Medical indications (part 1) patient preferences (part 1) quality of life, and (part 2) contextual features

Case analysis part 1

Your small team case analysis will Include: 4 assessment areas:

medical indications (part 1)

patient preferences (part 1)

quality of life, and (part 2)

contextual features (part 2).

Segment 1 will include analysis of medical indications and patient preferences. Segment 1 should be no more than 3 page in length.

 

Segment 2 will be due 3 weeks after segment 1. It will include assessment of quality-of-life considerations and contextual features and an organized problem-solving section that: 

 

defines the ethical problem(s)

identifies three or more alternatives for resolving the values conflict or distress

evaluates each of the option, and

makes a justified recommendation.

 Segment 2 should also be no more than 3 pages in length.

 

You may select any case from Kuczewski’s Ethics casebook for hospitals, with the exception of case 9 that I analyze extensively as an example for you. You may also use a case from a scholarly source such as the American Medical Association’s online ethics journal: Journal of Ethics | American Medical Association (ama-assn.org)Links to an external site.. Any case you select should have enough detail for your analysis to demonstrate your assessment for the 4 areas/topics and your problem solving skills.

 

 

 

Case 3: “He Doesn’t Know What He’s Saying” Advance Directives in Emergency Settings

 

Key Terms: Autonomy, Decision-Making Capacity, Competence, Informed Consent, Surrogate Decision Making, Advance Directives, Emergency Department Ethics, Physician Order for Life-Sustaining Treatment (POLST)

 

Narrative Mr. J, a sixty-five-year-old married man, presented at the emergency room in acute respiratory distress. He was anxious, alert, and gasping for air. His shortness of breath made talking with him difficult. He was accompanied by his wife and nephew. Mr. J was fairly well known at this hospital because he had been treated there for almost a decade for his chronic pulmonary disease. His illness progressed over the years to the point where he required assistance dressing and eating, and this assistance was provided by his wife, who cared for him at home. Mr. J had been admitted to the hospital ten months before, at which time he was intubated and placed on a respirator. Later, there was great difficulty weaning the patient from the machine, but the pulmonologist managed to do so after two weeks. According to the family, Mr. J expressed strong feelings at that time that he should never be placed on a ventilator again. During the current presentation, Mrs. J and her nephew spoke with the attending physician in the Emergency Department while Mr. J was taken to the treatment room. They explained what they believed to be the patient’s wishes. That is, they asked that Mr. J be given any helpful medications but not be intubated. They also asked that his code status be “do not resuscitate.” The family said that Mr. J should be made “comfortable” and that necessary medications could be given to him. The family did not enter the treatment room with the physician. The physician examined the patient; and in the presence of the nursing staff and respiratory therapists, the physician explained the need for intubation to Mr. J, who agreed to this by nodding his head “yes.” This process took place quickly due to the emergency conditions. Mr. J was intubated and placed on a ventilator within ten minutes of admission. Upon learning of the intubation, the family became very upset.

 

The Language and Issues of the Case Several problems are evident. Clearly, this case will be discussed in terms of the patient’s right to make his own decision—that is, patient autonomy. But whether this is an autonomous decision will require placing several matters in context: 22

 

1. Determining the patient’s capacity to consent to treatment (“decision-making capacity” or “competence”); 2. Identifying the role of previous directions (“advance directives”) in treatment decisions; and 3. Deciding the role of family or surrogates in interpreting the wishes of a patient.

