Running head: LEGAL AND ETHICAL DILEMMA 1

Legal and Ethical Dilemma

Elizabeth Ping – T-012

Sue Ryno

Spring Arbor University

Gerontology & Chronic Care NUR 341

March 30, 2010

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Legal and Ethical Dilemma

Ethical dilemmas for the older adult create complex problems that frequently involve

challenges in determining who should be the decision makers concerning a person's health care.

The following case study represents moral concerns that are common to the physically-declining

elder adult with end-of-life involvement. Discussion of this scenario provides a framework

covering my most immediate concerns regarding the case study, a discussion about the ethical

and legal dilemmas specific to honoring the nurse/patient/family relationship, and a plan for

discharge utilizing the quality of life model.

Case Study

Mrs. L was a 73-year-old Caucasian female who was oxygen-dependent and who had

congested heart failure and end-stage COPD. I had been taking care of Mrs. L. for the past five

years and have watched her physically decline over the last four months. In November, Mrs. L.

presented to the emergency room with an alteration of mental status, acute myocardial infarction,

hypoxia, and pubic ramus fracture. Mrs. L.'s respiratory failure indicated the need for supportive

ventilation, however, Mrs. L. was not intubated per her son (M)'s wishes. A week later, Mrs. L.'s

physician decided to send her home while (M) wanted to send his mother to a nursing home

despite Mrs. L.'s desire to return home. In the end, Mrs. L. decided to be admitted to a nursing

home instead of going home, though soon after discharge from the hospital, Mrs. L. was

diagnosed with colon cancer and had a prognosis of less than two months to live. The family, in

turn, agreed that Mrs. L. should return home to live her final days with their assistance. In

February, Mrs. L. died surrounded by the support of her family members.

Important questions upon hospitalization. My immediate concern for Mrs. L. is

whether or not she currently possesses the cognitive capacity to make her own decisions and
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whether or not Mrs. L. would currently desire to have supportive ventilation in light of her

rapidly declining respiratory status. These factors are significant because decisions made could

determine whether Mrs. L would survive or succumb. Important questions that I feel need to ask

during the assessment process include: Does Mrs. L. have a written advanced directive, a health

care proxy, durable power of attorney? What previously stated, clear and convincing

verbalization of health care wishes has Mrs. L. made to family members recently? Has anyone

ever talked to Mrs. L. about the right to self-determination and informed consent? Is Mrs. L.’s

entire family currently aware of Mrs. L’s declining health status? Is Mrs. L.’s emergency room

physician aware that Mrs. L’s daughter, (D), has voiced concern that her mother has always

wanted Mrs. L’s son (M) to make major health care decisions? Is Mrs. L.’s emergency room

physician aware that Mrs. L. has voiced to (M) that she does not want to live on a “machine” and

prolong her death if her quality of life was poor? Are Mrs. L., Mrs. L.’s family, and Mrs. L.’s

emergency room physician agreeable to alternatives to invasive ventilation such as temporary

use of noninvasive mechanical ventilation techniques by the use of a bi-level positive airway

pressure (BIPAP) machine for her exacerbation of COPD? What is Mrs. L’s religious

preference, and would she desire any pastoral care? How would Mrs. L. define a "poor quality of

life?" What is Mrs. L.'s current prognosis?

Nurse’s role as advocate and supporter. The role that I play in Mrs. L.’s care during

every phase of her hospitalization (i.e., at the time of Mrs. L.'s hospital admission and discharge)

is to act as advocate and sympathetic supporter of Mrs. L. and her family’s health care decision.

Advocacy, as defined by Guido (2006), involves the act of nurses who champion the legal and

ethical rights of the patient, assist patients in asserting their rights to autonomy, and strive to

protect the health and safety of the patient (p. 9). Specifically, I would need to recognize how
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my own moral attitudes to Mrs. L.'s care might conflict with treatment interventions, recognize

the importance of familial relationships to Mrs. L., and recognize that Mrs. L. has the ultimate

decision-making authority and autonomy while she is mentally competent.

Supportive measures during the time of initial hospitalization would include initiating

appropriate comfort measures such as pain relief as needed and assisting Mrs. L.'s family

members in expressing their concerns for Mrs. L.'s well-being. During the time of Mrs. L's

decision to either return home or go to a nursing home, it would be my responsibility to inform

Mrs. L. of the of any unanticipated consequences of both actions.

Prior hospitalization. If I would have been Mrs. L.’s primary nurse during her previous

hospitalization, I would have been very concerned that Mrs. L. had been readmitted to the

hospital every three weeks for the past four months and would have emphasized the importance

of creating a means by which Mrs. L. could have maintained her healthcare desires in the event if

she were to become mentally or physically incapacitated. In addition, I would have completed a

comprehensive physical examination that could have revealed her colon cancer sooner.

Moreover, I would need to provide information regarding the idea informed consent for

her rights. Meiner and Luekenotte (2006) discussed the Patient Self-Determination Act (PSDA)

as a law that requires hospitals to inform patients of their protected rights for accepting medical

interventions and the different consequences that might follow. (p. 48). Accordingly, I would

have communicated the basic ideas of self-determination and informed consent to Mrs. L. to

allay her fears that she has the right to make her own decisions as long as she is of the mental

capacity to do so. I would have then encouraged Mrs. L. to choose provisions that would create a

vehicle of her wishes in the future such as the formulation of an advanced medical directive
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(AMD), a legal will, durable power of attorney, and/or a decision diagram (Meiner &

Luekenotte, 2006, pp. 44-6).

