ETHICAL CASE ANALYSIS

Ethical Case Analysis
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Case Presentation
Advance Directives – Who`s in Charge?
Mrs. Wayne is a 68 year old female, admitted following a serious motor vehicle accident in which she sustained a serious head injury resulting in an intracranial hemorrhage near the brain stem as well as a fracture of the left arm and dislocated left shoulder. Her condition is grave, complicated by an underlying diagnosis of diabetes and a prior kidney transplant that is now showing signs of failure. She has had a difficult course in the ICU, suffering three additional cardiac arrests with resuscitation. She is relatively stable after two weeks but on full respiratory support. She has remained largely unresponsive and members of the care team are in agreement that the patient will not recover a meaningful level of functioning or even stabilize to the point of transfer to a long term care facility. Members of the care team are expressing high levels of distress over what they believe to be treatment that is not in the patient`s best interests and violates her advance directive. They believe further aggressive treatment is unwarranted, including dialysis and placement of a PEG tube, and are refusing to perform additional resuscitation should the patient arrest again. Their recommendation is to make the patient a DNR and transition to palliative care with the goal of withdrawing life support in the next few days.
She is married with 3 grown children. Her husband and children have remained at the hospital almost continuously since the accident and are often observed praying in her room or in the waiting area with other friends and a minister from their church. They believe God will grant a miracle if they just give Mrs. Wayne enough time. At the time of her kidney transplant five years ago, she did place a living will in her record stating that she would want dialysis if her kidney failed but would not want to be maintained permanently on a respirator or have CPR initiated unless there was a high likelihood of full recovery. The husband and children claim they were unaware of any such directive, and state that her religious beliefs would not be consistent with any form of refusal or withdrawal of treatment. They have refused the recommendation to initiate a Do Not Resuscitate Order. They are insisting that the hospital provide every possible treatment alternative to maintain her and have threatened legal action should the hospital attempt to enforce the prior living will.
This morning, Mrs. Wayne`s younger sister arrived from Canada. She is a nurse and claims to have helped Mrs. Wayne prepare the living will during her transplant admission. She is adamant that Mrs. Wayne would not want to be maintained in this condition. She has tried to explain the medical realities to the husband and children however, they have now demanded that she have limited access to Mrs. Wayne and have prohibited her from speaking with Mrs. Wayne`s physicians or nurses.
The Ethics Committee has conducted a consultation and is concerned that the family is not being realistic about the prognosis and that the advance directive appears legally enforceable in this situation. They support the care team`s assessment that continued aggressive treatment is not in the patient`s best interests. Based on the committee findings, the critical care physicians are demanding that Administration intervene to support the care team. Being the VP of Clinical Services, I have been asked to come up with an ethically sound plan of action.
Case Study Analysis: 8-Step Model for Ethical Decision Making
In this case, a clinical ethical dilemma has been identified. The family`s request for care conflicts with the patient`s advance directive and places us in a difficult position of either honoring the patient`s wishes or satisfying the family`s request. Using Bennett-Woods (2001), the 8-Step Model of Ethical Decision Making, I will identify relevant facts pertaining to this case, along with any pertinent information I need, state the practical problem, present the most significant ethical question(s), identify the theoretical basis for my analysis, prepare arguments and counterarguments, present options, and clearly state my final action.
Step One: Gather Relevant Information
Clinical Indications
* 68-year-old female who has suffered a serious motor vehicle accident, sustained a serious head injury resulting in an intracranial hemorrhage near the brain stem, fracture of the left arm, and dislocated left shoulder.
* Prognosis for recovery is grave.
* Intracranial injury or Traumatic Brain Injury (TBI) is a major cause of death. Beginning at age 30, the mortality risk after head injury begins to increase. Persons age 60 and older have the highest death rate after TBI and 75% die from the primary and secondary effects of trauma on the vital centers of the central nervous system (MD Guidelines, 2013).
* “Injuries to other parts of the body in addition to the head and brain. Trauma victims often develop hypermetabolism or an increased metabolic rate, causing muscle wasting and the starvation of other tissues. Complications related to pulmonary dysfunction can include neurogenic pulmonary edema, aspiration pneumonia, and fat and blood clots in the blood vessels of the lungs (Ribbers, 2013).”
* Underlying diagnosis of diabetes and a prior kidney transplant that is now showing signs of failure.
* Has had three additional cardiac arrests with resuscitation
* Anoxic injury most likely after cardiac arrest (Kolias, Guilfoyle, Helmy, Allanson, and Hutchinson 2013).
* Pre and post-existing disease complicates head trauma: Metabolic: endogenous or exogenous, such as hypoxia, hypoglycemia, sepsis, hepatic or renal failure (Reeves & Swenson 2008).
