Question

Scenario Summary

You are the new director of risk management at Little Falls Hospital, which is a 450-bed tertiary care facility in a major urban area in the Northeast. The hospital is an integrated health system that provides the full array of inpatient and outpatient services. The hospital enjoys a reputation for quality care in the area.

As the new risk manager, you have been briefed about a patient care case that needs your attention.

·         The patient is a 45-year-old woman, Lydia, who is currently paralyzed and can only communicate through head nods as a result of a car accident over 6 months ago.

·         The patient is currently on a ventilator for respiratory assistance and receives tube feedings.

·         The professionals in the hospital are uncertain as to whether the patient is capable of understanding information and making her own decisions.

·         It is reported that the patient has an advance directive, but no one has been able to secure a copy of the document.

Your Assignment

You have been asked by Felicia Larue, the hospital CEO, to give a briefing on the patient situation and alternative actions that may be taken by the hospital to ensure that the rights of the patients are preserved and the risks to the hospital are minimized. Prepare a 500-word summary of the important components of this case, the laws that may have an impact on this case, and alternative courses of action that the hospital may pursue to satisfy the parties that are involved with the scenario. The strategies and recommendations should be as specific as possible and include the resources needed for implementation. Your primary text and journal and website research must be used as a reference to support your analysis.

Key Players

Mr. Bevins—Patient's Spouse

Lydia and I have been married for 4 years, and I know that she would not want to be kept alive in this fashion. She and I have had many conversations and discussions about end-of-life decisions, and living like this would not be her choice. I do not know the whereabouts of the advance directive, because she did this prior to our marriage, and my attempts to obtain a copy have failed. I am her guardian, and therefore the decision should be mine.

Eileen Redfield—Patient's Mother

I am Lydia's mother and it hurts me to see my daughter laying there so incapacitated. Ending her life is not the answer. A couple of the physicians have implied that she might get better and live a better life, although others have given me little hope for recovery. A miracle is always possible, and I want to give my child every chance she can to live.

Dr. Bob Pritchard—Patient's Physician

I have been taking care of Lydia for the past 90 days. Although she does demonstrate progress in very small increments, her level of functioning has not significantly improved. This is compounded by the fact that Lydia also suffers from breast cancer—a condition diagnosed and treated successfully before the accident. I am not sure what advice to give the family about the patient's long-term survival.

Answer 1

The issue tends to arise when there is a conflict between the patient ,family members and or the medical team.There are no legal statutes pertaining to this issue except in case of extremis .Amajority of their decisions are based on two important and distinct principles.In legal matters ,competence is a property of an individual determined by a normative standard based on current moral beliefs of the society.Therefore a functional approach is used to establish a patients competence.it involves meeting the three specific criteria.free action,authenticity,and effective deliberation.

In free action ,a patient must be capable of action that is intentional and completely voluntary.It cannot be the result of coercion,duress or undue influence.For authenticity ,one must be certain that the patient is acting on character,that is consistent with his or her values,attitudes and life plans.As for effective deliberation ,the patient must realize that a decision has to be made.He or she should be aware of the consequences and alternatives and then be able to make an informeddecision based on an informed evaluation.Therefore a competent patient should be acting freely and within characterwhile also being able to deliberate and express clearly the issues at hand.Given this approach,it is easy to see how determining the competence of a patient can be very difficult.For those times when it is not clear,a physician can request a psychiatric consultation.A psychiatrist or any other physician can deem a patient incompetent ,but it only becomes legal and binding when argued in front of a judge and determined in a court of law.In most cases ,it is not necessary to go the courts because the patients family or other concerned persons do not contest the patients competence and treating physicians plans .When a patient is deemed incompetent necessary to appoint a surrogate to make health care decisions.This is usually done by informally by simply designating a family member or next to kin to speak on behalf of the patient.When there is no available family,a conservator needs to be appointed by the court.

References.

Jonsen AR,Siegler M,Winslade WJ:Clinical Ethics,2nd ed.New York,Macmillan,1986.

Nathanson JA :When does a patient have the right to refuse lifesaving medical treatment? Can Med Assoc J 150:1323-1326,1994.