"I'm Leaving Tonight": Ethical Principles and Legal Duties When a Patient With Pancreatitis Wants to Leave Against Medical Advice
[Student Name]
University of Phoenix
NSG/426: Integrity in Practice: Ethic and Legal Considerations
Week 1 Assignment
[Instructor Name]
[Date]
The patient, unit and staff are a composite written for a model paper. No real patient is described.
At 9 p.m. on the third day of his hospitalization for acute pancreatitis, a composite 52-year-old warehouse manager pulled on his jeans and told his nurse he was leaving. His pain was improving but not controlled without intravenous medication, he had not yet tolerated solid food and his laboratory values were still abnormal. His daughter was graduating from college the next morning, three hours away, and he said nothing would make him miss it. The nurse's first impulse was to keep him safe; her responsibility was to keep him informed, and those turned out to be different things. This paper applies the four principles of biomedical ethics and the relevant legal duties to her response.
The Four Principles
Beauchamp and Childress (2019) describe four principles that guide ethical reasoning in health care. Respect for autonomy requires respecting the decisions of people capable of making them. Beneficence requires acting for the patient's good. Nonmaleficence requires avoiding harm. Justice requires fair treatment and fair distribution of benefits and burdens. None of the principles automatically outranks the others; applying them requires weighing them in the specific situation.
Autonomy. The patient is an adult who, on the evidence of his conversation, understands his condition and has a clear reason for his choice rather than confusion or withdrawal. If he has decision-making capacity, respect for autonomy supports his right to refuse continued hospitalization, even if the choice is risky.
Beneficence. Continuing treatment would benefit him: controlled pain, monitored fluids and early recognition of complications such as worsening inflammation. Beneficence also includes his own view of his good; attending his daughter's graduation matters deeply to him.
Nonmaleficence. Leaving carries risk of harm: uncontrolled pain, dehydration and missed complications. Forcing him to stay, however, would also cause harm, to his dignity, to his relationship with the care team and possibly to his willingness to return if he worsens.
Justice. Justice asks that he be treated as any capable patient would be, without judgment because his pancreatitis is related to alcohol, and that any follow-up he needs is offered as readily as it would be to others.
The Legal Duties
Several legal duties apply. First, the duty to respect a competent patient's refusal of treatment: a competent adult may refuse care, and detaining such a patient without legal authority can constitute false imprisonment. Second, the duty to assess decision-making capacity, which rests on four abilities: expressing a choice, understanding the information given, seeing that the facts are true of oneself and weighing the options (Appelbaum, 2007). Third, the duty to inform: the patient must understand the risks of leaving so that his refusal is informed. Fourth, the duty to notify the provider responsible for his care. Fifth, the duty to document accurately what was discussed, the patient's capacity and his decision.
Alfandre (2009) observed that discharges against medical advice are common, that patients who leave have higher readmission rates and that the traditional approach of having patients sign a form releasing the hospital from liability offers limited legal protection and can damage the therapeutic relationship. Alfandre recommended focusing instead on informed decision making, harm reduction and arranging follow-up.
Ethical and Legal Duties Compared
The legal duties set a floor: the nurse must not detain a competent patient, must ensure he is informed and must document. The ethical duties reach further. The ANA Code of Ethics calls on nurses to respect patients' self-determination and to advocate for their health and safety (American Nurses Association [ANA], 2015). Legally, the nurse could satisfy her obligations by informing him, calling the provider, obtaining a signature and letting him go. Ethically, beneficence and nonmaleficence ask her to reduce the harm of his choice and to keep the door open for his return.
The two can also point in different directions. A nurse worried about liability might try to pressure him to stay by exaggerating risks or implying his insurance would not pay, which would violate both ethics and law. In this case, as in most, the legal and ethical duties are best met together: the law protects his right to choose, and ethics shapes how the nurse supports that choice.
The Nurse's Response
The nurse sat down with the patient and asked about the graduation, which made clear she was not dismissing his reason. She assessed his capacity by asking him to explain in his own words what pancreatitis is, what could happen if he left and what his options were; he answered clearly. She paged the hospitalist, who came to the bedside, explained the risks and offered an alternative: an early discharge the next morning after a dose of oral pain medication, with prescriptions and a follow-up appointment, if his morning laboratory results were stable. The patient agreed to stay overnight on that plan. The nurse documented the conversation, his capacity, the risks explained, the alternative offered and his decision. The next morning, he left with oral medications, written warning signs, instructions to avoid alcohol and a clinic appointment in three days.
If He Had Lacked Capacity
The analysis would change if the patient had lacked capacity, for example if he had been confused from withdrawal or an infection. Respect for autonomy protects capable choices, not choices driven by a condition that impairs understanding. In that case, the nurse's legal and ethical duties would shift toward protecting him: notifying the provider urgently, using the least restrictive measures to keep him safe while the cause of confusion was treated and involving a surrogate decision maker if one was available. Even then, restraint would be a last resort governed by hospital policy and regulation. Recognizing that the same request can call for different responses depending on capacity is why capacity assessment comes first.
Conclusion
A patient who wanted to leave against medical advice presented a conflict among autonomy, beneficence and nonmaleficence. The legal duties, assessing capacity, informing, notifying the provider and documenting, set the minimum, and the ethical duties, advocacy and harm reduction, guided how the nurse met that minimum. By treating his reason as legitimate and seeking an alternative, she respected his autonomy while reducing harm, meeting her ethical and legal obligations at once.
References
Alfandre, D. J. (2009). "I'm going home": Discharges against medical advice. Mayo Clinic Proceedings, 84(3), 255-260. https://doi.org/10.4065/84.3.255
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Publishing.
Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840. https://doi.org/10.1056/NEJMcp074045
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
How this NSG 426 Week 1 example is structured
The NSG/426 shelf page describes the opening weeks as setting the four principles and the difference between an ethical and a legal duty. The paper uses one common dilemma so both can be seen at work in the same decision. The principles are applied one by one, the legal duties are set out separately, and the section comparing them is where the week's central distinction is made explicit. The resolution shows the nurse meeting both kinds of duty at once. Students search this week as NSG 426 Week 1, NSG426 Wk 1 or NSG/426 Wk 1; all three are the same assignment.
NSG/426 Week 1 questions, answered
What does NSG/426 Week 1 usually ask for?
The course shelf describes the opening weeks as setting the four ethical principles and the difference between an ethical and a legal duty. Many sections ask for a short paper or case response applying the principles to a situation and explaining the related legal obligations.
Can a nurse stop a patient from leaving against medical advice?
Not if the patient has decision-making capacity and is not a danger under an applicable legal standard. Restraining a competent adult can be false imprisonment. The nurse's duties are to assess capacity, inform, notify the provider, offer alternatives and document.
What is the difference between an ethical and a legal duty?
A legal duty is enforceable by law, such as obtaining consent or documenting accurately. An ethical duty comes from professional values and moral principles, such as advocating for the patient's wellbeing. They often overlap, but ethics can ask more of a nurse than the law requires.
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