A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward

Wang Na; Shi Ruxia; Guan Bi; Zhong Qiongyao

doi:doi:10.11648/j.sr.20261404.27

Research Article |

| Peer-Reviewed

A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward

Wang Na, Shi Ruxia^*, Guan Bi, Zhong Qiongyao

Published in Science Research (Volume 14, Issue 4)

Received: 11 June 2026 Accepted: 27 July 2026 Published: 26 August 2026

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Abstract

As the trend of population aging intensifies, an increasing number of elderly patients are receiving end-of-life care in general wards, and the use of non-specialized palliative care units is becoming increasingly common, posing significant ethical challenges. This study focuses on an 86-year-old female patient receiving end-of-life care in a neurosurgery ward and employs the “four-theme approach” (medical indications, patient preferences, quality of life, and contextual characteristics) to conduct a systematic analysis of the ethical dilemmas. The core conflicts identified include: 1) balancing medical indications (the principles of beneficence and non-maleficence) with respect for the autonomy of the patient and family; 2) the challenge of defining “quality of life,” as well as the dilemma of balancing the potential benefits and burdens of artificial nutrition and hydration; 3) the impact of contextual factors—such as family dynamics, cultural beliefs, and institutional constraints—on feasible pathways. This case highlights the urgent need for ethical assessment tools in general wards and explores how to assist nursing teams in developing theoretical frameworks and resolving conflicts, conducting culturally sensitive family communication, and advocating for system-level ethical support measures to ensure dignified and ethically sound end-of-life care for elderly patients in non-hospice settings.

Published in	Science Research (Volume 14, Issue 4)
DOI	10.11648/j.sr.20261404.27
Page(s)	261-265
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2026. Published by Science Publishing Group

Keywords

Palliative Care, Geriatric Multimorbidity, Ethical Analysis, Case Study

1．引言

随着现代医疗技术的发展，临床护理伦理问题决策越来越复杂，这是医患纠纷问题和伦理争议日益增多的原因，主要关注ICU患者、肿瘤患者

[1]

。近年来，尽管国内学者发现护士自身道德责任意识正在提高，但是临床工作中仍在识别道德问题和确定其正确的伦理处理方式等两方面存在问题。研究表明在生命末期照护中，医生和护士普遍经历着因制度限制、家庭意愿冲突或无法缓解患者痛苦而产生的道德困境

[2]

。护士在临终关怀中常因“执行非受益性治疗”“在资源限制下无法提供理想的舒适照护”以及“其关系性关怀的核心价值受到系统挤压”而经历显著的道德痛苦

[3]

。绝大多数终末期患者仍是在其原发病科室走完生命最后一程

[4, 5]

。然而，非安宁病房的医护人员如何在非专科环境中识别伦理困境、平衡医疗干预与患者尊严，已成为当前临床伦理研究的紧迫议题。本研究通过呈现并剖析一例在神经外科病房离世的老年共病患者的临床历程，探索如何帮助临床团队识别、梳理并应对非安宁疗护病房环境下的安宁疗护伦理困境，并为类似情境的护理实践提供参考框架。

2．个案情况

患者为86岁女性，罹患多种慢性疾病（包括高血压、冠心病等），长期于养老机构居住，日常需无创呼吸机支持，但受伤前可扶拐行走。患者家庭背景复杂：丧偶，育有六名子女。长子已故，次子身患基础疾病且常住外地，三位女儿为主要照护者及医疗决策代理人，并承担费用。值得注意的是，患者因长子曾在ICU离世的经历，事前已表达过拒绝接受ICU治疗的意愿。患者因在家中摔倒致头部硬膜下血肿，收入神经外科病房。入院时神志清楚，但存在营养不良及多系统功能衰竭的风险。其住院过程的关键决策点如下：

