Category: uncategorised

Ethical dilemmas are rarely clear-cut in practice. One situation that has stayed with me involved an elderly patient with advanced chronic obstructive pulmonary disease (COPD) who was admitted in acute respiratory distress. He was alert, oriented, and had a clearly documented advance directive stating that he did not want intubation or mechanical ventilation. However, as his condition worsened, his family became increasingly distressed and insisted that everything possible be done, including intubation. This created a significant ethical dilemma: honoring the patients clearly stated wishes while responding compassionately to a grieving family who wanted more time.

At the heart of this situation was the ethical principle of autonomy. The American Nurses Association (ANA, 2015) Code of Ethics emphasizes that nurses are responsible for promoting and protecting a patients right to self-determination. Respecting autonomy means honoring informed decisions patients make about their own care, even when those decisions are difficult for others to accept. At the same time, principles such as beneficence and nonmaleficence require healthcare providers to act in the patients best interest and avoid harm (Beauchamp & Childress, 2019). Intubating this patient against his expressed wishes would have violated his autonomy and potentially prolonged suffering.

Emotionally, this situation was challenging. The family was visibly overwhelmed and fearful of losing their loved one. Their requests were rooted in love, not disregard for his wishes. As Saunders (2014) notes, ethical dilemmas often arise when deeply held values conflict in emotionally charged environments. I found myself feeling torn, wanting to support the family while also feeling a professional and moral obligation to advocate for the patients documented preferences.

The healthcare team responded by first confirming that the advance directive was current and clearly applicable to the situation. A family meeting was arranged with the physician, nursing staff, and social workers present. During this conversation, we carefully reviewed the patients documented wishes and explained what intubation would entail, including the likelihood of prolonged mechanical ventilation and decreased quality of life. An ethics consultation was requested to ensure that the patients rights were fully supported and that the decision-making process was transparent.

Importantly, the patient was still able to communicate. Despite fatigue, he reaffirmed that he did not want to be intubated. Hearing this directly from him shifted the tone of the discussion. The team then explained how comfort-focused care would prioritize symptom management, including oxygen therapy, medications for dyspnea, and palliative support. Gradually, the family began to understand that honoring his wishes was not giving up, but rather respecting his values.

The plan of care transitioned to palliative measures, consistent with his directive. He passed peacefully two days later with his family at his bedside. Although the situation was emotionally difficult, I felt reassured that we had upheld ethical practice and patient-centered care. This experience deepened my understanding of moral distress, which can occur when clinicians feel pressured to act against their ethical convictions (Epstein & Hamric, 2009). In this case, clear communication, interdisciplinary collaboration, and reliance on ethical principles prevented that distress from escalating.

Reflecting on this experience, I learned that ethical competence involves more than knowing theoretical principles. It requires advocacy, courage, and empathy. Supporting families through grief while protecting patient autonomy is one of the most complex responsibilities nurses face. Grounding decisions in ethical frameworks and professional standards helps ensure that compassion and integrity guide practice, even in the most emotionally charged circumstances.

Ethical Dilemma in Practice

While working on a cardiac unit, I experienced an ethical dilemma that continues to influence how I approach end of life discussions. One of my patients had a rapidly declining condition. As her health worsened, she became confused and eventually lost the capacity to make her own medical decisions. Before this decline, she had expressed that she did not want aggressive life prolonging measures and did not want to continue returning to the hospital as her condition progressed. Once she lost decision making capacity, however, her family insisted that she remain a full code and continue receiving all possible life saving treatments.

This situation created tension between respect for patient autonomy and the authority of surrogate decision makers. Ethically, patient autonomy requires honoring previously expressed wishes. In practice, once a patient no longer has decision making capacity and formal documentation is limited or unclear, families often assume control over medical decisions. In this case, the family requested continued hospitalization and aggressive interventions even as her condition declined further with each admission.

The care team attempted to have direct conversations with the family. We reviewed her prior statements and explained the likely progression of her disease. We discussed what aggressive measures would realistically involve and how they might impact her comfort and quality of life. Despite these discussions, the family continued to push for full treatment. The patient was repeatedly brought back to the hospital against what she had previously communicated she wanted.

This experience highlighted the emotional complexity that often accompanies surrogate decision making. (Childers, 2021) describe how family members may override a patients expressed wishes due to grief, denial, or fear. Their work emphasizes that surrogate decisions are frequently influenced by emotional distress rather than the patients previously stated preferences. That framework helped me better understand what we were seeing in this case. The familys insistence on aggressive care appeared rooted in difficulty accepting her decline rather than intentional disregard for her autonomy.

