Blurred Lines at the Bedside: A Call for Ethical Presence

Published on: March 19, 2026

In nearly every shift in the ICU, nurses face ethical questions that influence patient care stories. Some questions seem routine and easy to handle, while others suddenly emerge with urgency and doubt. Amid these stories and the chaos, nurses confront moral challenges, often asking: Just because we can, does it mean we should? There’s a desire to slow down, gather more facts, and reflect not only on what we are doing but also on why we are doing it.

The ethical issues often feel personal, as I observe how patients’ stories unfold and sometimes feel slightly responsible for their outcomes. Some of these stories stay with me—the 51-year-old dying from terminal cancer who pleads for more time with his teenage children and says, “I’m not ready to die,” or the 73-year-old who tells her family surrounding her bedside, “it’s okay—just let me go.” The raw emotions teach me when to advocate, when to question, when to comfort, and when to hold space for what cannot yet be decided.

Death was often seen as a “failure” rather than a natural part of life. Clinical teams questioned whether administering too much medicine could cause more suffering instead of providing healing. Frequently, the person in bed couldn’t make decisions for themselves and hadn’t left a clear plan for others to follow. Having meaningful advance care plans and well-prepared loved ones was something I rarely encountered. Even when patients had advance care plans, the conclusions drawn from checked boxes rarely captured the full complexity of the situation.

The Weight of Decisions

The weight of decisions felt heavy. Nurses stand by their patients or loved ones, seeking answers to moral questions amid overwhelming emotions and mental exhaustion. When expectations about what medical treatment and technology could do didn’t match the realities of the circumstances or treatment requests, nurses did their best to advocate for their patients while also creating space to seek clarity. We asked, “If your mother could participate in this conversation, what do you think she would tell us?” The stakes were high. Attempts to balance competing priorities and obligations became routine. Some of the most difficult ethical challenges occurred when medical recommendations involved limited treatment options despite pleas to “do everything.”

Discussing treatment preferences with patients who want “everything” requires more in-depth exploration. What are the contextual factors behind the request? Many clinicians aren’t trained or comfortable having difficult conversations, especially when things aren’t going as they hoped. The lived experiences of caring for people whose needs, fears, values, and vulnerabilities evoke the intense emotions of others who hold their lives in their hands can leave deep moral scars. These moral scars can negatively affect overall well-being, workforce stability, and patient outcomes.

Where Ethical Questions Begin

Ethical dilemmas rarely present themselves in a clear way. Instead, they tend to emerge as a gut reaction to questions often posed in the language of “should”:

• Should a cognitively impaired patient be restrained for lifelong dialysis?
• Should a life-prolonging intervention be used if there is reasonable medical certainty that the patient is actively dying?
• Should the family be allowed to override a decision a patient made during times when they previously had decision-making capacity?

Ethical questions should make one pause and consider conflicting values or duties. Recognizing these issues early is a crucial responsibility for bedside staff. Finding answers to ethical questions is a calling.

The healthcare industry faces significant challenges, including aging populations, rising chronic disease burdens, workforce shortages, and intense regulatory demands.  Furthermore, hospitals are dealing with unprecedented financial pressures from rising operational costs and reimbursement cuts, which compel them to reduce essential services and place greater demands on an already strained workforce.

Dr. Jessica Zitter discusses a new form of heroism, highlighting the impacts of false hope, the avoidance of tough conversations, and the illusion that death is optional. When seeking clarity on ethical dilemmas, clinicians need the tools to navigate the complex landscape and to know when, where, and how to seek support from ethics consult services and/or ethics committees.

Elements of an Ethical Culture

Healthcare is fundamentally an ethical profession. Every day, healthcare professionals navigate questions involving autonomy, beneficence, nonmaleficence, and justice. The increasing exposure to a growing number of ethical dilemmas should prompt organizational leaders to pay greater attention to the role ethics plays in addressing these challenges and to invest in ethics services and in fostering an ethical culture. The American Association of Critical-Care Nurses (AACN) recommends that every organization take action to identify triggers for and to address moral distress. Managers should routinely create space for their teams to pause, reflect on their experiences, name their emotions, and collaborate with peers to address moral distress.  Without the tools, support, and space for ethical deliberation, moral distress could become widespread.

