The patient is an 88-year-old man with an extensive cardiac history who has been a resident of a skilled nursing facility for the past 3 years. Comorbid conditions include type 2 diabetes (15 years) and severe peripheral vascular disease. For 6 months the patient has suffered from a serious left leg wound that has not responded to treatment and that has become much worse over the past 2 months. At this point, the leg is gangrenous to above the ankle, and the normal course of treatment would be to remove the leg above the circulatory problem. However, the patient is refusing surgery and states that he wants "to die with all of my limbs intact." The patient has been assessed with mild to moderate dementia and has named his daughter as his durable power of attorney. The nurses on the unit, the daughter, and the primary care physician all realize that an amputation is necessary to save the patient's life.

Dilemma: Several ethical issues are relevant to the resolution of the situation. The obligation to respect the patient's autonomy in the decision to refuse an amputation puts his life at risk. However, after hearing about the need for surgery and the likely outcome without the surgery, he continues to state, "I want to die with all of my limbs intact." The daughter and some of the nurses who care for the patient question his ability to make such a decision.

As a nurse we want to protect our patient's rights for autonomy and self-determination, but at the same time we want what is in the best interest of the patient's health. What are the ethical issues in this case study? Who has the legal right to make this decision? Using the nursing process, define how you would work through this ethical issue.