NR-579 Week 6 Ethics and Surrogate Decisions: How to Write It

What NR-579 Week 6 asks for

Why do ethics papers written by strong clinicians so often score in the middle? Because clinical instinct arrives at the right answer quickly, and this stage is not grading the answer. It is grading the route. A nurse with fifteen years of experience can look at a family insisting on continued artificial nutrition in advanced dementia and know within a minute where the case should land. Writing that minute out is a different skill: it means naming the principle on each side, showing why the case is genuinely contested rather than merely uncomfortable, and defending a resolution that a reasonable colleague could still disagree with.

Picture a Monday at a community health center that runs a small geriatrics service out of two rooms at the back of the building. An eighty-four-year-old man with advanced dementia has come in with his nephew, who holds a healthcare power of attorney signed four years ago and who has never been in the building before. The patient's daughter, who does the daily care and has no legal standing, is in the waiting room and has already told the front desk that her father would not want a feeding tube. The nephew wants everything done. There is a legal answer here, a clinical answer, and a moral question about whose account of the patient's values is closer to the truth, and none of the three lines up neatly with the others. A write-up that resolves this in one paragraph has not seen the case. A write-up that separates the authority question from the substitution question, and treats each on its own terms, is doing the graded task.

Deliverables at this depth are usually a written ethical analysis of a de-identified situation you encountered or observed, sometimes with a posted response to a case supplied in the classroom. Expect the scoring rows to reward framework application and defensible reasoning far above description. If a discussion runs this week, be careful in it: ethics threads invite opinion, and opinion posted without a principle behind it reads as exactly that. Posts do not reopen after submission in Canvas.

The distinction to install this week is between a moral distress narrative and an ethical analysis. Moral distress is what you felt when you believed the right course was blocked. Ethical analysis is a reasoned account of whether it actually was. Both belong in graduate writing, but only one of them can be scored against a principled-reasoning row, and students who blur them lose the row while writing something genuinely heartfelt.

The placement boundary, stated plainly

This manual supports the written layer only. Clinical hours, encounter counts, time logs, site documentation, preceptor evaluations and every signature attached to any of them are your own verified record. They are never drafted for you, never reconstructed after the fact and never estimated to close a gap. That boundary is at its most important in an ethics stage, because the temptation here runs the other way from the usual one: not to fabricate a log, but to improve a case. Do not sharpen a real situation into a better teaching example by adding a conversation that did not happen or a family member who does not exist. If the case you lived is untidy, write the untidy case. Untidiness is the material this stage is made of.

Every patient, family member and colleague in your written work has to be de-identified before it reaches the page. Ethics cases are more identifying than clinical ones, because a conflict is memorable and a small community is small. Strip names, dates, room numbers, exact ages, employers, distinctive family configurations and any detail that would let a reader from your own region reconstruct the situation. Write the man in his eighties with advanced dementia and a distant relative holding decision-making authority, not the specifics that would let a colleague name him. If you are describing a disagreement in which a named clinician took a position, de-identify the clinician too. Your analysis has to survive being read by the people who were in the room.

What can be taught here is entirely on the writing side: how to select a case that has real ethical content, how to lay out competing obligations without caricaturing either, how to apply a published framework without letting it flatten the case, how to write a defensible position that acknowledges its own cost, and how to anchor all of it in published ethical and palliative literature.

The NR-579 Week 6 method, step by step

Seven moves that turn an uncomfortable memory into a scored ethical analysis.

1. Test whether the case is actually contested

   Ask whether a competent, informed colleague could hold the opposite position for good reasons. If nobody could, you have a communication problem or a knowledge gap rather than an ethical dilemma, and writing it up as ethics will lose the analysis row. Pick a case where the disagreement survives full information.

2. Separate the authority question from the substitution question

   Who is legally entitled to decide, and what standard should that person be deciding by, are two different questions that students collapse constantly. A surrogate with unquestioned authority can still be reasoning from her own preferences rather than the patient's known values, and that gap is often where the real case lives.

3. Reconstruct the patient's voice from the record you have

   Say in writing what is actually known about this person's values, where that knowledge came from, and how strong the evidence is. A prior conversation reported by one relative, an advance directive completed years earlier and a pattern of past choices are three different qualities of evidence. Rank them explicitly.

