Reference no: EM133581519

Case 1: Mr. Jones is a 92 year old gentleman with acute congestive heart failure. He has a long list of comorbidities, and his prognosis is guarded. Upon discussion with Mr. Jones' family members present, the medical resident documents a "do not resuscitate decision" in the electronic record on day one of hospitalization. On day three of hospitalization, Mr. Jones' daughter, named as agent in Mr. Jones' durable medical power of attorney, arrives from out of town and speaks to the attending physician, asking him to cancel the DNR order and resuscitate, if necessary. This is handwritten in the progress notes, which are scanned into the electronic record, but the electronic field where DNR orders are documented is not changed. In addition, in the daily progress notes entered by the medical resident, the day one discussion resulting in the DNR order continues to be copied and pasted into the record each day, making it appear that the DNR order is still in force. Mr. Jones' son disagrees with the daughter's decision and feels it was uninformed; he complains that he (as a registered nurse) was in a better position to make the correct decision. Unfortunately, on day 5 of hospitalization, Mr. Jones' condition deteriorates and he has a cardiac arrest. "Code Blue" is called by the nurse on duty, and the team arrives to begin resuscitation. Shortly after they begin, the unit clerk enters the room and tells the team that "this patient is DNR." Resuscitation is canceled and Mr. Jones dies.

1. Who had authority to decide whether Mr. Jones should be resuscitated? Is any information that is necessary to answer this question missing from the scenario? If so, what else must be known to answer this question?

2. Who should be responsible for documenting DNR decisions?

3. What should happen if a record reflects conflicting documentation?

4. Are there circumstances in which family members should NOT be allowed to make DNR decisions on behalf of a patient?

5. How did the format and capabilities of the electronic record contribute to the confusion in this case? What could be done to address those problems?

Case 2: A middle-aged man was involuntarily committed to a state psychiatric hospital because he was considered dangerous to others due to severe paranoid thinking. His violent behavior was controlled only by injectable medications, which were initially administered against his will. He had been declared mentally incompetent, and the decisions to approve the use of psychotropic medications were made by his adult son who had been awarded guardianship and who held medical power of attorney. While the medications suppressed the patient's violent agitation, they made little impact on his paranoid symptoms. His chances of being able to return to his home community appeared remote. However, a new drug was introduced into the hospital formulary which, if used with this patient, offered the strong possibility that he could return home. The drug, however, was only available in a pill form, and the patient's paranoia included fears that others would try to poison him. The suggestion was made to grind up the pill and surreptitiously administer the drug by mixing it in pudding. Hospital staff checked with the patient's son and obtained informed consent from him. The "personal values and...personal goals" of the son and other family members were seen to substitute for those of the mentally incompetent patient-and these goals included the desire for the patient to live outside of an institution and close to loved ones in the community. This was the explicitly stated rationale for the son's agreeing to the proposal to hide the medication in food. However, staff were uncomfortable about deceiving the patient, despite having obtained informed consent from the patient's guardian.

1. Do you think the ends justify the means? In other words, does the goal of discharging the patient from an institutional setting into normal community living justify deceiving him? Explain your reasoning.

2. Do you think it is ever ethically permissible to deceive clients? Under what circumstances? Why or why not?

3. To what degree should family members or legal guardians have full capacity to make decisions or give consent on behalf of those under their care? Explain.

4. Do you think severely mentally ill people retain any rights "to determine what shall be done with [their] own [bodies]?" Why or why not?

5. Are there risks in surreptitiously medicating a paranoid patient? Would this confirm the patient's delusions of being "poisoned" by others or escalate his resistance to treatment? Are these risks worth taking in view of the potential to dramatically improve his mental functioning and reduce his suffering?

6. Since psychiatric patients have the right to treatment, does the strategy to surreptitiously administer medications serve this goal? Do you think this is ethically justifiable? Why or why not?

7. Does the history of the forcible treatments of persons with disabilities and other powerless populations affect how you view this case? Explain.