NCLEX-RN Palliative Care, End-of-Life Nursing & Ethical Decisions: 6 Original NGN Cases

Quick nursing answer: Safe end-of-life and palliative nursing integrates comfort assessment, patient autonomy, informed consent/refusal, advance-care planning, culturally respectful communication and responsible symptom reassessment. A DNAR order does not automatically stop all other appropriate care; palliative support can begin alongside cancer treatment. This free resource includes six original three-stage clinical cases, twelve nursing judgment questions and 48 option-specific explanations.

Prepared 7 November 2026 by the Medline Academy Editorial Team. Individual RN clinical review remains pending. Institutional educators are Ainstin S Dennis, RN and Tincy Mathew, RN, but their credentials do not imply that either personally reviewed these new cases. Ethical and legal rules vary by nursing jurisdiction. This page is for NCLEX-RN preparation, not legal or medical advice.

Palliative versus hospice versus last-days care: important distinctions for NCLEX-RN

The 2026–2029 NCLEX-RN Test Plan includes Psychosocial Integrity, Management of Care and Basic Care and Comfort. The examination asks for clinical judgment, not memorization of one country’s specific advance-directive form. Rights, decision-making capacity and surrogacy must be interpreted within applicable local law, institutional policy and clinical circumstances.

Nursing ethical principle: Compassionate care is active. Assess what matters to the person, support a chosen family member or advocate, communicate transparently, and use clinician-authorized treatment plans. Do not use your own values to decide what a patient must want.

Six original NGN palliative and ethical decision cases

Each fictional case unfolds over three observations or discussions. Select a single best option and read all rationales; valid nursing responses may include simultaneous assessment, communication and support.

Case 1: Palliative care while anticancer treatment continues

Nursing judgment focus: Recognizing that palliative support is not limited to the final days

Time point	Fictional communication or nursing record
At consultation	A 62-year-old receiving systemic therapy for metastatic cancer reports pain, fatigue, anxious thoughts and sleep loss.
After discussion	The patient asks whether palliative care means their treating oncologist will stop all anticancer treatment.
Care conference	The RN learns that the patient wants both symptom relief and an informed discussion of future treatment goals.

Decision 1: Which nursing response gives the most accurate explanation?

1. Palliative care may begin alongside disease-directed treatments and focuses on symptom relief, quality of life and patient-defined goals.
2. Receiving palliative care automatically means all anticancer treatment is stopped.
3. Palliative care can address physical pain but not fear, social concerns or spiritual needs.
4. A patient must be unconscious before palliative care can begin.

Open the correct response and rationales for all options

Best choice: A. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Palliative care may begin alongside disease-directed treatments and focuses on symptom relief, quality of life and patient-defined goals.	Correct	NCI describes palliative care as appropriate throughout the illness and compatible with cancer treatments when clinically indicated.
B — Receiving palliative care automatically means all anticancer treatment is stopped.	Incorrect / less appropriate	Palliative support is not synonymous with ending treatment or electing hospice services; treatment choices are individualized.
C — Palliative care can address physical pain but not fear, social concerns or spiritual needs.	Incorrect / less appropriate	Holistic palliative care includes emotional, social and spiritual support alongside physical symptom management.
D — A patient must be unconscious before palliative care can begin.	Incorrect / less appropriate	Supportive palliative services can benefit alert patients at many stages of serious illness.

Decision 2: What should the RN do when multiple unmet needs emerge?

1. Promise a cure so the patient feels less worried.
2. Cancel the upcoming oncology appointment without consulting the patient or team.
3. Assess symptoms and patient priorities; facilitate communication with oncology/palliative care and document preferences.
4. Tell family members to decide all treatment questions even when the patient can participate.

Open the correct response and rationales for all options

Best choice: C. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Promise a cure so the patient feels less worried.	Incorrect / less appropriate	Unrealistic reassurances can undermine informed choices and trust.
B — Cancel the upcoming oncology appointment without consulting the patient or team.	Incorrect / less appropriate	The nurse should not unilaterally change established treatment plans.
C — Assess symptoms and patient priorities; facilitate communication with oncology/palliative care and document preferences.	Correct	Shared decision-making and interdisciplinary referral support symptom control and goals-concordant care.
D — Tell family members to decide all treatment questions even when the patient can participate.	Incorrect / less appropriate	A person with decision-making capacity should be involved in the way they choose.

Primary clinical/ethical source: Read the source guidance for this topic.

