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    To Download - 4th Year Ethics Case Analysis To Download - 4th Year Ethics Case Analysis Document Transcript

    • 4th Year Ethics Case Analysis<br />Ashlee Roberts<br />MUSM c/o 2010<br />12/30/09<br />The case analysis that will be described in the following paper is regarding a seventy five year old male with a closed head injury and residual mental deficits causing deterioration of his overall health. Most significantly, his status rendered him unable to receive enteral nutrition and therefore he required multiple gastrostomy tubes to be placed in an effort to provide adequate caloric intake. I encountered this patient while rotating through a surgical externship at another hospital. This man was not one of my assigned patients, but I ended up spending a good portion of time taking care of him during this rotation. I remember standing at the side of the patient bed with the nurse as I observed the interaction between the family in the corner, seeming quite oblivious to the situation, and the uncomfortable patient who was unable to speak, and at that point this case struck my interest.<br />Mr. M was an elderly African American man who was admitted to the hospital about one week before I began my rotation due traumatic head injury after an assault. The injury was so severe that afterward he was unable to function independently including loss of the ability to speak, eat, or get up to use the bathroom. Because Mr. M was incapable of communicating his wishes, and because there was not an advanced directive including no durable power of attorney, the responsibility of decision-making regarding interventions for Mr. M’s health care now fell to the family. Mr. M’s health situation was explained to the family, and they voiced that they would like to have everything done to keep him alive. At this time the next step was to place a gastrostomy tube to ensure he would receive adequate nutrition. After consent was obtained from the family, the surgical procedure was performed without complications. The patient was then sent home with plans to live with the family who would care for him. Three days after Mr. M was discharged, he was brought back to the hospital by his family because he had pulled his g-tube out. At this point the surgical team, which I was on, was consulted to replace it. The patient was taken to the operating room to replace the gastrostomy tube that day and was sent back to the floor under the care of the internal medicine team who had admitted him. Several days later, while still in the hospital, the patient pulled this second tube out. At this time the nurse immediately placed a foley catheter into the ostomy site to preserve the tract so that the patient would not have to go back to the operating room for another repeat operation, and instead could have the gastrostomy tube placed back through the original ostomy site at bedside immediately after removing the foley. Surgery was again consulted to replace the second gastrostomy tube with a third tube. This was done at bedside and the Mr. M’s hands were tightly bound with restraints and mittens were placed on them so that he could not pull at the tube. Mr. M still managed to fight against the restraints and writhe enough to cause inflammation and damage to the tract where the g-tube coursed, and the following day there began to be a sanguinous fluid output into the collection bag. With close observation and multiple saline flushes, the bleed finally resolved, and the decision was then made to place a permanent gatsrostomy tube to prevent further complications. The patient was again taken back to the operating room and the procedure was successfully completed. The following day the fourth and now permanent g-tube was deemed to be functioning, and the patient was discharged home to be cared for by the family. <br />After three trips to the operating room, four gastrostomy tubes, and nineteen days in the hospital, Mr. M finally had a functioning g-tube. The family was satisfied, believing that the appropriate care had been given to their family member. But whether or not this was the best course of action for this particular patient is in question. First, the principle of substituted judgment, where the decisions of the surrogate ought to reflect the wishes of the patient, seemed shaky. The family continued to have the g-tube replaced despite the patient continuously removing it himself. Whether or not this removal was intentional or not is debatable as the patient’s mental function was severely depressed, noted by his consistent inability to respond to verbal questions or commands. Substituted judgment is a principle that is often less accurately executed when loved ones attempt to correctly accomplish the true wishes of the patient. Some believe this is likely due to the complex psychology involved in the process of group decision making. Another study supports that many surrogate decision makers often doubt the ability of a physician to predict medical futility, and therefore the decision process is skewed. The ultimate overriding domain, however, is that decisions are made so that interventions are based on the patient’s best interest. In this case, it was not overtly clear whether the family’s wishes were clearly supporting or clearly opposing the patient’s best interest. One may be quick to think that the placement of a g-tube is obviously in the best interest of any patient who cannot eat, and therefore the decisions of the family must be in line with the best interest of the patient. However, the number of times the tube was placed due to the patient dislodging it questions how accurate the family actually was in their ‘substituted judgement.’