Question

Helene Maxwell was a 65-year-old woman who lived alone. Her husband had passed away 12 years ago after an automobile accident, and she had one daughter, who was actively serving in the military overseas, stationed in Iraq. She awoke on a Monday morning not feeling well. She was a bit nauseated with severe heartburn. She had taken an antacid with no relief, and the pain grew worse. Helene had no history of cardiac trouble and was the picture of health for her age, ate right, never smoked, and walked two miles every day, so she did not suspect she was having a heart attack. Eventually, Helene began to feel dizzy and called her physician, Dr. Tondra Washington. Dr. Washington’s nurse spoke with Helene and directed her to call 911 immediately.

Helene followed the order to call for help and was transported to Middletown General Hospital. During her initial interview with the nursing staff in the Emergency Department, she indicated that she had a living will and a do not resuscitate order on record at Middletown General from an observation visit three months ago. Helene told the nurse that she had numerous hospitalizations, both inpatient and outpatient, over the past 10 years. Dr. Washington arrived at the emergency room and requested prior records.

Mondays are always very busy in the Health Information Services department at Middletown General Hospital. The call for Helene Maxwell’s records was received by Rachelle, who had been with Middletown General for 15 years. It was a routine request for records that appeared, in the computer, to be incomplete and should have been filed in the incomplete record file room. There were deficiencies for two physicians, neither of whom had recently been in to complete their records.

When Rachelle was unable to locate the records in the incomplete file area, she checked the dictating areas, the permanent records room, and areas with charts pulled for studies, and she still had no luck in locating the record. While she was searching, Robert answered a call from the Emergency Department, stating that they needed Mrs. Maxwell’s records immediately because they needed the living will and the order for do not resuscitate. Robert began to help Rachelle in the search for the records. They searched the entire department and enlisted the help of other members of the Health Information Services team. Nobody was having any luck, and Dr. Washington came to the department, abruptly stating the urgency of the situation. She had checked with her office staff, and Mrs. Washington had never given them copies of the living will and the do not resuscitate order, so the only known available copy was the one in her hospital records.

Rachelle went to get Marvin, Director of Health Information Services, from an administrative meeting so that he would be aware of the situation and hopefully provide suggestions of additional options to locate the lost record. Meanwhile, Helene Maxwell went into cardiac arrest, and cardiopulmonary resuscitation was initiated because there was not any available documentation to direct otherwise. Helene was intubated and transferred to the intensive care unit with mechanical ventilation.

Dr. Washington had the nursing staff initiate the process to find out how to contact Mrs. Maxwell’s daughter, Sarah, in Iraq. She told the nurses that once contact with Sarah was established, she would like to personally talk to her because of the nature of the situation. Eventually, Sarah was located, informed regarding her mother’s condition, and plans were in place for her to come home on leave.

When Sarah got home, she searched her mother’s house for the original documents and was unsuccessful. She had no idea who her mother’s attorney was or whether she had even gone through an attorney to complete the documents. Sarah was upset about the hospital not being able to locate her mother’s chart with the do not resuscitate order and living will. By the time she had arrived, Mrs. Maxwell had a feeding tube inserted and was not functioning at all on her own. Sarah was faced with a difficult decision and had no idea what her mother’s wishes were in the living will.

Discussion Questions

1. What internal and external forces impact this case?
2. What are the legal issues addressed in this case?
3. What are the ethical issues addressed in this case?
4. How are the ethical issues in this case covered in the American Health Information Management Association Code of Ethics?

Using the case method, evaluate possible actions that should be taken and determine the best option.

Answer 1

Living will: A document ( legal) made by a person , when still legally fit to do so expresding a desire to be allowed to die instead of being kept alive by artificial means, in the event of being severely disabled or suffering from a terminal illness.

Internal and external forces

There are various internal and external factors that affect the medical services provided by a heathcare organisation. The above case scenario is dealing with Mrs.Maxwell' End of life Care and related issues . The external factors that impact the case are:

* Availability of Physicians / resources :

Insufficient number of Physicians in the Emergency department made Dr. Washington to be busy and couldn't complete Mrs. Maxwell's document .

* Collaboration among providers : Dr. Washington and Health information Services team couldn't collaborate properly on Mrs. Maxwell's document storage

* Improper storing of documents/ files

* Legislation related to loss of Medical documents and Living will: Loss of Medical documents may attract legal actions as Medical records are legal documents.

Intetnal factors that impact the case are:

* Problems related to leadership : Leadership problems among HIM team

* Problems related to Education and training : Insufficient training related to the proper handing over and storage of patient's files.

* Ineffective management of resources and forces

* Ethical and legal issues with missing documents

* Ethical dilemma of Sarah about mother's End of life Care

Legal issues

* Missing of Medical documents of the patient Mrs. Maxwell, can attract legal actions, if her daughter Sarah decides go with court or law. The Hospital and the personnel related the case has to bear the loss or fine from the Court.

Ethical issues :

As Mrs. Maxwell informed in the Emergency room that she had a living will and Do not resuscitate order, the Health care professionals were not able to  perform the End of life Care, but as they couldn't find the documents and Mrs. Maxwell's condition became worst, health care providers were forced to start Cardiopulmonary Resuscitation and Mechanical ventilation. Health professionals and her daughter will be in Ethical dilemma regarding the continuation of Life support. Sarah may not be able to find what her mother's last wishes as the Living will got lost.You

Ethical issues and AHIMA's Code of ethics :

  American Health Information and Management Association ( AHIMA) proposed Code of ethics for the members of AHIMA. According to AHIMA code of ethics, " An AHIMA member has to advocate, defend and uphold individual's right to privacy and Confidentiality and also to Preserve, secure and protect personal health information in any form of medium" . In the above case Dr. Washington couldn't hand over the document to the Health information Service Department and service team couldn't do the follow up with records. Both the Dr. Washington and Health information Service team has to face the consequences as they violate the Code of Ethics of AHIMA. They could not preserve, secure and protect Mrs. Maxwell's documents.

The best Option:

As the DNR document is missing, health care team may not be able to take a decision. Ms. Sarah can talk with her mother's attorney ( if one is there) and / or can take a decision for her own as she is the only responsibile member in the family. According to her decision health care team can continue the treatment. Sarah can take decision that is most suitable for her mother, as she know het better than others.