NURS 6914 Week 7 case analysis example

Speaking of Death Without Inviting It: Informed Consent and Advance Care Planning With a 78-Year-Old Diné Grandfather Newly Diagnosed With Metastatic Gastric Cancer

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College of Nursing, Walden University

NURS 6914: Advanced Palliative Concepts and Interdisciplinary Perspectives

Instructor Name

Month Day, Year

Speaking of Death Without Inviting It: Informed Consent and Advance Care Planning With a 78-Year-Old Diné Grandfather Newly Diagnosed With Metastatic Gastric Cancer

The Case

A 78-year-old Diné grandfather, a retired silversmith who lives with his wife on the Navajo Nation, has been admitted to a regional hospital two hours from home. Imaging and biopsy show gastric cancer that has spread to his liver. The oncologist has proposed palliative chemotherapy and must obtain informed consent; hospital policy also requires that every newly admitted patient with a serious diagnosis be offered an advance directive discussion. His granddaughter, a registered nurse, takes the unit nurse aside. She explains that her grandfather holds traditional beliefs in which speaking about death or bad outcomes may help bring them about, and she asks the team not to "talk him into dying" with prognosis figures and questions about resuscitation. The oncologist replies that he cannot treat without consent. The team asks the palliative nurse practitioner to help find a way forward.

The composite family, their words and the hospital are invented. The case draws on published work about one set of traditional Diné values and must not be read as describing all Diné people, many of whom hold different views.

The Cultural Concern in Its Own Terms

Carrese and Rhodes (1995) interviewed Navajo informants about Western practices such as advance care planning and disclosure of risk. Many described a traditional value of thinking and speaking in a positive way, and saw discussion of negative possibilities, such as death or complications, as potentially harmful because words can shape reality. Several informants regarded standard advance care planning conversations as a dangerous violation of that value. The authors suggested that clinicians discuss negative information in the third person, as something that has happened to others, or through a hypothetical frame, and that they ask patients how they would like such matters discussed.

This is the granddaughter's concern, stated as a belief the family holds, not a stereotype the team brings. The practice of cultural humility asks clinicians to learn from the patient and family what matters to them rather than applying a checklist of group traits, and to examine their own assumptions about what good care looks like (Tervalon & Murray-García, 1998). The team's own assumption, that direct disclosure is always respectful, is one of them.

The Ethical Tension

Informed consent rests on the principle of respect for autonomy: a patient must understand the nature, risks and alternatives of a treatment in order to agree to it (Beauchamp & Childress, 2019). The oncologist is right that chemotherapy cannot proceed without his agreement. But autonomy does not require that information be delivered in only one way, and a patient may choose how much he wants to hear and who should hear it with him. Relational autonomy holds that people make choices within relationships and communities, and that respecting a person may mean respecting the way he wishes to involve his family, provided the family is supporting rather than overriding him (Ho, 2008).

The team's task, then, is not to choose between disclosure and silence. It is to learn from him how he wishes to receive information, and to meet the requirements of consent in a way that does not violate his values.

Why Not Simply Follow the Granddaughter's Request?

The granddaughter's request comes from love and cultural knowledge, but she cannot decide for him while he has capacity. Following her request without asking him would assume that he shares every part of her view. He may want plain information; he may want her to hear it for him; he may want a traditional healer consulted first. Only he can say. There is also a practical risk: if the team withholds the diagnosis at the family's request and he later learns of it from a bill, a pharmacy label or a visitor, he may lose trust in everyone involved, including his granddaughter. Kagawa-Singer and Blackhall (2001) caution that cultural background is a starting point for questions, not a prediction of any individual's preferences.

A Route Forward

Use a professional interpreter. He is more comfortable in Diné bizaad. A trained medical interpreter, not his granddaughter, will interpret, so that he hears the team directly and the granddaughter is free to be family rather than intermediary. The team will meet the interpreter first to agree on how difficult concepts will be phrased.

Ask before telling. The nurse practitioner will begin: "Some people like to hear everything about their illness; some prefer that the doctors talk mostly with their family; some like to speak about these things in a certain way. How would you like us to talk with you?"

Frame in the third person when he wishes. If he prefers, the oncologist can explain the proposed treatment and its risks as experiences of others: "Some people who take this medicine feel very tired; a few become sick enough to go to the hospital." This conveys what consent requires without predicting his own death.

Adapt advance care planning. Rather than asking what he wants if his heart stops, the team can ask who should speak for him if he becomes too tired to talk with the doctors, and what is most important to him in the time ahead. The resuscitation discussion can be deferred or held with the person he names, if he chooses.

Offer traditional healing. If he wants a traditional healer or a ceremony, the social worker and chaplain will help arrange space, time and, where possible, a pass home for it. Many hospitals serving Diné patients already have policies for this, and the team will follow the hospital's.

Document the process. His preferences about communication, and the way consent was obtained, will be recorded so that other clinicians follow the same approach.

Conclusion

This case does not require the team to abandon informed consent or to override a family's values. It requires the team to ask the patient how he wants to be informed and to adapt its language to his answer. Doing so honors both his autonomy and his culture, and it gives the oncologist a consent he can trust because it was obtained in terms the patient accepted.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Carrese, J. A., & Rhodes, L. A. (1995). Western bioethics on the Navajo reservation: Benefit or harm? JAMA, 274(10), 826-829. https://doi.org/10.1001/jama.1995.03530100066036

Ho, A. (2008). Relational autonomy or undue pressure? Family's role in medical decision-making. Scandinavian Journal of Caring Sciences, 22(1), 128-135. https://doi.org/10.1111/j.1471-6712.2007.00561.x

Kagawa-Singer, M., & Blackhall, L. J. (2001). Negotiating cross-cultural issues at the end of life: "You got to go where he lives." JAMA, 286(23), 2993-3001. https://doi.org/10.1001/jama.286.23.2993

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. https://doi.org/10.1353/hpu.2010.0233