NUR 460 Module 7 Ethical Decision-Making Final Project Example

A Signature After Morphine: An Ethical Decision-Making Analysis of Witnessing Consent From a Sedated Patient

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Edson College of Nursing and Health Innovation, Arizona State University

NUR 460: The Art of Nursing

Instructor Name

Month Day, Year

A Signature After Morphine: An Ethical Decision-Making Analysis of Witnessing Consent From a Sedated Patient

Most of the hard ethical moments in nursing come quietly, folded into routine requests like a signature on a consent form. This paper analyzes one such request using a stepwise ethical decision-making process: identify the problem, gather the facts, identify the people involved and their values, consider the options, apply ethical principles and the ANA code, decide and act, and reflect.

The Situation

At 1:30 a.m., a 34-year-old man arrived in the emergency department of a small hospital with abdominal pain. A CT scan showed appendicitis. He received intravenous morphine for severe pain at 1:50 a.m. At 2:05 a.m., the visiting general surgeon, who had to be in the operating room before a scheduled case in the morning, explained the procedure at the bedside and asked the nurse to witness the patient's signature on the consent form. The patient's eyes were half closed, his speech was slow, and when the nurse asked what operation he was having, he said, "My stomach, I think." The surgeon said the patient had understood when it was explained and that delay would push the surgery to morning.

Step 1: Identify the Ethical Problem

The problem is whether the nurse should witness a consent signature when she doubts the patient currently has the capacity to give informed consent. The tension is between the patient's right to make an informed decision and the pressure to proceed quickly with a needed operation.

Step 2: Gather the Facts

Valid consent depends on a capable patient being told what will be done, what could go wrong, what good it should do and what else could be tried, grasping that information, and choosing freely. The surgeon is responsible for obtaining consent; a nurse who signs as witness is usually vouching that the patient personally signed, seemed to understand, and was not pressured. The patient's appendicitis is urgent but not an immediate emergency; the surgeon planned to operate within hours, not minutes. Opioids can impair attention and comprehension, and the patient's answer suggested he did not grasp the procedure. Hospital policy allows emergency treatment without consent only when delay would seriously threaten life or health.

Step 3: Stakeholders and Values

The patient values relief of pain and safe treatment, and he has a right to understand what will be done to him. The surgeon values timely surgery and efficient use of limited operating time in a small hospital. The nurse values patient advocacy, honesty and her own professional integrity. The hospital values both safe care and legal protection, since a consent obtained without capacity may not be valid.

Step 4: Options

Option A: Witness the signature as requested. This is fastest, but it means attesting to something the nurse doubts, and it may leave the patient undergoing surgery he did not understand.

Option B: Refuse to witness and say nothing further. This protects the nurse but does not solve the patient's problem or help the surgeon.

Option C: Share her assessment with the surgeon, suggest waiting until the morphine's peak effect passes and reassessing understanding, and offer to help explain the procedure again. If the surgeon disagrees, she escalates to the nursing supervisor under the chain of command.

Step 5: Apply Principles and the ANA Code

Respect for autonomy requires that consent be informed and voluntary, which requires capacity; a signature alone does not satisfy it (Beauchamp & Childress, 2019). Beneficence supports timely surgery, but a short delay to allow comprehension does not meaningfully increase risk in this case. Nonmaleficence warns against harm, including the harm of operating on someone without his informed agreement. The current code (American Nurses Association, 2025) directs the nurse's first loyalty to the patient, asks nurses to speak up for patients' rights, and expects integrity in professional acts. Signing as a witness while doubting capacity would conflict with both.

Step 6: Decide and Act

The nurse chooses Option C. She tells the surgeon calmly that the patient could not say what operation he was having and that she cannot attest to understanding at this moment. She suggests rechecking in about 30 minutes, after the morphine's peak effect, and offers to sit in on the explanation. The surgeon agrees reluctantly. At 2:45 a.m., the patient is more alert, explains in his own words that his appendix will be removed and that there is a risk of infection, and signs. The nurse documents both assessments.

Her choice also considered what would happen if the surgeon refused. She had already decided that she would not sign, would document her assessment and the conversation, and would call the nursing supervisor, who could involve the administrator on call. Knowing the next step in advance made it easier to speak calmly in the moment. She also thought about the patient's experience: a delay of 30 minutes in a man with a stable appendicitis, in exchange for being able to say yes to his own surgery, was a trade he would likely choose if asked. In fact, when he was more alert, he thanked her for explaining again.

Step 7: Reflect on Accountability and Moral Distress

The nurse acted within her scope and accepted accountability for her signature, which carries professional meaning. She also felt pressure and some fear of the surgeon's reaction, a common source of moral distress, which arises when a nurse sees the right course but cannot take it. Having a process to follow, and a supervisor to call, reduced that distress. Moral courage in nursing has been described as including advocacy, honesty and acceptance of personal risk (Numminen et al., 2017), all of which this small act required. The case also suggests a system fix: the hospital could adopt a brief capacity check before consent for patients who have received sedating medication, so that nurses are not left to resolve the problem alone at 2 a.m.

Conclusion

A witness signature is not a formality. When a patient's capacity is in doubt, the nurse's duty is to the patient's right to understand. A structured ethical decision-making process helped turn a stressful request into a clear, defensible action that respected the patient and still allowed timely surgery.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

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

Numminen, O., Repo, H., & Leino-Kilpi, H. (2017). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878-891. https://doi.org/10.1177/0969733016634155