Ethics/CaseAnalysis-Mrs - Professional Portfolio



Ethics/CaseAnalysis-Mrs. Green

Lauretta Onwukwe

University of Texas medical Branch

Geriatric Syndromes and Psychosocial Issues of Older Adults

Dr. Rounds, Linda

October 7, 2011

ETHICS/CASE STUDY ANALYSIS PAPER (MRS GREEN)

The care of the elderly, especially those affected by Alzheimer’s disease poses some ethical issues. Ethical dilemmas occur when there are at least two conflicting choices of how to deal with something and neither leads to a positive outcome. In caring for a patient with end-stage Alzheimer’s disease who has severe cognitive impairment and physiologically and physically depreciated, the clinician is caught in these ethical dilemmas. Hence, it is very pertinent for a clinician to be aware of ethical principles such as autonomy, beneficence, non-malfeasance, and justice, otherwise known as four “prima facie” of ethical principles to guide him or her in decision making regarding medical interventions and treatment.

In the case of Mrs. Green, more research on Alzheimer’s disease slightly changes my opinion and decision regarding her care especially in the issue of tube feeding. Mrs. Green was in the late stage of Alzheimer’s disease which is characterized by loss of ability to remember, communicate, or process information, general incapacitation with severe to total loss of verbal skills, unable to care for self, immobility, problem swallowing, and incontinence. In fact, Alzheimer’s disease is the most common form of dementia, a serious brain disorder that impacts daily living through memory loss and cognitive changes (Robinson, L, Saisan J. &Segal J. 2011). There is currently no cure for this disease and the prognosis is very poor. A research by the New England Journal of Medicine on patients with advanced dementia shows that advanced Alzheimer’s disease is indeed a terminal illness and has poor life expectancy than for a patient with severe heart failure, terminal cancer, or major stroke. (Lipschitz, D. 2009). Due to the aforementioned, I would apply the principles of futility. I will first question the futility of nutrient treatment in end-stage Alzheimer’s disease. Technical provision of nutrition and hydration is medically ineffective and therefore unnecessary in late stage of Alzheimer’s disease. I would recommend the removal of tube feeding as a result discontinue restraint. An American physician in a clinical ethics consultation study stated “I think it’s futile (nutrition in end-stage Alzheimer Alzheimer’s disease) because preserving life of a severely demented person by putting a surgically implanted tube in them is to me pointless. I would not want this, number one. Number two, there's some medical evidence; there's growing medical evidence that it's not even effective at late stage Alzheimer's (disease)”. (Nagao, N. et al. 2008). He implies that medically administered nutrition and hydration simply prolongs the dying process and is meaningless to a patient with an advanced cognitive disease. This is relevant to Mrs. Green in which placement of gastrostomy tube (PEG) caused her a lot of complications, ultimately and indirectly led to her demise. We can ascertain from the above that nutrition did not improve her quality of life; it rather subjected her to torture and more agony. Then is the question of the rationale behind invasive procedure for end-stage Alzheimer’s patient against palliative care.

With the acquisition of broad knowledge of the characteristics of end stage Alzheimer’s disease, I would recommend palliative care for Mrs. Green. The purpose of palliative care is to improve the quality of life of patients and their families facing life-threatening illnesses, through the prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems. Palliative care provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten nor to postpone death. (Lofmark, R., Nilstun, T. & Bolmsjo, I. 2007). One of the critical issues for patient in the late stage Alzheimer’s disease is pain management and reduction of discomfort. Though, the patient is unable to report pain and discomfort, it is primarily the duty of the clinician to assess for pain and treat accordingly. Consideration of Mrs. Green’s religious belief should also play a significant role in her care. Being a catholic, it is deemed necessary to invite a Roman Catholic priest for blessing and prayer in accordance with her religious beliefs. In addition, music therapy should be employed especially playing her favorite music since she was a lover of music. Being at the end stage of Alzheimer’s disease in which death is imminent, I would suggest provision of comfort care to prepare her and significant others for end of life which is accomplished by palliative care rather than giving false hope by the placement of gastrostomy tube .