Case 2: A capable patient refuses another burdensome procedure

Nursing judgment focus: Autonomy, informed refusal and decision-specific capacity

Time point	Fictional communication or nursing record
Morning	A 70-year-old with advanced cancer is awake, oriented and states that another invasive procedure conflicts with their goals.
Noon	After receiving an explanation of options, risks and alternatives, the patient accurately repeats the information and reaffirms the refusal.
Afternoon	A relative insists the nurse obtain consent anyway because the family believes the procedure is necessary.

Decision 3: What is the RN’s best immediate response to the patient’s refusal?

1. Tell the patient they cannot refuse when family wishes differ.
2. Respect the expressed refusal, verify that the clinician knows, document the patient’s words and facilitate a further informed discussion if needed.
3. Sign the consent in place of the patient to avoid delay.
4. Conceal possible burdens of the treatment because it might cause distress.

Open the correct response and rationales for all options

Best choice: B. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Tell the patient they cannot refuse when family wishes differ.	Incorrect / less appropriate	Adults with relevant decision-making capacity generally retain the right to informed refusal, subject to applicable jurisdictional law.
B — Respect the expressed refusal, verify that the clinician knows, document the patient’s words and facilitate a further informed discussion if needed.	Correct	The nurse advocates for a voluntary informed decision, communicates it and ensures the treating team follows appropriate consent policy.
C — Sign the consent in place of the patient to avoid delay.	Incorrect / less appropriate	Signing for a capable patient without authorization is not acceptable.
D — Conceal possible burdens of the treatment because it might cause distress.	Incorrect / less appropriate	Material treatment choices and risks must be explained transparently by the responsible clinician.

Decision 4: How should the nurse respond to the family disagreement?

1. Assume family members automatically supersede all competent patient decisions.
2. Threaten or publicly shame the relative for disagreeing.
3. Ask the relative to sign a new document secretly and disregard the patient’s refusal.
4. Explain the patient’s decision-making role sensitively, offer a care-team discussion and request ethics consultation if conflict persists.

Open the correct response and rationales for all options

Best choice: D. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Assume family members automatically supersede all competent patient decisions.	Incorrect / less appropriate	A capable patient’s expressed preferences normally have priority over family pressure.
B — Threaten or publicly shame the relative for disagreeing.	Incorrect / less appropriate	A respectful and professionally mediated discussion is safer and more therapeutic.
C — Ask the relative to sign a new document secretly and disregard the patient’s refusal.	Incorrect / less appropriate	Circumventing informed consent undermines autonomy and record integrity.
D — Explain the patient’s decision-making role sensitively, offer a care-team discussion and request ethics consultation if conflict persists.	Correct	Open communication and ethical support address disagreements while protecting the patient’s rights and local legal obligations.

Primary clinical/ethical source: Read the source guidance for this topic.

Case 3: A DNAR order is mistaken for an order to withhold all care

Nursing judgment focus: Distinguishing limitations of resuscitation from ordinary beneficial care

Time point	Fictional communication or nursing record
Morning	An adult with serious illness has a documented do-not-attempt-resuscitation (DNAR) order matching the current record.
Afternoon	They develop a treatable pneumonia and report distressing dyspnea; the care plan still supports symptom management and certain treatments.
Handoff	A colleague says, ‘The patient is DNAR, so no medicine, oxygen or nursing assessment is needed.’

Decision 5: Which understanding of the DNAR order is correct?

1. It means all food, fluids, comfort measures and ordinary nursing care must stop.
2. It prevents any assessment when the patient becomes breathless.
3. It directs resuscitation limitations as documented, but other indicated treatments must follow the patient’s broader goals and orders.
4. It allows a nurse to rewrite all treatment preferences without consulting the patient or clinicians.

Open the correct response and rationales for all options

Best choice: C. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — It means all food, fluids, comfort measures and ordinary nursing care must stop.	Incorrect / less appropriate	DNAR governs the specified resuscitation decisions; it does not automatically end comfort and appropriate treatment.
B — It prevents any assessment when the patient becomes breathless.	Incorrect / less appropriate	Nursing assessment and compassionate symptom relief continue and may be essential.
C — It directs resuscitation limitations as documented, but other indicated treatments must follow the patient’s broader goals and orders.	Correct	The team distinguishes CPR decisions from ongoing symptom relief, antibiotics or other disease-directed care as individually agreed.
D — It allows a nurse to rewrite all treatment preferences without consulting the patient or clinicians.	Incorrect / less appropriate	Care-plan decisions must follow the patient’s wishes, authorized clinicians and the jurisdiction’s rules.

Decision 6: What should the RN do when new dyspnea occurs?

