Ethical Dilemmas: Jamilah Shah
COMPETENCIES
3048.1.4 : Ethical Dilemmas
The graduate evaluates ethical dilemmas in healthcare.
INTRODUCTION
Task 1: Ethical Dilemmas Essay
Ethical and legal problems arise in healthcare organizations when the decision-making capacity of an elderly patient is uncertain, particularly when the patient’s decisions are at odds with the rest of the family’s preferences. The scenario provided here is about this type of situation.
This performance assessment will provide you with experience in sorting through the sometimes-competing issues related to a scenario such as the one described, as well as experience in formulating actions that can help guide a healthcare organization through ethical problems that arise in caring for elderly patients.
Note: Students may rely on conversations and notes gleaned from cohort lectures and Boot Camp.
SCENARIO
You are the healthcare administrator at a local hospital. A social worker has come to you to discuss the case of Jamilah Shah, a patient who has recently been admitted to the hospital. Jamilah is a 90-year-old woman who was brought to the hospital after collapsing at the side of her bed. EKG and lab tests revealed a heart attack.
More than 40 years ago, Jamilah emigrated with her wealthy husband (now deceased) and their three sons from Turkey to the United States. Jamilah was a homemaker and learned only basic English, but her children are fluent English speakers. The children are now all in their 50s. The family retains Turkish culture and norms, including the sons acting as patriarchs for the family. Even though Jamilah is highly educated (in Turkey she was trained as a lawyer), the sons make many of the family decisions. Two of the three children are in successful careers. The remaining child, the youngest son, Bashir, owns a small market and struggles financially.
Until yesterday, the day of her admission, Jamilah resided in an extended care facility (ECF), where she has lived since her husband’s death. She reportedly has severe chronic obstructive pulmonary disease and adult-onset diabetes mellitus.
Jamilah has no advance directives on file. Because of her communication difficulties, the emergency department physician started her on anticoagulants while trying to contact her next of kin. The ECF sent paperwork to the hospital, listing Bashir as the emergency contact. Bashir was contacted and is now at the hospital with his two brothers. He has informed the care team that he is the decision maker, and he wants his mother to have a Do Not Resuscitate (DNR) order with no intervention of any kind other than comfort care.
The social worker has come to you with concerns that this decision may not reflect Jamilah’s wishes. When the social worker was visiting with Jamilah alone, Jamilah reached for her hand and said, “Please help me. I want to live.” The social worker shares concerns about the interactions observed between Jamilah and her sons, stating that the relationships seem unsupportive. The hospital’s ethics committee has not yet been involved. The social worker also reports that the emergency physician requested a cardiology consultation, which was just completed. The consultant documented that “Because the family has requested only comfort care, and due to the patient’s multiple comorbidities, the patient will be managed medically, with no intervention, and will not receive cardiac catheterization or be considered for coronary bypass surgery.” If nothing is done, Jamilah will likely die within days.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
Note: Complete these prompts by using complete sentences.
Note: The web links “Advance Directives” and “Determining Competency for Medical Decisions” found below may be used to assist you in completing this assessment.
A. Write an essay (suggested length of 5–7 pages, not including attachments). Do the following:
1. Describe three potential ethical dilemmas presented in the scenario: one related to autonomy, one related to beneficence, and one related to non-maleficence.
a. Analyze legal implications associated with each of the potential ethical dilemmas described.
2. Referencing the scenario, complete the attached “Questions Derived from the University of Washington Paradigm.” Using those answers, describe, in the essay, what happens when following each of these courses of action:
• Course of action 1: Follow Bashir’s wishes
• Course of action 2: Refuse to follow Bashir’s wishes
• Course of action 3: Briefly delay the decision to gather additional information and other perspectives
As a part of the description of what happens when following each of the courses of action, if a question is not applicable for a given course of action, explain within your essay why it is not applicable.
Note: The completed “Questions Derived from the University of Washington Paradigm” should be included as an attachment to your task submission rather than in the body of the essay itself.
3. Putting yourself in the role of healthcare administrator, describe in the essay what should happen next within the scenario by doing the following:
a. Describe two resources that could have made or could still make Jamilah’s wishes more clear.
i. Explain how each resource could have made Jamilah’s wishes more clear.
b. Choose and justify the correct course of action (in response to Bashir’s demands for only comfort care):
• Course of action 1: Follow Bashir’s wishes
• Course of action 2: Refuse to follow Bashir’s wishes
• Course of action 3: Briefly delay the decision to gather additional information and other perspectives
i. Choose one of the courses of action from prompt A3b that you did not justify and explain how possible consequences show that it is not the correct course of action.
