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Chapter 11
Suggestions for Thought
Case Presentation
Determining What Is Best for the Patient
Mr. Zumma, a former butcher who is 84 years old, has had evidence of memory loss and
periodic confusion for about 18 months. He has been functional at home, able to do personal
care, household chores, and shopping, and has been on no medication. One night he came into
the bedroom with two straight razors and told his wife to stay still so he could slit her throat. She
was able to escape by exiting through a nearby door and running to a neighbor’s house. Reluctant
to call the police because “he is not a criminal,” she called her son, who came and calmed his
father down. On the advice of another family member, Mrs. Zumma contacted a geriatric
psychiatrist, who immediately hospitalized Mr. Zumma and started him on Haldol. When he got
worse, the physician increased the dose of the medication. Although he was walking and talking
when he was admitted, after 1 day in the hospital the patient became incontinent, could not walk,
was drooling, and had to be restrained. The decline in his condition throughout the week in the
hospital concerned Mrs. Zumma, and she approached the psychiatrist about taking him on a
previously planned vacation. The psychiatrist indicated that this would be impossible, and that
the patient would need to go to a nursing home. With persistence, however, Mrs. Zumma was
able to convince the psychiatrist to discontinue the medications, after which Mr. Zumma’s
condition improved and he walked out of the hospital and did well on the vacation trip. Although
he still gets confused, he remains functional without medication at home, where his wife makes
sure that all sharp or dangerous objects are kept hidden.
Think About It
When Interventions Do More Harm Than Good
•
How did the physician’s attitude of “knowing what is best” factor into the case of Mr.
Zumma?
It is evident that the treatment prescribed by the physician had an adverse effect on Mr.
Zumma. How might an attitude of “knowing what is best” for a patient may make a
practitioner less than willing to re-evaluate the treatment and consider that it may need
to be reviewed and revised? How might Mr. Zumma’s outcome have been different if his
wife had not persisted in urging the physician to discontinue the medication?
•
What ethical issues are evident in this case?
One issue is the conflict between trying to do good (giving the medication) and avoiding
causing harm (the adverse effects). Although the medication was given in part to promote
patient (and staff) safety, it also caused harm to the patient. Consider other issues related
to patient autonomy, advocating for what is best for the patient, and working in
partnership with families.
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•
If you were the nurse caring for Mr. Zumma, and his wife approached you with her concerns
about his condition, how would you respond?
In your response consider the qualities and skills noted in Resource 5 of the introduction.
How would qualities like empathy, attentive listening, caring presence, and others be
incorporated into your response? Role-playing this scenario with classmates may be
helpful as you deliberate your response.
•
Describe patient and family values that you believe influenced decisions about Mr. Zumma’s
care.
Consider values such as respect for persons, loving relationships, being there for each loved
ones, and others.
Case Presentation
Language and Informed Consent
Mohano is a 67-year-old deaf man who was admitted to the hospital with atrial fibrillation. The
nurse notes that he is alert, apparently oriented, and able to follow simple directions that she acts
out, although he does look apprehensive as she cares for him. Mohano’s social history indicates
that he was brought into the hospital by a community worker who looks in on him because he is
deaf and illiterate and has no family in the area. She indicated that he came to the area as a
migrant worker a number of years ago, along with a brother who died the previous year. She also
noted that two of his five siblings were also deaf, and they had developed a type of sign language
that was understood only by family members. At the interdisciplinary care conference, the
medical resident who is in charge of his case voices frustration because of the need to get the
patient’s permission to do a stress test and to talk to him about medications and risk for stroke.
She suggests that they should just get the patient to make an X on the form so they can go ahead
with the treatment protocol, because it is in the patient’s best interest to do so. The social worker
suggests that they get an interpreter for the deaf to come in and try to talk to him through sign
language, although she is not sure he will understand.
Think About It
Obtaining Informed Consent When There Is No Common Language
•
What ethical dilemmas are evident in this case?
