At the Intersection of Hospice and Obstetrics, a True Test of Patient-Centered Care

By Jacob Molyneux, senior editor

Renee Noble with her newborn daughter, Violet. Photo by Heidi Ricks.

Renee Noble with her newborn daughter, Violet. Photo by Heidi Ricks.

We’d like to draw attention to a particularly frank and thought-provoking article in the October issue of AJN. “A Transformational Journey Through Life and Death,” written by a perinatal nurse specialist who is also a bioethicist, describes a hospital’s experience in meeting the needs of a patient with two very different, potentially conflicting, medical conditions.

It was a sunny afternoon in mid-October when I first met Renee Noble. I had already heard about her from staff who had given Renee and Heidi Ricks, her friend and doula, a tour of the neonatal ICU and were taken aback when they asked to see the Hospice Inn as well. The nurses knew that Renee had been diagnosed with ovarian cancer, but no one had said anything about it being terminal. Heidi had insisted that after Renee delivered she would need hospice inpatient care. Alarmed, the staff had called me, the perinatal clinical nurse specialist, after Renee and Heidi left.

In addition, this is a patient with strong preferences about her own care, preferences that may be at odds with the more conventional approaches to treatment held by many nurses and physicians.

Refusing standard lifesaving cancer treatment, treating herself with Chinese herbs, and wanting a home delivery—how would the staff work with someone who had made these choices that virtually none of us could understand? How would we ever come to agreement about her care or the care of her baby? How would we resolve conflicts about treatment decisions? It seemed that caring for this patient would upend clinical and ethical decision-making standards. The conventional exchange of information used to elicit “informed consent” wouldn’t be sufficient this time.

The author draws readers into her own dilemmas and those of her colleagues, and the narrative gives a vivid sense of the evolving encounter with a person who first inspires skepticism and then, in various ways, a deepened understanding of the meaning of “patient-centered care” and the intimate connection between birth and death.

The article is well worth a read, and should inspire discussion and debate among nurses and others about the many bioethical issues it brings to the fore. (The article will be free until November 1.)

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. amygetter October 26, 2014 at 12:42 am

    One of my dying patient’s told me “dying and birthing are opposite sides of the same coin”. Thank you for sharing this beautiful story of mutually supporting and learning through both experiences.

  2. Angelina October 23, 2014 at 1:14 am

    What I think??? ABSOLUTELY AWESOME! This is the way it is meant to be – dying the way you want to die! Dying with dignity and having your wishes honored. As a healthcare worker, I salute the people who worked so hard to give Renee the amazing gift of doing it her way! Thanks!!!!!!!

  3. Peggy October 22, 2014 at 11:11 pm

    An absolutely beautiful article! Thank you for sharing this.

  4. Barbara Glickstein October 22, 2014 at 4:43 pm

    So moved. So much to reflect on after reading the full article. Thank you for leading me there this afternoon Jacob Molyneux. Will share widely.

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