“Functioning as our better selves leads to better outcomes for patients and everyone.”

Tarris (Terry) Rosell, PhD, DMin, HEC-C

Published October 2026

Anyone who has spent time around a person with advanced dementia knows that the disease can be heartbreaking, unpredictable and, at times, frightening. Dementia can completely change someone’s personality. A person who once welcomed assistance may suddenly strike the aide helping them bathe. Someone who was gentle throughout their life may yell, kick or push. Dementia can damage the parts of the brain responsible for perception and impulse control, while leaving patients unable to explain that they are frightened, confused, hungry or in pain. 

How should caregivers respond when a patient becomes dangerous? 

A recent NPR article by Jordan Rau examines that question through the experience of Marjorie Tingley, an 85-year-old Michigan woman with dementia. Her memory care facility reported repeated episodes of hitting, kicking and elbowing staff and sought permission from her sons to use medication to control her agitation. Concerned about their risks while questioning whether they were truly necessary, her sons resisted medication use. 

The conflict eventually became severe. Tingley was repeatedly sent to the emergency department, received a 30-day eviction notice and was ultimately transferred to another facility, where she passed from her illness. Her family later sued the original facility, which has denied the allegations of medication misuse. 

Caregiving Can Be Dangerous

The case raises an uncomfortable ethical question: When does treating agitation become treating the inconvenience of agitation? 

Medications are not inherently unethical. Severe aggression can endanger caregivers, other residents and patients themselves. In some circumstances, medication may be clinically appropriate and ethically justified. Geriatric psychiatrist Lauren Gerlach told NPR that aggressive behaviors are often better addressed through non-medication interventions, but acknowledged that some behaviors become severe enough that medication is necessary. 

However, there is another person in this ethical equation: the caregiver. 

Personally, I have never been overly concerned that someone might physically hurt me during the workday – and I’ve worked in education. All joking aside, imagine being responsible for bathing, dressing and toileting a frightened patient who does not understand why you are touching her and responds by hitting or kicking you.

You know the behavior is caused by disease. You know she deserves patience and compassion. You also know you may be hurt the next time you enter the room. I cannot fathom the patience and grace of healthcare professionals and caregivers who face this reality Every. Single. Day.  

The Moral Distress of Competing Obligations

There are, of course, professional provisions to address this issue. The American Nurses Association Code of Ethics for Nurses recognizes that nurses have ethical duties not only to their patients, but to themselves. Provision 5 addresses nurses’ duties to themselves, including responsibilities related to their own health, safety, integrity and well-being. Compassionate care does not require accepting unreasonable threats to personal safety. 

However, this can create competing ethical obligations. Caregivers must protect vulnerable patients while also protecting themselves, their colleagues and other residents from harm. When caregivers know what compassionate care should look like but find themselves unable to provide it because of safety concerns, staffing limitations, institutional constraints or competing responsibilities, moral distress can follow while creating an untenable situation in which no one truly wins.  

But is sedation the most appropriate first course of action? Before suppressing a behavior, we should ask what that behavior might be communicating. Is the patient in pain? Frightened? Overstimulated? Experiencing an infection? Does the patient understand why a stranger is removing their clothing or touching their body?  

Harmful Medications Violate Non-Maleficence

 In Tingley’s case, her sons specifically requested that she be evaluated for a urinary tract infection because infections had previously contributed to her agitation. Testing ultimately confirmed she did have a UTI, and she received antibiotics thus reducing some of her agitation. 

That detail matters. 

The antipsychotic medications that Tingley was administered even prior to testing for the UTI carry serious risks for older adults with dementia, including an FDA-required warning about an increased risk of death (black box warning). More broadly, psychotropic medications can contribute to delirium, falls and hospitalization. Yet a JAMA study estimated that one in four Medicare beneficiaries with dementia may be inappropriately prescribed antipsychotics or other brain-altering medications before exploring other options. 

I am not a medical professional, but since there is a black box warning on these specific antipsychotic meds, I can logically conclude that this overuse violates the ethical principle of non-maleficence because these medications are known to increase harm for the patients. 

Creating Systems That Protect Both Patients and Caregivers

The principle of beneficence, however, requires us to take seriously the safety and well-being of everyone involved – patients and caregivers.  

The goal therefore cannot be never medicate, never sedate! Nor should it be keep the patient sedated and calm at all costs. The goal should be the least restrictive, least harmful intervention capable of protecting the patient and those around them while preserving as much dignity, awareness and personhood as possible. 

I, of course, don’t have a solution on how to achieve and implement this level of balance in dementia care. Perhaps the most important distinction is between care and control. A quiet patient is not necessarily a well-cared-for patient. Sure, sometimes calm means suffering has been relieved. But sometimes it means the person experiencing the suffering has simply been made less capable of expressing it. We cannot resolve difficult issues by silencing them, nor can we resolve ethical challenges by narrowing our focus to only one person, one principle or one harm. 

As we know, ethical challenges often arise because two legitimate obligations pull us in different directions. But those competing obligations do not require us to place the people involved in opposition to one another. The patient with dementia and the caregiver standing beside them are not adversaries. Both are vulnerable. Both deserve protection. Both deserve compassion.