Ethics

Personal views. Even though (M) could argue that Mrs. L. had previously voiced to her

family that she would not want to live on a "machine" if she did not have a good quality of life, I

would still feel the responsibility to initiate supportive ventilation. I believe that ventilation

should have been pursued because I was not aware of Mrs. L's definition of "quality of life," and

her prognosis at the time of hypoxia was uncertain. For instance, Mrs. L. could potentially need

life support for the remainder of her life or only for several hours. Furthermore, I recognize that

Mrs. L. had 26,000 is her bank account. Although I had known Mrs. L. for over five years, I was

not aware of her family's motives; (M) could have potential financial gain from allowing his

mother to die. Finally, Mrs. L.'s verbalizations concerning ventilation were anecdotal, and there

were no legal documents to prove Mrs. L's wishes regarding health care interventions or who

should speak for her in the event that she cannot verbalize for herself.

I believe that (M) should have allowed his mother to return home as long as Mrs. L. was

cognitively competent and the physician agreed that care at home was appropriate. I feel that

(M) was not following his mother's desire of living at home even though he honored her desire of

no "machines" by not choosing intubation and mechanical ventilation only a week before.

Ultimately, as long as Mrs. L.'s physician had deemed that Mrs. L. is able to make sound

judgments, (M) cannot refuse to take his mother home if she disagrees with going to a nursing

home.

Beneficence. An argument for the decision to intubate and pursue mechanical

intervention stems from the idea of beneficence or doing good. Guido (2006) described that
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beneficence should always be involved as the preferred method of delivering care and that doing

good must be inherent in the action itself, have the end goal of doing only good, be void of an

undesired effects that are associated with attainment of the good effect, and that there must be a

favorable balance toward the desirable effect over undesirable effects (pp. 5-6). A person could

argue that with short term mechanical ventilation, the overall good effects of preserving Mrs. L.'s

life outweighed the undesirable effects of potentially allowing premature death.

Autonomy. The right for a person to be involved in the decision-making process and

represent their autonomy should be upheld given that informed consent is the legal and ethical

standard for patients (Meiner & Luekenotte, 2006, p. 43). The decision to withhold intubation

would be supported by the nurse's obligation to sustain a patient's autonomous desires. This idea

is reflected by Guido (2006) who expressed that autonomy should be maintained even when a

health care professional disagrees with treatment interventions (p. 5). (M) could argue that his

mother had previously expressed a desire not to live on "machines" and that intubation and

mechanical ventilation would be in direct contradiction to Mrs. L.'s right to make her own

decisions.

Elder abuse and abandonment. Meiner and Luekenotte (2006) defined domestic elder

abuse as maltreatment of a person by a family member and abandonment as the desertion of an

older adult who has taken custody of the older adult or by the person who has assumed

responsibility for providing care to the older adult (p. 36). I believe that (M) did constitute the

act of domestic elder abuse because he had caused Mrs. L. to become emotionally upset because

he was not following her wishes to return home. Alternatively, I believe that (M) did not

constitute the act of abandonment since there had been no written documentation or verbalization

of (M) presiding as health care agent furnished since Mrs. L. had recovered from her hypoxia.
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Therefore, (M) had not yet taken custody over Mrs. L.'s care. Additionally, an extended care

facility would have allowed Mrs. L. safe and continuous care that would met her many physical

needs.

Discharge Plans

The quality of life model can be used to guide Mrs. L.'s discharge plans from the nursing

home and into end-of-life care at home by the family. Meiner and Lueckenotte (2006) defined

the quality of life model as a multi-dimensional idea that encompasses a person's attitudes toward

physical well-being, interpersonal well-being, and psychological well-being (pp. 403-4).

Consecutively, palliative care for Mrs. L. would include assessing and addressing concerns

found within the three spheres of the quality of life model.

According to the National Hospital and Palliative Care Association (n. d.), ways in which

quality of life can be preserved include considering Hospice to assist in the needs of a patient's

physical well-being (such assessing pain and providing pain relief), ensuring that patients are

psychologically prepared through discussion of end-of-life wishes and making sure that they are

honored, and addressing the patient's interpersonal well-being by including the patient's family in

care discussions (par. 1-6). Additionally, hospice can aid in the education of what to expect

preparing for the life event of death and dying for Mrs. L. and her family.

The ethical responsibilities of the nurse providing end-of-life care is a challenging

process that forces the nurse to explore personal moral views and integrate the family's and

patient's desire or refusal of health care interventions into one congruent plan. In the case study

of Mrs. L., I am professional bound to be aware of and make ethically-sound decisions

concerning Mrs. L., and I have presented my personal views concerning what should have been

done at each stage of Mrs. L's journey, the ethical and legal dilemmas of autonomy, preservation
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of life, and elder abuse, and a comprehensive plan of can for Mrs. L. using the quality of life

model as a guide.
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References

Guido, G. W. (2006). Legal & ethical issues in nursing (4th ed.). Upper Saddle River, NJ:

Prentice Hall.

Meiner, S. E. & Lueckenotte, A. G. (2006). Gerontologic nursing (3rd ed.). St. Louis, MO:

Mosby Inc.

National Hospital and Palliative Care Association. (n. d.). Keys to quality care. Retrieved from

http://www.nhpco.org/i4a/pages/index.cfm?pageid=3303