2.1．拒绝转入ICU（入院第3天）

患者出现心力衰竭加重伴低氧血症，符合转入ICU的医疗指征。然而，基于患者本人先前的意愿，三位女儿经商议后，明确拒绝了转科建议。

2.2．拒绝置入鼻饲管（入院第7-11天）

随着病情进展，患者经口进食量锐减，营养指标持续恶化，置入鼻饲管的医疗必要性凸显。尽管医护团队反复建议，家属仍多次拒绝此操作，仅同意继续尝试经口进食与有限的静脉输液。

2.3．转向舒适疗护（入院第13天）

患者意识水平下降至浅昏迷，外周静脉通路难以建立。经多学科评估，认为患者已进入临终阶段。医护团队与三位女儿召开家庭会议，共同决策停止所有静脉输液及经口喂养，将治疗目标正式转向以症状缓解和舒适为主的安宁疗护

[6]

。

2.4．营造安宁疗护环境（入院第15-18天）

调整病房，为患者创造安静、私密的临终环境。在得知患者可能存在“见到儿子”的未了心愿后，协调其次子前来探视。探视期间，患者出现细微的生命反应。次子探视结束后不久，患者生命体征逐渐下降，最终在亲属陪伴下平静离世，家属情绪平和。

3．伦理剖析

3.1．医疗指征：行善与不伤害原则

从纯粹的医学适应性角度，患者存在明确的积极干预指征：入院初期的心衰加重伴低氧血症符合转入ICU进行高级生命支持的指征；随后持续恶化的营养状况与吞咽障碍，也使得置入鼻饲管进行肠内营养支持具有了医学必要性。这些建议的核心伦理基础是行善原则，即医务人员有义务采取可能对患者有益的措施，以及不伤害原则，即应避免因不作为而导致的营养不良、感染等可预见的伤害。然而，本案例的关键在于，当“医疗上最优”的干预措施（如转ICU、置入鼻饲管）与患者及其家属的明确意愿相抵触时，简单的医学指征便不足以决定行动方向。这迫使医疗团队必须超越单纯的病理生理考量，深入评估干预措施在特定患者身上可能带来的真实获益与潜在负担。例如，对于一位86岁、有多种严重共病且已表达过拒绝ICU意愿的患者，有创操作和ICU环境本身带来的应激，是否可能构成新的伤害？当患者临近生命终点时，鼻饲管供给的营养在多大程度上能改善其预后或生活质量，而不是仅仅延长死亡进程？对这些问题的反思，是将行善/不伤害原则从抽象教条转化为个体化临床判断的关键。

3.2．患者偏好：尊重自主原则

尊重患者自主权是医学伦理的基石

[7]

。本案例中，患者的偏好通过两种方式体现：一是其事先表达的意愿（基于长子于ICU离世的创伤经历而拒绝ICU治疗），二是当其失去决策能力后，由家属作为替代决策者行使的权利。家属（三位女儿）多次拒绝侵入性操作（转ICU、置鼻饲管），并最终共同决定转向舒缓疗护，均可视为在尝试执行患者本人可能做出的选择。此处引发的核心伦理争议在于：如何确保替代决策真正符合患者的真实意愿与最佳利益，而非仅仅是家属自身的情感、负担或价值观的投射

[8]

。这要求医护人员不仅是信息的传递者，更是决策过程的协作者与引导者。团队通过多次家庭会议，反复解释医疗状况、预后及各种选择的可能后果，正是在努力构建一个“知情同意”的基础。尽管最终的决定与医疗推荐不符，但充分沟通确保了该决定是在理解潜在后果后作出的，这体现了对自主权实质而非形式的尊重。

