Clinical Decision-Making - Essay Example

Key Features of the Case Dr. Chuck Smith who is a general practitioner comes from a vacation to find Mr. Tobias John one of his patients critically ill. Mr. John is 75 years old and has multiple illnesses which include heart failure and terminal COPD (Chronic obstructive pulmonary disease). Joan John who is Tobias’ wife of 50 years meets Dr. Smith at the hospital’s gate and frantically tries to explain the condition of his husband. She explains that her husband’s condition worsened and she was forced to call the ambulance to rush him to the hospital. At the hospital, Mr. John is put on artificial ventilation and the antibiotics prescribed to treat his pneumonia seem not to be effective. She had also been advised by the doctors handling her husband’s case to transfer him to the university hospital because his breathing condition was worsening. At the university hospital, chances of improving Mr. John’s breathing problems are high because they can perform tracheotomy. In order to collaborate Joan’s story, Dr. Smith checks the patient’s medical records and discovers that the doctor in charge has followed aggressive care from Mr. John and has been put on full code. The chart does not indicate any advance directive from Mr. John although two attempts had been previously made to wean or remove him from the ventilator. Dr. Smith is fully aware that it was not the wish of Mr. John to be put on continued care especially the tubing. On the other hand, Joan is also her patient and he knows that she is afraid of death. To add to this problem, the doctor is aware of the fact that the procedure of removing a ventilator is not very common at that small hospital and as such, there is no policy to govern terminal weaning. Two Legal Considerations in the Case All states have laws that govern the right of a person to make known his or her wishes with regards to medical treatment. While these laws with regards to end life decisions often vary, the preferences expressed in wills are upheld even in jurisdictions that do not regard recognise some documents. Withholding some therapies like artificial nutrition and hydration may be subject to specified requirements in certain jurisdictions. Moreover, some jurisdictions may specify some conditions that warrant a binding legal document. In other circumstances, the law may define and limit the scope of who can be a surrogate decision maker and the decisions that a surrogate can make without a written document. Health care providers are often expected to aid surrogates to make sound decisions based on healthcare values, patient’s desires and medical knowledge (Forrest and Quill, 2004, p. 710; Mitchell, S.L. et al. 2009, p. 1570). In this regards, one of the legal considerations of this case is the autonomy of the surrogate who in this case is the wife Mrs. Joan. Since the wife is the legally recognised surrogate or next of kin, she had all the rights to make the decisions she made. However, she may not have had the best experience and medical knowledge but his directives had to be respected and that is the reason why the hospital complied. On the other hand, the husband had no advance directive and therefore decisions could be made based on prevailing circumstances. The other legal consideration of this case is making of decisions that have no policies covering the issues involved. In this case, the hospital had no policies governing terminal weaning of ventilation. In such instances, a standard of decision making is usually used which balances between benefits and burdens of treatment in the light of the patient’s conditions and circumstances. Surrogates should make their decisions based on these standards except in circumstances where there are other viable expressed options or wishes. Surrogates do not have the authority to make medical or treatment decisions based on personal values unless there is specific directions in guardianship document (Hudson, Aranda and Kristjanson, 2004, p. 21; Trotzuk and Gray, 2012, p. 58). Two Ethical Considerations in the Case One of the ethical considerations of this case is to respect the wishes of the decisions that are made with regards to palliative care of the patient. On the one hand, there was no advance directive by the patient and therefore the surrogate or next of kin Mrs. Joan had to make all decisions. On the other hand, there are the best clinical directives that should be followed for the best outcome. According to General Medical Council (2010, p. 10), it is always challenging to balance the two opposing views. However, the best outcome of the situation should always take precedence over the two divergent views. The law is not very clear about the way forward but medical