When prima facie duties collide: Ethical responses to refusal of basic nursing care

Abstract

Background

When patients refuse basic nursing care in the hospital setting, ethical tension arises between promoting patient dignity by providing hygiene and honoring bodily autonomy by respecting patient refusal of interventions.

Research Aim

To describe patient factors, clinical context, and the role of ethics consultation when basic care is refused to identify implications for future practice and/or policy.

Research Design

We conducted a retrospective qualitative content analysis of adult and pediatric ethics consultation documentation between January 2015 and December 2025 at a quaternary academic medical center, screening 2,381 consultations to identify cases involving refusal of basic nursing care. We collected patient demographics, admission and clinical information, reasons for ethics consultation, and actions taken by the ethics consultation service. Data were summarized via descriptive statistics, and categories were abstracted to develop a framework.

Participants and Research Context

Patients receiving inpatient care at an academic medical center in the Midwestern United States.

Ethical Considerations

University of Michigan IRBMED deemed the study exempt (HUM00256591).

Findings

34 ethics consultations for 29 unique patients involved refusal of basic nursing care. Patients were adults (100%), with an average LACE score of 12.8; 15 (44%) had decision-making capacity. Care over objection was provided in 16 (47%) of cases, and physical restraints were used in 2 (6%) cases. Refusals involved hygiene (18, 53%), wound care (15, 44%), and repositioning (9, 26%), and occurred across nursing units and clinical services. Refusals were addressed through persuasion (9, 26%), soft paternalism (13, 38%), hard paternalism (3, 9%), or permitted refusal (9, 26%).

Discussion

Ethics consultation involvement resulted in four approaches to refusal of basic nursing care based on patient agency, decision-making capacity, and clinical context.

Conclusions

When refusal results in dignitary or physical harm, healthcare teams should address barriers and encourage participation. In rare circumstances, care over objection is ethically permissible with multidisciplinary input.

Keywords

refusal of basic nursing care theory/philosophical perspectives clinical ethics four principles approach rights theory empirical approaches

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