A forty-five-year-old man with a three-year history of cardiovascular disease ha

Question

A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether or not he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent. The attending physician is convinced that the patient has lost decisional capacity while two family members are equally convinced that he has decisional capacity. The patient’s wife and two other children are ambivalent about his competency to make decisions. The prognosis for recovery of safe swallowing and speech approaches zero because of the dense damage to the cerebral cortex visible on brain imaging. Two neurological consultants have verified that recovery is likely to be minimal and that permanent, severe disability will be the outcome.

The patient does not have an advance directive. The patient’s wife says that they never did discuss his preferences about life-sustaining treatment. She is convinced that he would not want to live in this disabled condition, but is uncertain whether to request the placement of a feeding tube. Two of her four adult children are strongly opposed to the tube placement, while the other two insist that not to do so would be to “kill our father.” The patient’s wife is torn between these two positions, but finally requests that the tube be placed.

The attending physician and the rest of the treatment team are opposed to placing the feeding tube. Their argument is that the patient has “minimal consciousness” and will not improve. They define this as a futile situation with no reasonable expectation of recovery. Furthermore, two nurses claim that during previous hospitalizations for episodes of cardiovascular events the patient told them that he would not want to be sustained by artificial means — not by ventilators, renal dialysis, or tube feeding. It is their position that the patient has expressed his preference to not be kept alive in a futile situation.

The family requests an ethics consultation.

1. The family is divided over whether or not their husband/father should be placed on a feeding tube.

If the husband is deemed competent, who makes the final decision? _________

If not competent, who is the husbands’ official surrogate? ___________

The burdens the treatment (feeding tube) imposes should not be a consideration for the adult children? True_________ False _________

Ethics committees play an advisory role? True _______ False______

Ethics committees act as advocates for the healthcare team? True______ False ________

Decisions of ethics committee are legally binding? True____ False____

Please briefly answer/discuss the following:

The judgment of futility should be a conclusion of a communications process, not a beginning. How would you propose beginning the communication process with the family in this case?

First consider, what is the purpose of an ethics committee?

What information should be shared?

Who should be present?

What alternatives are on the table in this case?

Should the nurses’ statements be considered?

As part of the healthcare team, what is your goal in participating in the discussion?

Explanation / Answer

Ans) Ethics consulatation is the team of consultants that provide and approve best mode of treatment to be given to the patient if or whenever there is any discrepency between the family of patient and healthcare provider staff of the hospital, also they provide better asistance in identification , analysis and resolution of any unresolved or moral conflicts amongst the healthcare providers and family and patient within that particular clinical condition and setting. Ethics consultation committee is an advisory committee not the decision making committee.

If a patient or in above case the husband is deemed competent then the decision is the wholesole decision of the husband only according to his medical will.

In the above case if the patient (Husband) is not competent then the responsibilty according to laws for taking decisions about whether or not feeding tubes be placed will be decided by the current Spouse, as she acts as the current healthcare representative , also the adult children of the patient may she get involve for making decision.

The imposed treatment of feeding tube should be a consideration for adult children, as after the spouse the adult children comes in list for decision making, hence Its True to consider adult children for treatment approach.

Ethics committee plays an advisory role True. Ethics committee is the advisory board not the decision making committee, as they only suggest proper proposal but the decision is that of the family and healthcare team.

Ethics committee acts as advocate for the healthacre team True . Ethics committee within the hospital is the committee formed by highest authorities including physician and social workers who provides policies for hospital and generate plans for treatment protocols in conflict situations.

Decisions of ethics committee are legally binding False. Decisions of ethics committee are only advisory and therefore they are not legally bound to any decision by any ofthe involved be it family member , healthcare provider.

Judgement of futulity- In the above case the communication will be started when an ethics cosultation is requested by the patients family as to they can on their behalf ask the nurse to send the proposal and then the ethics committee will gather facts , ask questions from the family members who are spouse and adult children, also questions will be asked from the healthcare providers. Questioning may lead to the ethics committee to properly listen and then try to find resolution. Ethics committee identifies , analyses and hen finds resolution in a proper tension free state without creating any complex legal situation.

Ethics team can however involve patient himself for this treatment plan , as it was said that he can answer to questions in yes and no , so there can be trial asking question for the feeding tube with him. Then the spouse wanted him to be placed on feeding tube , as in patients incompetent state spouse has the role in making decisions. Asult children may also get involved in decision by their mother for decision. The nurses statements can be listened but according to me they can be in a biased state as to follow the decision of the healthcare team which does not want the patient on feeding tubes, so nurses statement could be contradictory.

Being part of the healthcare team in decision making i would listen to all phases of situations. I will try his spouse to understand the worse condition that could happen to her husband if the feeding tubes did not work well, on other hand alongwith ethics committee members i would listen their resolution of the condition and will try to make decision by listening to all the inclusives not only own will. Hence decisions are to be taken by analysing the complete situation and not only to one member.

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