Question

You are the nurse coordinator of the Neurology ICU at Metropolitan Hospital. Last week, a homeless patient was admitted after he was found unresponsive outside of the hospital emergency room. He had experienced a stroke and was in need of non-emergency surgery to stop the bleeding. The doctors performed the surgery and the patient was improving, but the patient had a long road of recovery ahead and the doctors did not know whether the patient had any support system available or whether they had done the right thing by operating. The following week, a pediatric patient underwent a risky procedure that doctors didn’t think was advisable, but it was at the request of the child’s parents. The child is in the ICU, and has not been responsive since the surgery. Doctors on the unit are upset about both situations and would like more guidance on how your ICU is going to handle such events in the future.

They would like you to give a presentation to the Neuro ICU that addresses the following scenarios where an incompetent patient requires non-emergency neurologic surgery. Assume that the providers in your ICU know absolutely nothing about the ethics of decision-making.

Using what you have read this week, craft a brief PowerPoint presentation (no more than 500 words total, 10-15 slides) providing step-by-step instructions for dealing with decision-making in the following cases:

1. A homeless patient without a surrogate, living will, or family members who is unable to express his preferences about surgery, and
2. A pediatric patient undergoing care in which the team is divided about its medical appropriateness but the child’s parents are demanding it.

In each of these cases, who ultimately should decide what type of care the patient gets? What standard is being used: best interests or substituted judgement? Does the severity of the condition or length of recovery matter? Are there limits in each case in terms of whether we can know, for certain, that we are respecting the wishes of the patient?

In scenario 1, particularly, who do you recommend to make this decision? What should he/she/they consider in doing so? Are there other alternative decision-makers?

These are both difficult cases that stretch out ethical guidance but they are not uncommon in a clinical situation. Think creatively and do your best to fuse the information you have learned this week into a cohesive presentation about these challenging cases.

Answer 1

ETHICAL PRINCIPLES

THEY ARE MAINLY FOUR ELEMENTS

AUTONOMY- the ultimate power of decision must lie in the patient

BENEFICIENCE - do good

NON-MALEFICENCE- do no harm

JUSTICE- equal treatment for equal disease

Most often the four doesn't well go together.

Let us split and see the scenarios

In the first case, the power of autonomy is lost. The patient is unable to make choices for himself.

He is also not conscious of his condition.

It might be ethically incorrect to treat him without him having been informed about the possible choices, the benefits and the harm.

It might also call in for a legal claim if the patient comes out with a claim of not been informed

This would stand valid even if the doctors did only good and no harm to the patient.

Though short term harm in view of long term benefits could be ethically justified, the legal sides are still different

The second scenario

The doctors chose the less risky and more beneficial choice for the child, yet the parents asked for the surgery and put the child in risk.

Here autonomy was validated and held against non-maleficence.

Though legally the parents could not claim against the doctors as they themselves did choose the operation, the doctors are in dilemma for having had to put their ethical principles at stake

The power of autonomy should be guaranteed and respected, however non-maleficence and beneficience lies purely on the doctors and they are in complete stress out of the choice

In a simple glance, the first choice would seem more right than the second

The first has legal limitations while the second- ethical

The doctors are safe in the eyes of law more in the second scenario.

The challenges and limitations

Autonomy-

· The power of choice lies with the patient or with the guardians in case of minors

· The patient might make a wrong choice

· The doctor will have to compromise his judgment for the choice of the patients

· Unnecessary investigations might have to be done just for the choice of the patients

· Medical appropriateness might be underestimated

· The other principles of ethics could not be held against the power of autonomy

Beneficence and non-maleficence

· Sometimes the short term harm will not be justified in the eyes of the patients

Justice

· It seems justice is easier and the most logical of the four ethical principles

· However, in a set up with overwhelming patients , this is often compromised

· For instance, in an emergency , the only ventilator might be given to the patient with longer chance of recovery or younger and longer life ahead of them.