Question

Madisyn (Maddy) Whitfield, 25, has been a graduate student at a prestigious state school on the West Coast, studying for her master's degree in Health Psychology. She has attended school part-time because she must also work and allow enough time for all the hours of fieldwork mandated by her program.

Due to a chronic health condition, Maddy must be cautious about not overworking or overstressing herself, another reason for not attending school full-time. As a junior in high school, Maddy was diagnosed with Crohn's disease, a chronic inflammatory disease of the gastrointestinal tract. While there is no cure for Crohn's, there are several medications and life style modifications that can keep the disease in remission the majority of the time. It is normal for patients to experience cycles of remission and relapse and to go through the periods of flare-up with relatively few severe consequences. Without proper care, however, patients are more likely to experience flare-ups. The more severe and the more frequent the flare-ups, the higher the chances that the patient will require surgery because of permanent damage to the intestinal tract. Until a few years ago, Maddy had only experienced a few minor flare-ups of her disease. She had taken control of her health from the time of her diagnosis and was able to keep herself relatively healthy by seeing her Crohn's specialist regularly, taking the necessary medications, eating healthily, and exercising frequently.

Since graduating from college, however, Maddy's health has been declining. No longer covered under her father's PPO (preferred provider organization) health insurance, she stopped going for regular check-ups with her IBD (inflammatory bowel disease) doctor and could rarely afford the out-of-pocket expenses for medications. She had been able to continue her healthy eating habits and activity level while living at home, but since starting graduate school and moving away from home, that has not been the case. Time and money constraints do not allow Maddy to properly care for herself, and the stresses of school and her disease have contributed to her worsening flare-ups. In the past year she has been experiencing shorter and shorter periods of remission followed by longer periods of relapse. Unable to continue at the same pace, last month Maddy had to take a leave of absence from school, so that she could continue her job as a waitress and support herself.

Last week, Maddy began to experience excruciating lower back pain, chills, fever, malaise, and fatigue. Maddy had suspected kidney stones as this was a periodic occurrence; she had developed kidney stones in the past and assumed that these would pass just as the others had. She resisted going to the doctor because of her lack of health insurance. While it is not unusual for patients with Crohn's disease to develop kidney stones, because of Maddy's severe flare-ups, her body was so dehydrated and malnourished that the stones couldn't pass and only grew larger. She had eventually come to the point of being unable to eat or drink anything.

When her friends saw how rapidly she was declining they stepped in and brought her to the emergency room where routine blood and urine tests were done, and an abdominal x-ray was ordered. Based on her symptoms and health history, dehydration was suspected and nurses immediately started Maddy on IV fluids while they waited for all the test results to come in. Eventually, doctors determined that Maddy needed to be admitted. Not only was she dehydrated, but she was also severely malnourished. In addition, she had two very large kidney stones, which had caused an infection. Once she was admitted, nurses continued the IV fluids, started Maddy on IV antibiotics, and inserted an NG (nasogastric) feeding tube.

Maddy spent five days in the hospital until doctors were convinced that she could keep enough food and fluid in her system to remain sufficiently nourished. It was no mystery to Maddy why this crisis happened; she knew as well as the doctors that she needed to start taking her Crohn's medications again. She was discharged with strict instructions to follow up with her Crohn's specialist within the next few days and to start treatment accordingly. The nurses at the hospital also set up a pre-op appointment for surgery to remove the kidney stones. Because of the size and location of the stones, and the infection, the stones must be removed by percutaneous nephrolithotomy. In this procedure, a surgeon would make a small incision in Maddy's back, insert a hollow tube into her kidney, and remove the stones through the tube. Doctors had wanted to do the surgery while she was in the hospital, but Maddy refused, knowing that she could not afford to pay for the surgery. While the procedure is relatively minor, it does require anesthesia and a hospital stay of two or three days. It also requires a catheter be inserted into the kidney to allow it to drain and heal. Without health insurance, Maddy knew that covering the costs would be impossible, and she chose to leave AMA (against medical advice) to take some time to figure out a plan and decide what options were available to her, if any.

As she had already taken a leave of absence from school, given her current condition, Maddy decided to take some time off work and go home to stay with her family for a while. Although Maddy is close to her family, she has not told them about recent occurrences, and they have no idea that she spent several days in the hospital. Maddy's father recently lost his job, and her mom has only been able to find part-time work. They have been struggling for the past eight months to make ends meet, trying to raise their two other children on a part-time salary without any benefits. Maddy has been aware of the situation, and for that reason, has not wanted to bother her family with her situation. With nowhere else to turn, however, she now decides to go home to focus on recovering and figuring out what do from here.