1. Assess distress and respiratory status, use authorized comfort interventions, notify the responsible clinician and clarify the scope of the care plan.
2. Abstain from all communication because dying patients no longer have rights.
3. Automatically start CPR solely because the patient is breathing uncomfortably.
4. Tell the family that every medication is now legally prohibited.

Open the correct response and rationales for all options

Best choice: A. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Assess distress and respiratory status, use authorized comfort interventions, notify the responsible clinician and clarify the scope of the care plan.	Correct	DNAR does not justify neglect. Current goals and orders guide symptom management, oxygen therapy where appropriate and any treatment offered.
B — Abstain from all communication because dying patients no longer have rights.	Incorrect / less appropriate	Patient dignity, comfort and shared decisions remain central.
C — Automatically start CPR solely because the patient is breathing uncomfortably.	Incorrect / less appropriate	CPR decisions follow the valid resuscitation order; breathlessness requires assessment, not automatic CPR.
D — Tell the family that every medication is now legally prohibited.	Incorrect / less appropriate	This overstates DNAR and may cause avoidable distress or harm.

Primary clinical/ethical source: Read the source guidance for this topic.

Case 4: Distressing breathlessness in the final days of life

Nursing judgment focus: Individualized comfort, medication safety and symptom reassessment

Time point	Fictional communication or nursing record
14:00	Adult with advanced lung disease is thought to be in the last days of life, with individualized comfort-focused goals.
15:00	They describe air hunger despite resting; pulse oximeter reads 94% on room air. Their wish is to avoid burdensome procedures.
16:00	The team considers non-pharmacological measures and a carefully prescribed medicine for breathlessness while monitoring comfort and sedation.

Decision 7: Which RN action is most appropriate for the distressing breathlessness?

1. Assume dyspnea is impossible with oxygen saturation 94%.
2. Assess the symptom, position for comfort, consider appropriate airflow/fan measures and collaborate on ordered individualized relief.
3. Insist on invasive ventilation without discussing goals or indicated benefit.
4. Ignore requests for help because treatment goals are focused on comfort.

Open the correct response and rationales for all options

Best choice: B. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Assume dyspnea is impossible with oxygen saturation 94%.	Incorrect / less appropriate	Patient-reported breathlessness is clinically important; pulse oximetry alone does not measure the subjective burden.
B — Assess the symptom, position for comfort, consider appropriate airflow/fan measures and collaborate on ordered individualized relief.	Correct	NICE emphasizes individualized non-pharmacological and prescribed pharmacological symptom care that respects patient goals.
C — Insist on invasive ventilation without discussing goals or indicated benefit.	Incorrect / less appropriate	Interventions should align with clinical needs, authorization and the patient’s informed preferences.
D — Ignore requests for help because treatment goals are focused on comfort.	Incorrect / less appropriate	Comfort-focused care requires active symptom assessment and intervention, not abandonment.

Decision 8: What should be reassessed after a prescribed opioid or other symptom-control intervention?

1. Only the time that a medication was given.
2. Assume respiratory depression is harmless and never check consciousness.
3. Repeat medicine doses automatically without regard to response or orders.
4. The person’s perceived relief, respiratory effort, alertness, unwanted sedation and current wishes.

Open the correct response and rationales for all options

Best choice: D. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Only the time that a medication was given.	Incorrect / less appropriate	Administration time is important but cannot show whether breathlessness or side effects changed.
B — Assume respiratory depression is harmless and never check consciousness.	Incorrect / less appropriate	Unwanted sedation or breathing compromise must be assessed and escalated.
C — Repeat medicine doses automatically without regard to response or orders.	Incorrect / less appropriate	Safe titration requires a prescribed plan and evaluation of efficacy and harms.
D — The person’s perceived relief, respiratory effort, alertness, unwanted sedation and current wishes.	Correct	Symptom control is a balance of benefit, comfort and adverse effects with adjustments under the authorized care plan.

Primary clinical/ethical source: Read the source guidance for this topic.

Case 5: Family requests IV fluids for a patient who is nearing death

Nursing judgment focus: Mouth care, assisted hydration decisions and possible overload

Time point	Fictional communication or nursing record
Day 1	A patient with advanced illness is increasingly sleepy, has a dry mouth and takes only small sips.
Day 2	Family fear the patient will suffer unless a large IV fluid infusion begins immediately.
Day 2 later	The patient has poor swallowing, edema and reduced kidney function; goals of care and comfort are being reviewed.

Decision 9: How should the RN respond to concerns about thirst and hydration?