3.3．生活质量：行善与不伤害原则的再审视

生活质量并非一个单一的医学指标，而是一个融合了生理、心理、社会及精神维度的主观概念。在安宁疗护语境下，医疗决策的目标从“治愈疾病”转向“提升剩余生命的质量”。在本案例中，关于“生活质量”的评估出现了分歧：医疗团队认为，营养支持可能改善身体机能从而提升生活质量；而家属则认为，避免鼻饲管等侵入性操作，减少患者的痛苦与束缚，才是对其生活质量的维护。此冲突迫使团队深入反思：对于此位高龄、多病、处于生命末期的患者，何种干预最能体现“行善”？是可能延长生命但伴有不适的措施，还是专注于解除痛苦、保障尊严的舒缓护理？最终，团队采纳了家属的意愿，当患者无法经口进食后，团队并未选择鼻饲管进行肠内营养支持，而是接受了轻度脱水状态。循证医学表明，在终末期，轻度脱水有时可减少肺部分泌物、水肿及呕吐，反而可能增加患者的舒适度。这一决策体现了“行善”与“不伤害”原则在生命末期的特殊诠释：当治愈无望时，最大的善行可能就是避免无益的、可能增加痛苦的干预，从而保障临终的安宁与尊严

[9, 10]

。

3.4．情境特征：公正与关怀的视野

3.4.1．家庭与文化情境

国内家文化及家庭集体决策模式在本案例中显著。决策由三位女儿共同商议作出，并考虑了未在场的儿子的情感角色（最终安排其探视以了却心愿）。这种“家庭自主”模式要求医护人员将家庭视为一个整体关怀单元，其沟通与支持策略，需区别于强调个人自主的西方模式。

3.4.2．医疗系统与资源情境

患者所在地区安宁疗护资源（如专门的临终关怀病房或居家服务）的可及性有限，这使得“转至更合适机构”的建议难以落实。因此，在神经外科病房内营造安静的疗护环境、调整护理重点，成为一种务实且充满关怀的“变通”。同时，当前的医保支付政策与医院绩效考核体系通常不利于收治此类治疗性干预少、住院时间可能较长的患者，这对科室和医护人员构成了隐性压力，也凸显了系统层面对安宁疗护支持不足的公正性问题。

3.4.3．科室与专业情境

神经外科并非安宁疗护专科病房，医护人员相关的专业知识、技能与经验可能相对不足。然而，正是这种“非专科”背景的病房，使得本案例更具普遍意义。它揭示了在所有临床科室推广基础安宁疗护理念与伦理决策能力的紧迫性，以确保任何地方的患者都能在生命终点获得有尊严的照护。

4．讨论与启示

4.1．结构化伦理框架是化解决策困境的实用工具

护士在生命末期决策中的伦理挑战与姑息实践，明确指出伦理困境在非专科照护环境中尤为突出，非安宁疗护专科团队容易陷入情感与专业的混沌，且护士缺乏系统的决策支持框架

[11]

。案例针对类似伦理困境，如在面对“转ICU还是尊重意愿？”“营养支持还是舒适优先？”等，引入“四主题法”这类结构化伦理分析框架具有重要价值。它并非提供现成答案，而是赋予团队一种共同语言和系统性思维流程。通过依次审视医疗指征、患者偏好、生活质量和情境特征，团队能够将感性、碎片化的争议，转化为对各项伦理原则的具体表现与冲突的理性辨析

[11, 12]

。例如，它促使团队追问：当“医疗指征”建议鼻饲时，从“生活质量”角度，该操作对此特定患者是改善还是负担？在“情境特征”中，家庭文化如何影响对“患者偏好”的理解？这种结构化的讨论，有助于避免决策被单一因素（如单纯的医疗技术可行性或家属的即时情绪）主导，从而在复杂情境中做出更加平衡、深思熟虑且可辩护的护理决策。

4.2．家庭沟通与文化敏感性是安宁疗护的核心护理技能

本案例的每一个关键决策点，都伴随着与患者三位女儿的密集沟通。这凸显了在患者失去决策能力时，护士作为沟通枢纽与协调者的关键角色。有效的沟通远不止于告知病情和获取签字；它要求护士深入理解家庭的决策动态、未言明的情感负担（如对长子去世的创伤记忆）以及深层的文化价值观。案例中，团队对次子角色的敏感处理——最终安排其探视以满足患者可能的“执念”——是文化敏感性实践的典范。这一沟通实践与本土化安宁疗护模式的研究发现相呼应。黄泽欢等

[13]

