Ethics

History
This is an 84 year old female resident of a local nursing home who fell in the bathroom. She hit her head which caused a laceration and a large hematoma. She was transported to the emergency room where she remained alert and oriented. Routine CT scan in the ER revealed a large subdural hematoma pressing on her brain.  The ER physician felt she should transfer to a neurosurgeon and she accepted transfer

She has a past medical history of hypertension, depression, arthritis, hyperthyroidism, and a vague diagnosis of senile dementia.  She has a nephew who is financial power of attorney and an advanced directive stating if she were ever terminally ill or permanently unconscious, life-prolonging measures such as cardiac resuscitation, ventilator support, and artificial nutrition and hydration should be withheld. (Kuczewski  Pinkus, 1999, pg. 9). She also chose only comfort measures if debilitated.

At the transfer hospital, she was seen by a neurosurgeon who ask the nephew about burr hole surgery and the decision between them was to send her back to the nursing home to see if she would get better. After getting much worse, and another decision not to do surgery was made,  she finally did get better.

Autonomy and Competence
Self-governance is the conceptual root of autonomy(Miller  Wertheimer, 2010. pg.61). In the case of our patient, there has been previous autonomous behavior. She was quite active and able at the nursing home. She has understood and made her own decisions based on her desires as well as what she clearly thought was best for her. That includes the fact that she did assign a power of attorney and filled out an advanced directive. Upon arriving in the emergency room and throughout this illness there were several instances in which she could have continued her autonomy in decision making. In order to make an autonomous decision, according to Miller et.al. (2010), there are two things that must happen. The first is that the person has an intrinsic wanting or a desire to make that decision and the second is that the person must understand the decision. She must also be competent to make the decision which means that she had well informed decisional capacity (Jonsen, Siegler,  Winslade, 2006, pg. 73).

Ms. F. did make an autonomous decision in being transferred to the tertiary care hospital, however, it was not a competent one. Yes, Ms. F. was able to make the decision and out of the desire to she did, however, the emergency room physician never gave her information to help her make a competent decision. Ms. F. was not able to determine whether the treatment she might receive when she got there was treatment that she might want to have. Had she been given that opportunity one of two things might have happened. First, if she chose that she would not want to have such surgery, after being informed, she would have made an autonomous and competent decision to return to the nursing home. She might have also made an autonomous and competent decision to go to the tertiary hospital in which instance, the surgeon would not have wondered whether this was a procedure she wanted and she would not have been returned to the nursing home without allowing her a decision at all (Jonsen et.al., 2006).

Informed Consent and Disclosure
Ms. F did not have informed consent at any point in the process. First, as we have discussed, she did consent to be transferred but was not in any way informed of the things that she needed to know to make an informed decision and she was never consented at all when it came to the surgery. Furthermore, the nephew was only somewhat informed and he could not consent anyway. The surgeon did not determine whether there was anyone else to make that decision.  There was also no disclosure (Veatch, Haddad,  English, 2010, pg. 373). At the very least she and or her family should have been told the effects of not having the surgery as well as the affects of the medication she was placed on. It is not evident from this case as to whether any of that occurred.

Understanding, Voluntariness  Futility
To make a decision or give a consent a person must understand. This understanding must come in their own terms in a language that they can understand. To tell a patient or family that they have a subdural hematoma does not help them make a decision because there is no understanding (Miller, et.al., 2010). Ms. F not only did not understand her condition, she was never told. She only knew she had to go to another hospital, never why. There is however, indication that the nephew had understanding. Voluntariness is a condition that is free of persuasion, coercion, and manipulation (Miller, 2010). This is something that healthcare workers use often. An example would be the patient who does not want to go to a nursing home but no other place can be found so the nurse uses coercion or manipulation, you will only be there a little while and then you can make another decision.This case study does not indicate that Ms F was actually manipulated or coerced in any way.

Futility is the belief that nothing else being done will change the present condition. When Ms. F returned to the nursing home and continued to get worse, the condition appeared to be futile (Jonsen, et.al., 2006 pg. 85). Her primary physician decided that surgery was no longer an option and that she needed to just be observed. There was no expectation from him that things were going to get better. In the end they did but it is often the case under these circumstances that the patient would have died.

Surrogate Decision Making and Advance Directives
An advanced directive is a decision made by an authorized decision maker in conversation with a physician and is a legal document (Jonsen, 2006, pg. 85). There are different types of advance directives based on where they come from, but all should be considered the patients wishes (Jensen, 2006). Most states have what they consider as acceptable, there is also a Medicare advance directive form. There is the living will which is a little less formal document and is not acceptable in all states. Some different religions also have their own forms such as the Catholic and Jewish faiths.  It is recommended that when a patient has an advanced directive that it be followed when the patient gets sick. However, Ms F case is a little confusing as it often is. If one follows her advance directive the way it is written, at first thought one would believe that she would not want any kind of treatment but a second look makes one believe that she would have wanted the surgery as long as the expectation was that she would continue to be independent. She would also expect that post operatively that she would not be left on a ventilator. An advanced directive should only be used when a patient is unable to make decisions and in this case Ms. F was able.

Surrogate decision making can also be somewhat confusing. When a person is mentally incapacitated, a decision maker must make decisions for them (Jonsen, 2006, pg. 89). This should be an authorized person and having a medical power of attorney is always helpful, however in this case there was no medical power of attorney and a legal power of attorney is not the same thing. In most states when there is no designated medical power of attorney, the next of kin become the responsible people. That line usually goes spouse, parents, children, sibling and so on. In this case they were not aware there as a sister so even though the nephew only had designated financial power of attorney, he would also be the medical power of attorney because he was family. This would determine that if Ms. F was not able to make decisions, the nephew could make them for her.  The job then of the surrogate is to carry out what is known about the patients choices which in this case would be what was in her advanced directives. It appears then, that he probably made a appropriate decision. It is often very difficult for families to be placed in this position because it is difficult for them to make decisions that aunt would want over what they would want.

The Issue
Ms F came to the hospital able to make decisions and thinking that she was well prepared to do so, including having an advanced directive. However, bias on the side of the healthcare workers including the surgeon caused her to lose her right to make decisions in several ways. She was not informed, she was transferred with consent but not informed consent. She was competent to make her decisions but was not allowed to be autonomous and full disclosure did not happen. Once she could no longer make decisions, the nephew was ask to do that and that was the right thing to do. He was the only known relative and medical power of attorney or not, it was his decision to make. He in turn made a decision that was consistent with her advance directive.

All of this sounds great and meets all the theories but the practicality is much more difficult. It is very difficult for healthcare workers, especially physicians to allow decisions to be made that are not what they would want their patients to make. It still remains difficult for physicians to tell the truth when they talk with their patients also. They often tell part of the story but not the whole story. The emergency room physician here is an example. He told the patient that she could not be taken care of in the community hospital and needed to be transferred but he never said why. Was he afraid she might say she did not want that kind of surgery and then he would have to return her to the nursing home without the surgery This is the practicality of the decision making process.

In conclusion, ethical decision making is difficult. At the time of a crisis, it is difficult to think whether the ethical rules of autonomy and competence or consent and disclosure are being met. There are mistakes made and it is not uncommon for healthcare to overstep its bounds in making decisions for patients, often decisions that they might not have made for themselves. Ethics committees have not been a part of hospital care for a long time but the fact that they now are shows the need for continuous ethics education for healthcare workers.