Ethical issues require additional attention in the sphere of medicine. The presented case touches upon a variety of ethical issues and requires everyone involved to consider some hard choices. This paper will present the argument from the view of a case manager who is representing the patient, utilizing the ethical decision-making model.
Issues and Solutions
The first step in implementing the ethical decision-making model, in this case, is to gather all available information. Grace, the patient, was diagnosed with Alzheimer’s disease shortly after she retired to the Happy Valley Nursing Home. Despite her condition, she remained sociable and healthy. However, recently she became withdrawn, pale, and uninterested in eating. When the hospital found her platelet count to be abnormally low, they had to move her to City Hospital. The patient is not legally competent due to her Alzheimer’s disease, so her brother is the only one who can give consent for her treatment. Although he initially agreed to move her to City Hospital, it seems that he was not contacted when an experimental treatment was selected for her. After six days of being in the hospital, she has gone through a variety of examinations, which have established her spleen as the root of the problem. It is unknown whether the experimental treatment is working, but in her advance directive, she has stipulated that no extraordinary measures should be taken if she is dying. The professionals at City Hospital did not consider her advance directive, nor her Do Not Resuscitate request. However, her condition should not lead to immediate death and can be treated. Additionally, her arm has become affected with unknown complications due to an indwelling IV, which was used for supplemental nutrition. The ethical issue lies in whether it is best for the patient to keep the current treatment or consider alternatives.
The use of an experimental treatment without contacting her brother, and without considering the wishes expressed in her advance directive, is a very questionable tactic and borders on unethical behavior. A similar article on the topic of consent and patients with Alzheimer’s emphasizes the importance of gaining proper consent for any experimental treatment (Howe, 2012). The case study does not mention that any consent was given, however. As a case manager, I would argue for a new course of action that would be more in line with the wishes of the patient. To this end, three possible solutions present themselves.
The first solution is to stop the treatment outright because the consent of her brother was not given before it was implemented. I do not believe that this would be the best ethical decision because both the condition and the IV-related complications can be treated with the possibility of recovery. The wishes of the patient outlined in the advance directive only apply to situations in which she is dying, but the current situation suggests only that she lacks a sufficient number of platelets. However, it is possible that she would refuse the experimental treatment if given the opportunity.
The second option would be to move her from the experimental treatment to a more traditional one. This solution would be more in line with her advance directive while at the same time allowing her to receive treatment for her condition. The best of the available traditional options would have to be chosen (Riviere et al., 2015). The rules of care ethics demand that patients be treated for their ailments and that their self-sufficiency be prioritized (Post & Blustein, 2015). If Grace is not treated, she will not be able to feed herself due to her lack of appetite, which would only worsen her condition.
The third option would be to continue the use of the experimental treatment. In this case, her brother would have to agree that this is the best course of action. However, it is unknown whether this treatment is effective because she has only been at the hospital for six days so far. This fact suggests that it might not be the best course of action because there is no guarantee of positive results.
As a case manager, I would argue for the second option for a number of reasons. First of all, this option is most likely to result in the improvement of Grace’s condition, which is an essential goal of care ethics. Both the spleen condition and the IV complications would have to be treated accordingly (Nahirniak et al., 2015). Depending on the type of IV complications, the patient can either fully recover (Di Nisio, Peinemann, Porreca, & Rutjes, 2015) or partially recover (Granzow, Soderberg, Kaji, & Dauphine, 2014). Either form of recovery would be an improvement, however. The second argument lies in the wishes of the patient. The advance directive suggests that the patient is cautious of extraordinary measures in medicine, and this experimental treatment is one such measure. Although a counterargument could be made that transitioning to a more traditional treatment would take more time, the lack of guaranteed results for the experimental treatment suggest that it may prove insufficient.
Conclusion
This case presents a complex dilemma that requires an understanding of ethics and medicine. It is likely that the hospital only tried to provide the best care possible, but their lack of consideration for the patient’s wishes, unfortunately, created a larger issue. This situation requires a balance of care and consent to properly address the needs of the patient.
References
Di Nisio, M., Peinemann, F., Porreca, E., & Rutjes, A. (2015). Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database of Systematic Reviews, 15(11), 1-65.
Granzow, J., Soderberg, J., Kaji, A., & Dauphine, C. (2014). Review of current surgical treatments for lymphedema. Annals of Surgical Oncology, 21(4), 1195-1201.
Howe, E. (2012). Informed consent, participation in research, and the Alzheimer’s patient. Innovations in Clinical Neuroscience, 9(5), 47-51.
Nahirniak, S., Slichter, S., Tanael, S., Rebulla, P., Pavenski, K., Vassallo, R., … Shehata, N. (2015). Guidance on platelet transfusion for patients with hypoproliferative thrombocytopenia. Transfusion Medicine Reviews, 29(1), 3-13.
Post, L., & Blustein, J. (2015). Handbook for health care ethics committees. Baltimore, MD: Johns Hopkins University Press.
Riviere, E., Saint-Léger, M., James, C., Delmas, Y., Clouzeau, B., Bui, N., … Boyer, A. (2015). Platelet transfusion and catheter insertion for plasma exchange in patients with thrombotic thrombocytopenic purpura and a low platelet count. Transfusion, 55(7), 1798-1802.