism or ill-equipped in the decision-making process in end-of-life situations. This article is concerned with the ethical relationships between patient autonomy and medical paternalism in end-of-life care for an advanced cancer patient. The nurse's role as the patient's advocate is explored, as are the differences between nursing and medicine when confronted with the notion of patient autonomy. The impetus for this discussion stems from a clinical encounter described in the following scenario.

Percutaneous endoscopic gastrostomy is an accepted technique for long-term enteral feeding. The demand of percutaneous endoscopic gastrostomy placement continues to increase because of the increasing numbers of vulnerable patients with chronic diseases coupled with the relative ease of insertion, and societal ambivalence about such treatment. Despite the demand and improvements in placement technique, the issue of tube feeding in vulnerable patients remains an ethical minefield, leading to considerable discussion and debate. This contentious area of clinical ethics is further complicated by the recent papal allocution regarding artificial nutrition and hydration. The case of Terri Schiavo should serve as a timely reminder of those problematic clinical and ethical issues inherent in percutaneous endoscopic gastrostomy placement and feeding in vulnerable patients.

O ne cannot help but notice the growing diversity in our population. We are indeed immersed in a global community. Never before have we-either as nurses or as patients-experienced such an eclectic mix of ethnicity, religion, race, culture, and nationality as we do today. Yet this breadth, depth, and mixing of cultures also challenges us as a society. As nurses, cultural diversity immediately and poignantly tests our ability to care truly for patients and to advocate for them appropriately, thoughtfully, and sensitively while demonstrating that we are not only clinically proficient but also culturally competent.As nurses, we often are charged with the expectation of cultural competence, especially when we consider our ethic of patient advocacy. To be culturally competent, the nurse must identify with his or her own worldviews and those of the patient while escaping the tendency to stereotype and apply misguided scientific knowledge and stigma. Cultural competence is acquiring cultural information and then using that knowledge. This heightened cultural awareness allows the nurse to both appreciate and acknowledge the entire picture and therefore improves the quality of care and health outcomes for the patients. Yet this application and awareness is far more easier said that done. It requires much sensitivity, time, adaptability, and inclination to master.With the constraints that modern day work settings already impose on professional nurses, is it unrealistic to expect a certain level of cultural competence from them? I offer the following basic and brief discussion of cultural competence within an ethical framework of patient advocacy as somewhat of a short course in attaining this often-assumed ability.Dealing with a patient's healthcare needs, his or her normal and not so normal bodily functions, means dealing with a patient at the most personal level. Beliefs about illness, pain, injury, and death can vary markedly between cultures. Indeed, in some cultures, seeking medical advice represents the last resort after a long and painful struggle. In others, the slightest discomfort prompts a visit to the clinic.According to Setness (1998), the Hmong culture believes that the body and soul are intrinsically connected and that illness signifies a wandering soul. In some cultures, death may be viewed as the ultimate reward, whereas in others, it represents a dreaded judgment (Setness, 1998). Similarly, the delivery of bad news (which is difficult irrespective of culture) often is withheld in some cultures (e.g., many Asian cultures). In these cultures, a poor prognosis is never shared with a patient (Karim, 2003).Cultural competency also means considering many options, being careful about casting opinions and making uninformed judgments. Take for example the D e p a r t m e n t E d i t o r

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