Organizational leaders should also consider the effects of toxic positivity and administrative harms, as these dynamics can unintentionally create cultures that dismiss staff’s moral concerns, leaving them feeling invalidated or unheard.  Research shows that suppressing negative emotions, instead of acknowledging and working through them, increases emotional exhaustion and mental health issues.  Consequently, disengagement, distrust toward leadership, compassion fatigue, burnout, and turnover can significantly affect culture and unintentionally affect patient outcomes.

A national survey revealed that hospitals investing in robust ethics programs see leaders become advocates of moral reasoning and foster environments of psychological safety. A top-down approach to developing an ethical culture begins by placing ethicists in senior leadership roles. Ethics committees and consultation services should not be viewed as separate from the clinical encounter or only called upon when the stakes are high. Instead, adopting a “preventive ethics” approach involves providing regular educational opportunities for staff to learn how to apply ethical principles and frameworks in clinical scenarios, and creating space for reflective debriefings to explore opportunities. While specific scenarios may differ, the core principles of ethics remain consistent. Hospitals that proactively provide ethics training and institutional ethics support see measurable benefits across quality of care, teamwork, and workforce sustainability.

Teamwork and Collaboration Enhance Ethical Presence

Healthcare professionals aim to uphold essential ethical standards by respecting their patients’ values and preferences and providing interventions that deliver reasonable benefits. However, many clinicians encounter situations where these obligations conflict, making ethics a vital part of clinical practice. Healthcare complexities continue to grow—with more technology, chronic illnesses, fragmented care, mistrust, and unanswered questions. At the core, there remains something fundamentally simple: human beings make choices that affect others’ lives amid uncertainty.

Ethical presence honors humanity and fosters humility. At its best, it causes us to slow down. It aligns intention with action. It helps clinicians navigate uncertainty with integrity- even in circumstances when the options are seemingly “bad,” and we must move forward by choosing which path before us is the least “bad”. And it reminds us that care is not only technical; it is moral.

Ethics isn’t a philosophical contest or a verdict. It involves concepts and personal contexts that shape ethical thinking, evaluate moral reasoning, and justify whether an action is considered ethically permissible. People approach decisions differently, and conflicts often occur when two parties choose different methods. How can one identify good decisions in clinical practice? Medical judgments are made by trained healthcare professionals based on diagnosis, treatment procedures, and outcomes. Patients and their families make value judgments influenced by their experiences, goals, and priorities. It is ethically problematic when patients, families, or healthcare professionals make judgments outside their roles. How should one respond to those hoping for a miracle? Like other appeals, it’s important to first explore the meaning behind the request.

I remember caring for a 21-year-old woman whose mother prayed for a miracle every day while her daughter lay on a ventilator, battling complications from COVID-19 and multi-organ failure. The prognosis was weeks, sometimes just days. A simple question: “Tell me what a miracle looks like for her?” had never been asked before. When I finally asked, her mother responded, “That she is comfortable and pain-free.” Because she was unable to speak due to the endotracheal tube and was sedated by medications, the young patient may not have known her mother was holding her hand. She never opened her eyes again. I still think of her and wonder—were her wishes respected? If someone had explored the meaning behind that request 13 days earlier, would things have turned out differently?

Ethical decision-making involves teamwork, and collaboration enhances the integrity of the choices. Different perspectives help prevent any single viewpoint from dominating the conversation. Working together to clarify values, align goals, and create a shared understanding supports ethical decision-making.

• It’s the nurse who asks, “Tell me what you understand about your circumstances so far.”
• It’s the physician who says, “I hope with you—and I worry, too.”
• It’s the social worker who considers, “What supports do they need moving forward?”
• It’s the behavioral health specialist who recognizes the trauma behind the anger.
• It’s the ethicist who asks, “What do you hope for?”
• And it is every clinician who pauses long enough to ask not only what they are doing, but why.

 AUTHOR

Stephanie Van Slyke is a part-time Clinical Ethicist at the Center for Practical Bioethics and a Senior Coordinator of Ethics at a Level II Trauma Center in Traverse City, Michigan. She holds a Master of Science in Bioethics from Creighton University and an undergraduate degree from Saginaw Valley State University. With over 23 years of experience in healthcare, Stephanie brings deep expertise in acute and intensive care, patient care management, advance care planning, and ethics program development.