This case illustrates a number of ethical concerns. As you review the ANA Code of Ethics
for Nurses pay particular attention to Provisions 1.1, 1.4, and 2.1 and how lack of a
common language between nurse and patient creates potential barriers to providing safe
care. Review as well ethical principles, particularly respect for persons, respect for
autonomy, beneficence and nonmaleficence. Consider the conflict between the
physician’s sense of doing what is best for the patient and the patient’s right to selfdetermination.
•
What do you think about Mohano’s decision-making capacity?
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As you reflect on this question consider that Mohano has been making decisions
regarding his life. Appreciate as well that the challenges in communicating choices does
not necessarily imply the inability to make appropriate choices.
•
Do you think it is possible to obtain an informed consent from Mohano? Support your
position with discussion of elements of informed consent and decision-making capacity. Are
there things clinicians can do to help Mohano understand his health situation?
Incorporate into your answer information summarized in Box 11.1 -The Content of
Informed Consent. Consider whether you think these required elements can be achieved
with Mohano. Be creative in identifying ways to communicate with him. Review Step 2 of
the Decision-Making Model. Consider who is legally empowered to make decisions in
this situation. It is also important to consider other key participants such as the
community worker and any friends he may have.
•
In a situation such as this, it is evident that the patient has a language, although it is not
understood by the health care providers, and that he has been able to care for himself with
some assistance. How would these factors enter into determination of his decision-making
capacity?
It is evident that these would be important factors to consider. Review Box 11.2 Elements
of Decision-Making Capacity. How might these elements be assessed in Mohano’s case?
Much of the concern revolves around the inability of heath team members to
communicate effectively with the patient. Do you think this justifies making decisions for
the patient?
•
How does the inability of the health care provider to communicate with a patient affect
determination of the patient’s decision-making capacity?
As you reflect on this question consider the directive that nurses have a primary
commitment to the patient and must advocate for the health and safety of the patient. An
ethnocentric attitude would suggest that patients should see things from the same
perspective as health care providers. The fact that the patient does not communicate in
the same way as the health care providers, although frustrating for all, does not give
providers the authority to override his self-determination.
•
What are the implications of denying Mohano important services because of lack of common
language and subsequent inability to ensure informed consent?
As you reflect on this question consider the impact on his overall health. Discussing this case
with classmates can help you see a broader perspective and consider creative approaches to his
care.
Case Presentation
Terri Schiavo
The well-publicized case of Terri Schiavo illustrates a number of ethical issues regarding end-of-
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life care decisions made in the absence of advance directives. It is an example, as Quill (2005)
notes, of medicine, ethics, law, and family working together poorly to meet the needs of a patient
in a persistent vegetative state. Terri Schiavo had a cardiac arrest in 1990, reportedly triggered by
severe hypokalemia related to an eating disorder, and was left paralyzed and severely brain
damaged. For 15 years she was sustained by artificial nutrition and hydration via feeding tube.
Reports of her neurological exams indicated that she was in a persistent vegetative state, which
includes some reflexive response to noise and light, basic gag response, and periods of
alternating sleep and wakefulness, without signs of cognition, emotion, or willful activity. In the
absence of advance directives, her husband was made her legal guardian and health care
surrogate. Reports indicate that the relationship between Ms. Schiavo’s husband and her family
(parents and siblings) had been strained since around 1993, and that they held vastly different
opinions about what Ms. Schiavo would want and should have. Based on reports of medical
experts and diagnostic tests, the state court of appeals ruled that there was clear and convincing
evidence that supported the diagnosis of a persistent vegetative state. Stating that his wife would
not want to be kept alive indefinitely in this condition (because of a reported statement she had
made when she was cognizant that she would not want to be kept alive on machines), her
husband requested that the feeding tube be discontinued. Ms. Schiavo’s family, however, found
other medical practitioners who believed that her condition could improve with therapies (for
which there was no research evidence), and they would not accept the diagnosis of persistent
vegetative state. Between 2001 and 2003 the courts authorized removing the feeding tube two
different times, ruling that the evidence showed that she would not have chosen life-prolonging
interventions given her condition. Because of legal action initiated by her family, the tube was
reinserted each time. In the midst of an ongoing legal battle (during which a guardian ad litem
was appointed) and massive media attention, public debate, and political and religious rhetoric,
her feeding tube was again removed March 18, 2005. Multiple legal appeals to reinsert the tube
were denied, and she died 13 days later.