人在构建“医养融合安宁疗护模式”时明确指出，有效的“家庭沟通”与“文化融入”是该模式不可或缺的核心要素。本案例中，医护人员对患者家庭动态的敏锐洞察与对“儿子探视”这一文化心理需求的主动回应，正是对这一模式要素的生动诠释。这种基于共情与尊重的沟通，不仅能获取更真实的“患者偏好”信息，更能缓和家庭内部的焦虑与内疚，建立信任联盟，使艰难的替代决策得以在相对平和、支持的氛围中达成，从而维护了患者与家庭的整体福祉

[14]

。

4.3．主动创造人性化照护空间

本案例发生在神经外科病房，而非专业安宁疗护病房，这反映了普遍的现实资源限制

[12]

。尽管存在医保政策倾向于急性治疗，科室考核关注床位周转等情况，团队并未消极接受现状。他们展示了如何在现有框架内进行创造性的、以患者为中心的“变通”。从治疗目标上，果断从“治愈”转向“舒适”；在环境营造上，主动调整病房，创造安静、私密、充满阳光的告别空间；在护理措施上，以加强基础护理、控制症状（如排痰、口腔护理）替代无效的侵入性治疗。这些实践与《安宁疗护患者人文关怀专家共识》

[15]

所倡导的核心精神高度契合。实践也证明，人性化的安宁疗护并非完全依赖于专用硬件，更核心的是一种照护理念的转变和护理行为的重构。它要求护士和护理管理者具备在制度缝隙中倡导并实践“最佳关怀”的能动性与智慧，应将安宁疗护的人文关怀贯穿于环境营造、症状管理、精神心理支持等全方位照护中。

4.4．对普通病房护士伦理能力与知识提出新要求

本案例揭示，为老年共病患者提供有尊严的临终关怀，将成为所有临床科室护士不可回避的责任。这对其能力构成提出了新的要求：超越基础的疾病护理，必须具备初步的生命末期症状评估与管理能力、高阶的沟通能力与家属支持技巧，以及基础的临床伦理决策知识。在本案例中，护士团队主动将护理重点从‘执行医嘱’转向‘管理舒适’，并通过持续沟通将家属转化为共同决策的伙伴，这些行动在微观层面上，正是护士主动重构临床情境以符合实践与其道德信念，从而缓解自身道德困境的体现。因此，培养护士的伦理决策、高级沟通及症状管理能力，远不止是技能清单的扩充。它关乎是否赋能护士，使其在一个复杂工作环境下，仍能作为患者尊严的有效捍卫者而非被动执行者，这对其职业福祉与道德完整性至关重要

[16]

。此外，本案例聚焦于生命终末期的即时伦理决策与关怀实践，但是安宁疗护的理想形态应更早地介入疾病进程。一项随机对照试验表明，对晚期癌症患者及时实施“护士主导的增强支持性护理”，能显著改善其生活质量、减轻症状负担与心理困扰

[17]

。

5．结论

本个案研究通过详细呈现一例合并老年共病的终末期患者在普通病房的安宁疗护历程与伦理决策，生动说明了在非专业安宁疗护环境中实施高质量临终照护所面临的挑战与可能性，强调了以家庭为中心、文化敏感性的极端重要性，通过持续的沟通、共情的理解与情境化的判断，为特定患者及其家庭寻找最可接受的、充满关怀的路径，并最终指向了对临床护士队伍进行相关能力培养的紧迫需求。

致谢

本文为四川省护理学会护理科研项目（H23042）、成都中医药大学委校联合项目（WXLH202501297）的阶段性成果之一。

诚挚感谢患者及家属的信任与配合，为本案例的伦理分析提供了重要基础。

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Na, W., Ruxia, S., Bi, G., Qiongyao, Z. (2026). A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Science Research, 14(4), 261-265. https://doi.org/10.11648/j.sr.20261404.27

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Na, W.; Ruxia, S.; Bi, G.; Qiongyao, Z. A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Sci. Res. 2026, 14(4), 261-265. doi: 10.11648/j.sr.20261404.27

