NURS 6228 Health Promotion of the Elderly: Ethical Dilemmas in Long-Term Care (FNP)

Ethical Dilemmas in Long-Term Placement of Elderly Men

Placing elderly men in long-term residential care raises complex ethical issues in modern healthcare. As the adult male population ages, they face higher rates of functional disabilities, cognitive impairments, and chronic illnesses. This creates situations in which the elderly male patient wants to remain independent, which may conflict with healthcare providers’ concerns about quality of life, health outcomes, and safety. Among elderly men, these decisions can be especially difficult, as they may be strongly tied to personal, social, and cultural identities centered on control over decision-making, self-reliance, and independence. Family Nurse Practitioners (FNPs) and healthcare organizations are often tasked with balancing these competing ethical principles while ensuring compliance with professional standards and legal requirements. This paper explores the ethical dilemma of whether healthcare providers, including FNPs, should respect the autonomy of elderly male patients who refuse long-term residential care despite facing significant safety and health risks, or prioritize non-maleficence and beneficence by supporting institutional care placement. This ethical dilemma has significant implications for healthcare providers, organizations, patients, and families, affecting care outcomes, legal responsibilities, and clinical decisions.

Identification of the Ethical Dilemma

Elderly men aged 65 and older are most affected by this ethical dilemma because they often face increasing social isolation, functional dependence, physical frailty, multiple chronic conditions, or cognitive decline. They may include men diagnosed with advanced cardiovascular disease, stroke-related disabilities, Parkinson’s disease, dementia, or other conditions that impair their ability to live independently and safely. Many of these individuals live alone after the death of a spouse and may have limited social support, which increases their vulnerability to negative health outcomes. As their healthcare needs become more complex, healthcare professionals and family members may conclude that long-term placement in a nursing home or assisted living facility is necessary to ensure continuity of care and safety (Ouslander et al., 2022).

The ethical dilemma occurs when an elderly male patient with some decision-making ability refuses institutional placement despite clear evidence that staying at his current residence risks health issues such as medical decline, malnutrition, medication errors, neglect, or injury. Respecting the patient’s autonomy supports his right to choose his living situation. However, healthcare professionals also have an ethical obligation to prevent harm and promote health (Ouslander et al., 2022). Therefore, FNPs and other providers may face situations where honoring the patient’s wishes could significantly jeopardize his health, while pushing for placement might compromise his self-determination and personal autonomy. Neither option is fully ethically acceptable, creating a true ethical dilemma.

This dilemma impacts various stakeholders. The primary stakeholder is the elderly patient, whose quality of life, safety, dignity, and independence are directly affected. Family caregivers may experience moral conflicts, financial burdens, caregiver strain, and emotional stress as they try to balance safety concerns with respecting their loved one’s wishes. FNPs and interdisciplinary care teams must navigate ethical and legal issues while maintaining therapeutic relationships. Healthcare organizations also face challenges related to resource allocation, regulatory compliance, risk management, and liability. The conflicting interests of these stakeholders complicate decisions about long-term patient placement (Ouslander et al., 2022).

Scope of the Problem

The impact of long-term placement dilemmas on elderly male patients is significant. Many seniors see independence as tied to masculinity and personal identity, which makes moving into residential care facilities emotionally difficult. Research indicates that involuntary or highly pressured institutionalization can result in lower quality of life, feelings of abandonment, anxiety, and depression (Sun et al., 2021). Conversely, staying in unsafe environments may lead to hospitalization, self-neglect, medication errors, falls, and early death. Therefore, patients face substantial risks regardless of the decision ultimately made.

Family caregivers often face significant challenges when the placement decision becomes contentious. They frequently take on responsibilities such as managing emergencies, assisting with daily activities, coordinating healthcare appointments, and ensuring medication adherence. When the elderly patient refuses placement in a care facility, the caregiver may experience burnout, emotional exhaustion, and chronic stress. Recent studies show that prolonged caregiving duties are linked to higher rates of anxiety, depression, sleep disturbances, and a lower quality of life (Bongeli et al., 2024). Family conflict can arise when relatives cannot agree on the most appropriate course of action. Such disagreements can harm family relationships and complicate care planning efforts.

