Four Topics Approach in Ethical Nursing Practice

There was a situation in my nursing career when I had to make a serious decision regarding ethics, and I do not think I would have been able to do it without the help of the Four Topics Approach. The patient was a seventy-year-old female, and she had chronic kidney pain. She was diagnosed with kidney stones, and an operation was strongly suggested to remove them. However, the patient refused to have an operation, which might have led to adverse outcomes.

The first thing to consider was the medical indications. The problem was acute since it posed a threat to the patient’s health and life. Percutaneous nephrolithotomy was advised in the given case as the best solution (Neisius, Jibara, Lipkin, & Preminger, 2017). The goals of treatment were to remove kidney stones and improve the patient’s health condition. The probability of success of a different treatment option was not as high as under the terms of percutaneous nephrolithotomy. Therefore, the only way to reach beneficent outcomes for the patient was the operation.

Another topic I had to deal with was related to the patient’s preferences and respect for her autonomy. The woman was informed of the risks in case she refused to be operated. It was specifically emphasized to her that there was a high risk of coronary heart disease (Ferraro et al., 2013). The patient was mentally capable, so there was no possibility to ask anyone else to make her decisions for her. However, her daughter knew about the situation, and she tried to persuade her mother to agree to be operated.

The next issue was respect for autonomy. Based on evidence-based practice, the patient’s prospects to return to normal life without treatment were rather poor. She would constantly feel pain and discomfort. An ethical issue concerning improving the patient’s quality of life was whether we should have done the operation without her consent. However, no such measures were taken, and the plan of life-sustaining treatment was developed for the woman.

The last part of the framework concerns the principles of justice and fairness. The patient’s confidentiality was not limited, her daughter already knowing about the problem. There were no conflicts of interest that might impact the decision.

Applying the Four Topics Approach helped me to make a better decision. Without this framework, I would have probably insisted on doing the operation. However, taking into account each stage of the framework, I realized that the patient was the only one who could choose whether to be operated and instead of violating the ethical principles by disregarding her desire, we created a life-sustaining treatment plan that would enable the patient to have a more or less comfortable life.


Ferraro, P. M., Taylor, E. N., Eisner, B. H., Gambaro, G., Rimm, E. B., Mukamal, K. J., & Curhan, G. C. (2013). History of kidney stones and the risk of coronary heart disease. JAMA, 103(4), 408-415.

Neisius, A., Jibara, G., Lipkin, M. E., & Preminger, G. M. (2017). Kidney stone treatment: Percutaneous nephrolithotomy. In F. C. Hamdy & I. Eardley (Eds.), Oxford textbook of urological surgery (pp. 142-151). Oxford, UK: Oxford University Press.