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1. If Ed is not placed on a ventilator, what will happen to him?

If Ed is not placed on a ventilator, he may develop hypoxemia or respiratory failure due to his lung congestion that is a common complication of pneumonia when client is severely ill. And because Ed is seriously ill due to his defective gag reflex and pneumonia he will have difficulty maintaining adequate oxygen throughout his body. Aggressive therapy may include hemodynamic and ventilatory support to combat peripheral collapse, maintaining arterial blood pressure, and to provide adequate oxygenation.

2. Was it ethical and appropriate for Dr. Martin to call Bert? No. it is not ethical and appropriate for Dr. Martin to call Bert because discussion about the clients information should be done in a private area where it is unlikely that the conversation will be overheard. It will be a threat to confidentiality to divulge any information using telephone or other computer-based technologies because it may result in unchecked access to health information. In addition, personal and health information is often made available to numerous individuals, which may increase the potential for misuse of health care information. Communication should be confined to the appropriate settings and with appropriate individuals, and occur for the appropriate purposes of facilitating patient care. Was Ed no longer able to take care of himself? Who makes that judgment? Though Ed is seriously ill due to his lung congestion, he can still communicate verbally and based on the basis of advance directives he can still take care and decide for himself. Even Dr. Martin thought Ed is somewhat retarded living will must be honored. Because according to the policy statement of The American Association on Intellectual and Development Disabilities, health care providers must discover and honor the treatment wishes of persons with intellectual disabilities through: observing and interacting with individuals over time to understands what is important to them; encouraging expressions of preferences regarding end-of-life care before situations requiring decision making occur; and for capable individuals, documenting preferences through living wills, personal vision statements, health care proxy instructions, and other indicators of ones wishes. Dr. Martin should collaborate with other health care providers (Psychologists, Psychiatrists, Respiratory Therapist etc.) if Ed is can still decide for himself due to his condition. He needs to provide evidences that the client is unable to take care of himself for him to honor Bert who has the durable power of attorney to decide for Ed.

3. Should Dr. Martin tell Eric anything? If so, what? The general rule regarding release of a patients medical record is that information contained in a patients medical record may be released to third parties only if the patient has consented to such disclosure. If Dr. Martin disclosed certain information about the clients health status he will violate confidentiality. And according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA): regulates what Dr. Martin may and may not tell other people, such as Eric. Basically, personal health information must be kept private, but in the event the patient is incapacitated, the health care professional may disclose personal information if in his/her judgment the disclosure is in the best interests of the patient. 4. If Dr. Martin tells Eric about Eds medical situation, what should Eric do? Can Eric authorize Dr. Martin to use the ventilator? As a family member, Eric should support his Uncle Ed and try to communicate with him about his condition. He should also discuss his Uncles health status with his Mother and Uncle Bert to be able to formulate a better decision for his health. He needs to be knowledgeable about his uncles condition for him to give his views to help Eds well-being. He cant authorize Dr. Martin because he is not the one who is entitled the Durable Power of Attorney. Thus, the client stated in his advance directive that he did not want a ventilator, a feeding tube, or drastic cardiopulmonary measures such as CPR. 5. What should Bert tell Dr. Martin to do? Bert should ask Dr. Martin if theres other ways to treat his brother. He should also discuss the living will of Ed though seriously-ill, he can still communicate verbally about his wishes and still needed to be followed. He must also inform Dr. Martin that even though he has a Durable Power of Attorney, he still needs to respects his brothers living will according to his advance directives. After knowing his brothers health status he needs to insist other possible ways to elevate Eds well-being. But if the ventilator and feeding tube will be the last resort, Dr. Martin needs to inform Bert and his family about the benefits and risks of the interventions. And by having the knowledge, Bert needs to ask assistant in educating his brother to be able to update his advance directives and to provide him the ventilator and feeding tube, if really necessary. 6. Would your opinion change if Ed simply has a case of mild pneumonia and, if appropriately treated, could resume normal life? No. Though Ed has a case of mild pneumonia hes still dont have a control over his esophagus that will later aggregate the problem. If the mild pneumonia would be treated hes still not be able to resume normal life due to his defective esophagus. Thus, he is still prone to have aspiration and infection due to food and water that goes into his lungs. That is why hes still need