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AMA Style

Na W, Ruxia S, Bi G, Qiongyao Z. A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Sci Res. 2026;14(4):261-265. doi: 10.11648/j.sr.20261404.27

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@article{10.11648/j.sr.20261404.27,
  author = {Wang Na and Shi Ruxia and Guan Bi and Zhong Qiongyao},
  title = {A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward},
  journal = {Science Research},
  volume = {14},
  number = {4},
  pages = {261-265},
  doi = {10.11648/j.sr.20261404.27},
  url = {https://doi.org/10.11648/j.sr.20261404.27},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.sr.20261404.27},
  abstract = {As the trend of population aging intensifies, an increasing number of elderly patients are receiving end-of-life care in general wards, and the use of non-specialized palliative care units is becoming increasingly common, posing significant ethical challenges. This study focuses on an 86-year-old female patient receiving end-of-life care in a neurosurgery ward and employs the “four-theme approach” (medical indications, patient preferences, quality of life, and contextual characteristics) to conduct a systematic analysis of the ethical dilemmas. The core conflicts identified include: 1) balancing medical indications (the principles of beneficence and non-maleficence) with respect for the autonomy of the patient and family; 2) the challenge of defining “quality of life,” as well as the dilemma of balancing the potential benefits and burdens of artificial nutrition and hydration; 3) the impact of contextual factors—such as family dynamics, cultural beliefs, and institutional constraints—on feasible pathways. This case highlights the urgent need for ethical assessment tools in general wards and explores how to assist nursing teams in developing theoretical frameworks and resolving conflicts, conducting culturally sensitive family communication, and advocating for system-level ethical support measures to ensure dignified and ethically sound end-of-life care for elderly patients in non-hospice settings.},
 year = {2026}
}

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TY  - JOUR
T1  - A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward
AU  - Wang Na
AU  - Shi Ruxia
AU  - Guan Bi
AU  - Zhong Qiongyao
Y1  - 2026/08/26
PY  - 2026
N1  - https://doi.org/10.11648/j.sr.20261404.27
DO  - 10.11648/j.sr.20261404.27
T2  - Science Research
JF  - Science Research
JO  - Science Research
SP  - 261
EP  - 265
PB  - Science Publishing Group
SN  - 2329-0927
UR  - https://doi.org/10.11648/j.sr.20261404.27
AB  - As the trend of population aging intensifies, an increasing number of elderly patients are receiving end-of-life care in general wards, and the use of non-specialized palliative care units is becoming increasingly common, posing significant ethical challenges. This study focuses on an 86-year-old female patient receiving end-of-life care in a neurosurgery ward and employs the “four-theme approach” (medical indications, patient preferences, quality of life, and contextual characteristics) to conduct a systematic analysis of the ethical dilemmas. The core conflicts identified include: 1) balancing medical indications (the principles of beneficence and non-maleficence) with respect for the autonomy of the patient and family; 2) the challenge of defining “quality of life,” as well as the dilemma of balancing the potential benefits and burdens of artificial nutrition and hydration; 3) the impact of contextual factors—such as family dynamics, cultural beliefs, and institutional constraints—on feasible pathways. This case highlights the urgent need for ethical assessment tools in general wards and explores how to assist nursing teams in developing theoretical frameworks and resolving conflicts, conducting culturally sensitive family communication, and advocating for system-level ethical support measures to ensure dignified and ethically sound end-of-life care for elderly patients in non-hospice settings.
VL  - 14
IS  - 4
ER  -

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Author Information

Wang Na

Nursing Department, Fifth People's Hospital of Chengdu, Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, China

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Shi Ruxia

Department of Urology, Fifth People's Hospital of Chengdu, Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, China

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Guan Bi

Nursing Department, Fifth People's Hospital of Chengdu, Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, China

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Zhong Qiongyao

Department of Neurosurgery, Fifth People's Hospital of Chengdu, Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, China