1. Offer attentive mouth/lip care and safe sips if the patient wishes and can swallow, assess discomfort, and facilitate an individualized clinician-led hydration discussion.
2. Independently start a large-volume fluid infusion without assessing the clinical context.
3. Assure the family that assisted hydration always prolongs life.
4. Ban all mouth care and any comfortable sips because the patient is dying.

Open the correct response and rationales for all options

Best choice: A. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Offer attentive mouth/lip care and safe sips if the patient wishes and can swallow, assess discomfort, and facilitate an individualized clinician-led hydration discussion.	Correct	NICE advises mouth care and evaluating potential benefits and harms of clinically assisted hydration; neither automatic IV fluid nor automatic withholding fits everyone.
B — Independently start a large-volume fluid infusion without assessing the clinical context.	Incorrect / less appropriate	Fluid overload may increase breathlessness and edema; hydration must be individualized and authorized.
C — Assure the family that assisted hydration always prolongs life.	Incorrect / less appropriate	NICE notes uncertainty about effects on duration of life in the last days and requires honest communication.
D — Ban all mouth care and any comfortable sips because the patient is dying.	Incorrect / less appropriate	This can worsen dryness and distress; safe oral comfort should be offered based on swallowing ability and wishes.

Decision 10: If the team authorizes a trial of assisted hydration, what must be monitored?

1. Only the total amount given; symptoms are unimportant.
2. No observations are needed because hydration is always beneficial.
3. Comfort/thirst, respiratory findings, edema, fluid balance and whether treatment aligns with patient preferences.
4. Automatically increase fluid each time the patient becomes sleepier.

Open the correct response and rationales for all options

Best choice: C. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Only the total amount given; symptoms are unimportant.	Incorrect / less appropriate	Fluid volume alone cannot establish clinical benefit or harm.
B — No observations are needed because hydration is always beneficial.	Incorrect / less appropriate	Assisted hydration can cause fluid overload and symptoms; re-evaluation is required.
C — Comfort/thirst, respiratory findings, edema, fluid balance and whether treatment aligns with patient preferences.	Correct	NICE recommends frequent reassessment (including at least 12-hourly monitoring after initiation) for possible benefits and harms.
D — Automatically increase fluid each time the patient becomes sleepier.	Incorrect / less appropriate	Drowsiness has multiple causes; escalating fluid without assessment may harm the patient.

Primary clinical/ethical source: Read the source guidance for this topic.

Case 6: Agitation, pain and spiritual distress in the last days

Nursing judgment focus: Assessment of potentially reversible distress and respectful family involvement

Time point	Fictional communication or nursing record
18:00	An adult with terminal illness becomes restless and grimaces. The family reports they were calm earlier.
18:20	The nurse learns there has been no voiding for hours; pain medicines are being reviewed by the team.
19:00	The patient requests spiritual support and asks that one family member be present. Other relatives disagree about care.

Decision 11: What should the nurse prioritize when agitation appears?

1. Give sedating medicines automatically without checking discomfort or possible causes.
2. Dismiss the agitation as inevitable and take no action.
3. Force the patient into isolation solely to avoid family discussion.
4. Assess pain, bladder retention, medication effects, delirium and other reversible contributors, while seeking authorized symptom treatment.

Open the correct response and rationales for all options

Best choice: D. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Give sedating medicines automatically without checking discomfort or possible causes.	Incorrect / less appropriate	Sedation without assessment can mask pain, retention or other treatable contributors and may cause harm.
B — Dismiss the agitation as inevitable and take no action.	Incorrect / less appropriate	Distress in dying adults should be assessed and relieved when possible.
C — Force the patient into isolation solely to avoid family discussion.	Incorrect / less appropriate	Isolation is not a routine response and may conflict with expressed wishes.
D — Assess pain, bladder retention, medication effects, delirium and other reversible contributors, while seeking authorized symptom treatment.	Correct	Even near death, distress may have treatable causes; symptom assessment and skilled palliative review are appropriate.

Decision 12: What is the best nursing communication and collaboration plan?

1. Impose the nurse’s own spiritual beliefs on the family.
2. Ask whom the patient wishes to involve, facilitate spiritual/cultural support and interpreters as needed, and coordinate an honest team discussion.
3. Tell the patient that family members must make all choices regardless of decision-making capacity.
4. Promise a precise time of death to reassure everyone.

Open the correct response and rationales for all options

Best choice: B. This response is safest among the options provided for the individual fictional case.