to be in a feeding tube to prevent aspiration and to be able to provide him adequate nutrition. 7. Would your opinion change if Ed is known to have a defective gag reflex and will probably need the ventilator and feeding tubes for the rest of his life? Yes. Because a defective gag reflex may create further health problems and must be manage immediately. Thus, ventilator and feeding tubes will be helpful it can also have complications that may risk Eds health condition. But the main goal of every health care practitioner is to prolong the clients life and to provide all possible health interventions to make Ed live comfortably. Thats why Ed and his family must be informed about the risks and benefits of the said health interventions to formulate a decision suited in clients values and views. 8. If Ed has clearly indicated in his Advance Directive that he does not want to be put on a ventilator, why does Dr. Martin want to put Ed on a ventilator? Is that ethical? Dr. Martin thought that the ventilator will relieve Eds lung congestion due to his pneumonia and ineffective gag reflex. In that way, it will help his client to promote adequate oxygen and to avoid possible aspiration. Though Dr. Martin wanted to help Ed to make his condition better he must be aware about the laws concerning advance directives and living wills of clients. Its ethical to provide all the possible intervention to make your clients be better; thus, it is not ethical to breach your clients autonomy in making a decision. As the Patient self-Determination Act of 1990 has stated that requires all adult patients to be informed in their rights to accept or refuse medical or surgical treatment and the right to execute an advance directive. But there are some times that a health care provider may reject a medical decision made by or by the health proxy based on the advance directive. When the decision goes against the individual health care providers conscience When the decision is against the health care institutions policy If the decision violates accepted health care standards

In such cases, the health care provider or facility must tell you right away. You may be transferred to another facility that will honor your decision. 9. Since Ed said he does not want to be put on a ventilator, would it be ethical for Bert to authorize a ventilator anyhow? Under what circumstances? No, it would not be ethical for Bert to authorize a ventilator, unless the Ed will change or revoke his directive. Though Bert was assigned a durable power of attorney, it is clearly stated in his living will that he dont want to be put on a ventilator. And as the patient made his wishes clear, then they must be followed despite any possible objections from the agent.

Unless, Bert would talk to Ed about his condition and to update his advance directives to be able to allow him to decide what is right for him. Because the living will of Ed may contradict the decision making of Bert in authorizing a ventilator. If possible, changes should be signed, dated, and witnessed. Ed should also inform his agent, family, loved ones, and health care practitioners if he change or cancel his advance directives. 10. Would removing a ventilator and feeding tube the next day be wrong? Yes. Because the ventilator and feeding tube would prolong Eds life removing it will be unethical. In medical terms it is considered as Passive Euthanasia, defines as stopping life-sustaining treatment, such as breathing machines or feeding tubes. This allows a terminally ill patient to die naturally, without further prolonging death. In other countries Euthanasia is legally done but in some circumstances, ethical dilemmas may occur. 11. Bert has just been told that he needs surgery to treat blockages in his renal arteries. If Bert is unable to make decisions about Eds health care, who would? Because Bert is unable to make decision, the advance directive of his brother will be honored. No one is allowed to make decisions for Ed because only Bert was authorized to decide for him unless the patient change or revokes it; or he authorized other family member. Eric and his mother will need to go to court and ask for authorization, unless Ed is terminally ill or unable to communicate verbally. 12. If Ed had indicated in his Advance Directive that he wanted everything possible to be done to keep him alive, could Bert decide to refuse placing Ed on a ventilator? No. Bert has no right to refuse placing Ed on a ventilator because it will breach the clients advance directives. The advance directive of Ed would still be a basis for his family to decide and if other members of the family may opposed they need to bring it to the court and discuss their views on how they will decide for the patients health status. Bert must state his reason for not allowing ventilator for his brother and he must present evidence that his decision is right for Ed. 13. Imagine that Erics mother thinks that Ed should be kept alive no matter what. Should that make a difference to Bert? To Dr. Martin? Erics mother has the right to give her views on his brothers health condition. But the advance directive of Ed would still be a basis for his family to decide and especially when other members of the family will opposed. It will also affect Berts decision making as having the durable power of attorney. Bert should first ask Ed if he will consent him to divulge any information regarding his health condition to Erics mother. If unable, he must discuss pertinent data only that will help Erics mother to give her advice. But still his decision and the advance directive of Ed will

be honored. Because problems may occur if everyone in the family does not know about or does not support the choices that are outlined in Eds advance directives. To Dr. Martin, arguments, family conflicts, emotional objections can sometimes lead him to the safest route of care aggressive treatment that can prolong death for a long time. It will be easy for him to do what he needs to do as a health care provider because of the conflicts that arise to the front-liners of decision making the family. Conflicts in the family would lead to delaying the clients well-being thus, giving an opportunity to Dr. Martin to do what is necessary for his patient. 14. Dr. Martin is trying to communicate. How did he do? First, Dr. Martin needs to communicate with Bert and Eds family to discuss the benefits and risks of ventilator and feeding tubes. In that way, Bert and his family will be a bridge in informing Ed regarding the possible effects of the interventions in his health condition. He must also inform Bert that Ed he will need to update his advance directives due to his health condition and the years that the advance directive is done. Aside from the family of Ed, Dr. Martin should need to ask guidance to other health institutions, health care providers and legal assistant (Psychologist, Nutritionist, Respiratory Therapist, lawyers etc.) that will help him educate the client regarding his health condition. To help Ed and his family decide what is the best intervention for the client. But Dr. Martin must maintain his Eds autonomy and confidentially to protect his right.


Medical Surgical Nursing Volume 1, 12th Edition by Smeltzer et al. 2010 pages 25-29, 395-418, 554-565, 561, tters/advancedirectives/advance-directives-faqs