Think About It
• What do you see as the ethical issues in this case?
Review ethical principles discussed in Chapter 3 from the perspectives of all involved.
Consider, for example, whether continuing life support is of benefit to the patient (doing
good), or causing potential suffering (avoiding harm). How might providing care that is
perceived as possibly causing suffering for a patient cause an ethical dilemma for a
nurse? If, as the husband indicated, she would not want to be kept alive in this condition,
how is patient self-determination potentially being violated?
• What is your opinion of the ethical nature of the various decisions that were made? What
values, beliefs, and information have shaped your opinion?
As you deliberate your response, consider factors such as your beliefs about who should
be empowered to make decisions in this situation, sense of quality of life, suffering,
medical futility, and understanding of ethical principles. There is no right or wrong
response and you may find merit in aspects of each decision. Discussing with
classmates may help you clarify your personal perspective and consider other
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perspectives as well.
• Based on your understanding of the case, if you were appointed guardian ad litem for Ms.
Schiavo, what would you recommend regarding life-sustaining measures? Support your
position with what you understand to be the facts in the case and the ethical reasoning that
would guide your recommendation.
This question is meant to make you reflect and think about the emotional and factual
elements of this case. Pay attention to your emotional reaction to the situation. Also be
objective in looking at the facts as presented. Apply the Ethical Decision-Making
Model as a way to gather data and identify conflicting moral claims and explore
potential strategies. Discussing this with classmates may help you clarify your position
while seeing other perspectives.
• How might have Ms. Schiavo’s end-of-life care been different if she had completed advance
directives?
Consider her personal care, the ways the family dynamics affected her care, and the
impact on nurses and others providing her care.
• Quill (2005) notes that the media coverage, distortion by interest groups, and emotional
overtones associated with this case show what can happen when someone becomes more of a
precedent-setting symbol than a unique human being. How do you feel about public treatment
and discussion of a situation such as this? How do you think you would have felt if she were
your family member?
It might be helpful to first consider how you would feel if this were your family member.
Then consider the impact of media coverage on all those involved in her care and
making decisions about her care.
• How might you deal with a situation in which family members of a patient who is terminally
ill (and unable to make decisions for self) or in a persistent vegetative state hold vastly
different views of both the patient’s condition and of what the patient would want regarding
end-of-life care?
Use the Ethical Decision-Making Model to guide you in this process, particularly in
regard to gathering data and exploring potential strategies. Discuss qualities and
skills of the nurse that would facilitate this process, such as being non-judgmental,
attentive listening, incorporating elements of a therapeutic nurse-patient relationship.
Role-playing the scenario with classmates can help you gain insight into ways to
approach the situation.
• How might the health care system, ethics, law, and the family work more effectively together
to preserve the dignity and meet the needs of a patient in Ms. Schiavo’s condition?
Consider the kind of information about a patient’s condition and realistic prognosis that would
help family members make decisions. Consider as well how personal beliefs (of family and
health care providers), emotional responses, cultural and religious perspectives, and the like
contribute to the dialogue about end-of-life decisions.
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Case Presentation
The Absence of Advance Directives
Ninety-year-old Mr. Moshe did not have advance directives when he was admitted to the
hospital with Alzheimer’s disease and renal failure. Although he was coherent at times and could
converse with caregivers, the doctor determined that Mr. Moshe did not have decision-making
capacity and named his daughter Zelda, with whom he had been residing, as his surrogate. The
nursing staff questioned this choice because of their concerns about the quality of care Mr.