Option	Assessment	Detailed ethical or clinical explanation
A — Impose the nurse’s own spiritual beliefs on the family.	Incorrect / less appropriate	Patient-directed support respects beliefs and avoids coercion.
B — Ask whom the patient wishes to involve, facilitate spiritual/cultural support and interpreters as needed, and coordinate an honest team discussion.	Correct	The patient should guide involvement when able, and disagreements should be addressed compassionately through a multidisciplinary plan.
C — Tell the patient that family members must make all choices regardless of decision-making capacity.	Incorrect / less appropriate	The patient’s values and capacity remain central even in the last days.
D — Promise a precise time of death to reassure everyone.	Incorrect / less appropriate	Clinicians cannot predict the exact time of death reliably; honest acknowledgment of uncertainty is better.

Primary clinical/ethical source: Read the source guidance for this topic.

Free nurse’s ethical and comfort-care worksheet

After choosing an answer, record what the person actually wanted, whether their capacity and goals were assessed, whether there is an authorized treatment or limitation order, your safe RN action, and the outcome to re-evaluate. A correct letter in a practice item cannot validate end-of-life professional competence.

Malayalam-English palliative care vocabulary

How this page builds upon Medline Academy®’s existing nursing resources

This is an applied decision-case library about end-of-life ethics and symptom relief. Read it alongside Management of Care: ethics, consent and delegation, Fundamentals: Basic Care and Comfort, high-risk medication safety, prioritization and safe nursing delegation, oncology emergency cases, NGN formats and scoring, free NGN case library and free worksheets. The focus here is specifically on patient values, comfort and ethical clinical decisions, not duplication of the general ethics guide.

Ethical clinical judgment: a patient-goals decision record

Palliative and end-of-life questions are rarely solved by recalling a single definition. A safer learning approach distinguishes patient goals, decision-making capacity, informed preference, the current care plan, applicable law and what an RN may appropriately do. Use one of the six fictional cases and complete the following original reflection.

1. Patient perspective: write the preference or concern actually expressed in the case. Avoid substituting a family member’s assumption or the learner’s personal belief.
2. Clinical and ethical issue: identify whether the main challenge concerns symptom assessment, communication, a treatment refusal, an existing order, or uncertainty about decision-making authority.
3. Nursing response: describe the appropriate assessment, supportive communication or team clarification within the case context. Distinguish listening and advocacy from making an unauthorized treatment or legal decision.
4. Reevaluation: record what patient comfort, understanding or goal-concordance outcome you would check next. If the facts are incomplete, state what you would need to verify rather than guessing.

Connect the topics: explore oncology emergency recognition for a different priority framework and teach-back and medication reconciliation for communication during transitions. Review management of care when the correct action depends on nursing role, team collaboration or established policy.

Scope reminder: jurisdiction-specific consent and surrogate decisions depend on current law, institutional policy and the individual circumstances. This worksheet does not assert independent RN sign-off or provide individual medical or legal instructions.

Frequently asked questions

Does palliative care mean all anticancer treatment stops?

No. NCI recognizes palliative support can coexist with disease-directed cancer treatment, depending on goals and clinical circumstances.

Does a DNAR order mean the nurse should stop all care?

No. DNAR addresses defined resuscitation interventions. Comfort, assessment, suitable treatment and respectful communication continue according to the care plan.

Who decides if a capable person refuses a procedure?

The patient should be enabled to make an informed decision. The legal framework and capacity assessments vary by jurisdiction; nurses advocate and document accurately.

Is IV fluid always beneficial or always harmful in the last days?

Neither. NICE emphasizes individual assessment, mouth care, possible trial of assisted hydration, monitoring for benefit and fluid overload, and respect for the patient’s preferences.

Should terminal agitation always be sedated immediately?

Not automatically. Assess distress, pain, urinary retention, medication effects and other contributing factors while collaborating on authorized symptom relief.

Are these official NCLEX-RN cases reviewed by the founders?

No. They are original Medline Academy Editorial Team learning cases. Individual RN clinical review remains pending; no NCSBN endorsement is claimed.

Authoritative palliative, ethical and NCLEX-RN references

• NCSBN — 2026 NCLEX-RN Test Plan
• NCI — palliative care and cancer
• NICE NG31 — care of dying adults in last days
• NICE NG142 — end of life service delivery and advance planning
• NICE NG197 — shared decision making
• AMA — palliative and end-of-life ethical guidance
• ANA — Code of Ethics for Nurses, updated 2025

Editorial disclosure: Original fictional educational cases written by Medline Academy Editorial Team. Individual RN clinical review pending. No clinical, legal or hospice service is being offered through this article. Actual decisions require the person’s preferences, informed consent, appropriate surrogate/capacity process, current orders and local laws. See editorial review policy and official sources library. Sources checked 7 November 2026.