The patient is an 88-year-old man with an extensive cardiac history who has been a resident of a skilled
nursing facility for the past 3 years. Comorbid conditions include type 2 diabetes (15 years) and severe
peripheral vascular disease. For 6 months the patient has suffered from a serious left leg wound that has
not responded to treatment and that has become much worse over the past 2 months. At this point, the leg
is gangrenous to above the ankle, and the normal course of treatment would be to remove the leg above
the circulatory problem. However, the patient is refusing surgery and states that he wants “to die with all
of my limbs intact.” The patient has been assessed with mild to moderate dementia and has named his
daughter as his durable power of attorney. The nurses on the unit, the daughter, and the primary care
physician all realize that amputation is necessary to save the patient’s life.
Dilemma: Several ethical issues are relevant to the resolution of the situation. The obligation to respect
the patient’s autonomy in the decision to refuse an amputation puts his life at risk. However, after hearing
about the need for surgery and the likely outcome without the surgery, he continues to state, “I want to die
with all of my limbs intact.” The daughter and some of the nurses who care for the patient question his
ability to make such a decision.
As a nurse, we want to protect our patient’s rights for autonomy and self-determination, but at the same
time, we want what is in the best interest of the patient’s health. What are the ethical issues in this case
study? Who has the legal right to make this decision? Using the nursing process, define how you would
work through this ethical issue.
Sample Solution