Ethics Consultation Process. Maggie Procunier RN BSN Bioethics & Patient Rights South Miami Hospital. Morals. An individual’s own code for acceptable behavior They arise from an individual’s conscience They act as a guide for individual behavior They are Learned. Ethics.
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Maggie Procunier RN BSN
Bioethics & Patient Rights
South Miami Hospital
Patient is an 89 year old male admitted with Hyperkalemia, ESRD, HTN, and Bladder Cancer. Patient’s past medical history includes recurrent bladder carcinoma, CVA, hernia repair and hemodyalisis. Patient was admitted due to weakness and 2 weeks of diarrhea for which he had refused to be dialyzed for 7 days.
Patient lives at home with wife and daughter who are both his healthcare surrogates. Based on patient’s poor prognosis, oncologist had recommended on previous admissions that patient be made Hospice Care with comfort measures.Case #1
Daughter and wife have refused Hospice care and want patient to be dialyzed and continue aggressive treatment to include full resuscitation if cardiopulmonary arrest. Daughter and wife have requested all physicians to refrain from speaking to patient about his prognosis.
At this time all physicians have followed daughter and wife’s request not let patient know that his cancer has returned, except for the “new” attending physician.
88 year old male with extensive medical history including end stage Parkinson's disease. He was admitted due to pneumonia and was intubated and now is in Intensive care unit. Patient’s wife was identified as proxy since patient had never completed an Advance Directive or had a Living Will.
2 weeks have passed and patient has been unable to be weaned from ventilator.
Wife continues to indicate she wants to take patient home on the ventilator…
Attending physician did not feel that wife’s request to take patient home were realistic nor did he feel patient would have “a good quality of life.”
His recommendations were Comfort Measure/Withdraw of life support.
Palliative Care is involved and many family conferences have been held. Wife refuses to make patient a Do Not Resuscitate, or sign any type of withdrawal papers. She wants “full care”
She continues to verbalize she wants to take patient home.
Wife had full time 24 hour care team at home taking care of patient and she wants to take him home.
Ethics consult is called by attending physician….
Palliative Care and ethics consultant met with wife and she understood that if he went home, he would have to have a tracheotomy. Recommendations from team was to arrange Respiratory department to show caregivers and wife how to take care of patient once he was at home with tracheotomy.
Wife agrees to tracheotomy and a consult is requested.
Wife was also informed of him having to go to a skilled nursing facility first and then after he was stronger would be able to go home.
Patient was trachedand discharge to skilled nursing facility for rehab.
54 year old male - history of previous subdural hematoma, HTN, and atrial fibrillation. Patient aspirated and coded. He is in intensive care unit on ventilator and Dopamine for hemodynamic stability.
Attempts at weaning have been unsuccessful…wife (healthcare surrogate) signed consent for tracheotomy in order for patient to be weaned off ventilatoras recommended by pulmonologist…
On the same day wife signed consent for tracheotomy, Primary Care Physicians during rounds feels that his prognosis is poor, and his recommendation for plan of care is to have patient made CMO and eventually withdrawal of life support should be initiated, he did not agree with pulmonologist recommendations…
Pulmonologist does not agree with current plan to make patient CMO and withdrawal and wants to continue therapy…”he can improve, give him time”.
Pulmonologist contacts wife regarding the scheduling of the tracheotomy, and is surprised to find out that she has signed papers for Comfort Measures Only & withdrawal of ventilator…
Family is now confused with conflicting goals of care…wife has agreed to CMO and withdrawal of vent after speaking with attending but is still not sure she is doing the right thing…she would like to give time but “how long?”
Staff is torn between wife’s decision and her verbalization of “confusion” and physician’s recommendations and conflicting opinions by pulmonologist and attending physician…
Pulmonologists calls for ethics consult…patient is not withdrawn awaiting ethics recommendations…
** Ethics Consult was requested by pulmonologist…