The Responsibility of Health Condition - Case Study Example

? Ethics: Legal aspects of nursing Ethics: Legal aspects of nursing The ethics committee has a crucial responsibility of resolving the ethical dilemma surrounding the case of Mr. Ignacio Suarez. Mr. Suarez was diagnosed with renal disease and is in the kidney transplant waiting list. Recently the patient has suffered a hemorrhagic stroke in the course of dialysis treatment. This has left him aphasic with right sided hemiplegia. Fortunately, there is a kidney available and the patient can undergo a kidney transplant. Evidently, Mr. Suarez is in a very critical health state and this casts doubt over his eligibility as a kidney transplant recipient. The physician is reluctant to perform the surgery because of the patient’s recent stroke. However, Mr. Suarez’s adult children are insistent that the surgery should commence. As the main caregivers, they are charged with the responsibility of managing their father’s health condition. It is for this reason they push for the best medical care for their father. In light of the unfolding events, there is an ethical dilemma. The ethical committee should act in the best interest of the patient. Due consideration should be made for the physician’s evaluation. There are few kidneys available for transplant but there are many patients in need of kidney transplant. Unfortunately, many patients have succumbed to death during the waiting period. It is disheartening that there is a worldwide shortage of kidneys available for transplant. Potential kidney donors are living donors or deceased donors. For deceased donors they can either be non-heart beating donors (donation is made after cardiac death) or heart beating donors (donation is made after brain death). There has been an increase in the kidney donations made by both living donors and non-heart beating donors, but the donations from heart beating donors have declined. Therefore, the crucial process of deciding on the most deserving donor presents a major ethical problem. The physician should conduct an extensive medical evaluation on Mr. Suarez. Most important, s/he must give a report on the expected outcome of a kidney transplant. If Mr. Suarez’s health condition will improve after the kidney transplant, they should recommend the surgery. Given Mr. Suarez’s cardiac complications, a cardiac evaluation is necessary. Physical examination and history is essential for transplant candidates. Patients exhibiting cardiac failure are highly predisposed to cardiovascular events peri-operatively and post-transplantation (Suphamai &. Danovitch, 2007). Abnormal ECG results would warrant further cardiac evaluation. Mr. Suarez’s age is above 50 years, and a stress test should be administered. However, there is need to appreciate the current critical health state of the patient. Several independent medical experts on kidney transplants should be consulted by the ethics committee. They should give a report of the expected kidney transplant in light of the hemorrhagic stroke. There is need to determine if the stroke is a major risk factor that predisposes the patient to a critical health state. If there is a high possibility of an unsuccessful surgery, Mr. Suarez’s eligibility for a kidney transplant declines. The kidney transplant is for the purpose of saving a life and if there is a likelihood of an unsuccessful surgery, it would not be ethical to select Mr. Suarez as a kidney recipient. Comprehensive information is required on the physical and mental health state of Mr. Suarez. Mortalities are mainly caused by malignancy, infection and cardiovascular disease as they are the main complications arising from immunosuppression in the majority of kidney transplant recipients. The transplant assessment process also requires a comprehensive evaluation of Mr. Suarez’s psychosocial, medical and surgical history (Pham et al. 2010). This evaluation is a challenge for transplant physicians as they have to screen for complex medical issues in potential candidates, and another challenge is the non standard criteria for rejection and acceptance across transplant centers. In addition, transplant physicians must consider the re-evaluation and optimal management of any patient in the wait list during the waiting period (Shrestha, 2009) Kidney transplantation is highly recommended for medically suitable patients suffering from end stage renal disease (ESRD). Improvements in patient outcome after undergoing kidney transplantation have liberalized the selection of patients. This has enabled the inclusion of high-risk category patients as potential kidney transplant candidates. Such patients include: ABO blood group-incompatible patients, highly sensitized patients, and T-cell positive cross-match patients. An extensive immunologic evaluation should be conducted on Mr.Suarez that will comprise of human leukocyte antigen (HLA) typing, ABO blood group determination, cross-matching and screening for antibody to HLA phenotypes. This information is crucial to prevent antibody-mediated hyper-acute rejection and to proceed with more thorough protocols in positive T-cell cross-match and highly sensitized patients (Gallon, Leventhal & Kaufman, 2002). Mr. Suarez made a living will in which he stated that should he sustain a life threatening injury or illness, he did not want to be resuscitated. The ethics committee may need to address the validity of these directives that were initially issued by the patient. A Do Not Resuscitate (DNR) order is usually issued by patients who do not want to be resuscitated following life threatening arrhythmia or cardiac arrest. This decision on patient resuscitation should be made after a careful evaluation of the potential for clinical benefit if the patient’s decision is upheld as well as the most possible outcome. The decision to withhold cardiac resuscitation is difficult following the perceived and real differences of both considerations. In the