Moshe had been receiving from Zelda and her husband Josh. As Mr. Moshe’s health began to
deteriorate rapidly, the nurses inquired about his DNR status. Josh replied he wanted Mr. Moshe
kept alive, and that this was what Mr. Moshe wanted also. Zelda concurred with this. Although
Zelda’s four siblings called frequently inquiring about their father, Zelda would not inform them
about their Mr. Moshe’s condition nor allow them access to him. Because of this conflict and
their concerns regarding the motives for his DNR status, the nurses notified the physician about
the family issues and requested an ethics committee consultation to determine the best interests
of the patient. The nurses also noted that the physician had not signed the surrogate form as
required by their state law, so legally there was no surrogate. The ethics committee
representative convened a family meeting that included all five siblings, the physician, the
primary nurse, and a member of the pastoral care team. After explaining that the purpose of the
meeting was to discuss the type of care that would be in the best interests of their father, not to
resolve family issues, the physician was asked to discuss Mr. Moshe’s current health status and
prognosis. All of the children were given the opportunity to ask questions of the physician and
primary nurse. Then each family member was asked to voice what their father valued in life, and
what they believed to be his wishes regarding end-of-life care. Even though some of the siblings
had not spoken to each other for nearly 10 years, they each stated that their father had told them
he would never want to be on life support. Zelda, who was asked to speak last, agreed, much to
the dismay of her husband, that her father would not want to be placed on life support. The
siblings also requested that they be allowed to visit their father and to call and check on him.
When they were informed that there currently was no legal surrogate for their father, they all
agreed to have Zelda continue in that role, providing that she allow them access to him. They
stated that even though they were upset with her, they believed she loved him and provided good
care for him. To close the meeting all family members were invited to go join together at their
father’s bedside, where they shared prayer and family stories. Mr. Moshe died that night.
Think About It
Considering the Patient’s Best Interests
• Because Mr. Moshe was coherent at times, do you think the physician should have asked him
what he would want regarding life support?
Review Box 11.2 – Elements of Decision-Making Capacity. Incorporate your knowledge
of decision-making capacity and principles of patient self-determination into your
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deliberation on this question. Discussing your reflections with classmates may help
you clarify your thoughts and consider other perspectives.
• What do you think of the physician’s choice of a surrogate for Mr. Moshe? What factors do
you think he considered in appointing Zelda as surrogate? Are there factors you think he
should have considered that he may not have?
Consider, for example, that Mr. Moshe had named Zelda as his surrogate and that she
had ongoing close personal contact with him. Also consider that there was some
question about the quality of care he was receiving from Zelda. As you deliberate your
response to this question review the legal process for choosing a surrogate in your
state at http://www.caringinfo.org/i4a/pages/index.cfm?pageid .
• As the nurse caring for Mr. Moshe, what would be your concerns regarding his situation? How
do you think you would have responded in this situation?
Incorporate your knowledge of the ANA Code of Ethics for Nurses, particularly
Provisions 1, 2, 3, and 4 into your response to this question. Also include qualities and
skills of the nurse that would facilitate your response.
• How did the process of the family meeting address the communication that is needed for
making end-of-life decisions?
Delineate specific aspects of the family meeting that facilitated communication among the family
members and encouraged collaborative decision-making focused on the primacy of the patient’s
interests.