 

Perspectives and Key Points of View Emergency room physician: The physician was reluctant to take the family’s initial request at face value. He believed that a patient who presents at the emergency room should receive the kind of care that is standard in such emergency situations. Thus, he has the normal presumption to treat in the emergency situation. Furthermore, he was also reluctant to give the family’s request priority because the patient was conscious. Although the patient’s decision-making capacity is at issue, the physician believed that he should presume the patient to be competent to consent to life-saving interventions unless clearly shown otherwise. After the fact, the physician wondered whether he had done the right thing. The family (Mrs. J and nephew): The family members believed that they knew the patient’s real wishes because they had a long period during which to discuss the future course of treatment. They also believed that if Mr. J contradicted what they believed to be his genuine wishes, it must be due to hypoxia or the coercive atmosphere of the treatment room. They dreaded the possibility that the prolonged agony of the previous difficult weaning period would be repeated. Mr. J was generally conscious during those attempts, and they watched the patient linger in fear and suffering for two weeks. They also feared that they would be “killing” Mr. J if they withdrew the respirator after unsuccessful weaning attempts. In contrast, they also believed that it would have been acceptable if Mr. J had not been started on the mechanical ventilator in the first place. They felt that the emergency room physician had betrayed them and undermined their familial role as the interpreters of the patient’s wishes.

 

What Actually Happened No information is available on the outcome of this case. See the notes in our cheat sheet and tips at the end of the chapter for more thoughts on how a clinical ethics consultant might approach it.

 

 

 

 

 

Case 9 example below.

 

Medical Indications

Case 9 (2nd ed)/Case 6 (1st ed)

67 yo woman

Presenting problem/s (PP): Sepsis, probably caused by entero-bacteria passing through portions of the 

colon wall weakened by the CA

Medical history (Hx):

 Non-resectable (i.e., inoperable) colon cancer since 6 mo ago

 Recurrent episodes of sepsis

Signs/Symptoms (S/S) on admission:

 Generalized edema (swelling)

 Emaciated appearance/wasting

 Skin excoriations (abrasions)

 Paralysis of lower extremities; limited movement of upper extremities

Diagnoses (Dx):

 Sepsis 

 Colon CA

 “Spinal disease”

 

Characterization of condition(s):

 The colon CA is “terminal” in the general sense of causing death.

 The recurrent episodes of sepsis are critical and possibly end-stage terminal.

Initial goal(s) of care

Note: Goals of medical care should not be confused with patient preferences for care; the goals of care 

are what medicine could reasonably hope to accomplish in terms of benefit and avoidance of iatrogenic 

(i.e. health care caused) harms.

1. Providing relief and support near time of death 

2. Avoidance of harm to the patient in the course of care 

3. Education and counseling of patient re her condition and prognosis

Or

1. Prolongation of life

2. Maintenance of quality of life through relief of pain and suffering 

3. Maintenance of compromised status 

4. Education and counseling of patient and family re her condition and prognosis

 

 

 

 

 

After 3 days:

New Signs/Symptoms (S/S):

 Acute shortness of breath

 Acute GI bleed

 Lethargy

 Confusion

New Diagnosis (Dx):

 Either CHF (Congestive Heart Failure) or a PE (Pulmonary Embolism)

Note that “differential diagnosis” means that the diagnosis is either one or the other.

After transfer from the ICU to the step-down unit:

New Signs/Symptoms (S/S):

 Intermittently improved mental status

 Abdominal pain

Signs and Symptoms (S/S) over several days:

 Declining awareness, frequent disorientation and unconsciousness

 Pleural effusion

 Atrial arrhythmia

 Severe hypotension, refractory to intervention

 Anuria

 Massive generalized edema

 Oozing serous fluid from skin and puncture sites

 Fixed and dilated pupils

New Diagnosis (Dx):

 Possible metastasis to brain

 Later, possible “brain death”; permanent loss of higher brain function

Prognosis (Prx):

 Pt is actively and irreversibly dying and any intervention will only prolong life a short while

Goals of treatment

Note: Goals of medical care should not be confused with patient preferences for care; the goals of care 

are what medicine could reasonably hope to accomplish in terms of benefit and avoidance of iatrogenic 

(i.e. health care caused) harms.

1. Allow natural death; because the pt has lost higher brain function, the patient can no longer 

experience pain or its relief, so “relief and support” is not an attainable goal.

2. Education and counseling of patient re her condition and prognosis

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