Honoring Patient’s Wishes and End of Life Decision- Making Capacity
Neurosurgical patients often challenge their caregivers with moral issues that arise during their care. As the population ages, end-of-life decision making and flexible planning need to be stressed so patients can be included in their care decisions and better communicate with the healthcare team. This case study illustrates how one team of nurses used an ethical decision-making model and a caring perspective to help a patient successfully navigate a complex healthcare system as they advocated for her increased involvement in her care.
Case Study
Miss. S. is a 79-year-old retired chemist. She has never married and has no children or living siblings. Her closest relatives are several nieces and nephews, whom she has seen intermittently over the years. Since her retirement, Miss S. has lived alone in a rural area with her cats in a glass house suspended between large trees. She is independent and lives frugally, yet comfortably.
One evening, Miss S. stumbled and fell backward on her porch, hitting the back of her head. She felt weak all over and experienced tingling in her arms and hands, but was able to crawl to the phone and call 911. Paramedics took her to a nearby community hospital. After plain X rays of the cervical spine showed a high-cervical fracture, Miss S. was airlifted to an academic medical center and admitted to the neurosurgery service.
Miss S. was a delightful woman, slight in stature with frail skin and severe osteoporosis. She was placed in a halo body jacket and underwent uneventful cervical spine stabilization. Because of her advanced age and potential respiratory issues, she was placed in the neurosurgical intensive care unit postoperatively. After the first 48 hours, Miss S. developed difficulty eating; a swallowing evaluation demonstrated partial paralysis of the pharynx and vocal cords. A small-bore feeding tube was placed to prevent aspiration pneumonia. Within a few days, she was transferred to the neurosurgical unit and she began working with occupational and physical therapists. The neurosurgeon and social worker began talking to Miss S. about discharge planning. Because she would require halo immobilization for several months and lived alone, she was not a candidate for admission to an inpatient rehabilitation facility. She was vehemently opposed to placement in a skilled nursing facility, but additional issues with pneumonia halted further discussion and she was transferred back to the intensive care unit in acute respiratory distress. She improved enough to be transferred back to the neurosurgical unit after several days, but the team elected to place her in the neurosurgery step-down unit to monitor her more closely. The three-bed unit had two other patients, both of whom were men, and one man was loud and confused. The other patient also was noisy, and he rarely turned off his television. Miss S. had little control over her surroundings and grew more depressed as other complications, such as skin breakdown around the pin sites on her forehead, developed.
Miss S. was difficult to mobilize even with the assistance of physical therapy. Because of her slight frame, she often toppled over after sitting up. She had little return of oral function and could not eat. Early one morning, with the team on rounds, Miss S. took control. She told the resident and nurse clinician that she had thought all night about an appropriate discharge plan, and she began to describe physician-assisted suicide. She said she would refuse to spend another penny on her own health care, especially when the money could be left to her family instead. She had been miserable for several weeks, and she saw no end in sight. In addition to asking for her feeding tube to be removed, she wanted help in ending her life. She was awake, alert, oriented, and specific in her wishes. The plan that Miss S. presented to her healthcare team left them stunned and unprepared; however, she acted in the same manner as many patients who value autonomy. She was identifying her need for a sense of control and her desire to shape priorities while having her own psychosocial concerns addressed (Winzelberg, Hanson, & Tulsky, 2005).
Miss S. had lost trust and control and consequently felt powerless. Patients value autonomy differently than healthcare providers and often express different definitions in which they emphasize control and psychological needs over creating advanced directives (Winzelberg et al., 2005). To resolve this disconnect, Miss S. attempted to exercise her autonomy by taking control of a decision the healthcare team naturally would not support. The future looked dim to Miss S., yet she was not in a terminal state. This is an important distinction when discussing physician-assisted suicide or withdrawing care (Smith & Daniels, 2002). The healthcare team was invested in beneficence and nonmaleficence (Burkhardt & Nathaniel, 2002). They did not recognize suicide as an option in terms of their own personal moral beliefs, and also were bound by the restrictions of state law. They could, however, support a part of Miss S.’s request to withdraw care.
1. Would you support Miss. S decision and why?
2. Can you list out 3 options the medical staff have in this situation?
3. What role does patient autonomy, justice, non maleficence, and/or beneficence played in this case? Explain each?
4. What role does the patient and nurses moral values, rights, and/or preferences, plays in this case?
5. What do you think is the outcome?
Answer all the above questions in your post. Be specific and draw on materials and the textbook for shaping your answers as well as your experiences, values, morals and preferences. Make sure your first post, you use references to support your positions and be prepare to discuss in class next week. Remember, you must post twice and your first post will be answering my questions above and your second or more posts will be answering other classmates posts. The two presenters this week will post first on Friday and the discussion board will be open to the class starting Saturday morning 08:00 am until Tuesday night, 11:59 pm.
Note – 600 words
Questions 2
Your first extra credit will be on Esmin Green (There are 2 videos in Week # 1 Folder). This opportunity is worth 5% of 25% you will be given a chance to earn over the next few weeks. The format for the paper is below for you to follow:
1. Title page
2. Key Terms page (Just list 5 terms)
3. Content page (you will be using the framework on page 7, Table 1-1.
4. You have a choice on how you answer: (1) You can answer the questions using paragraph format or you can (2) write out the question – the below it, indent your paragraphs and then answer the question.
5. Make sure you reference in your paper and then post all references on the Reference page.
1} In plain terms, what is the problem or dilemma?
2} What are the medical facts and issues
3) What are the concerns, values, and preferences of the physicians
4}What are concerns, values, and preferences of the patients?
5} What are the ethical issues?
6} What ethical guidelines are at stake
7} What practical considerations need to be addressed?
Esmin Green case can be found on YouTube video, 600 words