4. Create three policy recommendations that you could make as an administrator to help your employees and the facility’s medical staff handle similar situations in the future.
a. Justify each policy recommendation.
Note: You may use laws, regulations, and/or ethical principles as recommendations in part A4 and as part of your justification in part A4a.
B. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
File Restrictions
File name may contain only letters, numbers, spaces, and these symbols: ! - _ . * ' ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg, wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z
QUESTIONS DERIVED FROM THE UNIVERSITY OF WASHINGTON PARADIGM
Course of Action One – Follow Bashir’s Wishes
MEDICAL INDICATIONS
The Principles of Beneficence and Non-maleficence
• What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
• Using this course of action, describe, in full sentences, necessary considerations via
1. beneficence
2. non-maleficence
3. autonomy
• In what circumstances are medical treatments not indicated?
• What are the probabilities of success of various treatment options?
• In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy
• Has the patient been informed of benefits and risks, understood this information, and given consent?
• Is the patient mentally capable and legally competent, and is there evidence of incapacity?
• If mentally capable, what preferences about treatment is the patient stating?
• If incapacitated, has the patient expressed prior preferences?
• Who is the appropriate surrogate to make decisions for the incapacitated patient?
• Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of Beneficence, Non-maleficence, and Respect for Autonomy
• What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
• On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
• What ethical issues arise concerning improving or enhancing a patient’s quality of life?
• Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
• What are plans and rationale to forgo life-sustaining treatment?
• What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness
• Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
• Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
• What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
• Are there financial factors that create conflicts of interest in clinical decisions?
• Are there problems of allocation of scarce health resources that might affect clinical decisions?
• Are there religious issues that might affect clinical decisions?
• What are the legal issues that might affect clinical decisions?
• Are there considerations of clinical research and education that might affect clinical decisions?
• Are there issues of public health and safety that affect clinical decisions?
• Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?
Course of Action Two - Refuse to Follow Bashir’s Wishes
MEDICAL INDICATIONS
The Principles of Beneficence and Non-maleficence
• What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
• Using this course of action, describe, in full sentences, necessary considerations via
1. beneficence
2. non-maleficence
3. autonomy
• In what circumstances are medical treatments not indicated?
• In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy
• Has the patient been informed of benefits and risks, understood this information, and given consent?
• Is the patient mentally capable and legally competent, and is there evidence of incapacity?
• If mentally capable, what preferences about treatment is the patient stating?
• If incapacitated, has the patient expressed prior preferences?
• Who is the appropriate surrogate to make decisions for the incapacitated patient?
• Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of Beneficence, Non-maleficence, and Respect for Autonomy
• What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
• On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
• What ethical issues arise concerning improving or enhancing a patient’s quality of life?
• Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
• What are plans and rationale to forgo life-sustaining treatment?
• What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness
• Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
• Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
• What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
• Are there financial factors that create conflicts of interest in clinical decisions?
• Are there problems of allocation of scarce health resources that might affect clinical decisions?
• Are there religious issues that might affect clinical decisions?
• What are the legal issues that might affect clinical decisions?
• Are there considerations of clinical research and education that might affect clinical decisions?
• Are there issues of public health and safety that affect clinical decisions?
• Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?
Course of Action Three- Delay Treatment
MEDICAL INDICATIONS
The Principles of Beneficence and Non-maleficence
• What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
• Using this course of action, describe, in full sentences, necessary considerations via
1. beneficence
2. non-maleficence
3. autonomy
• In what circumstances are medical treatments not indicated?
• In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy
• Has the patient been informed of benefits and risks, understood this information, and given consent?
• Is the patient mentally capable and legally competent, and is there evidence of incapacity?
• If mentally capable, what preferences about treatment is the patient stating?
• If incapacitated, has the patient expressed prior preferences?
• Who is the appropriate surrogate to make decisions for the incapacitated patient?
• Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of Beneficence, Non-maleficence, and Respect for Autonomy
• What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
• On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
• What ethical issues arise concerning improving or enhancing a patient’s quality of life?
• Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
• What are plans and rationale to forgo life-sustaining treatment?
• What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness
• Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
• Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
• What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
• Are there financial factors that create conflicts of interest in clinical decisions?
• Are there problems of allocation of scarce health resources that might affect clinical decisions?
• Are there religious issues that might affect clinical decisions?
• What are the legal issues that might affect clinical decisions?
• Are there considerations of clinical research and education that might affect clinical decisions?
• Are there issues of public health and safety that affect clinical decisions?
• Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare
Ethical Dilemmas: Jamilah Shah
Name:
Institution:
Due Date:
Ethical Dilemmas: Jamilah Shah
Describe three potential ethical dilemmas presented in the scenario: one related to autonomy, one related to beneficence, and one related to non-maleficence.
An ethical dilemma is a problem that arises in making the best decisions about two or more complex scenarios that will breed different consequences which are not acceptable to the parties affected ethically (White, 2014). In Jamilah Shah's case, there are three potential ethical dilemmas. First, there is a possibility of Jamilah Shah recovering which is her solemn wish based on the statement she gives to the social worker (autonomy). Based on the principles of healthcare, it is upon the medical practitioner to ensure that the patient's needs are addressed first at all times. Jamilah has no underlying mental condition. Her decision to live is of sound mind and shows that she is willing to fight her disease. It is upon the medical health practitioner to ensure that this need is addressed. If the hospital or healthcare professionals have a different opinion at all, they are required to share the same with the patient. However, the final decision has to be left with the patient or their next of kin. The principle of autonomy is legally binding, and a healthcare organization will be called to answer upon reports they have infringed on a patient's rights. For example, if a patient requests for a DNR and while issuing the said instructions, they were in their right mind, then the healthcare professionals have to obey the same. If not, they are to be held accountable before the law.
The second ethical dilemma is based on Bashir's decision, her son and next of kin, who wants the doctors not to attempt to revive her; that is, he wants a Do Not Resuscitate (DNR). Bashir wants his mother to be given the best medical care possible with the least disturbance possible. This is called non-maleficence. This means that the patient is given the best medical care possible without necessarily disturbing her peace in case her time of death draws near. If it happens that this principle is not adhered to, the patient or their family could sue the healthcare organization. The principle of non-maleficence dictates that no harm should befall the patient during treatment. So, if it happens that the patient is taken through a great deal of pain courtesy of the mistakes and issues within the healthcare organization, the patient could take legal action.
Finally, the healthcare administrator can wait and gather additional information on the issue before arriving at a conclusive decision that best suits both parties. This is called beneficence, and it entails acting for the benefit of the patient. It infers that healthcare professionals must ensure that their actions are geared towards protecting the patient, preventing harm, and providing a healthy environment. The above aspects mainly constitute the quality of care that a patient gets to receive while in a healthcare establishment. If the said conditions or quality of care infringes on their healthcare physically or otherwise, a patient could decide to sue the establishment. The hospital environment, as well as the decisions made, need to be patient-centered, and with a touch of safety concerns. However, if these are not adhered to, the patient could sue the hospital and maybe report how the hospital environment infringed on their mental wellbeing.
Describe, in the essay, what happens when following each of these courses of action:
The first course of action: Follow Bashir's wishes.
When the health administrator follows Bashir's wishes not to resuscitate his mother, it means that the mother's desire to live has been drastically minimized too when she gets a heart complication again based on her disease. This will lead to Jamilah's death within a matter of days, based on the extract.
The second course of action: Refuse to follow Bashir's wishes
When the health administrator ignores Bashir's wishes, this gives Jamilah a fighting chance in case she gets another heart attack. Unfortunately, this will cause strive between the health administrator and Bashir because his concern has not been addressed.
The third course of action: Briefly delay the decision to gather additional information and other perspectives.
This is another good course of action because it gives the healthcare practitioners involved in Jamilah's case to develop other alternatives or treat her. Unfortunately, it inconveniences both the patient and her next of kin. There is a lot of uncertainty in both cases. Jamilah wants to live based on what she told the social worker, and not arriving at a reasonable choice immediately increases her chances of demise since there is a likelihood she will die soon. On the other hand, Bashir wants his mother to be given the best care immediately even though he does not want her to be resuscitated in case of any cardiac complications. There is an urg...