Reference no: EM133683828

Arthur, Elsie, Rebecca and Aiden: Arthur Anderson is a 58-year-old semi-retired male who lives with his wife, Elsie, an Endorsed Enrolled Nurse who is also 58 years of age. They have been married for 38 years and have two children, Rebecca who is 25 years old, and an unexpected surprise who came along when they were in their 40's in Aiden, who is 14 years old. Arthur has a history of hypertension and type 2 diabetes. He takes prescribed medication daily for these ailments and is usually compliant with his healthcare management. Elsie works part time at the local hospital near where they live in the Gold Coast hinterland. Rebecca is aware of Arthur's medical history in case she is relied upon to help with decisions if Elsie is absent. Recently while gardening, Arthur suddenly experienced some dizziness, shortness of breath and chest discomfort. He sat on the grass and called 000 on his mobile device, with paramedics arriving soon after. Arthur & the Paramedics Once at Arthur's premises, the paramedics assessed his vital signs, administered GTN in tablet form, and performed an electrocardiogram (ECG), which indicated some abnormal cardiac activity consistent with a heart attack. The paramedics advised that Arthur should go with them to hospital for further investigation, however by this time he was feeling a little better. He also did not want to go to hospital and wait around for a bunch of tests that would not tell him anything new - he had experienced hypertension for many years and a bit of chest discomfort, but this always eased on rest. He hated being hooked up to machines and "drips". He and Elsie had talked about that neither of them wanted to be kept alive by some noisy ventilator. He refused further care and declined to go with the paramedics. He could manage on his own. As the paramedics were packing up to leave Arthur again experienced some chest pain and grimaced due to the pain. The paramedics attempted to reassess him, but he refused saying he would be going inside and lying down until his wife returned. She was a nurse, and he would be fine once she was home from her shift. The paramedics had to leave without completing a further assessment of Arthur. They stressed, at length, that it was in Arthur's interest to seek medical attention to find why the chest pain was occurring. Elsie When Elsie arrived home a few hours later she found Arthur unresponsive on their bed and called 000. He was cool and clammy to touch. Again, paramedics arrived quite quickly and assessed Arthur. He did not respond to voice or touch. They connected him to oxygen and ECG leads. His Glasgow Coma Score (GCS) was 4 - 5. They inserted an intravenous (IV) cannula into his left cubital fossa and commenced IV fluids. The ECG showed that Arthur was experiencing ventricular fibrillation. He was transported to hospital with lights and sirens, Elsie was bundled into the Ambulance to accompany her husband. She held his hand on route. He did not rouse during transport. Medical Assessment Once at the hospital, the medical team assessed Arthur, taking blood samples and inserting an indwelling urinary catheter. His GCS was unchanged. The nurses collected a urine sample from the catheter. Arthur was sent for a head and chest computerized tomography CT scan. The blood test results showed elevated troponin levels that indicated Arthur had experienced a significant blockage to his heart resulting in a myocardial infarction. The head CT showed he had also suffered a severe stroke to the right side of his brain. The initial results of his medical assessment indicated it was unlikely he would regain consciousness. He was triaged to the intensive care unit (ICU) following his CT scans and placed on respiratory support, a heparin infusion and supplemental IV fluids with glucose. He was diagnosed as being in a comatose state, a "persistent vegetative state". The medical team was of the opinion that any further treatment would have no real therapeutic benefit and could be more harmful. It was not in Arthur's best interest to continue. The team propose removing the respiratory support, IV therapy and heparin infusion. Elsie and Decision Making The medical team discussed the situation with Elise. She was in shock about how sudden Arthur's health had deteriorated. The Registrar was kind and recognised her shock, providing somewhere for her to sit and digest the situation. He asked if Arthur had an Advanced Health Directive at all, or an enduring power of attorney. Elsie revealed he had meant to get around to it but had not yet. After a long discussion with the Registrar, an Acute Resuscitation Plan (ARP) with a do-not-resuscitate order covering subsequent cardiac arrest or further evidence of stroke was put in place. She understood the reasons for this as she had been a nurse for a very long time. Elsie was documented as agreeing with the ARP in Arthur's medical notes. She understood that prolonging treatment could do more harm than good. She is aware that Arthur would not want to suffer or be in pain. They had both discussed not wanting to be "hooked up to machines and kept alive". Aiden and Rebecca Elsie called Rebecca letting her know what had happened and asked her to bring Aiden to the hospital as soon as possible. Rebecca said she was in the surgical waiting room at the hospital, and that she had been trying to call, but Arthur wasn't answering his phone and neither had Elsie. Aiden had been in a cycling accident on his way home from school and was currently undergoing surgery for a broken fibula and tibia of his left leg. She had no idea who had consented to the surgery. Neither did Elsie. Rebecca decided to wait for Aiden to come out of surgery while Elsie waited with Arthur. Once Aiden was out of recovery and admitted to the surgical ward, he was able to tell her that he had been bought in by ambulance after being knocked off his bike by a car that had not seen him. The doctors assessing him had tried to contact his parents and sister but had been unsuccessful. They had asked if he was okay with having an x-ray of his leg because they thought it was broken based on the paramedic's assessment and his pain level. Aiden said he had agreed because he knew why they wanted the x-ray. The doctors were correct, his leg was broken, and he had a big laceration from his left check to his shoulder that would need stitches with both wounds requiring surgery. They had discussed the risks and benefits of surgery and he had understood what they wanted to do. So, he had agreed. Rebecca took all this in and wondered if the doctors had overstepped the mark; shouldn't they have waited until someone was available? She would have to worry about that later. She paid for Aiden to have the TV on in his hospital room and headed to the ICU. Rebecca and Decision Making Once there, Elsie explained about the ARP and decision not to take heroic measures if Arthur experienced another myocardial infarction or if his stroke worsened. Elsie recognised that it was preferable to allow Arthur his dignity and pass away peacefully. Rebecca was of the opinion that her father seemed fine, and that he only looked like he was sleeping in the ICU bed. She disagreed with the ARP and believed that active treatment should continue. Aiden was too young to lose his father and she wanted the treating team to try everything before just giving up on Arthur. She could see he had IV fluids running and was hooked up to something in a long syringe called Heparin. If he was so bad, why would he have that stuff attached to him? She is unable to accept the clinical assessment that Arthur will not regain consciousness and wants all measures taken to keep him alive so he can recover. Ethical Problems and Decision Making