jurisprudence should always come into play when some circumstances arise. It is very clear that Mr. John’s wife had no medical experience or knowledge with regards to COPD and therefore her decisions were to be directed by the doctors. As much as it was the right of the wife to dictate the way forward, medical jurisprudence also was very important to strike a balance. The other ethical consideration in this case is the best care of the patient which determines the outcome of the scenario. Eggenberger and Nelms (2004, p. 666) posit that end of life decisions are in most times challenging because the decisions taken may in fact hasten the death of a patient. There are some ethical and legal prohibitions with regards to some actions such as terminal weaning. In other instances, some actions may be permissible or in consideration of faith or religious subscriptions of the patient. These permissible actions include such undertakings as allowing of supplemental artificial ventilation or sedation of patients which arises from time to time. The doctor was very aware that the wife Mrs. Joan was afraid of death and any decision that could lead to death could adversely affect her. Matters pertaining to decisions of surrogates and especially the spouse of a patient are hard to overrule. In this case, the decision had to be balanced between different factors which favoured both the surrogate and the patient. This is because the decisions made by the doctor must be based on medical knowledge and medical experience is often required (Hoefler, 2000, p. 240). Reflection on how the Case was Managed This case was fairly managed given the extraneous circumstances that surrounded it. However, the hospital has to be blamed for the eventual outcome of the case. This is because the hospital lacked very important policies that govern important medical issues such as terminal weaning which arises from time to time. On the other hand, the doctor in charge of the case was only trying to respect the wishes of the surrogate who insisted that she did not want her husband to die (Baker, et al, 2012, p. 117; de Haes & Teunissen, 2005, p. 348). Given these circumstances, it is understandable that the hospital was only interested in providing the best care regardless of the medical jurisprudence of the case. It was therefore decided that the best way forward was to transfer Mr. John to the University Hospital so that tracheotomy could performed on him to save his life. It is understandable that this transfer was necessitated by lack of terminal weaning policies in the hospital that Mr. John was hospitalised in. Decisions with regards to palliative care are confounding and confusing. Relatives or even the patients may make decisions that do not lead to the best outcome but sometimes they need to be overruled. Since, this is an end of life case scenario, the decisions made by both the clinicians and the surrogate was meant for the best of the patient. References Baker, et al, 2012, ‘Anticipatory care planning and integration: A primary care pilot study aimed at reducing unplanned hospitalisation’, British Journal of General Practice, vol. 62, no. 595, pp. 113-20. de Haes, H., & Teunissen, S. 2005, ‘Communication in palliative care: a review of recent literature’, Current opinion in oncology, vol. 17, no. 4, pp. 345-350. Eggenberger, S. and Nelms, T. 2004, ‘Artificial hydration and nutrition in advanced Alzheimer's disease: facilitating family decision-making’, Journal Of Clinical Nursing, vol. 13, no. 6, pp. 661-667. Forrest, L. and Quill, T. 2004, ‘Making decisions with families at the end of life’, Am Fam Physician, vol. 70, no. 4, pp. 719-723. General Medical Council 2010, ‘Treatment and care towards the end of life: Good practice in decision making’, General Medical Council, London. Hoefler, J.M. 2000, "Making decisions about tube feeding for severely demented patients at the end of life: Clinical, legal, and ethical considerations", Death studies, vol. 24, no. 3, pp. 233-254. Hudson, P. L., Aranda, S. and Kristjanson, L. J. 2004, ‘Meeting the supportive needs of family caregivers in palliative care: challenges for health professionals’, Journal of palliative medicine, vol. 7, no. 1, pp. 19-25. Mitchell, S.L. et al. 2009, ‘The clinical course of advanced dementia’, New England Journal of Medicine, vol. 361, no. 16, pp. 1529-1588. Sampson, E, Gould, V, Lee, D, and Blanchard, M, 2006, ‘Differences in care received by patients with and without dementia who died during acute hospital admission: a retrospective case note study’, Age and Ageing, vol. 35, no. 2, pp. 187-9. Trotzuk, C. and Gray, B. 2012, ‘Decisions Concerning End-of-life Care for Their Child’, Journal of Pediatric Health Care, vol. 26, no. 1, pp. 57-61. Read More