At the same time, the situation created moral distress within the team. (Hwu and Pai, 2025) found that nurses often experience ethical strain when they believe care being delivered does not align with what a patient would have chosen. That description matched how many of us felt. We were legally required to follow surrogate decision making authority, yet it felt inconsistent with the patients earlier wishes.

The situation was eventually managed through interdisciplinary involvement. Ethics consultation and palliative care were brought in to facilitate structured discussions. Eventually the focus shifted more toward comfort oriented measures, but it required repeated conversations rather than a single intervention. The resolution was gradual and emotionally complex for everyone involved.

This experience reinforced the importance of early advance care planning. As a registered nurse, I recognize that one of my responsibilities is to initiate clear conversations about goals of care before capacity is lost. Encouraging documentation of advance directives and discussing realistic disease trajectories may prevent similar conflicts. It also reminded me that ethical dilemmas in practice are rarely simple. They require balancing autonomy, beneficence, family dynamics, and legal standards while maintaining compassion for everyone involved.

References

Childers , J. (2021, June 9). shes not ready to give up yet!: When a family member overrides the patients medical decisions. Journal of pain and symptom management.

Hwu, L.-J., & Pai, H.-C. (2025, April 24). Exploring ethical dilemmas and coping strategies in nursing: A FOCUS Group Study of nurses and nursing students. Nursing & health sciences.

GI & Endocrine

Brandy Fields

St. Thomas University

NUR 502

Dr. Morgan

February 12, 2026

GI & Endocrine

Gastroesophageal reflux disease or GERD as it is most referred is the backward flow of gastric contents from the stomach into the esophagus. The gastric contents can go beyond the esophagus extending into the oral cavity, larynx, or lungs causing esophagitis and inflammation of the other affected mucosal surface (Azer & Goosenberg, 2025). Individuals older than fifty years of age, body mass index greater than thirty, alcohol consumption, lack of physical activity, and the consumption of foods high in fat or acidic contribute to the formation of GERD (Azer & Goosenberg, 2025). The underlying pathophysiology to GERD lies in abnormalities in the lower esophageal sphincter. Relaxation of the lower esophageal sphincter, the presence of hiatal hernias, decreased pressure, and obesity contribute to GERD (Dlugasch & Story, 2023).

Acid clearance can be another contributing factor if there is an impairment of peristalsis and lack of bicarbonates in salvia to neutralize acid. Delayed gastric emptying and increased intra-abdominal due to pressure changes further contribute to the development of GERD. Overtime repeated exposure of the esophageal lining to acidic gastric contents or chyme led to inflammation of the esophagus or esophagitis. Patients may report symptoms of heartburn, regurgitation of food, nausea, dry cough, or the sensation of a lump in the throat (Dlugasch & Story, 2023). Barrett esophagus, strictures, ulcerations, chronic laryngitis, asthma exacerbation, and esophageal cancer can potentially arise due to GERD. (Dlugasch & Story, 2023).

Evidence-Based Guidelines

A symptom-based approach is recommended for patients with classic GERD with the absence of major complications. Classic symptoms such as heartburn or regurgitation can be managed with the use of an eight-week trial of a premeal proton-pump inhibitor therapy (Katz et al., 2021). Symptoms such as gastrointestinal bleeding, unexplained weight loss, and persistent vomiting may warrant further diagnostic evaluation. Endoscopy, esophageal pH monitoring, and esophagus manometry are among diagnostic implementations in the treatment and management of GERD. In addition to the pharmacological approach, patients should be educated on lifestyle modifications that can assist in the management of symptoms (Dlugasch & Story, 2023). Maintaining a high fowler position after eating, weight reduction, eating small frequent meals, and the avoidance of late-night meals can assist in the management of GERD (Dlugasch & Story, 2023).

Advance Nurse Practice and Patient Education

Symptoms and other contributing factors are the greatest indicator of complicated or uncomplicated GERD. As mentioned above, patients with uncomplicated GERD will be present with the classic symptoms of heartburn and regurgitation. In those cases, where there are no other symptoms or correlations to disorder progression, the NP can render treatment. Patients presenting with more advanced symptoms such as gastrointestinal bleeding, unexplained weight loss, or anemia warrant referral or endoscopic evaluation. Patients should be provided with clear directions on medication administration to include the importance of timing to meals. Patients should also be encouraged to manage weight and make food choices that decrease the risk of symptom flare ups.