Furthermore, the ethical dilemma significantly impacts FNPs. They play a key role in advocating for patient-centered outcomes, facilitating family discussions, coordinating care, and evaluating cognitive capacity. They must carefully determine whether the patient has the ability to make informed decisions while respecting individual rights and professional responsibilities. Ethical distress may occur when the FNP believes a patient’s decision places them at serious risk but is ethically and legally obligated to honor it (Ahokas et al., 2025). According to Vinckers and Landeweer (2024), moral distress is a significant concern among healthcare professionals involved in complex geriatric care decisions, particularly when safety and autonomy are in conflict.

Healthcare organizations face financial and operational challenges related to placement dilemmas. They must ensure compliance with patient rights regulations while maintaining standards for quality and safety. Failing to properly assess decision-making capacity or document clinical recommendations can expose them to legal risks. Additionally, repeated hospital admissions due to unsafe living conditions can increase healthcare costs and resource utilization. Healthcare systems are increasingly recognizing that unresolved placement disputes lead to avoidable prolonged stays, emergency department visits, and hospitalizations among elderly patients (Rahemi et al., 2023; Sehatkarlangrodi et al., 2025). As a result, placement-related ethical dilemmas impact organizational performance and patient outcomes.

Discussion of Legality

Legal considerations affect how FNPs and healthcare organizations determine long-term placement options for elderly patients. A key legal principle is the presumption of decision-making ability. It is generally assumed that adults are capable of making decisions unless evidence shows otherwise. Capacity assessments focus on the individual’s ability to understand relevant information, appreciate the consequences of each decision, reason through available options, and communicate a choice. Decision-making capacity is not automatically compromised by cognitive decline, such as a dementia diagnosis (Ouslander et al., 2022). Therefore, FNPs must conduct careful capacity assessments and thoroughly document findings before recommending interventions that may restrict individual autonomy.

FNPs are legally required to respect a patient’s autonomy while ensuring their safety. When a cognitively intact older adult refuses placement in a nursing home, providers generally cannot force institutionalization merely because they, other clinicians, or family members disagree with the patient’s decision. The principle of informed refusal mandates that the patient is informed of and understands the potential risks of declining the recommended placement. Thorough documentation of patient preferences, assessments, and discussions is crucial in reducing legal risk and demonstrating compliance with professional standards (American Association of Nurse Practitioners, 2023).

When a patient’s capacity is impaired, legal mechanisms such as healthcare proxies, conservatorship, guardianship, and durable powers of attorney may become relevant. Guardianship proceedings allow courts to appoint individuals authorized to make decisions on behalf of the patient who lacks capacity. However, guardianship significantly restricts personal liberty and should only be pursued when less restrictive options are inadequate. Current legal and ethical frameworks prioritize supported decision-making whenever possible to preserve individual autonomy and rights (Largent et al., 2023).

Healthcare organizations also carry significant legal responsibilities. Federal regulations, including those under the Nursing Home Reform Act, require safeguarding patient rights, encouraging self-determination, and implementing personalized care plans. These organizations must establish policies and procedures that support ethical decision-making, proper documentation practices, capacity assessment, and informed consent. Failing to follow these standards and procedures can lead to reputational damage, accreditation issues, legal action, and regulatory penalties (Bodenheimer et al., 2023).

Legal requirements significantly influence clinical decision-making. FNPs must balance legal standards with ethical considerations by carefully distinguishing between situations that call for protective interventions and those where patients have a legal right to make decisions. Even when clinicians believe that institutional placement would ensure greater safety for the patient, legal obligations often require respect for the preferences of competent patients (Bodenheimer et al., 2023). As a result, legal frameworks emphasize the importance of evidence-based decision-making, patient-centered communication, and individualized assessment.

