MN506 Unit 4 ethical dilemma analysis example

"Please Don't Tell Anyone": Autonomy and Protection When a Capable Older Adult Asks His Nurse to Keep Financial Exploitation Secret

[Student Name]

Purdue University Global

MN506: Health Policy, Ethics, and Legal

Unit 4 Assignment

[Instructor Name]

[Date]

The patient, family and agency are composites written as a model document. No real person or case is described.

Case Summary

The patient is a composite 84-year-old retired railroad worker who lives alone and receives home health nursing twice a week for diabetes management and a healing foot wound. A capacity assessment documented by his physician one month ago found that he understands his conditions, his treatment options and his finances and can reason about them. On the last two visits, his nurse found that his insulin had not been refilled; he said his son "had the card." He showed her a bank statement with large withdrawals over three months and told her his son, his only living family, had taken over his debit card after his wife died. He then asked her not to tell anyone: "He's all I have. If you report him, I'll lose him."

The Dilemma

The nurse must choose between honoring the choice of a capable man to keep his son's conduct private and protecting him from a harm, financial exploitation that has already interrupted his insulin, that he has chosen to tolerate.

Framework

The analysis uses principlism, which weighs four principles: respect for autonomy, beneficence, nonmaleficence and justice (Beauchamp & Childress, 2019). It also uses the American Nurses Association Code of Ethics, in particular Provision 1, which states that the nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person, and whose interpretive statements include the patient's right to self-determination, and Provision 3, which states that the nurse promotes, advocates for and protects the rights, health and safety of the patient (American Nurses Association, 2015). Each option below is tested against those principles and provisions.

Option 1: Silence

Keeping the secret honors his autonomy and his wish to protect his relationship with his son. It fails beneficence and nonmaleficence once the missed insulin is counted: interrupted insulin in a man with diabetes and a foot wound risks hyperglycemia, infection and hospitalization, and the exploitation is likely to continue or escalate. Financial exploitation of older adults is common, often committed by family members, and associated with harm beyond the lost money (Lachs & Pillemer, 2015). Silence also leaves the nurse aware of a pattern that endangers her patient's health, which Provision 3 asks her to address.

Option 2: A Report Over His Objection, Without Telling Him

Reporting to Adult Protective Services without his knowledge honors the duty to protect. But it treats his documented capacity as though it did not exist and makes a decision about his life without him, which contradicts Provision 1. It also risks the relationship with his nurse, the person most likely to notice if things get worse, and may lead him to refuse home health visits.

Option 3: Telling Him First, Then Reporting With Him

In the chosen path, the nurse tells him that she is worried about his safety, explains that she believes she must contact Adult Protective Services because his insulin has gone unfilled, and invites him to make the call with her. This path keeps the protective outcome but changes the manner: he learns of the report before it happens, hears why, and is given a role in it rather than having it done to him. Adult Protective Services can offer services such as help setting up direct pharmacy payment or a separate account for medication costs, and he remains free to accept or refuse them because he has capacity. The nurse also arranges an immediate fix for the insulin, a pharmacy delivery billed to his insurance, that does not depend on the son.

Justice

The fourth principle is easy to overlook in a case about one family, but it applies. Older adults who live alone, depend on a single relative and have no other visitors are among the least likely to have exploitation noticed by anyone. The home health nurse may be the only professional who sees this patient regularly. Treating his situation as private, when a patient with more family or social contact would be more likely to have it noticed and addressed, would leave the most isolated patients the least protected. Justice therefore adds weight to acting, while the manner of acting still matters for autonomy.

What the Nurse Documents

Whatever option is chosen, the record must be factual and complete. The nurse documents the missed insulin refills with dates, the patient's statement that his son holds the card, the bank statement she was shown, his request for confidentiality in his own words, the conversation in which she explained her concern, his response, the report made and its reference number, and the pharmacy arrangement for insulin. She does not record conclusions about the son's intent. Accurate documentation protects the patient if the case is investigated and protects the nurse if her decision is later questioned.

The Law, Set Apart

The composite state's adult protective services statute requires health professionals to report suspected abuse, neglect or exploitation of adults who lack capacity or who depend on others for their care. Whether this patient falls within the statute is arguable: he has capacity, but he depends on his son for access to his own money and, as the missed insulin shows, for medication. The nurse's decision does not rest on the statute alone, because even if reporting were not mandatory, the ethical analysis would still favor Option 3.

What Autonomy Lost

The chosen path is not free of cost. It overrides his explicit request that no one be told. He may feel betrayed even though he was told first, and he may be right that the report will damage his relationship with his son, possibly permanently. The analysis treats that as a real loss rather than a minor one. It justifies the loss by the seriousness of the harm already occurring, interrupted insulin rather than only lost money, and by choosing the path that keeps him as involved as possible. If the exploitation had been financial only, with his health unaffected, the balance would favor respecting his wish more strongly. The nurse will also return on her next scheduled visit and ask him directly how he is doing after the report, which keeps the relationship at the center of her care rather than ending it with the call.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Lachs, M. S., & Pillemer, K. A. (2015). Elder abuse. New England Journal of Medicine, 373(20), 1947-1956. https://doi.org/10.1056/NEJMra1404688