Wanda's care should also focus on family involvement in the care process to promote engagement and improve the provision of culturally acceptable nursing care. Ethical issues influence how different cultures approach issues related to advance health care directives and this may be the case in Wanda's case. According to Sowmini, & De Vries (2009) the use of advance health directives is shaped by both cultural ideas and social resources. Discussion of end-of-life decisions in dementia can raise ethical dilemmas and this is a topic that should be approached with care and support provided to the patient and family as it is a sensitive topic. Assessment of decision-making competence and consent to treatment normally arise as the complexities of the disease process continue to progress. As a result, conflicts of interest emerge in the process of providing care and can influence nursing staff. There is a legal duty of care obligation that healthcare professionals must fulfill when caring for patients who lack capacity. Staff have a duty of care to people lacking capacity (Nazarko, 2006, p.179). Wanda was admitted with the understanding that she will only stay for two weeks, but she is now a permanent resident and this can be seen as telling her lies. Nursing staff may be faced with the dilemma of whether to reinforce this to help her settle, as this may be considered unethical. Capacity to consent to treatment should be assessed and this is normally difficult in patients with dementia. A guardianship issue must be considered for a decision on Wanda's behalf