* Mrs. Wayne is relatively stable after two weeks but on full respiratory support.
* Mrs. Wayne has remained largely unresponsive
Patient Preferences
At the time of Mrs. Wayne`s kidney transplant five years ago, Mrs. Wayne, place a living will in her record stating that:
* She would want dialysis if her kidney failed
* She would not want to be maintained permanently on a respirator
* She would not want to have CPR initiated unless there was a high likelihood of full recovery.
Quality of Life
* Mrs. Wayne will not recover a meaningful level of functioning.
* Mrs. Wayne will not stabilize to the point of transfer to a long-term care facility.
External Factors
* The family of Mrs. Wayne declared unawareness of the existence of a directive.
* The family claimed that refusal or withdrawal of treatment would be inconsistent to their religious beliefs particularly that of Mrs. Wayne`s.
* The family refused the recommendation to initiate a Do Not Resuscitate Order and is insisting that the hospital provide every possible treatment alternative to maintain Mrs. Wayne.
* The family has threatened legal action if in case the hospital attempt to enforce the prior living will.
Professional Factors
* “The Nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient.” (ANA, 2001, Provision 3).
* “The nurse`s primary commitment is to the patient, whether an individual, family, group, or community (ANA, 2001, Provision 2)
* “The Nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, …” (ANA, 2001, Provision 1, including Interpretive Statements 1.1, Respect for Human Dignity, 1.2, Relationship to Patients, 1.3 the Nature of Health Problems and 1.4 Right to Self-Determination).
Legal Factors
* The hospital facility has to present a proof of the stated living will which stipulated Mrs. Wayne`s unwillingness to be maintained permanently on a respirator or have CPR unless there was a high likelihood of full recovery.
Step Two: Identify the Practical Problem
The practice problem concerns what I should do as VP of Clinical Services.
Step Three: Identify the Ethical Issues and Questions
A number of ethical issues are brought up including the following:
* If omission of life support is Mrs. Wayne`s intention in her living will, should Mrs. Wayne be permitted to disallow CPR?
* What is my professional and personal duty in such situation being the VP of clinical services?
I have recognized the following primary and secondary ethical questions on which to base my analysis:
* Primary Question: Is omission of life support morally acceptable when the burdens of sustained life prevail over benefits?
* Secondary Question: Am I, as VP of Clinical Services, morally compelled to interfere in a patient`s choice to omit life support and disallow CPR should arrest take place?
Step Four: Select the Ethical Principles and/or Theories to be considered
I will consider the questions above through the use of the following ethical perceptions and theories:
* Consent: The acceptance of the will of those needed to carry out the intention.
* Imputability: The person performing the act is liable for such act.
* Conditional voluntariness: A person is forced by circumstances beyond his control to perform an act which he would not do under normal conditions.
* Man acts towards an ultimate end: The ultimate end is an account of which man decides to act. It is what is desired through the actions. It is what confers meaning to an activity. The concept of motive implies that there is something important to be achieved.
* Conscience: It is the proximate norm of morality. It is proximate because it is what directly confronts an action as good or bad. Its function is to examine, to judge, and to pass a sentence on all moral actions.
* Utilitarianism: The greatest value is pleasure. But man, being a sociable animal, must conduct his affairs in a way that would benefit others. Thus, the greatest moral good is that which offers the ultimate happiness to the majority of people.
* Christianism: Christianity is based on the teachings and life of Christ. Christ taught that the greatest value is love and God is love. Christian morality is essentially based on love which embraces even an enemy.
* Fidelity: Maintain loyalty
* Autonomy: Sensible individuals must be allowed to be self-determining.
* Nonmaleficence: People are supposed to act in behaviors that do not trigger harm.
Step Five: Conduct an Analysis and Prepare a Justification
Mrs. Wayne`s quality of life, as stated above, will not recover a meaning level of functioning. Here condition does not appear to stabilize to the point of transfer to a long term care facility. Mrs. Wayne has stated a preference for dialysis if the kidney failed. Mrs. Wayne also expressed her desire not to be maintained permanently on a respirator and not to have CPR initiated unless there was a high likelihood of full recovery.
