Author: Bernard Mwega, KRCN, BSCN, RNN (on going).


Definition:Advance directives are legal documents that specify a patient’s wishes before hospitalization and provide valuable information that may assist health care providers in decision making e.g. a living will, durable power of attorney for health.

The professional nurse has 3 major roles

Practitioner role

The practitioner role of the nurse involves those actions that the nurse takes when assuming responsibility for meeting the health care and nursing needs of clients (patients and significant others). This role is the dominant role of nurses.

 Leadership role

The leadership role is inherent within all nursing positions and is not just based on titles. This role involves those actions the nurse executes when assuming responsibility for the actions of others that are directed toward determining and achieving patient care goals. Nursing leadership is a process involving four components: decision making, relating, influencing, and facilitating.

Research role

Participation in the research process is a responsibility of nurses both academic and clinical practice. The primary task of nursing research is to generate evidence base for nursing practice. Studies are needed to determine the effectiveness of nursing interventions and nursing care.

 What is our role in dealing with advance directives?

Nurses should freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone. Having interdisciplinary communication when all members of the health care team can voice their concerns and come to an understanding of the moral situation. The use of an ethics consultant or consultation team could be helpful to assist the health care team, patient, and family to identify the moral dilemma and possible approaches to the dilemma.

Advance directives will usually pose an ethical dilemma to the nurse, however, the nurse can exercise their right of being a contentious objector, A dilemma refers to a conflict between two alternatives. Ethical dilemmas occur when; a problem exists between ethical principles, deciding in favor of one principle usually violates another, or when a situation involves a conflict between two contradictory principles or values. Ethical issues have always affected the role of the professional nurse.

Some of the common ethical issues confronting a nurse are:

  1. a) Confidentiality: We all need to be aware of the confidential nature of information obtained in daily practice. If information is not pertinent to a case, the nurse should question whether it is prudent to record it in the patient’s chart.
  2. b) Dilemmas: In the practice setting, discussion of the patient with other members of the health care team and students is often necessary. Widespread use of computers and the easy access people have to them. This may increase the potential for misuse of information, which may have negative social consequences.
  3. c) Restraints: The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones. Before restraints are used, other strategies, such as asking family members to sit with the patient, should be tried (Rogers &Bocchino, 1999).
  4. d) Veracity: Telling the truth (veracity) is one of the basic principles essential in nurse – patient relationship. Ethical dilemmas may occur in informing patients of their diagnoses when the family and physician have chosen to withhold information. Veracity versus the nurse’s duty to care where disclosing information may worsen the patient’s condition due to stress.


  1. e) Inappropriate tasks: A nurse may decline to provide care where they feel incompetent or when or if it conflicts with their moral values, for instance procuring an abortion, (contentious objector).To avoid conflicts with one’s duty to care a nurse, when applying for a job, should ask questions regarding the patient population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice.


  1. f) End-of-Life Issues

Dilemmas that center on death and dying are prevalent in medical-surgical nursing practice and frequently initiate moral discussion. The dilemmas are compounded by the fact that the idea of curing is paramount in health care. With advanced technology, it may be difficult to accept the fact that nothing more can be done, or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations.

  • Euthanasia

The word is derived from Greek words euandthanatoswhich means a gentle and easy death. It is a method of terminating life without pain. It could be done passively through withholding or withdrawing treatment or actively through overtreatment. The dilemmas in this case include, it conflicts with duty to save life, prolonging life at the expense of comfort or quality of life and or may deny others chance in case of scarce resources.

  • Do-not-resuscitate orders

The “do not resuscitate” (DNR) order is a controversial issue. When a patient is competent to make decisions, his or her choice for a DNR order should be honored, according to the principles of autonomy or respect for the individual. The dilemma is that the DNR order is subject to misinterpretation but ethically, all patients deserve and should receive appropriate nursing interventions, regardless of their resuscitation status.

  • Living will

This is a Written statement of a patient’s wishes regarding utilization of medical therapies should the patient lose decision-making capacity. Living will procedures vary from state to state. “Durable power of attorney” (DPAHC) designates a health care agent (proxy) who is authorized to make medical decisions for the critically ill upon losing incompetence to decide. A dilemma: may occur when the Will conflicts with the duty to care or the wishes of the relatives/proxy.

  • Pain control

The administration of analgesia should be governed by the patient’s needs.

The use of opioids to alleviate a patient’s pain may present a dilemma for nurses. Patients with excruciating pain may require large doses of analgesics. Fear of respiratory depression or unwarranted fear of addiction should not prevent nurses from attempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally, the patient’s respiratory status should be carefully monitored and any signs of respiratory depression reported to the physician.

  • Life support

In cases where the patient is not competent to make the decision and the family  refuses to consider a DNR order as an option the nurse may be told to perform a “slow code” (i.e. not to rush to resuscitate the patient) or may be given a verbal order not to resuscitate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to follow hospital policies, communicate with the physician who may discuss the matter with the family and share with colleagues who are faced with similar situations for support.

  • Food and fluid

A dying patient may request that no more food or fluid be administered. Many individuals think that food and hydration are basic human needs, and therefore should always be maintained. However, some consider food and hydration as means of prolonging suffering. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or withdrawing sustenance.

  • Preventive Ethics

As previously mentioned, a dilemma refers to a conflict between two alternatives. In such instances, one’s moral decision is to choose the lesser evil of the two. However, various preventive strategies are available to help nurses anticipate or avoid certain kinds of ethical dilemmas.



Bernard is from Kenya. He is a dynamic nurse with excellent nursing and leadership skills and a trace record of dealing with clinical excellence in a professional manner through direct nursing care. He is one of the passionate and excellent contributor in Lead Nurse Africa professional Discussions.He is currently practicing as a Nursing Service Manager in Kenya.


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Lead Nurse Africa is a Pan-African nursing organization dedicated to public health promotion and professional development.


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