NSG 423 Unit 5 competing obligations decision record example

Confidentiality or Public Safety? A Home Health Nurse, an Older Man With Early Dementia Who Still Drives, and a Daughter Who Wants Him Reported

Student Name

Department of Nursing, Herzing University

NSG 423: Policy, Trends, & Ethics in Nursing

Instructor Name

February 19, 2026

Confidentiality or Public Safety? A Home Health Nurse, an Older Man With Early Dementia Who Still Drives, and a Daughter Who Wants Him Reported

The Situation

Mr. H. is a composite 81-year-old widower receiving home health nursing after a hospitalization for pneumonia. During the third visit, the home health nurse, Ms. Porter, noticed that he could not recall her visit two days earlier and had left the stove on. His primary care clinician diagnosed mild dementia six months ago. Mr. H. drives himself to the grocery store and to church, about three miles each way, several times a week. His daughter, who lives an hour away, took Ms. Porter aside and said her father had scraped the side of his car on the garage and gotten lost driving home from church last month. She asked Ms. Porter to report him to the state motor vehicle department so that his license would be reviewed. Mr. H., when the nurse raised driving with him, said, "Driving is the only thing I have left. Don't you go telling anybody."

In this composite state, health professionals are permitted, but not required, to report in good faith to the motor vehicle department a person whose medical condition may impair safe driving, and are protected from liability for doing so. Ms. Porter must decide what to do.

The Obligations, Stated as Duties to Named Parties

To Mr. H.: a duty of confidentiality regarding information obtained in his care, and a duty to respect his autonomy, including his choices about his life, so long as he has capacity for the decision in question. The nursing code of ethics treats the patient as the nurse's primary commitment and privacy and confidentiality as a core obligation (American Nurses Association [ANA], 2015).

To other people on the road, and to Mr. H. himself: a duty to prevent serious, foreseeable harm. The code also recognizes that confidentiality is not absolute when there is a risk of serious harm to the patient or others.

To his daughter: a duty of honesty in responding to her concerns, but not a duty to do what she asks. She is not the patient, and she is not his legal decision maker.

What Is Known and What Is Not

Known: he has a diagnosis of mild dementia; he has had one minor collision with his own garage and one episode of getting lost while driving, both reported by his daughter, who has not ridden with him recently. Evidence-based guidance on driving in dementia identifies several factors that increase risk, including a caregiver's rating of driving as marginal or unsafe, a history of crashes or citations, and lower scores on cognitive screening, while also noting that many people with mild dementia continue to drive safely for a time (Iverson et al., 2010). Not known: how he actually drives now, whether his clinician has discussed driving, and whether he has capacity to make decisions about driving. A reviewed approach to older drivers with cognitive impairment recommends clinical assessment and, where indicated, a formal driving evaluation rather than a decision based on diagnosis alone (Carr & Ott, 2010).

Applying the Framework

Using the four principles of biomedical ethics, respect for autonomy, beneficence, nonmaleficence, and justice (Beauchamp & Childress, 2019): Respect for autonomy weighs heavily, because Mr. H. has told her not to share this, and his diagnosis is mild. Autonomy depends on capacity, and capacity is decision-specific; he may be able to decide about driving even with mild dementia, or he may not, and that has not been assessed. Nonmaleficence weighs toward acting, because a driver whose cognition is declining can harm himself and others, and the two reported incidents are consistent with early risk. Beneficence supports finding a way for him to keep as much independence as is safe, such as alternative transportation. Justice concerns the people on the road who have no say in the matter but bear some of the risk.

The principles point in different directions only if the choice is framed as report or stay silent. They converge on a third course: an assessment that would tell everyone, including Mr. H., whether he can drive safely.

The Options, Priced

Report to the motor vehicle department now, without his consent: protects the public if he is unsafe; costs his trust, likely ends his willingness to accept home health visits, and acts on secondhand reports of two incidents without any clinical assessment.

Keep the confidence and do nothing: preserves his trust; leaves a possible risk to him and others unaddressed and ignores his daughter's report.

Raise the concern with his primary care clinician, with his knowledge, and ask for a driving assessment: preserves trust as far as possible, puts the question before the person best placed to evaluate capacity and driving, and leads to a formal evaluation that could either support his continued driving or show that he should stop. Costs: time, during which he continues to drive, and his displeasure at the concern being raised at all.

The Decision

Ms. Porter chose the third option. She told Mr. H. directly: "I'm not going to report you to anyone behind your back. But I'm worried about your driving after what happened at church, and it's part of my job to tell your doctor what I see. I'd like your doctor to help figure out whether driving is still safe, so it's based on how you actually drive and not on anyone's guess." He was angry but agreed she could tell his doctor. She told his daughter what she was doing and why she was not reporting him herself, and called the primary care office the same day, requesting a visit within two weeks and a referral for a formal driving evaluation.

She also set a condition for her own reconsideration: if she learns of a further incident, such as a crash, a near miss reported by a neighbor, or getting lost again, before the evaluation, she will ask the clinician to consider an immediate report, and she would support one herself. That condition was documented.

Who Carries the Outcome

If he is found unsafe, the clinician's report and the loss of his license will be hard for him, and Ms. Porter will help arrange rides through the county's senior transportation service. If he drives safely until the evaluation, the approach will have preserved his trust and his independence as long as was safe. If something happens in the meantime, Ms. Porter will carry the knowledge that she chose not to report immediately, a cost she accepted because the evidence available did not yet justify overriding his refusal.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Carr, D. B., & Ott, B. R. (2010). The older adult driver with cognitive impairment: "It's a very frustrating life." JAMA, 303(16), 1632-1641. https://doi.org/10.1001/jama.2010.481

Iverson, D. J., Gronseth, G. S., Reger, M. A., Classen, S., Dubinsky, R. M., & Rizzo, M. (2010). Practice parameter update: Evaluation and management of driving risk in dementia. Neurology, 74(16), 1316-1324. https://doi.org/10.1212/WNL.0b013e3181da3b0f