Introduction
Person-centred care (PCC) is a cornerstone of modern nursing practice, especially in the context of adult nursing and the care of confused elderly persons. This approach prioritises the individual’s needs, values, and preferences, ensuring that care delivery respects their dignity and autonomy. However, providing safe and effective PCC to elderly patients with confusion, often due to conditions like dementia or delirium, presents unique ethical challenges. This essay explores the ethical concepts underpinning PCC, focusing on autonomy, beneficence, non-maleficence, and justice, and how these principles apply to adult nursing for confused elderly individuals. By examining these concepts through relevant literature and practical examples, the essay aims to highlight the importance of ethical decision-making in achieving safe and effective care outcomes. The discussion will also address the potential tensions between these ethical principles and the complexities of applying them in real-world nursing scenarios.
Defining Person-Centred Care and Its Ethical Relevance
Person-centred care, as defined by the Health Foundation (2014), is an approach to healthcare that focuses on tailoring services to the individual’s unique needs, respecting their personal goals and circumstances. In the context of adult nursing, particularly for confused elderly persons, PCC becomes ethically significant as it directly engages with fundamental principles of healthcare ethics. These principles, often framed within Beauchamp and Childress’s (2013) biomedical ethics framework, include autonomy (respecting patient choice), beneficence (acting in the patient’s best interest), non-maleficence (avoiding harm), and justice (ensuring fairness in care delivery). For confused elderly patients, who may struggle with decision-making capacity due to cognitive impairment, applying these principles requires careful consideration and a nuanced approach to ensure both safety and ethical integrity.
Autonomy and Decision-Making in Confused Elderly Care
Autonomy refers to the right of individuals to make informed decisions about their care. In adult nursing, respecting autonomy is central to PCC, yet it poses significant challenges when caring for confused elderly patients. For instance, a patient with dementia may express preferences that appear inconsistent or potentially harmful, such as refusing medication. The Mental Capacity Act (2005) in the UK provides a legal framework for assessing capacity, stating that every adult is assumed to have capacity unless proven otherwise (Department of Health, 2005). Nurses must balance respecting autonomy with ensuring safety, often relying on advance directives or family input when capacity is diminished. However, as McCormack and McCance (2017) argue, even patients with cognitive impairment can express preferences through non-verbal cues or past values, which nurses must interpret sensitively. Thus, autonomy in this context demands a flexible, individualised approach rather than a rigid application of legal standards.
Beneficence and Non-Maleficence: Balancing Benefits and Risks
Beneficence and non-maleficence are closely intertwined ethical principles that mandate nurses to act in the best interest of patients while avoiding harm. In the care of confused elderly persons, beneficence might involve implementing interventions like regular reorientation or medication to manage agitation. However, such actions can inadvertently cause distress or dependency, breaching the principle of non-maleficence. For example, the overuse of sedatives to manage challenging behaviour in dementia patients has been criticised for reducing quality of life (Ballard et al., 2016). Indeed, NICE guidelines (2018) advocate for non-pharmacological approaches as a first line of intervention to minimise harm. Nurses must therefore critically evaluate the potential benefits and risks of each care decision, ensuring that actions align with the patient’s overall wellbeing rather than merely addressing immediate symptoms.
Furthermore, the concept of ‘least restrictive practice’ becomes relevant here. When a confused elderly patient exhibits wandering behaviour, for instance, restricting their movement might seem beneficial for safety. Yet, this could cause emotional harm by undermining their sense of freedom. Kitson et al. (2013) suggest that PCC requires nurses to explore alternatives, such as environmental adaptations, to reconcile safety with dignity. This highlights the delicate balance between beneficence and non-maleficence, requiring ongoing reflection and adaptation in nursing practice.
