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BUS-FPX4121 Case Study

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Case Study Scenario You are the health care administrator at Brookside Hospital, a privately owned, 250-bed facility located in a rural town in West Virginia. You receive an emergency call from the hospital director of security at 7:00 a.m. on a Thursday morning, just as you are preparing to leave your home for your 20-minute commute. Apparently, there has been a disturbance in the ICU waiting room involving family members of a new patient admitted through emergency services during the night. Security is attempting to de-escalate the situation and 911 has been called with law enforcement on the way.

When you arrive, you are met in your office by the director of nursing services and director of security for debriefing on the situation. The family members have been somewhat calmed and are located in the ICU family waiting area and the cafeteria of the hospital with security officers present. The daughter of the patient has demanded to meet with you immediately.

Back Story Joseph and Barbara Nichols have been married for 56 years. They have two children and five grandchildren. Both are in their late 80s and currently reside in a small home they purchased 30 years ago. Their home is located in the same suburban Pennsylvania neighborhood as their daughter, Mary, and her family. Mrs. Nichols suffers from advancing dementia and is easily upset and confused, but she is otherwise in good health. Mr. Nichols has suffered two heart attacks, yet is still able to care for himself and his wife with help from his daughter and a housecleaning and lawn service. Neither drives. Both are very independent individuals and have made it clear to their children that they wish to live out their lives and die peacefully in their own home.

This has been an issue between Mary and her brother, John, who resides in West Virginia. Mary defends her parents’ independent living choice and plans to help with securing increased home care as needed. Her brother repeatedly argues that it is in everyone’s best interest, especially with his mother’s dementia and father’s medical history, that the house be sold and his parents placed in a senior care living facility. At their parents’ request, Mary is designated as health care agent if needed, and they both have living wills. Both Mary and John are aware of their parents’ advance directive wishes. The couple relies on Medicare coverage for their medical needs and do not have long-term care insurance. Their source of income is adequate and includes social security and Mr. Nichols’ modest retirement pension. Neither are veterans.

Three days ago, Mary and her family left for an annual vacation to New York. They dropped off Mr. and Mrs. Nichols at her brother’s home to visit with his family for the week. As always, Mary left contact and medical information in a file with her brother.

On the evening prior to the early morning call, John and his wife had gone out, leaving their 14- year-old daughter at home alone with her grandparents. At 10 p.m., after retiring for the night, she was awakened by her grandmother crying out in the hallway, frantically searching for her husband. She was also highly agitated and confusedabout where she was. Together, they found Mr. Nichols unconscious on the bathroom floor. The granddaughter called 911 but was unable to reach her parents directly. The emergency personnel arrived to chaos, with both women hysterical. Mr. Nichols was treated by paramedics and rushed to the Brookside emergency department, where it was determined that he had suffered another heart attack and was placed in the intensive care unit. Mrs. Nichols and her granddaughter were escorted to the hospital by the local police.

BUS-FPX4121

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When John and his wife finally checked their phones, they rushed to the hospital to find Mr. Nichols unresponsive and on extensive life support. Mrs. Nichols and her granddaughter had been unable to communicate medical history. Neither remembered or mentioned the daughter Mary during all of the disturbance and emotional confusion. Mr. Nichols’ advance directives included a do-not-resuscitate (DNR) order, a do-not-intubate (DNI) order, and his stated preference for no life-sustaining equipment or devices.

After John called to give her the news, Mary and her family immediately drove straight through the night to the hospital. Upon their arrival, everyone in the family was stressed, afraid, hungry, and overtired. When Mary spoke to the charge nurse, she was short and curt, informing her that she would have to wait until after the shift change to get complete information and speak with an attending physician. Mary then discovered her father on life support and was unable to control her fear and frustration, lashing out in anger toward her brother.

Just as the nursing change of shift meeting began, a loud, verbal argument between Mary and John erupted in the ICU waiting area. The charge nurse briefly attempted to calm the families but called in Security, as the argument appeared to be escalating toward physical violence between Mary’s husband and her brother John.

Security has calmed the family and Mary is impatiently waiting to speak to you, the Brookside administrator, as she cannot understand how her father’s wishes were not respected and blames the facility for not taking more extensive efforts to research her father’s medical history and paperwork further. She also plans to lodge a formal complaint against the charge nurse for what she considers rude and unethical behavior toward her.

Post Script Two weeks later Mr. Nichols has gained consciousness and is on minimal life support at Brookside Hospital. However, without the life support, he is expected to live no more than a week or so. He is requesting to return to his home in Pennsylvania. His children and wife are divided and conflicted the over next steps to be taken. His daughter Mary is distraught. She feels that if her father is not taken home, he will not experience the death with dignity he wishes and deserves. She has taken a leave of absence from her job and is staying at her brother’s home with her mother to enable them to be at Brookside each day. This is straining her family’s finances and emotional well-being. She is also shouldering a burden of guilt for being on vacation when crucial decisions were made that compounded the situation. Her brother, John, is very frustrated and angry, as he feels that it is more appropriate to move his father to a hospice facility. He is increasingly vocal and adamant about selling the house and securing an appropriate placement for his mother. With all the stress and disruption, Mrs. Nichols’ level of confusion and anxiety has increased significantly and she is unable to fully understand and contribute to discussions and decisions.