Intervention

An effective way to address the ethical dilemmas associated with the long-term placement of elderly patients is to adopt structured decision-making (SDM) alongside interdisciplinary geriatric ethics consultations. Shared decision-making provides a collaborative framework where FNPs, patients, family members, case managers, social workers, and other healthcare professionals work together to assess available options. Rather than framing each choice as either complete institutionalization or independence, SDM encourages exploring alternatives such as assisted living arrangements, remote monitoring technologies, community-based supports, adult day programs, and home health services (Guo et al., 2025).

Implementing SDM starts with a thorough geriatric assessment to review cognitive function, functional ability, environmental safety, psychosocial status, physical health, and available support systems. Then, the FNP guides structured decisions that clarify patient concerns, goals, preferences, and values. Ethics consultations may be requested when there are disagreements among stakeholders or significant uncertainty about appropriate actions. Ethics committees can provide objective guidance grounded in organizational policies, legal requirements, and ethical principles. Recent evidence suggests that ethics consultation services enhance satisfaction, reduce conflict, and improve communication among the stakeholders involved in the complex healthcare decisions (Bell et al., 2022) Columbus State University FNP Program NURS 6228 Health Promotion of the Elderly – Ethical Dilemmas of in long term placement of elderly men essay .

Decision aids are an important tool within the SDM framework. These are evidence-based resources that present information regarding benefits, risks, and alternatives in a way that supports informed choices. They help elderly patients and families understand the available options while promoting meaningful participation in care planning. In addition, they improve communication consistency and reduce misunderstandings about care needs and prognosis (Gans et al., 2023; Lognon et al., 2022).

Organizational commitment is essential for successful implementation. Healthcare organizations should develop policies and standards that promote routine SDM training for clinicians, ethics consultation services, interdisciplinary collaboration, and patient capacity assessments. FNPs should pursue continuing education in geriatric ethics, communication strategies, and legal aspects of decision-making. Standardized documentation templates can further enhance consistent documentation and assessment practices (Broom & Bhuyan, 2026).

Evaluation of intervention effectiveness should include both process and outcome measures. Process measures may include utilization of decision aids, rates of documented capacity assessments, and the number of ethics consultations completed. Outcome measures may assess quality-of-life indicators, placement outcomes, incidence of falls, emergency department utilization, hospitalization rates, caregiver satisfaction, and patient satisfaction. Reductions in provider moral distress and family conflict may provide additional evidence of intervention effectiveness. Continuous monitoring allows organizations to identify areas for improvement and strengthen ethical decision-making processes over time (Broom & Bhuyan, 2026).

Conclusion

The long-term placement of elderly male patients who refuse institutional care despite serious safety concerns presents a complex ethical dilemma involving conflicting principles of autonomy, non-maleficence, and beneficence. Elderly males with frailty, cognitive impairment, chronic illness, and limited support systems are especially vulnerable to this issue. The dilemma affects multiple stakeholders, including FNPs, patients, families, and healthcare organizations, resulting in operational, legal, ethical, and emotional challenges. Legal standards concerning patient rights, informed consent, and decision-making capacity strongly influence clinical decisions and highlight the need for individualized assessments. Combining interdisciplinary ethics consultation with shared decision-making provides an evidence-based, practical approach to addressing these conflicts, supporting informed choices and maintaining patient dignity. As healthcare systems care for an increasing number of elderly male patients, creating ethically sound and legally compliant approaches to long-term placement decisions will remain crucial for providing patient-centered, high-quality geriatric care Columbus State University FNP Program NURS 6228 Health Promotion of the Elderly – Ethical Dilemmas of in long term placement of elderly men essay .

References

Ahokas, F., Silén, M., Höglund, A. T., & Hemberg, J. (2025). Care leaders’ moral distress in older adult care: A scoping review. Nursing ethics , 32 (5), 1545–1563. https://doi.org/10.1177/09697330251315939

American Association of Nurse Practitioners (2023). Standards of Practice for Nurse Practitioners . Author.