Case Presentation
A Challenging Patient
Rochelle, a 36-year-old woman who is a known cocaine addict, presented to the emergency room
(ER) with severe left leg pain and swelling. The triage nurse reviewed her chart and presenting
problem, noting that she had been seen 2 days prior for chest pain and left leg pain. Assuming
these complaints were evaluated then, the nurse sent her to the “fast track” area to be seen by the
nurse practitioner (NP). The NP noted that her chart was flagged regarding her cocaine addiction
and that the physician who had seen her at the previous visit, after doing an EKG, CBC,
electrolytes (which were normal), and a urine drug screen (which was positive for cocaine),
discharged her with diagnoses of chest pain and illicit drug use. The NP’s assessment revealed
no shortness of breath, cough, or chest pain. Severe swelling and skin tightness of the left leg,
with exquisite tenderness and positive Homan’s sign, were suggestive of deep vein thrombosis.
When the NP went to the ER physician saying that the patient needed to be evaluated by him,
she was told to keep the patient over there and do the work-up because he had a patient with a
similar problem in the ER.
When the ultrasound confirmed extensive deep vein thrombosis, the NP told the patient the
situation and that she needed to be hospitalized. The patient immediately said that she could not
stay because she had no one to watch her 9-year-old daughter, and she began to put on her shoes
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to leave. The NP told her that she could choose to leave but that the reason she (the NP) wanted
her to stay was that this was a very serious problem from which she could die. Rochelle’s
response was to start crying, saying that she thought she would go home anyway because she had
nothing to live for since her husband had died, so she would go home to die. When the NP called
Rochelle’s primary physician to alert him to the situation, he responded that he would come in to
see her only if Rochelle agreed to stay; otherwise, it would be a waste of his time. After
considerable effort, the NP contacted Rochelle’s mother, who reluctantly agreed to keep her
granddaughter when the NP explained the situation, and Rochelle agreed to stay.
Think About It
Dealing with Patients Who Make Apparently Unhealthy Choices
• What issues of patient self-determination are evident in this case?
Consider Rochelle’s choices in relation to the impact on her health as well as in relation
to what the nurse feels is doing good for her. Where do you see conflict among ethical
principles in this situation?
• How do you see lifestyle choices affecting Rochelle’s care? What ethical issues must be
considered here?
It is evident that her use of drugs is affecting both her health and her health care choices.
Incorporate into your response discussion of the interaction of ethical principles,
particularly beneficence, nonmaleficence, respect for autonomy, and justice. We
encourage you to reflect as well on how personal lifestyle choices affect your own
health and well-being.
• Take an honest look at how you think you might react to Rochelle, knowing that she
frequently shows up in the ER and is a cocaine addict.
Situations such as this elicit a variety of immediate reactions. As you reflect on your
response we would hope that you seriously consider any personal tendencies to
stereotype, judge, blame, and the like, as well as aspects of compassion and respect for
the personhood of the patient. This is not meant for you to be judgmental or berating of
yourself, rather it is to promote deeper self-awareness.
• As the nurse in this situation, how would you deal with the patient’s saying she could not stay?
What do you think of the way the NP handled it?
At this point in your education you may not be sure how you would handle such a
situation. Discussing or role-playing this with classmates can give you an opportunity
to try out different approaches.
• Evaluate ethical issues involved in the responses of the various health care practitioners in this
case.
Review ethical principles of beneficence, nonmaleficence, respect for autonomy, and
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justice. How do you see the various practitioners acting in ways that would benefit or
potentially cause harm to the patient? Do you feel that all practitioners treated the
patient fairly? How did the various practitioners treat the patient with respect (or lack
of respect) and promote (or not promote) the patient’s best interests.
• Interestingly, Rochelle was indigent, African-American, and without health insurance, and the
woman in the ER with similar complaints was middle class, Caucasian, and had health
insurance. Discuss the implications of these factors in this case. What health disparities are
evident in this situation?
Recall that health disparities are discrimination or perceived discrimination in the
delivery of health care to groups of people that leads to a delay in seeking health care
and poor healthcare outcomes. These inequities in health outcomes are often based on
race, ethnicity, cultural background, immigrant status, gender, socioeconomic status
and the like. Give specific examples of such disparities in this case situation.
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