4. Name the obligations on each side using published language

   Autonomy, beneficence, non-maleficence and justice are the standard vocabulary, but the scoring comes from applying them to particulars rather than defining them. Say which specific act the principle recommends here and which specific act it forbids, in this case, for this person.

5. Apply one named framework and let it do visible work

   Use a published ethical decision framework or a professional code, name it with its issuing body and year, and walk the case through its steps in order. A framework mentioned in the introduction and abandoned by paragraph three is worse than no framework at all, because the grader can see the abandonment.

6. State a position and name what it costs

   Take a side. Then write the strongest sentence you can in favour of the position you rejected, and say why it does not carry the day. An analysis that presents its own conclusion as obvious has not demonstrated that it understood the opposing case, which is exactly what the reasoning row is checking.

7. Close on the process, not on the feeling

   Finish with what should happen procedurally: an ethics consultation, a documented values conversation, a second surrogate discussion, a time-limited trial with defined endpoints. Palliative ethics is rarely resolved by a ruling; it is resolved by a better process, and naming the process is what turns your analysis into practice.

A layout and word budget for an ethical analysis

The frame our tutors keep beside an ethics submission, sized for a paper of roughly 1,300 to 1,600 words. It is our own outline rather than anything the university issues, and your week's rubric outranks it wherever the two disagree. Scale the targets proportionally if your assigned length differs, and drop any section your scoring rows do not ask for.

Evidence craft for palliative ethics writing

A principle is not a citation. Naming autonomy demonstrates vocabulary. Citing the published source that defines the professional obligation, with its issuing body and year in your sentence, demonstrates scholarship. Ethics rows in graduate practicum courses almost always sit next to support rows, and students lose the second while satisfying the first.

Use professional codes and position statements, not general philosophy alone. Nursing has a code of ethics with interpretive statements, and palliative and hospice organizations publish position statements on artificial nutrition, sedation, withdrawal of interventions and surrogate decision-making. Those documents are closer to your case than a survey of moral theory, and they carry more weight in a specialty course.

Keep legal and ethical claims in separate sentences. What a surrogate is legally permitted to do and what a surrogate ought to do diverge routinely, and merging them produces a paragraph that is wrong on both counts. Say what the legal position appears to be, note that it varies by jurisdiction, then argue the ethics separately.

Attribute contested empirical claims. Statements about what patients with advanced dementia experience, or about whether a particular intervention prolongs life in a given population, are empirical and belong to the literature. An ethical argument built on an unsupported empirical premise collapses at the premise, and a careful grader will find it.

Any number arrives with its base and its window. If you cite how often surrogates in a study chose differently from the patient's stated preference, give the count out of the total and the period studied before any proportion appears. Twenty-three of 118 surrogate decisions over eighteen months is evidence a reader can weigh. Nineteen percent is a figure with nothing underneath it.

Six mistakes that cost points in this week's territory

• A case with only one defensible side. If the family was simply misinformed, the paper is about communication, and it will not score against an ethical-reasoning row no matter how well it is written.
• Principles defined rather than applied. A paragraph explaining what beneficence means is a textbook excerpt. A sentence saying what beneficence recommends for this patient this week is analysis.
• The framework abandoned mid-paper. Naming a decision model in the introduction and then reasoning freehand is visible to any grader who knows the model, and it reads as decoration.
• The opposing case written as a straw argument. A counter-position summarized weakly so it can be dismissed easily tells the reader you have not engaged it, and that costs the row you were trying to win.
• Moral distress presented as analysis. How the situation affected you can occupy a closing paragraph if the rubric invites reflection. It cannot occupy the reasoning section.
• An ethics case that is still identifiable. Conflicts are memorable. An unusual family arrangement plus a service plus a region is an identification, even with the name removed.

Before you submit

• The ethical question is stated as a question before the situation is described
• Legal authority and the standard for substituted judgment are treated as separate issues
• The evidence for the patient's values is named with its source and its strength
• Each principle is applied to a specific act in this case rather than defined
• One named framework or code, with its year, is carried through the whole analysis
• The strongest counter-argument appears in its strongest form
• The paper closes on a process recommendation with defined endpoints
• No patient, family member or colleague could be identified from anything you wrote

Questions students ask about this stage

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