Ethics and Interdisciplinary Care

Reflection Paper on Ethics and Interdisciplinary Care

Part 1: 80 points

Ethics Scenario

You are a dietitian on a medical telemetry floor.  Newly transferred to your unit is a 56 y/o male initially admitted to the hospital for symptomatic uremia.  His inpatient course was complicated by catheter-associated MRSA bacteremia, right cephalic vein thrombosis and contraction of SARS-CoV-2 infection, all of which resulted in him needing to start on HD.  There was no renal recovery once started on HD, and now he is HD-dependent. His complete medical history includes: A-fib, CHF, COPD, CAD, DM, Depression, ESRD (not on HD PTA), HTN, and Obesity. 

The medical team has decided to consult the dietitian because the patient is clinically stable, but unable to be discharged due to his weight.  He initially came to the hospital from a NH.  He is unable to return to his NH and his application has been rejected by all other nursing homes in the area as they are unable to meet his medical needs.  Now that he is HD dependent, placement in a NH means he requires also being accepted into an outpatient hemodialysis clinic for routine HD sessions 3 x weekly. Unfortunately, no HD center in the area has a set-up that can support his weight.  In order to obtain a HD placement his weight must me under 450#.  His current anthropometrics are: height – 5’1″, post-HD weight of 470.8#, and BMI of 88.9 kg/m2.

The team would like you to assist in facilitating weight loss.  The problem is, the patient is not truthful about their intake.  They are ordering out fast food multiple times daily, having family members bring them food, and calling down to the hospital kitchen for multiple additional trays, all of which is documented by nursing, and the family admits to, but the patient denies.  The hospital is in a predicament as the patient needs to be discharged, but does not want to willfully engage in behaviors which will facilitate weight loss.  They are unsure of which path to take.  Initially the team placed the patient on a restrictive diet.  Though the patient complained he was being starved, he gained weight.  The next intervention by the team was to restrict ability to phone the kitchen, and alert staff not to provide the patient with additional foods – still he gained weight, as he was receiving foods from family and ordering out from restaurants.  As a result, the team next decided to place him on 1:1 (meaning a member of nursing staff was constantly at his bedside, and could monitor to ensure he was not eating foods aside from what is provided at meals).  The patient complained that this was cruel, invaded his privacy, and made a complaint to patient relations.  A family meeting/ goals of care discussion (GOC) was held with the medical team.  The decision was made to remove the 1:1, but to ban all visitors including friends, family, and food delivery workers until the patient has reached 450#.  Family requested that the target be increased to the patient having to drop to at least 440# before visitation could be restored, as pt had already stated that once he leaves this “prison” he is going to eat as much food as he can find, and so they were worried that he will regain weight soon after the ban is discontinued.  The team agreed to a target of 440#.  Patient expressed discontent that his birthday will pass without any celebration.  The team agreed that pt could be provided w/ 1 cupcake on his birthday and supervised visitation with family.

The team has consulted Bariatrics to see if they can help, but Bariatrics refused the consult stating they do not see “inpatient” patients.  The team also consulted Psych for motivational interviewing to help facilitate weight loss.  Psych completed the consult, but stated pt has no desire to change, and they decided not to continue to follow with patient as they felt motivational interviewing would be of no help.

The ball is now in your court.  The patient continues to deny he is overeating, and believes he is being treated unfairly by the hospital.  He feels that his patient rights are being infringed on.  However, it is also clear that his health would be significantly compromised should no intervention be done.  His quality of life is of utmost importance, but the question is how to facilitate quality of life in this scenario, and what exactly constitutes quality of life here – the patient’s desire to eat as he wishes, or the ability to get the patient out of the hospital and into a setting where he has a chance of having an improved social life and more independence.  Complicating the situation, is that the medical team also fears that the restrictive diet they have put him on will also result in malnutrition.

Consider the following chart:

Framework Principle Description Respect for the individual patient and his or her Respect for Autonomy ability to make decisions with regard to own health and future; right to self-determination Beneficence Doing and promoting good; preventing and removing evil or harm Nonmaleficence Doing no harm; avoiding harming Maximizing benefit to patients and society while Justice emphasizing equality, fairness, and impartiality Adapted from Beauchamp and Childress.3

Given the dimensions of clinical indications, patient preferences, quality of life, and contextual features, and considering the four ethical domains (autonomy, beneficence, maleficence, and justice), please in no more than two pages single spaced discuss how the 4 ethical domains apply to this scenario, identify 2 questions you would want to ask the patient and 2 questions you would want to ask the team to help clarify the ethical dilemma and your position as the RD, and identify at least 2 recommendations you would give to help facilitate a positive outcome for both sides here.

Points for this portion of the assignment will be awarded as follows: 10 points for discussion of each of the 4 ethical domains (40 points total), 5 points for each question you would ask the patient (10 points total), 5 points for each question you would ask the team (10 points total), and 10 points for each recommendation (20 points total).

Interdisciplinary Care Scenario (20 points)

Please watch the following video of an interdisciplinary care video: https://www.youtube.com/watch?v=OZWBrXql_3s&t=879s

While watching the video, please summarize the following in your response: 

Brief summary of patient scenario (5 points)

Brief statement of each team member, their role, and their suggestions/interventions for the patient. (5 points)

Critique of interdisciplinary coordination and communication. (5 points)

Suggestion of one additional intervention or alternate intervention to those made by the team, with the goal of improving the overall situation for the patient. (5 points)

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