Question 1: With Arthur now in a "persistent vegetative state" and any aggressive treatment could potentially harm him further, progressing with the current treatment is futile. The treating team therefore decides that withdrawal of treatment is the correct option and to create an ARP with a do- not-resuscitate. a. Using the Universal Declaration on Bioethics and Human Rights (Articles 3-7), identify one principle that is reflected in Arthur's medical team's clinical assessment of his situation. Describe what it requires to influence the medical decision made. b. Discuss how your selected principle may be used to guide decision making in relation to Arthur.

Question 2: Choose one value from the list provided below. Find two peer reviewed journal articles that discuss your chosen value.

• Both journal articles should discuss the ONE value you have chosen from the list provided.

• Discuss your chosen value with support of your discussion from your chosen journal articles.

• In your answer discuss why this value would apply to Elsie. (You should use the journal articles as your in-text referencing support, and they should be included in the reference list). i. Compassion ii. Respect iii. Hope

Question 3: Discuss one value that Rebecca may have about Arthur's situation? As for question 2, support your discussion with two peer reviewed journal articles about your value. Your value must be different from the previous questions.

Question 4: Analyse how the different values held by Elsie and Rebecca contribute to their different points of view about Arthur's care. Use peer-reviewed literature to inform your understanding of the two values. Legal Considerations and Decision Making: Legal considerations have a process that may be found in the relevant legal authority. Consider each legal authority that applies to questions 5 - 9.

Question 5: Aiden found himself in a situation where no adult could speak or consent to medical treatment for him. Refresh your memory about Aiden's surgery and the actions of the medical team caring for him by reading the case study again.

a. Discuss which legal authority was relied on by the surgical team to accept Aiden's consent for the surgery to his broken leg and laceration?

b. Include in your discussion how this legal authority applies in Australia - you MUST include the relevant legal authority.

Question 6: Arthur's refusal to be treated by the paramedics was a cause for concern as his medical condition deteriorated.

a. In relation to Queensland law, discuss whether the paramedics are legally liable for treating Arthur while he was unresponsive in his home when he had refused treatment earlier in the day

b. Discuss the rationale for the legal obligation to obtain consent to provide healthcare treatment to patients.

Question 7: Adults who do not have decision-making capacity cannot provide consent. Elsie was required to consent on Arthur's behalf as a substitute decision maker.

a. Identify all potential substitute decision-makers that health practitioners could rely on to provide consent for treatment. You must demonstrate your understanding of the Queensland legal authority that applies here and reference it correctly.

Question 8: Under the Queensland Guardianship law, describe the factors that must be considered by substitute decision makers when making decisions about medical treatment for someone such as Arthur. Your answer MUST include application of the facts and the relevant legal authority.

Question 9: Rebecca does not agree with Elsie's choice and decision about the ARP for Arthur. There is a course of action the medical team can take in this situation to potentially provide consent for treatment of Arthur if this disagreement continues.

a. explain the course of action that applies when there is a disagreement amongst two or more substitute decision-makers.

b. If legislation applies here, include it in your explanation.