case study 2805NRS Legal and Ethical Principles

case study 2805NRS Legal and Ethical Principles in Healthcare Doreen Richmond was a 68-year-old woman with chronic respiratory problems from her years of smoking, was obese and had diabetes. She’d had a particularly troubled life, and after getting involved with the ‘wrong crowd’ in her early 20s a substantial criminal history. Doreen’s last crime was an attempted burglary. Unfortunately, things went wrong. Doreen shot and killed a shop assistant, and then an attending police officer. Doreen was sentenced to life imprisonment. Doreen had been an inmate at the Queensland Correctional Facility (QFC) ever since. Vera Bennet was the Prison Governor at QFC and a Justice of the Peace. Doreen’s chronic illnesses meant that she frequently visited the prison doctor. At one of the last consultations, the doctor recommended that she fill an advance health directive, so that should anything happen, Doreen’s wishes could be considered. Doreen had always hated the idea that she might not be able to take care of herself in prison, so she completed the AHD, and had it witnessed by Vera Bennett. Doreen did not, however, appoint anyone as her enduring power of attorney. Because Doreen had been in prison so long, she’d lost contact with all of her relatives and friends on the ‘outside’. She did, however, develop a close friendship with another of the inmates, Bea Smith. Doreen and Bea made a pact to take care of each other for life. One Saturday morning Doreen become unwell. She was short of breath, complained of nausea and was clammy. After being assessed by the prison doctor, Doreen was transferred by ambulance to the emergency department. In the hospital, Doreen was reviewed by a cardiologist, Dr Rosie Bush, who diagnosed a serious cardiac dysrhythmia requiring the insertion of a pacemaker. Rosie asked Registered Nurse Pat, to contact Doreen’s next of kin to get consent for the procedure. Pat rang the QFC to see who the next of kin was, but Vera Bennet was not sure. Pat described Doreen’s current condition and the proposed treatment. Vera agreed that the pacemaker was the only option. Doreen was taken to the operating theatre for insertion of the pacemaker. Her condition deteriorated intra-operatively and she developed respiratory failure and acute renal failure. The procedure was abandoned, and Doreen was transferred to ICU for artificial ventilation and renal dialysis. When Bea heard what happened to Doreen, she was very upset. She called the hospital and spoke with the ICU Consultant, Dr Molly Bean. She told Molly that Doreen is her best friend in the world and that she wants everything possible to be done to get her better. Molly reassures Bea that Doreen is receiving the best of care and asks Bea if she is aware of what Doreen’s wishes were if she wasn’t able to fully recover. Bea tells Molly that Doreen has an advance health directive and that she does not want to be kept alive with machines. Following this conversation Molly documents in Doreen’s medical record ‘Not for CPR’. A week later, Doreen’s condition had stabilised, and a tracheostomy was inserted to provide comfort and assist with weaning her from the ventilator. By this time Doreen was awake and able to understand simple instructions. To everyone’s surprise, Doreen continued to rally. Her condition stabilised and improved and 16 days later she was well enough to be transferred to the ward with her tracheostomy tube in situ. Doreen was again under the care of Dr Rosie Bush. When she first reviewed Doreen, Rosie thought that it was unlikely that she would ever be well enough to be transferred back to QFC. A few days later, however, she noted that Doreen was quite stable. She told Doreen that with some rehabilitation she would be likely to recover. This pleased Doreen immensely because it meant she would see Bea again. One afternoon, nurses Ned and Roslyn were caring for Doreen on the ward. They entered her room to administer Doreen’s regular medication and to attend to pressure area care. Neither nurse had recently cared for a patient with a trache, or the in-line suction system used to suction secretions from it, but were reassured by another nurse that ‘there’s nothing to it’. Ned and Roslyn briefly looked at the system and thought they’d manage it okay. After administering the medication and turning Doreen on her side, Roslyn left the room. Shortly after, Doreen began coughing. Ned thought this may have been caused by a build of secretions and tried to suction them from the trache with an in-line suction system. Being unfamiliar with the setup, Ned was not aware that it had disconnected from the wall and the apparatus was ineffective. Ned tried to reattach the suction tubing, but while he struggled to get it working, Doreen was struggling to breathe. Roslyn heard the commotion and as she entered the room to assist, observed Doreen becoming quite cyanosed. Together, the nurses placed Doreen on her back and called the Medical Emergency Team (MET). The MET arrive promptly, and manually ventilated Doreen via her trache. Despite this intervention, Doreen’s heart rate dropped to 25 beats per minute, and she stopped making any spontaneous effort to breathe. At this point, Ned highlighted the ‘Not for CPR’ order in Doreen’s medical record. It was agreed that no further attempts to resuscitate Doreen should be made. Within several minutes, Doreen was asystolic and she died. Making Ethical Decisions Many different values influence decision-making in healthcare. This sometimes makes it difficult to know which is the ‘right’ decision. In this section, you need to consider the values that underpin different stakeholder decisions. You are required to refer to academic literature to support your response. 1. Doreen ‘hated the idea that she might not be able to take care of herself in prison’. Identify one value that is reflected in this statement and describe it. Then describe how it may affect Doreen’s decision-making. 2. Bea asked Molly to ‘do everything possible to keep Doreen alive’. Identify one value that is reflected in this statement and describe it. Then describe how it may affect Bea’s decision-making in relation to Doreen. In this section, you need to consider whether certain decisions are consistent with the following Universal Declaration on Bioethics and Human Rights Principles. 3. Discuss whether the decision made by Molly is consistent with Article 5 Autonomy and individual responsibility. 4. Discuss whether the decision made by the MET is consistent with Article 7 Persons without the capacity to consent. Making Legal Decisions When an adult has decision-making capacity, providing consent is one way of ensuring that their values are given priority. The law also promotes individual values, including autonomy by providing a framework for consent when an adult lacks decision-making capacity. Using structured sentences and paragraphs, answer the following questions about Doreen’s case and the law in Queensland. 5. When Doreen is first admitted to ICU, she does not have decision-making capacity. Provide a rationale for the legal obligation to obtain consent for Doreen’s tracheostomy in these circumstances. 6. Does the Prison Governor, Vera Bennett, have legal authority to provide consent for Doreen’s pacemaker insertion? Support your answer with Queensland legal authority. 7. Which of the stakeholders in the scenario have the legal authority to provide consent for the insertion of Doreen’s tracheostomy? Support your answer with Queensland legal authority. 8. Doreen completed her AHD in the presence of the prison doctor. What does the doctor need to determine to ensure that Doreen had decision-making capacity at the time it was completed? Support your decision with Queensland legal authority. 9. Discuss whether Dr Molly Bean can rely on Doreen’s AHD as a valid refusal of CPR. 10. With reference to the Healthcare Principle, describe the factors Doreen’s substitute decision-maker must consider when making decisions about her healthcare. SCIENCE HEALTH SCIENCE NURSING NRS 2805

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