Ethical and legal problems arise in healthcare organizations when the decision-making capacity of an elderly patient is uncertain, particularly when the patient’s decisions are at odds with the rest of the family’s preferences. The scenario provided here is about this type of situation.

This performance assessment will provide you with experience in sorting through the sometimes-competing issues related to a scenario such as the one described, as well as experience in formulating actions that can help guide a healthcare organization through ethical problems that arise in caring for elderly patients.

Note: Students may rely on conversations and notes gleaned from cohort lectures and Boot Camp.

Scenario

You are the healthcare administrator at a local hospital. A social worker has come to you to discuss the case of Jamilah Shah, a patient who has recently been admitted to the hospital. Jamilah is a 90-year-old woman who was brought to the hospital after collapsing at the side of her bed. EKG and lab tests revealed a heart attack.

More than 40 years ago, Jamilah emigrated with her wealthy husband (now deceased) and their three sons from Turkey to the United States. Jamilah was a homemaker and learned only basic English, but her children are fluent English speakers. The children are now all in their 50s. The family retains Turkish culture and norms, including the sons acting as patriarchs for the family. Even though Jamilah is highly educated (in Turkey she was trained as a lawyer), the sons make many of the family decisions. Two of the three children are in successful careers. The remaining child, the youngest son, Bashir, owns a small market and struggles financially.

Until yesterday, the day of her admission, Jamilah resided in an extended care facility (ECF), where she has lived since her husband’s death. She reportedly has severe chronic obstructive pulmonary disease and adult-onset diabetes mellitus.

Jamilah has no advance directives on file. Because of her communication difficulties, the emergency department physician started her on anticoagulants while trying to contact her next of kin. The ECF sent paperwork to the hospital, listing Bashir as the emergency contact. Bashir was contacted and is now at the hospital with his two brothers. He has informed the care team that he is the decision maker, and he wants his mother to have a Do Not Resuscitate (DNR) order with no intervention of any kind other than comfort care.

The social worker has come to you with concerns that this decision may not reflect Jamilah’s wishes. When the social worker was visiting with Jamilah alone, Jamilah reached for her hand and said, “Please help me. I want to live.” The social worker shares concerns about the interactions observed between Jamilah and her sons, stating that the relationships seem unsupportive. The hospital’s ethics committee has not yet been involved. The social worker also reports that the emergency physician requested a cardiology consultation, which was just completed. The consultant documented that “Because the family has requested only comfort care, and due to the patient’s multiple comorbidities, the patient will be managed medically, with no intervention, and will not receive cardiac catheterization or be considered for coronary bypass surgery.” If nothing is done, Jamilah will likely die within days.

Requirements

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Note: Complete these prompts by using complete sentences.

Note: The web links “Advance Directives” and “Determining Competency for Medical Decisions” found below may be used to assist you in completing this assessment.

A.  Write an essay (suggested length of 5–7 pages, not including attachments). Do the following:

1.  Describe three potential ethical dilemmas presented in the scenario: one related to autonomy, one related to beneficence, and one related to non-maleficence.

a.  Analyze legal implications associated with each  of the potential ethical dilemmas described.

2.  Referencing the scenario, complete the attached “Questions Derived from the University of Washington Paradigm.” Using those answers, describe, in the essay, what happens when following each  of these courses of action:

•   Course of action 1: Follow Bashir’s wishes

•   Course of action 2: Refuse to follow Bashir’s wishes

•   Course of action 3: Briefly delay the decision to gather additional information and other perspectives

As a part of the description of what happens when following each of the courses of action, if a question is not applicable for a given course of action, explain within your essay why it is not applicable.

Note: The completed “Questions Derived from the University of Washington Paradigm” should be included as an attachment to your task submission rather than in the body of the essay itself.

3.  Putting yourself in the role of healthcare administrator, describe in the essay what should happen next within the scenario by doing the following:

a.   Describe two resources that could have made or could still make Jamilah’s wishes more clear.

i.   Explain how each resource could have made Jamilah’s wishes more clear.

b.   Choose and justify the correct course of action (in response to Bashir’s demands for only comfort care):

•   Course of action 1: Follow Bashir’s wishes

•   Course of action 2: Refuse to follow Bashir’s wishes

•   Course of action 3: Briefly delay the decision to gather additional information and other perspectives

i.   Choose one of the courses of action from prompt A3b that you did not justify and explain how possible consequences show that it is not the correct course of action.

4.  Create three policy recommendations that you could make as an administrator to help your employees and the facility’s medical staff handle similar situations in the future.

a.  Justify each  policy recommendation.

 Note: You may use laws, regulations, and/or ethical principles as recommendations in part A4 and as part of your justification in part A4a.

B.   Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

C.   Demonstrate professional communication in the content and presentation of your submission.