Introduction 
It is not uncommon for patients to refuse nursing care. Frequently cited reasons for patients’ reluctance to undergo treatments include physical trauma and unreadiness for treatment, which are typically respected as personal decisions. Also, everyone has the right to expect that their choice will not be interfered with, even if it harms them. It also violates another fundamental human right and signifies substandard health care. However, nurses face ethical dilemmas when patients refuse care. As an example, patients are opposed to early mobilization after surgery.

Ethical considerations 
Respecting the patient’s choices, including refusing care, is necessary. The difficulty is when a patient’s refusal is blindly accepted or honored without adequate analysis. In such a case, pain reduces consciousness, and exhaustion can result in early ambulation refusal (Dubb et al., 2016). The failure to acknowledge this condition may suggest that nurses have not promoted patient autonomy effectively. When a patient with decision-making capacity refuses medical intervention, it is pivotal that healthcare professionals explore the reasons behind refusal. They can also guide the patient by informing them of the benefits and risks of delayed post-operative ambulation rather than forcing them to comply. These thoughtful responses could enhance patient decision-making (Pirotte & Benson, 2023).
A quick decision to override coercive refusal, such as physically forcing patients to move from bed to chair or verbally threatening them, is physically and psychologically harmful to the patient and may violate ethical practice. Our duty to help patients has limits. Forcing patients to participate in activities against their will may temporarily protect their interests, but psychological distress can occur.

Way forward 
Nurses have a role in facilitating patients’ ability to make informed decisions. This role includes promoting patient safety and being their voice (Nsiah et al., 2019). To achieve this, patient refusal of care should be considered a grey area. Appreciating the refusal does not mean unthinkingly following it out of respect for the individual. Respecting informed refusal helps nurses discover ways to advocate for patients’ preferences by enhancing their autonomy. Patient education, nurses’ positive encouragement, and treatment plan adjustments can achieve this goal (Leditschke, 2012). Information manipulation or threat to patients may undermine their refusal. Negotiation skills are crucial for nurses to provide accurate information without deceiving patients.
Meanwhile, a patient’s refusal may signify his or her need for more guidance. Patients often face multiple challenges in healthcare, including a large amount of information from healthcare professionals, the spread of inaccurate information by many people, and an overwhelming burden of anxiety due to unfamiliarity and unpredictability in healthcare. These considerations require nurses to talk to patients and understand their concerns rather than judge their refusal. Nurses can only identify and explore alternative care while allowing patients to make values-based decisions. This prioritization of the patient’s best interests promotes justice for patients. 
Furthermore, if patients cannot decide, nurses must wait until their capacity is restored. Family and close friends may be asked about the patient’s past and present desires, emotions, values and beliefs (Griffith, 2016). Suppose the nurses suspect the patient lacks adequate decision-making capacity and there is no substitute decision-maker. In that case, the healthcare team has to determine the patient’s competence, consult with additional healthcare professionals or coworkers with relevant specialized knowledge, and intervene according to their professional expertise and the patient’s best interests. A formal best-interest meeting can be held to create a comprehensive management strategy (Griffith, 2018). In addition, the organizational duty may include providing a clear treatment escalation plan and negotiating skills simulation training for nurses. Most importantly, an excessive focus on a patient’s autonomy and the duty to provide treatment could undermine ethical practice when accepting or overriding a patient’s refusal of care.

Ethical Considerations

Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
The author received financial support through the Government of Brunei Darussalam in service training scheme. 




References