References

Azer, S. A., & Goosenberg, E. (2025, July 6). Gastroesophageal reflux Disease (GERD). StatPearls – NCBI Bookshelf.

Dlugasch, L., & Story, L. (2023). Applied Pathophysiology for the advanced practice nurse. Jones & Bartlett Learning.

Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2021). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology, 117(1), 2756.

Attached Files (PDF/DOCX): NUR 531 Time Management Self-Assessment.pdf, NUR 531 Stress Management Self-Assessment.pdf, module 2 journal.pdf

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GI & Endocrine

Pathophysiology of Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a chronic disease because of retrograde masses of gastrointestinal fluid discharging to the esophagus, which leads to symptoms or damage to the mucosa. The dysfunction of the lower esophageal sphincter (LES) is the most prevalent pathophysiologic process that can be a temporary lower esophageal sphincter relaxation (TLESR), a reduction in LES tone, or morphologic abnormalities, including a hiatal hernia (Katz et al., 2022), when the process of refluxing of acidic substances of the stomach into the esophagus starts as a result of inadequately high pressure in the LES overcoming the defensive mechanisms against it, such as esophageal peristalsis and salivary buffering.

Acid exposure causes tissue injury to the esophageal mucosa, which causes inflammation or erosive esophagitis or morbidities, including Barrett’s esophagus. Acid and pepsin affect the integrity of the epithelia and activate esophagus chemoreceptors, which leads to heartburn and regurgitation symptoms (Katz et al., 2022). GERD is a widespread disease globally, and its prevalence is rising among most regions, which is causing a substantial burden and reduced quality of life worldwide (Dirac et al., 2020). Knowledge of these mechanisms aids in the early detection and proper management when dealing with clinical practice

Evidence-Based Diagnosis and Management (ACG 2022)

The American College of Gastroenterology (ACG) (2022) guideline claims that uncomplicated GERD can be diagnosed clinically, and patients who show common symptoms, including heartburn and regurgitation, without alarm features (Katz et al., 2022). First-line therapy should include an 8-week trial of a proton pump inhibitor (PPI) and should be taken once daily before meals. Endoscopy is implied in case of alarm symptoms, such as dysphagia, gastrointestinal bleeding, anemia, weight loss, or persistent vomiting.

Nonpharmacologic measures are highly advised and comprise loss of weight among overweight patients, head of the bed elevation, not taking food 2-3 hours before bedtime, and quitting tobacco (Katz et al., 2022). The change in diet must be made on a case-by-case basis, depending on the triggers of the symptoms. The pharmacologic management is mainly based on PPIs that are of better quality in their acid suppression and healing the mucosa than H 2 receptor antagonists. The minimum dose of therapy should be used, and it needs to be re-evaluated periodically (Katz et al., 2022).

Implications for Advanced Nursing Practice

Nurse practitioners (NPs) are important in giving a clear cut between the case of uncomplicated GERD and the one that needs referral. The patients who are sensitive to empiric PPI therapy and not alarming do not need urgent endoscopy. Nevertheless, the alarm symptoms, recurrent symptoms despite the best therapy, or the risk factors of the esophagus of Barrett make it necessary to refer to gastroenterology and potentially perform endoscopy (Katz et al., 2022). Since GERD (Dirac et al., 2020) is a global issue with a high and increasing incidence, advanced practice nurses should implement evidence-based practices to guarantee the prompt detection of complications and prevention of needless operations.

Patient Education and Adherence Strategies

Patient education is the key to adherence and outcomes improvement. The patients should be educated that they should take the PPIs 30-60 minutes before eating to reach their peak effect (Katz et al., 2022). Sustainable lifestyles change programs, in particular, weight management, are needed because obesity is a risk factor that can be changed to influence the occurrence and development of GERD (Dirac et al., 2020). Adherence is enhanced through follow-up visits, instructions, and assessments of realistic expectations. Patient-centered counseling and evidence-based management are the only ways in which nurse practitioners can reduce the symptom burden and eradicate the long-term complications.

References

Dirac, M. A., et al. (2020). The global, regional, and national burden of gastro-esophageal reflux disease in 195 countries and territories, 19902017: A systematic analysis for the Global Burden of Disease Study 2017. The Lancet Gastroenterology & Hepatology, 5(6), 561581.

Katz, P. O., et al. (2022). ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 117(1), 2756.