Competent Patients’ Refusal of Nursing Care

Abstract

Competent patients' refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a 'negotiated reliance' response where nurses and others tread as lightly as possible on the patient's autonomy while negotiating a compromise, but are obligated to match the patient's sacrifice by extending themselves beyond their usual professional practice.

Concept analysis: patient autonomy in a caring context

“…) and exercises autonomy as freedom of choice based on participation. Non‐compliance was described as an unusual expectation in nursing culture, where patients by habit frequently consented to nursing care irrespective of verbal or written consent (Dudzinski & Shannon ). Non‐compliance was defined as a patient's informed refusal of ordinary nursing care and could involve a lack of cooperation in nursing care activities, such as bladder or bowel management, even though such care provision was well known to the patient.…”

“Whatever My Mother Wants”: Barriers to Adequate Pain Management

“…15,16 However, negotiation has been proposed as a method of dealing with patients who refuse treatment. 17 This technique enables health care providers to reach a compromise with patients without affecting their sense of autonomy. In our case, the patient agreed to a low-dose morphine infusion after major efforts by our team to educate and counsel her.…”

Moral distress and the Australian aged care worker: A mixed methods study

“…Dudzinski & Shannon (2006) talk about a "negotiated reliance response" which they suggest may alleviate distress for practitioners. This involves discussions between all stakeholders, including the patient's family when appropriate; to facilitate a coordinated plan that recognizes the desires of all parties.…”

“…Disrespectful care delivery by other practitioners (Nordam et al, 2005), maintaining client confidentiality (Solum & Schaffer, 2003) , a patient's refusal of care deemed appropriate by nursing staff (Dudzinski & Shannon, 2006), and patient autonomy in decision making (Brazil et al, 2010) were identified as significant elements of job demands contributing to moral distress. Moral distress has also been linked to overly aggressive or futile care situations (Brazil et al, 2010;Epstein, 2010;Ferrell, 2006;Kain et al, 2009;Oberle & Hughes, 2001; E. Rice et al, 2008).…”

“…Elsewhere, a patient's refusal of care deemed appropriate by nursing staff (Dudzinski & Shannon, 2006) was identified as significant. A similar conflict was noted by both Montagnino (2007) and Kirk (2007), although they identified this situation within the nurse / family member relationship.…”