A sense of place for patients: living and dying

In references to an individual, agency refers to the capacity of the individual for meaningful action. Protecting and nurturing patient agency is a central feature of nursing work. The moral ideals and aim of nursing practice reflect a commitment to the patient that includes the patient as central to the determination of what happens to her or him. Whereas we most commonly think of the capacity to make these determinations as autonomy, I use the term agency because autonomy is a complicated and contested issue within philosophy and ethics. In an earlier issue, I suggested that an understanding of place is important to ethics. This is so because different places or institutions do different kinds of work, have different values, endow ethical concepts with different meanings, are structured by different visions, and are controlled and influenced by different kinds of knowledge and power. All these factors work together to determine a person's agency within a given place or environment. For example, home care providers cannot act in patients' homes in the same way they can act in a hospital, and providers cannot act in a school the way they act in a hospital. At the same time, patients' power to act is constrained in the hospital in ways that it is not in their homes. In the following narrative of an experienced home care nurse, I examine the ethical concern that can result from a commitment to patient agency by home care providers.