The ethical task is not to decide whose well-being matters more, but to create systems of care in which protecting one person does not require sacrificing the dignity or safety of another. Perhaps that is where we should begin: not by asking how we control a difficult patient or how much risk a caregiver should endure, but how we can care for both people in the room. 

Sources: 

Jordan Rau, “Drugs Are Widely Used to Sedate Dementia Patients. Her Sons Wanted to Keep Her Off Them,” KFF Health News/NPR, September 30, 2026. 

American Nurses Association, Code of Ethics for Nurses, 2025, particularly Provision 5. 

Mr. Ghanes is a 47-year-old male suffering from COPD and acute renal failure. He came to the emergency department after experiencing shortness of breath at the group home where he resides due to a traumatic brain injury (TBI) he suffered several years ago. His TBI has had a significant impact on his ability to receive treatment and care over the years, specifically making him prone to extreme hostility and agitation toward others. This includes members of the medical team, caregivers at the group home, and even other residents. These behaviors have made finding appropriate treatment and care facilities increasingly difficult.

Mr. Ghanes is currently waiting in the emergency department for an available hospital bed. However, the medical team is becoming increasingly uncomfortable continuing to care for him. He has become increasingly physically and verbally abusive toward the team, raising concerns among the nursing staff. The medical team is also concerned about admitting him because of the potential difficulties in finding an appropriate discharge placement. His group home has indicated that, because he will now likely require hemodialysis, he will not be permitted to return.

Due to Mr. Ghanes’s behavioral issues, the medical team has needed to sedate him repeatedly as he has become increasingly agitated while waiting. This has left many members of the team concerned, as they are unsure how long he will need to remain in the hospital, how long they will need to continue administering medication to keep him calm, and what options will be available for discharge.

I tend to believe that the majority of people who pursue careers in healthcare enter the field with the intention of doing good things for others. There are many noble professions that strive to create a better and safer world. But healthcare is somewhat unique in that there are immediate and direct outcomes, for better or for worse.

A patient presents to the hospital with a broken leg, and the emergency team is able to treat the injury. Or a patient is cured of an aggressive form of cancer. Or a patient receives orthopedic surgery following an injury. Healthcare provides the opportunity to see patients’ and families’ lives improve because of our direct involvement. 

It is rewarding, but it can also set a challenging standard. What do you do for patients you are unable to treat? Unable to help improve? Patients whose conditions you can only watch decline? This can be a challenging situation for anyone, but particularly for those trained to improve the health of others. 

Overuse of Sedating Medications

This challenge is frequently encountered when caring for patients with cognitive decline, such as dementia. There is no cure for these patients, and because of this, healthcare systems often fail to meet their needs. If there were a medication or procedure, the questions surrounding how best to treat these patients would be easier to answer. These are the situations that healthcare in the United States is best equipped to handle. But without a cure or a clear direction forward, the path becomes more complicated. The healthcare team’s best efforts may only offer an opportunity to improve or maintain patients’ quality of life.

This is exemplified by the overuse of sedating medications in these patients, particularly in emergency departments. These patients present to the hospital in need of treatment and care, but delivering that treatment is complicated by their conditions, and healthcare teams are not always fully equipped to meet their needs.

As a result, the easier solution is often implemented. It is not that healthcare teams are careless or uncompassionate toward these patients. Rather, they may genuinely lack the resources or means to meet their needs in any other way. And while this situation occurs in the ED, the truth is that it is a symptom of a much larger problem with healthcare delivery. While the ED is not well equipped to meet these patients’ needs, there are often few other places for them to go. 

Care Ethics Needed More than Ever

The experiences of patients suffering from cognitive decline, dementia, Alzheimer’s disease, and related conditions are examples of the failures of our modern healthcare system. We too often focus on treating the patient rather than truly caring for the patient. It is helpful in these situations to incorporate a care ethics approach, which “recognizes that human dependence on others is universal – in contrast to other ethical theories that present an image of humans as wholly independent, atomistic, or simply in competition with each other. All people depend on and require care from others to flourish and meet their needs. This is perhaps most obvious when people grow up, grow old, become sick, or experience a disability” (Santa Clara University, Care Ethics). 

And this problem is only getting worse. A research team led by Drs. Josef Coresh at New York University Grossman School of Medicine and Michael Fang at Johns Hopkins Bloomberg School of Public Health “projected that the number of new dementia cases in the U.S. will double over the next four decades, from about 514,000 in 2020 to about 1 million in 2060” (National Institutes of Health). 

Healthcare will need to adapt to the increasing needs of these patients with new approaches and continued compassion. It is not that medical teams lack empathy, but rather that they are constrained by the realities of the systems in which they work and the demands they are expected to meet. 

Sources: 

Care Ethics – Care Ethics – Markkula Center for Applied Ethics  

https://www.nih.gov/news-events/nih-research-matters/risk-future-burden-dementia-united-states 

Written By Ryan Pferdehirt, D.Bioethics, HEC-C, Vice President of Ethics Services, Rosemary Flanigan Chair & Cassie Shaffer Johnson, MA, Program Director of Ethics Services