Ethics in Patient Care
The case in question involves a 64-year-old patient who was brought in due to non-healing wounds on her lower extremities (pyoderma gangrenosum). The patient had been previously advised to follow wound management techniques but she ignored the instructions. Over time, it was established that she had psychological issues, specifically mood disorder, and was further confirmed to have no capacity to make rational decisions. Because of this and the fact that the patient’s family was inaccessible at the time, the judge directed the Office of the Public Guardian, and a guardian was chosen to act on her behalf. The judge further permitted the guardian to act on the patient’s behalf in approving treatment procedures. The patient has currently been advised to undergo surgery on her legs, but the treatment has been rescheduled severally due to her refusal to be treated. In some instances, her reasoning for not wanting to be treated was due to valid concerns such as lack of pain medication post-operation, and the need to be told earlier in order to be prepared for surgery. There is a concern that if she does not undergo the surgery soon, she would be forced to undergo amputations on both feet due to the exacerbating wounds. There is therefore an ethical conflict between allowing her autonomy over the treatment methods and timelines, and insisting on treatment after the approval of her guardian (an approach that will result in the need to sedate the client). The role of the ethics committee herein is to ensure that the decision made by the healthcare practitioners in the case are ethical and aimed at benefitting the patient more than the facility.
This particular case raises a lot of interest, not only in terms of the intended decision but also in the approach to be taken towards decision making. Understanding how each decision would affect the patient is paramount towards following it to success. The issue at stake in this particular case is patient autonomy. One of the ethical requirements of the healthcare industry is that patients should be treated as autonomous entities capable of making decisions as to the treatment methods and tools to be used in handling them (Wood, 2014). Patients have to be made to fully understand their individual cases, the options that they have at hand, and the implications of each of those options. Patients are then to be allowed to make independent decisions on whether to undertake any or none of the available treatment options. In this particular case, the patient has been made to understand the extent of damage that has been caused by the wounds on her legs as well as the possible solutions to be followed. She has also been made to understand the ramifications of failure to get the recommended treatment. Considering the requirement for autonomy, the patient would have been expected to make a decision, and the decision followed through. In case she chooses to go with the treatment, which appears to be the current situation although she repeatedly raises concerns about the timings, she would be treated. Otherwise, she would be allowed to go untreated. However, the particular patient’s psychological condition and lack of capacity to make the decision makes it difficult to push them into the autonomous zone.
Besides autonomy, I also realize the relevance of informed consent in healthcare through this patient’s case. According to Wood (2014), any treatment method selected for use on a patient should be explained to the patient, and the patient is allowed to approve or refute the process. The objective of informed consent inpatient care is usually to indemnify healthcare practitioners from being considered unprofessional or being considered to have engaged in medical malpractice. Informed consent also shows that the patient has authorized an invasive procedure such as a surgery to be conducted on them and is thus ready to face the consequences of the treatment process. Deciding to go ahead with any treatment in the absence of the patient’s informed consent would still raise concerns around unethical conduct. In this case, the patient has notably been unable to give their informed consent. From a general perspective, the patient would have been given the opportunity to make a choice. However, the patient’s history with medication and adherence to treatment demands has shown that she is incapable of voluntarily following them through. Additionally, the assignment of a public guardian to the patient as a result of her incapability to make rational decisions is an indication that even her demands may not guarantee her acceptance of the proposed treatment. As such, the patient cannot be considered rational in decision-making. The legal guardian can thus act on her behalf and the approval of the legal guardian would be final. The challenge would be the need to sedate the patient, which would be considered unethical to some extent.
This entire situation shows the need for more creative or unique approaches to handling this particular patient. The approaches would put into consideration the nursing code of ethics, nursing theories, and patient-centered practice as guidelines towards effective patient care.
Methods and Tools for Case Management
Notably, handling this patient’s case will need the application of various techniques to bring together the patient’s understanding and ethical considerations in order to achieve the desired treatment. The more humane approach to the actual surgery would be a process approved by both the patient and the guardian, and would not need the patient to be sedated. The first step in this would be to enlist counseling services for the patient. From the patient reports, it has been established that she is only suffering from mood disorders and inconsistencies. There is no indication that she has any of the more adverse psychological conditions such as Alzheimer’s and can be helped to manage her mood effectively. Accordingly, she would be made to understand the need for her treatment and surgery from a different perspective. Thereafter, she would be advised on the surgery needs and then given a date deemed suitable by the doctor. The patient would then be allowed to make her choice on whether to proceed with the treatment or not, and the patient’s choice was respected. While this process would be the most satisfactory for the patient, it may result in damage as an escalation of the patient’s condition may result in the need to amputate his legs. Furthermore, since the patient has no family, having his legs amputated would result in social and economic costs to the state as there would be no one willing to take care of her after the amputation.
For more immediate action, the ethics committee would not consider the violation of autonomy as unethical conduct. A guardian has already been assigned to care for the patient and to look out for her welfare on account of her inability to make rational decisions. In such a case, the decisions made by the guardian are considered representative of the patient’s decision. The autonomy of the patient is practiced by the guardian and the guardian can give informed consent on behalf of the patient. The consent of the guardian should therefore be considered sufficient authority for conducting the surgery. At the same time, the patient should be asked what other conditions she would want met before the surgery and informed of the availability of post-operation medications. This information should be given in advance rather than as a surprise. Following the satisfaction of these conditions, the doctor would set a date and upon approval by the guardian, the patient would be treated even if it means sedating her. Taking this second option will help prevent escalation, reduce the potential for harm and reduce the economic and social costs associated with this particular patient. In this way, the choice would be satisfying the conditions provided by the utilitarian ethical perspective, which is to optimize benefits for the greatest number of people as discussed by Sheskin and Baumard (2016). In this way, there would be satisfied for everyone and even the patient would recognize the efforts made to help her.
Ethical conduct in healthcare service delivery is paramount for all conditions. However, there are certain situations that raise ethical concerns for the involved patients and healthcare providers. The situation in the outlined case is an example of a case in which there seems to be a conflict between the ethical code of nursing practice and the actual patient condition
Sheskin, M., & Baumard, N. (2016). Switching away from utilitarianism: The limited role of utility calculations in moral judgment. PLoS One, 11(8). Retrieved from journals.plos.org/plosone/article?id=10.1371/journal.pone.0160084
Wood, D. (2014, March 3). 10 best practices for addressing ethical issues and moral distress. AMN Healthcare, Inc. Retrieved from www.amnhealthcare.com/latest-healthcare-news/10-Best-Practices-Addressing-Ethical-Issues-Moral-Distress/