Nurses as Ethical Guardians in the Intensive Care Unit: A Narrative Review of Bedside Ethics, Dignity, and Moral Responsibility

ICU nurses provide continuous bedside care to patients who are unable to self-advocate, creating ethical risks that may be overlooked in routine critical care. This narrative review aimed to explore four ethical domains faced by bedside ICU nurses: sensory awareness in sedated and neuromuscularly paralyzed patients, cross-gender intimate care, dignity maintenance for brain-dead organ donor patients, and management of Do Not Attempt Resuscitation (DNAR) orders.

A structured literature search was conducted in February 2026 in PubMed/MEDLINE, CINAHL, and Scopus. English-language peer-reviewed studies, professional guidelines, and bioethics frameworks published from January 2010 to December 2025 were reviewed, with seminal earlier sources included through citation searching. Narrative thematic synthesis and gap analysis informed the review.

Four interconnected ethical concerns were identified: the acoustic environment as an underrecognized ethical domain, privacy and modesty risks during cross-gender intimate care, potential reduction in care attentiveness after brain death declaration, and misinterpretation of DNAR orders as permission to reduce care intensity.

Across these domains, patient incapacity transfers immediate moral responsibility to the bedside nurse. The findings support the concept of ICU nurses as ethical guardians who protect dignity, privacy, comfort, and care preferences when patients cannot speak for themselves.

Integrated nursing-specific ethics education, clearer bedside communication standards, improved documentation of dignity-related preferences, and institutional support for moral agency are needed to strengthen dignity-preserving ICU care.