case of Mr. Suarez, there is need for the ethics committee to assess the real and not the perceived clinical differences of the two outcomes. Cardiac resuscitation should not be withheld if it will improve the health state of Mr. Suarez and increase his eligibility for a kidney transplant. Furthermore, it is standard care to perform cardiopulmonary resuscitation (CPR) when the hearts stops beating or if the patient is unable to breathe if there is no valid order from a physician to withhold CPR. It is the duty of the ethics committee to act in the best interest of the patient. However, a physician is ethically justified to withhold CPR if it has no clinical benefit for the patient. Clinical benefit is the probability of a clinical intervention yielding a desirable outcome. There has been prospective evaluation of CPR in various clinical situations. Knowledge of CPR success has been used to gauge its futility in various clinical conditions. CPR has exhibited 0% success probability in severe pneumonia, metastatic cancer, acute stroke and septic shock. In light of this knowledge, a CPR would be futile. The ethics committee may need to address respect of autonomy since Mr. Suarez had a living will but had not issued a DNR order. Living wills are not recognized across the United States. Many states have laws that uphold the patient’s right to refuse treatment. However, in the case of Mr. Suarez, the family insists on the best treatment for the patient. This entails CPR and a kidney transplant. For this reason a CPR should not be withheld even when the outcome is perceived as futile (Braddock, 1998). Courts have ruled in favor of families where physicians insist on enforcing a DNR. In the case of Sawatzky v. Riverview Health Centre Inc. , the plaintiff was contesting the physician’s decision to enforce a DNR on her husband without consulting her. In his ruling Justice Beard stated, "the courts have stated that a decision not to provide treatment is exclusively within the purview of the doctor and is not a decision to be made by the courts". Notably, it was the duty of a physician to act in the best interest of the patient. He added that a patient could sue a physician for negligence if treatment was withheld. The judge appreciated that the treatment was not controversial and would be administered by any medical professional who would find the patient after cardiac arrest irrespective of the DNR. Thus, the judge issued an injunctive order compelling the physician to administer CPR in case of cardiac arrest (Benson & Miller, n.d ). The hospital ethics should make a recommendation on the health state of Mr. Suarez after considering the conflicting position by the physician and family members. Most important, they should evaluate the realistic claims by the physician on patient outcome and make a ruling that best serves the interests of the patient. It is the duty of the ethics committee to resolve any ethical dilemma on patient care and treatment. The ethics committee should also make a decision that will protect the hospital’s administration from libel. The family of Mr. Suarez can sue the hospital for negligence. According to the moral model, the decision making process is based on sacral values that take precedence over all other factors. These sacral values evoke moral rules and prevent utilitarian motives (Morteza, 2008). The moral rules should always be upheld in every situation and there is no room for challenges. The nature of an action is of utmost importance as opposed to the utility of the outcome. This is applicable in the case of Mr. Suarez. It is important to provide the best medical care such as CPR and kidney transplant as withholding treatment is morally wrong. The physician’s action to provide treatment is morally right. No consideration should be made for any probable futile outcome after treatment. The physician should provide treatment and hope for the best outcome. In conclusion, the case of Mr. Suarez presents an ethical dilemma. The ethics committee may find the living will invalid as it is not a Do Not Resuscitate (DNR) order. Living wills are not recognized in many states. Independent physical, mental and psychosocial evaluation should be performed to assess the eligibility of Mr. Suarez in undergoing kidney transplant surgery. Advances in transplant surgery have been shown to increase the success of the outcome even for very critically ill people like Mr. Suarez who have suffered a hemorrhagic stroke. All these considerations should be made by the ethics committee as they consider the expert opinion that has been expressed by his physician. Ethics is deeply enshrined in the moral mode. On the basis of the model, the decision made should be in the best interest of Mr. Suarez. It is morally correct to avail the best treatment to the patient irrespective of the probability of failure. Thus Mr. Suarez should undergo kidney transplant surgery. References Benson, I.T. & Miller, B.B. (n.d.). Do Not Resuscitate": Whose Choice? Retrieved from http://www.consciencelaws.org/law/commentary/legal002.aspx Braddock, C.H. (1998). Do Not Resuscitate Orders. Retrieved from http://depts.washington.edu/bioethx/topics/dnr.html Gallon, L.G., Leventhal, J.R. &, Kaufman, D.B.(2002). Pretransplant evaluation of renal transplant candidates. Semin Nephrol. 22(6), 515-525. Morteza, D., Emmett, T., Ken, F. & Matthew, K. (2008). An Integrated Reasoning Approach to Moral Decision-Making. Proceedings of the Twenty-Third AAAI Conference on Artificial Intelligence. 1,1280-1286. Pham, P.T., Pham, P.A., Pham, P.C., Parikh, S. & Danovitch, G.(2010). Evaluation of adult kidney transplant candidates. Semin Dial. 23(6), 595-605. Shrestha, B.M. (2009). Strategies for reducing the renal transplant waiting list: a review. Exp Clin Transplant. 7(3), 173-179. Suphamai, B. & Danovitch, G.M. (2007). Evaluation of Adult Kidney Transplant Candidates. American Journal of Kidney Diseases. 50(5), 890-898. Read More