Instructions

Read and analyze the case.

Use this form to document your critique of the case. Be sure to provide all of the information asked of you. Responses should be in MS Word, 12 point font, complete sentences and grammatically correct.

Submit your analysis to GA View on or before the due date listed on your schedule. Ten percent (10%) will be subtracted from your final grade for this critique, each day you are late.

Who is affected or at risk in this case? Who are the stakeholders?

Summarize their situation (e.g., health status, predicament).

Clarify, what is the ethical dilemma or conflict?

Identify a stakeholder involved in this case then clarify/summarize

Their position. (Which side of the dilemma or conflict do they take and describe what that position is.)

The ethical principle(s) and values that support their position. (These are principles and values from the book and lecture. You’ll need to state the principles or values and describe how they apply to and support the stakeholder’s position).

6. As a Healthcare Administrator, using an identified Code of Ethics, what would you decide? (See the Code of Ethics document on the Course Content site and let me know which Code you are using. Also describe your decision.).

7. Why? (Why did you come to this decision? Why do you think it’s the right decision and can you justify it?)

8. List 1 additional decision alternative. (Remember, there are more ways to address an ethical dilemma than one single decision. What might be an alternative way to address the ethical dilemma? – do not restate your original decision – provide a second decision that would be your ‘second choice’.)

Answer 1

In the given situation Ms. Madisyn is 25 years old graduate who is doing her PG and affected severely with inflammatory bowel disease. By analyzing this case it is well known that Ms. Madisyn is at high risk and her health condition may get worse if she is not taking care of.

Ms. Maddy is affected with Crohn’s disease, it is characterized by inflammation of the lining of digestive tract, and this spreads deep and affects the tissues. There is no cure for Crohns disease. The patient has to take life long medications and need to do regular follow up and medical check up.

However Ms Maddy had taken control over her health was able to keep herself healthy by seeing her Crohn's specialist regularly, taking the necessary measures to control the severity. Since she is away from her home, time and money constraints do not make Maddy to care herself, and the stresses of school and her disease have contributed to her worsening flare-ups. Her friends made her to get admitted in hospital to get treatment. Dreadfully she developed renal calculi. Her condition is very horrific that no one extends their helping hand in terms of money and time.

She won’t be able to claim PPO health insurance since she’s 25 yrs and finished her graduation. PPO is a preferred provider organization provides discount charges for the customers if the get treatment from the company networks Doctors or other health workers.

Here the stakeholders for her condition will be their parents, her educational institution, her friends and herself.

Regarding their parents condition they have take care of her daughter. They are well known that she is diagnosed to have Crohns disease and she has to be in specified diet control and not to be overstressed and overworked. She would have been restricted to go for her Post graduation. Horrendously their parents allowed her to go away from her home and not aware about her health condition.

The educational institution and her friends not helped her during her stressful situation. An educational institution need to counsel the students according to their health condition they have to identify the problems of students and provide guidance for them.

She is the main reason for her condition to get worsening. She didn’t find help from her family members and she didn’t restrict herself from the activities what she suppose to avoid.

She is refusing the treatment and withdrawing from the physician advice it causes ethical dilemma for the health care workers.

Ethical dilemma may arise for patients, family members and health workers. Here Ms. Maddy refuses the treatment and planning for Discharge against Medical Advice. It creates the conflicts. So the physician may be face with the question of whether to continue the treatment or not. However respecting the wishes of patient and according to the patient’s right that right to take or refuse treatment the Doctors can discharge the patient with strict medical advice and with proper consent signature from the patient.

According to the code of ethics for health professionals

• Place the patient’s interests first, promoting patients’ health, safety, and rights

• Protect the autonomy and dignity of the patient

• Maintain confidentiality

• Practice with honesty and integrity

• Maintain competence

• Respect others, including colleagues, and other professionals

• Practice in a non-discriminatory fashion

Place the patient’s interest first the doctors can accept the decision taken by MS. Maddy

Four basic principles of code of ethics are

Autonomy: Respect the patient’s uniqueness and dignity,

Non mal efficiency: Prevent harm and harmful situation

Justice: treat individuals equally

Beneficence: remove harm and promote benefit.

The second choice is Maintain confidentiality, So the physician is not giving the information to their family members and others and accepted the choices of Ms. Maddy.