done

Final Project – Compiled Case Studies

Jane Doe

HSC312

May 2013

Professor X

HSC312 - Final Project: Compiled Case Studies May 2013

Jane Doe

Case Analysis: Sally & the DNR Case Analysis Template for use with each of the four scenarios in the final project:

1. Copy/paste the title of the question 2. Describe the most relevant ethical dilemma(s) presented (no more than two). 3. Briefly describe the primary issue or issues that are relevant in the scenario w/respect to

the dilemma.

4. Identify the most relevant stakeholder(s) (no more than 3) and briefly describe the situation from their perspective.

5. Analyze the dilemma, using scholarly discussion, from the perspective of the primary stakeholder (typically the patient). Include a discussion of at least two ethical theories

or bioethics principles studied in the course that relate to the dilemma and issues you

identified. Include any relevant legal concerns or requirements outlined in the readings.

6. Present your assessment, resolution or potential solutions for resolving the issue. Remember that there are no right answers, per se, so reflective questions can be as

appropriate as a firm conclusion.

7. Title page + APA formatted reference(s) The following example provides further insight into what is required for each element of the

template. Although the response is intentionally somewhat longer than what is expected, it

should help clarify the specific requirements.

1. Ethical Dilemma

Prompt objective: Identify the ethical dilemma and state the dilemma as a “should” question.

Note: there may be several relevant dilemmas that could be addressed; use the prompt question

as a guide to an issue to analyze. The objective is to present a cogent analysis of a relevant issue.

ISSUE: Should the attending physician sign a DNR without Sally’s consent?

2. Primary issues related to the identified dilemma

Prompt objective: Identify the relevant issues related to your dilemma. You should identify at

least two, but limit your selection of issues to a manageable number within the scope of the

assignment.

Informed consent; Surrogate decision making & substituted judgment; healthcare decision

making capacity; autonomy and the right to refuse treatment

3. Primary Stakeholders & Stakeholder positions:

Question objective: Identify 2-3 primary stakeholders including the patient, and briefly describe

their position:

Sally: 62 yr old woman with Stage IV breast cancer that is unresponsive to standard and

experimental treatment presents with shortness of breath requiring a Thorentisis, a difficult

procedure given her condition. Sally wants to live and refuses to discuss the terminal nature of

her condition.

HSC312 - Final Project: Compiled Case Studies May 2013

Jane Doe

Sally’s husband: Sally’s husband recognizes that Sally is dying and wants everything done for

Sally to make her comfortable. He agrees with the attending physician that CPR would make

Sally less, rather than more comfortable. He is Sally’s surrogate decision maker.

The attending physician: Believes that further testing and treatment for Sally is futile. He

questions whether Sally has the capacity to understand her condition and consent to the DNR.

4. Potential Solution Analysis:

Prompt objective: Analyze the ethical dilemma from the perspective of the primary stakeholder

(typically the patient), using the ethical theories and/or the bioethics principles that relate to the

dilemma. Keep your analysis focused on at least two or three moral theories or bioethics

principles, but do not attempt to address them all. There will generally be more issues and

principles/theories that would apply than you can cover in a short analysis. Include in your

discussion any known legal issues presented by the readings that may influence a decision. Apply

the facts to the theories discussed. Keep in mind that there may be several issues and theories to

discuss, but you are not required to find or address them all. The essay below is purposefully

more involved than the assignment requires providing a few examples of an ethical analysis.

Under the ethical and legal doctrine of informed consent provided by the Patient Self-

Determination Act, an adult patient with healthcare decision-making capacity has the right to

make an informed, autonomous choice to accept or reject medical treatment. (Munson, 2012).

The right to self-determination is defined by the bioethics principle of

Autonomy and refers to the patient’s right to make a voluntary choice that is meaningful to them

and free from external or personal influences. (Tong, 2007). Such influences may include fear,

denial, medication side effects, pain and guilt, among others. Healthcare decision-making

capacity requires that the patient can articulate and understand the nature of their condition and

the risks, benefits and consequences of accepting or rejecting treatment. Assessing decision-

making capacity requires an evaluation of the patient’s decision-making process, rather than an

evaluation of the choice itself. “…[T]he mere fact that a patient does not accept a health care

professional’s recommendation does not necessarily mean that the patient is incompetent" (Tong,

2007, p 53).

In order for a patient to evaluate the risks and benefits of an available option is the understanding

that a physician will provide complete and honest disclosure of all the associated medical facts

that may be pertinent to the patient (Canterbury vs. Spence, 1979). The need for such veracity in

caring for a patient is also a primary component of a physician’s ethical responsibility, according

to the American Medical Association (AMA, 2012). Performing a procedure without consent, or

withholding a viable treatment without disclosure, is a direct violation of the AMA mandate,

Informed Consent doctrine and a patient’s trust.