<br />Another issue to be addressed in the midst of making these decisions is quality of life. In 1993 the World Health Organization defined quality of life as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” <br />Quality of life, thus, is considered a subjective topic and is a difficult measure to assess through the eyes of someone else. It is viewed as relative based on an individual’s baseline not only in terms of health status, but also regarding socioeconomic status and personal values. How one decides for another person what the acceptable standards are for living out the rest of another person’s life seems like a mighty task, not to mention a lofty assumption to believe one is qualified to accomplish that task successfully. However, the medical team, family, and hospital ethics committee (if necessary) put their best efforts into attempting to ensure that the patient’s best interest is honored in the midst of emotion and reality. <br />When discussing quality of life, many think of the full duration of the rest of one’s life. Short-term periods are sometimes overlooked, especially in the case of an elective surgical situation. This patient not only left the hospital for the final time with a permanent feeding that he pulled out at every opportunity, but was also put through multiple repeated surgeries and bedside procedures for its placement. Understanding that quality of life is a subjective perspective, I believe that most who took care of Mr. B would agree that this patient’s stay in the hospital was miserable for him. In addition to his sub-optimal short-term quality of life, he was made to endure this for an extended period of time due to complications from his procedure. <br />This case allows many of the basic principles of ethics to be examined. First the accurate adherence to the autonomy of this patient, carried out by the family as the surrogate decision makers, is challenged as we consider if the patient truly received the treatment he wanted based on his reactions to the g-tube. The autonomy of a patient takes precedence over the principle of beneficence, but this becomes difficult to execute when unsure how reliable the autonomy actually is. Beneficence itself can also be questioned when assessing the risks versus benefits ratio for this patient. Mark H DeLegge and associates, in the article published in American Society for Gastrointestinal Endoscopy in 2005, state that “the decision to place the feeding tube should be based <br />on the presumption that it will provide net benefit to the patient and will not cause harm, that the benefits out- weigh the risk of the procedure itself…” In this case the benefits initially did outweigh the risks as the appropriate assumptions were made prior to the procedure that this operation would be done successfully one time resulting in a functional tube. However, we saw that this patient underwent multiple surgeries/procedures and spent an extended time in the hospital compared to the average hospital stay for a standard PEG tube placement. In retrospect, the risks exposed to this patient are evident and could have been more thoroughly evaluated by both the physician and the family. Perhaps the fault lies more on the medical team for being so quick to jump to another surgical intervention in order to satisfy the family’s wishes, rather than ensuring that the family understood each step of the medical treatment. Not only could there have been more focus on the risks associated with Mr. B’s procedures, but also on the family role of surrogate decision making and the importance of quality of life…all the while truly working in the very best interest of the patient. <br />REFERENCES<br />Berger JT, DeRenzo EG, Schwartz J. Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med 2008;149:48-53<br />Zier LS, MS, Burack JH, MD, MPP, BPhil, Micco G, MD, Chipman AK, MS, Frank JA, MD, White DB, MD, MAS. Surrogate Decision Makers’ Responses to Physicians’ Predictions of Medical Futility. Chest 2009: Vol 136, Issue 1<br />Zhao Li and Chan Kelvin. Quality of life assessment: An outcome estimation of Chinese medical treatment. Chinese Journal of Integrative Medicine 2003: vol.9: 299-301<br />DeLegge MH, MD, McClave SA, MD, DiSario JA, MD, Baskin WN, MD, Brown RD, MD, Fang JC, MD, Ginsberg GG, MD. Ethical and medicolegal aspects of PEG-<br />tube placement and provision of artificial nutritional therapy. Gastrointestional<br />Endoscopy 2005, vol 62, No 6; 952-959<br />