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APA Style

Na, W., Ruxia, S., Bi, G., Qiongyao, Z. (2026). A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Science Research, 14(4), 261-265. https://doi.org/10.11648/j.sr.20261404.27

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ACS Style

Na, W.; Ruxia, S.; Bi, G.; Qiongyao, Z. A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Sci. Res. 2026, 14(4), 261-265. doi: 10.11648/j.sr.20261404.27

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AMA Style

Na W, Ruxia S, Bi G, Qiongyao Z. A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward. Sci Res. 2026;14(4):261-265. doi: 10.11648/j.sr.20261404.27

Copy | Download

@article{10.11648/j.sr.20261404.27,
  author = {Wang Na and Shi Ruxia and Guan Bi and Zhong Qiongyao},
  title = {A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward},
  journal = {Science Research},
  volume = {14},
  number = {4},
  pages = {261-265},
  doi = {10.11648/j.sr.20261404.27},
  url = {https://doi.org/10.11648/j.sr.20261404.27},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.sr.20261404.27},
  abstract = {As the trend of population aging intensifies, an increasing number of elderly patients are receiving end-of-life care in general wards, and the use of non-specialized palliative care units is becoming increasingly common, posing significant ethical challenges. This study focuses on an 86-year-old female patient receiving end-of-life care in a neurosurgery ward and employs the “four-theme approach” (medical indications, patient preferences, quality of life, and contextual characteristics) to conduct a systematic analysis of the ethical dilemmas. The core conflicts identified include: 1) balancing medical indications (the principles of beneficence and non-maleficence) with respect for the autonomy of the patient and family; 2) the challenge of defining “quality of life,” as well as the dilemma of balancing the potential benefits and burdens of artificial nutrition and hydration; 3) the impact of contextual factors—such as family dynamics, cultural beliefs, and institutional constraints—on feasible pathways. This case highlights the urgent need for ethical assessment tools in general wards and explores how to assist nursing teams in developing theoretical frameworks and resolving conflicts, conducting culturally sensitive family communication, and advocating for system-level ethical support measures to ensure dignified and ethically sound end-of-life care for elderly patients in non-hospice settings.},
 year = {2026}
}

Copy | Download

TY  - JOUR
T1  - A Case Study on the Ethical Analysis of Palliative Care for an Elderly Patient in a General Ward
AU  - Wang Na
AU  - Shi Ruxia
AU  - Guan Bi
AU  - Zhong Qiongyao
Y1  - 2026/08/26
PY  - 2026
N1  - https://doi.org/10.11648/j.sr.20261404.27
DO  - 10.11648/j.sr.20261404.27
T2  - Science Research
JF  - Science Research
JO  - Science Research
SP  - 261
EP  - 265
PB  - Science Publishing Group
SN  - 2329-0927
UR  - https://doi.org/10.11648/j.sr.20261404.27
AB  - As the trend of population aging intensifies, an increasing number of elderly patients are receiving end-of-life care in general wards, and the use of non-specialized palliative care units is becoming increasingly common, posing significant ethical challenges. This study focuses on an 86-year-old female patient receiving end-of-life care in a neurosurgery ward and employs the “four-theme approach” (medical indications, patient preferences, quality of life, and contextual characteristics) to conduct a systematic analysis of the ethical dilemmas. The core conflicts identified include: 1) balancing medical indications (the principles of beneficence and non-maleficence) with respect for the autonomy of the patient and family; 2) the challenge of defining “quality of life,” as well as the dilemma of balancing the potential benefits and burdens of artificial nutrition and hydration; 3) the impact of contextual factors—such as family dynamics, cultural beliefs, and institutional constraints—on feasible pathways. This case highlights the urgent need for ethical assessment tools in general wards and explores how to assist nursing teams in developing theoretical frameworks and resolving conflicts, conducting culturally sensitive family communication, and advocating for system-level ethical support measures to ensure dignified and ethically sound end-of-life care for elderly patients in non-hospice settings.
VL  - 14
IS  - 4
ER  -

Copy | Download