A patient’s right to self-determination is foundational in bioethics. If the patient loses decision-

making capacity, laws and policies are in place to ensure that the patients’ expressed or implied

wishes are respected. Prior to losing capacity, a patient can appoint a healthcare proxy agent who

will make decisions for the patient, based upon the patient’s wishes and instructions. Critical to

the concept of a Health Care agent is the agent’s requirement that any decisions reflect the

patients’ known and implied wishes, rather than the agent’s own wishes for the patient. If no

HSC312 - Final Project: Compiled Case Studies May 2013

Jane Doe

such agent is named, a surrogate decision maker is appointed by state statute or facility policy to

make decisions for the patient, using their knowledge of the patient and the patient’s wishes,

values and spiritual beliefs.

Sally appears to be in denial about her condition and terribly afraid of death, as evidenced by her

general state of “panic” and her refusal to talk to the Resident about her condition. Most

importantly, Sally has stated that she wants to live, which may reflect any number of thoughts

and emotions from a sense of grief at her circumstances to denial of her terminal condition.

Because the physicians seem more focused on discussing their inability to help Sally, rather than

being ‘competent’ in her mind to perform the thorientsis, Sally may not see a value in discussing

her condition with them. Far from an irrational thought process, Sally’s refusal to talk may

actually be a heartbreaking testament to her ability to assess a situation and reach a rational

conclusion based on the facts. Further proof may be Sally’s insistence that she “…wanted the

emergency squad called to attempt resuscitation if she arrested at home” (Crigger, 1998). Given

her desire to live as long as possible, it would make sense that she would want every chance

available to live.

Presuming Sally does have capacity, she is entitled to receive full disclosure regarding anything

to do with her medical care—a right that extends to her rejection of a proposal that is in conflict

with her own goals. Consequently, if the attending physician institutes a DNR order without

Sally’s consent would constitute a violation of Sally’s right to self-determination. Important in

the discussion of full disclosure in Sally’s case is the fact that it no one has explained the

potential adverse consequences of performing CPR (Cardio-pulmonary resuscitation) on

someone in her current medical condition. From the facts presented, it is unclear how Sally

would respond if she knew there was a significant chance that if she survived CPR, she could

end up in a Permanent Vegetative State, permanently unconscious and kept alive by artificial life

support as a result.

The physician’s position that CPR is futile given the potential for harm and what he perceives as

negligible benefit, does not override Sally’s right to define what is and is not beneficial for her.

Acting on his own subjective values and interpretations, and ignoring Sally’s values and desires

would constitute an act of Paternalism, a direct violation of autonomy (Tong, 2007). While it is

true that a patient cannot demand an inappropriate treatment—one that would produce more

harm than benefit— it could be argued that CPR as a standard emergency procedure to ward off

imminent death does not pass the “inappropriateness” test. If a patient with capacity is provided

with full disclosure of the potential harms, it is the patient’s right to weigh the risks and benefits,

and make an informed choice. (Munson, 2012).

Similarly, if it is determined, that Sally lacks capacity; the doctor would still be potentially

outside his authority to institute the DNR without informing Sally’s surrogate decision maker.

While it is unclear whether Sally’s husband is her Healthcare proxy agent, as a person who

knows her best and her spouse, he would still have the presumptive right to use substituted

judgment and make the decision he believes Sally would make, if she could. Knowing Sally’s

express position on the issue of aggressive treatment, he has an obligation as the healthcare agent

to reject the DNR, regardless of his personal opinion and desire that Sally just receive comfort

care.

HSC312 - Final Project: Compiled Case Studies May 2013

Jane Doe

In addition to the ethical principle of Autonomy and the doctrine of informed consent, Care-

based Ethics also supports Sally’s right to reject the DNR. Care-based Ethics emphasizes values

and virtues such as compassion, empathy, kindness and most important, sensitivity to each

patient’s unique perspective and circumstances (Tong, 2007). Because Sally is adamant she

wants everything done right now to help keep her alive as long as possible, a physician

empathetic to Sally’s concerns and circumstances would not sign the DNR without at least

informing her and addressing her fears about death and her desire to preserve her life.

5. Recommedation:

Prompt objective: Present your assessment, resolution or potential solutions for resolving the

issue. Remember that there are no right answers, per se, so reflective questions can be as

appropriate as a firm conclusion.

Based on my analysis, the attending physician should not institute the DNR against Sally’s

express wishes and without her knowledge. Doing so would violate the ethical and legal

principles of autonomy and informed consent. I also recommend that Sally be seen by a

Palliative Care specialist or a medical professional trained in end-of-life care to help determine

whether Sally’s statements and behaviors demonstrate a lack of capacity, or are understandably

motivated by denial and fear. Minimally, the consult should help promote Sally’s overall well-

being by addressing her concerns in a compassionate and caring way. Lastly, only if Sally lacks

capacity should Sally’s husband, as her healthcare agent, be allowed to speak for Sally and

refuse the DNR. Because we do not know how Sally feels about remaining on life support should

CPR fail, Sally’s husband must adhere to the doctrine of substituted judgement and base a

decision upon his knowledge of Sally’s values and wishes, including her known spiritual beliefs.

Bibliography