Justice and Equity in Care Delivery
Justice, as an ethical principle, demands fairness and equity in the allocation of healthcare resources and attention. For confused elderly patients, who often have complex needs, ensuring justice can be challenging within resource-constrained environments like the NHS. For instance, these patients may require more time and specialised care, potentially leading to disparities if staffing levels are inadequate. A study by Dewing and Dijk (2016) notes that elderly patients with confusion are sometimes at risk of being deprioritised in busy clinical settings due to their perceived inability to advocate for themselves. This raises ethical concerns about whether PCC can truly be equitable under systemic pressures.
Additionally, justice extends to addressing biases in care. Nurses must be vigilant against ageism, which can manifest as assumptions that confused elderly patients are less deserving of intensive interventions. The Royal College of Nursing (2017) emphasises the need for training to challenge such stereotypes and promote equitable care. By advocating for fair treatment and access to resources, nurses uphold justice as a fundamental component of safe and effective PCC.
Practical Challenges and Ethical Tensions
Applying these ethical principles in practice is not without tension, particularly when principles conflict. For example, respecting a confused elderly patient’s autonomy by allowing them to refuse a necessary intervention may clash with beneficence if refusal poses a risk to their health. Similarly, ensuring justice by allocating extra time to one patient might compromise fairness to others in a resource-limited ward. These dilemmas require nurses to engage in ethical reasoning, often guided by codes of conduct such as the Nursing and Midwifery Council (NMC) Code (2018), which prioritises patient safety and dignity.
Moreover, cultural and familial dynamics introduce further complexity. A family may insist on a particular care approach based on cultural beliefs, which might conflict with evidence-based practice. Nurses must navigate such situations with sensitivity, ensuring that decisions remain patient-focused while acknowledging diverse perspectives. As Edvardsson et al. (2010) suggest, ethical competence in PCC involves continuous dialogue with stakeholders to resolve conflicts and prioritise the patient’s needs.
Conclusion
In conclusion, the ethical concepts of autonomy, beneficence, non-maleficence, and justice underpin safe and effective person-centred care in adult nursing for confused elderly persons. While autonomy demands respect for patient choice, it must be balanced with safety considerations, particularly when capacity is impaired. Beneficence and non-maleficence require nurses to weigh benefits against potential harms, often necessitating creative solutions to maintain dignity. Justice highlights the need for equity in care delivery, challenging systemic biases and resource limitations. However, tensions between these principles underscore the complexity of ethical decision-making in nursing practice. Ultimately, achieving safe and effective PCC for confused elderly patients demands not only adherence to ethical guidelines but also critical reflection and adaptability. The implications for nursing education and practice are clear: ongoing training in ethical competence and person-centred approaches is essential to address these challenges and ensure high-quality care.
References
- Ballard, C., Corbett, A., Orrell, M., Williams, G., Moniz-Cook, E., Romeo, R., Woods, B., Garrod, L., Testad, I., Woodward-Carlton, B., Wenborn, J., Knapp, M. and Fossey, J. (2016) Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial. PLoS Medicine, 13(2), e1002001.
- Beauchamp, T.L. and Childress, J.F. (2013) Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press.
- Department of Health (2005) Mental Capacity Act 2005. UK Government.
- Dewing, J. and Dijk, S. (2016) What is the current state of care for older people with dementia in general hospitals? A literature review. Dementia, 15(1), pp. 106-124.
- Edvardsson, D., Winblad, B. and Sandman, P.O. (2010) Person-centred care of people with severe Alzheimer’s disease: Current status and ways forward. The Lancet Neurology, 7(4), pp. 362-367.
- Health Foundation (2014) Person-Centred Care Made Simple. Health Foundation.
- Kitson, A., Marshall, A., Bassett, K. and Zeitz, K. (2013) What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing, 69(1), pp. 4-15.
- McCormack, B. and McCance, T. (2017) Person-Centred Practice in Nursing and Health Care: Theory and Practice. 2nd ed. Chichester: Wiley-Blackwell.
- National Institute for Health and Care Excellence (NICE) (2018) Dementia: Assessment, management and support for people living with dementia and their carers. NICE.
- Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
- Royal College of Nursing (RCN) (2017) Principles of Nursing Practice: Principles and measures for nurses working with older people. London: RCN.
