A 23-year-old woman was admitted to the hospital with sepsis, as well as mitral and aortic valve prolapse. She had a history of heroin abuse since age 14. She immediately underwent an aggressive course of antibiotic therapy and was taken to surgery for mitral and aortic valve repair. It was projected that she would not fully recover. During the 3 months that she was in the MICU, she continued to deteriorate and was taken back to surgery for a second attempt to repair the diseased valves. The signs and symptoms of heart failure quickly returned and she was placed on mechanical ventilation. It was determined that no further surgeries would be performed.

The palliative care team was consulted for the management of her pain. As time progressed, she showed signs of psychological distress. She became withdrawn and less willing to participate in her care. The patient was nonverbal because of long-term airway maintenance with a tracheostomy and mechanical ventilation. She was unable to be weaned from the ventilator. The patient used a dry erase board and pen to communicate regarding the presence of pain, and was also able to shake her head yes or no. Despite her withdrawn state and nonverbal desire to not participate in her care, nurses were expected to comply with the aggressive medical treatment that was prescribed for her. Staff burnout became a major problem.

Several nurses began to request to not be assigned to this patient. Some stated it was emotionally draining, because even if she recovered, she would return to abusing drugs. The psychiatrist was consulted to assist the patient and nurses with their psychological distress. The patient's grandmother, physician, as well as the healthcare and ethical teams, were involved in the decision-making process. It was eventually determined that the prognoisis was poor. Life support was withdrawn and her code status was changed to do not resuscitate (DNR). She quickly and quietly passed away.

A better understanding of the ethical principles of autonomy, beneficence, and justice would have eased the intensity of the nurses' moral dilemma and potentially empowered staff to be more active in advocating for this patient.

The principle of autonomy relates to allowing patients to make their own decisions regarding their healthcare. According to one book on ethics, "In the domain of health care, respect for the patient's autonomy includes actions such as [horizontal ellipsis] allowing the patient to refuse treatment."1 The patient was asked in the presence of her grandmother if she wanted to continue with her course of treatment, but the patient wrote "no" on her dry erase board. The patient's response was communicated to the physician as well as the healthcare and ethical team.

The second ethical principle that applies to this case is that of beneficence. According to experts, "Beneficence means taking action to promote the welfare of other people."1 Though the patient showed signs of not wanting the level of care she was receiving, staff continued to treat her aggressively with antibiotics, surgery, and mechanical ventilation. This care was administered under the premise that it was in the best interest of the patient.

The third ethical principle that is applicable to this case is that of justice. This patient had a right to receive the same care that any other patient with her condition would have received. Her history of drug abuse could not exclude her from receiving care.

This experience taught the staff the importance of understanding and incorporating ethical principles into our nursing practice. This understanding makes all staff members better prepared to handle the multitude of moral dilemmas that arise in the critical care environment.

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