# A 78-year-old woman with stage IV lung adenocarcinoma and multiple bone metastases reports pain 9/10. The son demands aggressive third-line chemotherapy; the daughter requests hospice referral. The patient is alert, fully oriented, and able to express her wishes. Which is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372704&lang=en  
> language: en  
> subject: Collaboration with Multidisciplinary Team  
> category: MOC

## Question

A 78-year-old woman with stage IV lung adenocarcinoma and multiple bone metastases reports pain 9/10. The son demands aggressive third-line chemotherapy; the daughter requests hospice referral. The patient is alert, fully oriented, and able to express her wishes. Which is the nurse's priority action?

## Option

1. Increase the opioid dose first to control her pain, then schedule a goals-of-care discussion.
2. Speak privately with the patient to elicit her own goals of care and treatment preferences. **✔ Correct answer**
3. Notify the ethics committee because the family conflict is interfering with care.
4. Request an immediate palliative care consult to settle the family disagreement.

**Correct answer: 2**

## Explanation

When a competent adult patient is alert, oriented, and able to express her own wishes, her voice — not the family's — directs care. The priority nursing action is to speak privately with the patient and elicit her own goals of care and treatment preferences. Family conflict in this scenario is a distractor: a palliative consult, ethics consult, or symptom management may all be appropriate later, but they cannot substitute for asking the decision-maker what she actually wants. Choice 4 places the conflict ahead of the patient's voice; choice 3 misuses the ethics committee; choice 1 medicates a key conversation away. Patient autonomy is the governing ethical principle.

## In-depth explanation

Two ethical principles guide this scenario. (1) Autonomy — a competent adult patient is the primary decision-maker about her own care, even when family members disagree with each other or with the patient. (2) Therapeutic communication — eliciting goals of care requires a private, unhurried conversation with the patient using open-ended questions ("What is most important to you in the time you have?"). Pain is significant at 9/10 and must be addressed, but the order is goals → plan → titrated comfort, not the reverse. Palliative consults follow patient-stated priorities; they do not generate them. Ethics committees are reserved for cases where decision-making capacity is absent, surrogates disagree about the patient's known wishes, or institutional policy is in dispute — not a family disagreement when the patient herself can speak.

## Clinical scenario

A **78-year-old woman** with **stage IV lung adenocarcinoma** and **multiple bone metastases** reports **pain 9/10**. The **son demands aggressive third-line chemotherapy**; the **daughter requests hospice referral**. The patient is **alert, fully oriented, and able to express her wishes**.

## Key concepts

- **Patient Autonomy** — The ethical principle that a competent adult patient has the right to direct her own medical care, including the right to refuse treatment. When patient and family disagree, the alert and oriented patient's expressed wishes prevail.
- **Goals-of-Care Conversation** — A structured, unhurried discussion with the patient about what matters most to her — quality of life, prognosis understanding, acceptable burdens, and treatment preferences. Foundation of any palliative or hospice plan and prerequisite to consult and care planning.
- **Ethics Committee Indications** — Convened when (1) the patient lacks decision-making capacity, (2) surrogates disagree about the patient's known wishes, (3) institutional policy is in dispute, or (4) clinicians and surrogates cannot reach consensus on a course aligned with the patient's values. Family disagreement when the patient can speak for herself is not an ethics committee case.

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