June 15, 2025

Ethics, Decision-Making and Boundaries in Long-Term Care

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Brookdale Senior Living offers multiple care levels for seniors in more than 600 communities nationwide. Brookdale helps you find the right care plan for yourself or your loved one. With amenities such as transportation services, salons and private dining rooms and activities such as gardening, fitness classes and trivia nights Brookdale caters to a wide range of interests and needs.

Ivan, who is living with mild dementia, insists on taking unaccompanied walks in the busy neighborhood surrounding his long-term care community. His care partners are concerned about his safety but are hesitant to restrict his freedom. What should they do?

Ivan, who is living with mild dementia, insists on taking unaccompanied walks in the busy neighborhood surrounding his long-term care community. His care partners are concerned about his safety but are hesitant to restrict his freedom. What should they do?

Juanita has verbalized her wishes to allow a natural death but has not signed a do-not-resuscitate (DNR) order or designated a healthcare surrogate. She has an aggressive form of cancer, which has not responded to treatment over the past year. She is now incapacitated and unable to make decisions about her care. Resuscitation may restore breathing and cardiac functioning but would not change the long term outcome for her. Her family is adamant about resuscitation. How should Juanita’s doctors respond?
Terrence has been diagnosed with an aggressive and incurable form of cancer, but he has not been told. His daughter, who has medical power of attorney, requested that his doctor not share the terminal diagnosis with him. Terrence’s doctor feels torn between his obligations to his patient and to the family. What’s the solution?These are just three examples of ethical dilemmas that physicians, nurses, CNAs, care partners, and other healthcare professionals encounter in long-term care. Decision-making can be a particular challenge in cases of cognitive impairment; end-of-life care; or when an individual’s choices may put them at risk.

Dilemmas like these may be a source of anxiety and uncertainty for the person or persons who must make decisions. Diminishing capacity complicates matters. How can you be sure you’re doing “the right thing” when it’s not clear what that is?

This post offers guidelines for approaching ethical dilemmas. It is not a road map to easy solutions — every case is different — but it will equip you with useful tools to evaluate ethical issues; identify practical ways to resolve common resident/patient dilemmas; understand how to balance individuals’ rights to make their own decisions with the need for others to make decisions on their behalf; and maintain professional boundaries.

Please note that healthcare practitioners must exercise their legal duties of care, particularly where ethics and law may overlap in the areas of confidentiality, patient capacity/informed consent, surrogate decision-making and advanced directives. For example, autonomy is identified as a human right subject to ethical considerations, but informed consent is a legal issue. Even thought a patient who does not have the capacity to provide informed consent has legally granted decision-making to family members, this delegation does not compromise their overall human right to autonomy. Surrogates must consider both legal and ethical implications when making health care decisions for others.

Seven Key Ethical Principles

Seven key ethical principles guide healthcare professionals in their interactions with residents/patients in long-term care:

Autonomy. Patients have the right to make decisions about their own lives — including whether to accept or reject treatment, and to be respected in the expression of their own values, opinions, perspectives and beliefs.
Beneficence. Healthcare professionals have an obligation to demonstrate compassion for their patients and to take positive action to help them.
Fidelity. Healthcare professionals must be loyal and trustworthy, keeping their promises by performing their duties as expected and with competence.
Justice. Healthcare professionals are expected to treat others equally, fairly and impartially.
Nonmaleficence. This principle, often expressed as “First, do no harm,” means healthcare professionals have a duty to protect patients from harm. They must be competent in their care delivery, and they must report to third parties if they suspect a patient is being abused or otherwise harmed.
Veracity. Healthcare professionals must tell the truth in their interactions with residents/patients, so the resident/patient or healthcare surrogate has all the facts needed to make an informed decision about their care.
Accountability. Healthcare professionals are professionally and personally accountable for the care and services they provide. They must be ready to explain their intentions, actions or decisions and to accept responsibility.

Complicating Factors

Even with these principles, however, situations are not always clear-cut. As the three fictionalized scenarios above illustrate, sometimes ethical principles clash with each other. Ivan’s care partners must weigh his autonomy against nonmaleficence, or their responsibility to protect him from harm. Juanita’s doctors find themselves in a position of either honoring her wishes (autonomy) or providing treatment that may prolong her life (beneficence). Terrence’s doctor may feel that he must choose between veracity and beneficence.

Other complicating factors can include:

Healthcare professionals’ heightened roles as older adults’ capacity diminishes
Strong emotional bonds that can develop over time between care partner/healthcare professional and resident/patient
Competing interests or guidance from professional codes of ethics, such as those for nurses and social workers; state and federal laws and regulations; advance care directives; institutional rules, policies and procedures; medical protocols as defined by a physician; and individual moral, religious or personal beliefs

Who Makes the Decision?

Healthcare professionals should respect the autonomy of a resident/patient who possesses the mental capacity to understand health- and treatment- related information to make informed choices about their care. The individual might have expressed their wishes and preferences through an advance care directive, such as a health care power of attorney, living will or DNR order.

If the resident/patient lacks the ability to make decisions and has not expressed their wishes through a legal document such as those mentioned, decisions might fall to a guardian, a surrogate or a healthcare proxy. A physician assessment will determine the individual’s capacity for understanding their condition, treatment options and prognosis. In other cases, a court will determine the individual’s competency, with physician input.

A family member or other guardian may have been granted a healthcare power of attorney (HCPOA) or medical power of attorney (MPOA) to make decisions on the resident/patient’s behalf. In these cases, the principles guiding decision-making are the patient/resident’s best interests, including consideration of the risks and benefits of the proposed treatment; and the substituted judgment standard, based on what the designated agent believes the patient/resident would have wanted.

Preventing or Resolving Conflicts

To prevent conflicts, healthcare professionals should:

Set reasonable expectations from the outset for the help they will provide.
Immediately consult their supervisor, a nurse or a peer about any concerns.
Discuss concerns with the resident/patient and agree on a course of action.
Involve family members or a POA consistent with the resident/patient’s wishes.

When ethical issues do arise, healthcare professionals should keep in mind that there are no absolute answers. They must examine the situation individually, based on the specific details, considering all the relevant information. Such dilemmas often call for a cross-disciplinary discussion involving the patient, when possible, along with family, care staff and possibly ethical and/or legal advisers.

A planned approach such as this will help resolve the dilemma:

Gather and review the facts.
Confer with other nurses, peers, attending physician, medical director, chaplain and other healthcare professionals.
Discuss with the resident/patient and family.
Schedule a care conference or discuss with the organization’s ethics committee.
Agree upon a preferred course of action for the interested parties.

Recognizing and Respecting Boundaries

One way to prevent conflict is to avoid crossing boundaries by maintaining healthy relationships with residents/patients. Especially with long-term relationships, healthcare professionals and residents/patients develop strong bonds, so it’s important to understand the limits, keeping the relationship professional rather than personal.

Actions that cross boundaries include sharing personal information, failing to see behavior as symptomatic, becoming overly involved or giving preferential treatment, using nicknames or other endearments, getting too physically close, accepting gifts/tips/favors, and engaging in a romantic or sexual relationship.

By maintaining professional boundaries, healthcare professionals can have positive and helpful relationships with residents/patients, communicate realistic and reasonable expectations, avoid stress and potential employment issues, and provide the best possible care.

Learn More

The information in this blog post is drawn largely from Ethics, Decision-Making and Boundaries in Long-Term Care, our latest presentation in the Brookdale Continuing Education (CE) Series. To learn more about these topics, please join us for this presentation.

To find out more about how Brookdale can partner with you in supporting your patients, reach out to us.

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