Bell, J. A. H., Salis, M., Tong, E., Nekolaichuk, E., Barned, C., Bianchi, A., Buchman, D. Z., Rodrigues, K., Shanker, R. R., & Heesters, A. M. (2022). Clinical ethics consultations: a scoping review of reported outcomes. BMC medical ethics, 23 (1), 99. https://doi.org/10.1186/s12910-022-00832-6

Bodenheimer, T. S., Grumbach, K., Willard-Grace, R. (2023). Understanding Health Policy: A Clinical Approach (9th ed.). McGraw Hill LLC.

Bongelli, R., Busilacchi, G., Pacifico, A., Fabiani, M., Guarascio, C., Sofritti, F., Lamura, G., & Santini, S. (2024). Caregiving burden, social support, and psychological well-being among family caregivers of older Italians: a cross-sectional study. Frontiers in public health , 12 , 1474967. https://doi.org/10.3389/fpubh.2024.1474967

Broom, K. D., & Bhuyan, S. S. (Eds.) (2026). Fundamentals of Healthcare Management: Theory and Practice . Springer Publishing Company.

Gans, E. A., van Mun, L. A. M., de Groot, J. F., van Munster, B. C., Rake, E. A., van Weert, J. C. M., Festen, S., & van den Bos, F. (2023). Supporting older patients in making healthcare decisions: The effectiveness of decision aids; A systematic review and meta-analysis. Patient education and counseling , 116 , 107981. https://doi.org/10.1016/j.pec.2023.107981 c

Guo, J., Jiang, S., Dai, Y., Xu, X., Liu, C., & Chen, Y. (2025). Shared decision-making competency and its associated factors among palliative care nurses: a cross-sectional study in China. BMC nursing , 24 (1), 141. https://doi.org/10.1186/s12912-025-02747-0

Largent, E. A., Peterson, A., & Karlawish, J. (2023). Supported decision making: Facilitating the self-determination of persons living with Alzheimer’s and related diseases. Journal of the American Geriatrics Society , 71 (11), 3566–3573. https://doi.org/10.1111/jgs.18596

Lognon, T., Plourde, K. V., Aubin, E., Giguere, A. M. C., Archambault, P. M., Stacey, D., & Légaré, F. (2022). Decision aids for home and community care: a systematic review. BMJ open , 12 (8), e061215. https://doi.org/10.1136/bmjopen-2022-061215

Ouslander, J. G., Studenski, S., High, K. P., Asthana, S., Supiano, M. A., Ritchie, C. S., & SchmadeR, K. (2022). Hazzard’s Geriatric Medicine and Gerontology (8th ed.). McGraw Hill LLC.

Rahemi, Z., Malatyali, A., Bacsu, J. R., Sefcik, J. S., Petrovsky, D. V., Baker, Z. G., Ma, K. P. K., Smith, M. L., & Adams, S. A. (2023). Healthcare Utilization and Advance Care Planning among Older Adults Across Cognitive Levels. Journal of applied gerontology : the official journal of the Southern Gerontological Society , 42 (12), 2294–2303. https://doi.org/10.1177/07334648231191667

Sehatkarlangrodi, S., Zargoush, M., Longo, C. J., & Ghazalbash, S. (2025). Shaping older adults’ care policy: a scoping review of key determinants in post-acute and community reintegration transitions. BMC health services research , 25 (1), 1236. https://doi.org/10.1186/s12913-025-13433-x

Sun, C., Ding, Y., Cui, Y., Zhu, S., Li, X., Chen, S., Zhou, R., & Yu, Y. (2021). The adaptation of older adults’ transition to residential care facilities and cultural factors: a meta-synthesis. BMC geriatrics , 21 (1), 64. https://doi.org/10.1186/s12877-020-01987-w

Vinckers, F., & Landeweer, E. (2025). Moral distress among healthcare professionals in long-term care settings: a scoping review. Philosophy, ethics, and humanities in medicine : PEHM , 20 (1), 8. https://doi.org/10.1186/s13010-025-00171-5 Columbus State University FNP Program NURS 6228 Health Promotion of the Elderly – Ethical Dilemmas of in long term placement of elderly men essay