The four “prima facie” of ethical principles are of great significance in caring for incapacitated patients. These are patients that are unable to make informed medical decisions or choices due to severe cognitive impairment or other debilitating diseases. The four “prima facie” of ethical principles are autonomy, beneficence, malfeasance, and justice. Futility is another ethical principle that will be utilized in Mrs. Green’s case. The principles of autonomy refer to the duty to respect a patient’s right to self-determination (Ham, R. 2007). Justice Cardozo in one of his rulings stated “every human being of adult years and of sound mind has a right to determine what shall be done to his body” (. Ham, R. 2007). The most interesting thing in his ruling is sound mind. Decision-making capacity is a critical requirement in providing informed consent which calls for exercising autonomy. In Mrs. Green’s case, due to severe cognitive impairment, autonomous decision was eluded. She could not make any decision regarding her treatment, and unfortunately, has no advance directive and durable power of attorney. Nurses as patient’s advocate will make positive contribution based on the knowledge of the patient acquired through comprehensive assessment. The clinician, including other members of the medical team, and the family, should be cognizant of the benefits of any treatment regimen. The principle of beneficence refers to the clinician’s responsibility to provide benefit or help to the patient, i.e. “to do good.” (Ham, R. 2007). This implies that any medical intervention that provides no benefit should be avoided. I think that the principle of beneficence was not properly applied in the case of Mrs. Green. Placement of PEG tube did not benefit her at all. It neither improved her quality of life nor prolonged her life; rather it subjected her to an unimaginable situation that I believe none of us would like to be in. In essence, it is ethically inappropriate to render any medical treatment that will not benefit a patient especially the most vulnerable and mentally incapacitated that are unable to make informed decision concerning their health care.

The principle of nonmaleficence on the other hand states that throughout the physician-patient relationship, the physician shall “at the least, do no harm”. It is necessary for all clinicians to determine the objectives of an intervention and weigh them against the potential risk of adverse outcomes. (Ham, R. 2007). One will ask, what are the goals of PEG tube placement? Did the goals outweigh the risks? The risks of PEG tube placement on a patient with end stage Alzheimer’s disease outweigh the benefits; hence PEG tube placement wouldn’t have been done. The authors of all the articles I read agree that nutrient treatment and transfusion are not beneficial in prolonging life. It is then important for clinicians to have knowledge of the consequences of any decision made regarding patient’s care. The clinician should also consider the futility of any treatment and ask if the proposed treatment will yield the intended outcome. In the case of Mrs. Green, I wonder if such ethical consideration was put in place.

Though, Mrs. Green’s case is a very sympathetic and unfortunate one. The lesson learned will bring a change to the health care system. Her case was compounded with lack of advance directive; hence I would suggest that it will be significant for hospitals to incorporate advance directive and durable power of attorney in their admission process. Making informed decision regarding their healthcare when they are cognitive and competent will go a long way in saving clinicians from ethical dilemmas. Secondly, in a situation where clinician is left with making sole decision for a patient’s care, it is very imperative to employ ethical principles.

Reference:

Ham, R. J, Sloane, P.D, Bernard, M.A, & Flaherty, E. (2007). Primary care geriatrics: a case-based

approach. Philadelphia, Pennsylvania. Mosby.

Lipschitz, D. (2009). End stage Alzheimer’s requires good decision. Retrieved from



requires-good-decisions.htm. October 6, 2011.

Lofmark, R, Nilstum, T, & Bolmsjo, I. A. (2007). From cure to palliation: concept, decision, and

acceptance. Retrieved from

/?tool=pmcentrez. October 6, 2011.

Nagao, N at el. (2008). Clinical ethics consultation: Examining how American and Japanese

experts analyze an Alzheimer’s disease. Retrieved from

pmc/articles/PMC2268696/?tool=pmcentrez. October 6, 2011.

Robinsin, L, Saisan J., & &Segal, J. (2011). Alzheimer’s disease: symptoms, stages and coping

with alzheimer’s disease. Retrieved from

alzheimers_disease_symptoms_stages.htm. October 6, 2011.

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