Preference utilitarianism permits for respect of people`s choices and wished as initial asses primary actions of utility. Omission of life support and refusal for CPR is not innately immoral in the perspective of utilitarianism and Mrs. Wayne can be considered in here choice grounded merely on her preferences. Despite her choice being inconsistent with mine, as VP of Clinical Services, and her family, the main concerns are undoubtedly the protection or loss of her life and the preference she obtains from life. Furthermore, there does not appear to be a compelling concern to preserve Mrs. Wayne`s life that would validate interfering with her basic freedom including a choice to deny CPR as well as to omit respirator and other life support. Fidelity entails that the hospital staff should retain their loyalty to Mrs. Wayne and to uphold their agreement. In this event, it is apparent that I would be put in a situation where my loyalty will be in conflict. First, I have to be loyal to my patient and this entails keeping up to the wishes of the client and providing the best care as well as securing her privacy and retaining confidentiality and not disobeying the trust she has rendered to the health team. I also have to be loyal to my profession and this entails respecting people`s dignity and the honoring the uniqueness of the patient. It also necessitates keeping Mrs. Wayne`s confidentiality and privacy.
Autonomy signifies that an individual who is competent be allowed the right of self-determination. In this case, the health team knows better regarding the health condition of Mrs. Wayne. Nonmaleficence implies that I should avoid any action that can cause harm to the patient. The question in this case involves the basic nature of harm. Continued CPR to Mrs. Wayne will ultimately cause brain damage and broken ribs. This could merely lead to worse consequences.
Step Six: Consider One or More Counterarguments
Pro-life does not deny the significance of life. Towards its promotion, there are situations which may justify granting the wish of a patient at the end-of-life care particularly the patient`s illness is no longer bearable or curable. In Christian ethics, pains and sufferings are natural companions of life. They are tests of endurance and a form of uniting oneself with the sufferings of Christ. Thus, no relief from pain may be forced on a patient who does not give her consent. However, Mrs. Wayne does not have this kind of religious view. Nonetheless, moral law does not compel the use of extraordinary methods and devices, usually also very expensive, in order to prolong life which is given up for lost. Withdrawing life support devices to allow nature to take its due course is not considered immoral. What is prohibited on moral grounds are all positive and direct actions intended to extinguish life, such as injection of poison or overdose of drug. In the case presented, it is clear, five years ago, Mrs. Wayne has already rendered her wishes. At that time she was still cognizant and was fully aware of the decision she was making. Despite the objections of the family, it is my duty to honor and respect the patient`s rights.
Step Seven: Explore the Option for Action
1. Respect the decision which the patient made five years ago.
2. Explain to the family the possible implication and violation if they do not conform to the preference of Mrs. Wayne. Ethics tell us that DNR is not a sin and as such would be respected if asked for by the patient. What is inappropriate is retaining the patient on a life support which can be very costly.
3. Mrs. Wayne has several complications which were further triggered after the accident. Therefore, omission of life support is justified.
Step Eight: Select and Justify Action
Life is precious. It is our main concern and duty. Health is everyone`s personal accountability. Health is a joint responsibility of the society and the individual. In dying, what choices are there? Personal attitudes as well as public opinion have significantly altered over the years. Individuals are increasingly looking for means to live longer. The desire to have options in dying comes from concerns and fears related to prolonged dying as an outcome of technological interventions. At some point in our lives each of us will face the issue of how vast has been the use of medical technology in making an individual live longer. Whether to prolong life or not may turn out to be a serious issue when the decision has to be made with little forethought or adequate planning. The decision becomes even more complex when the loved one is hospitalized and health is deteriorating. The questions of how much intervention and when are a lot more serious. Do we resuscitate? It is at this juncture that decisions declared in a living will become significant.
In the context of advanced directives, the problem sets in for health professionals when such advanced directive was not rendered at the time the patient was still cognizant. However, in the case of Mrs. Wayne, she has stated her willingness to be out of the respirator if ever time comes that she would no longer be as functional as she was before. Mrs. Wayne also stated her desire not to be resuscitated. Mrs. Wayne is merely dependent on the support of the respirator. In ethics, moral law does not encourage the use of certain methods and equipment that are expensive for the sake of making the patient live longer. Ethics encourage the use of natural methods and allowing nature to conduct its due course.
References
American Nurses Association (2001). ANA code of ethics for nurses with interpretive
statements. Retrieved from www.nursingworld.org.
Kolias, A. G., Guilfoyle, M. R., Helmy, A., Allanson, J., and Hutchinson, P. J. (2013). Traumatic brain injury in adults. Practical Neurology Journal, 13, 228-235. doi:10.1136/practneurol-2012-000268
MD Guidelines (2013). Medical disability advisor: intracranial hemorrhage. Retrieved from http://www.mdguidelines.com/intracranial-hemorrhage
Reeves & Swenson (2008). Disorders of the Nervous system: Cranial and spinal trauma. Retrieved from http://www.dartmouth.edu/~dons/index.html
Ribbers GM. (2013). Brain Injury: Long term outcome after traumatic brain injury. International Encyclopedia of Rehabilitation. Retrieved from http://cirrie.buffalo.edu/encyclopedia/en/article/338/

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