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Four Topics Method For Analysis of Clinical Ethics Case Stud

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Felicia Skipper

on 30 July 2015

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Transcript of Four Topics Method For Analysis of Clinical Ethics Case Stud

Four Topics Method For Analysis of Clinical Ethics Case Study

Case Study:
The End of Life

Medical Indications
The Principles of Beneficence and Nonmaleficence
Quality of Life
Principles of Beneficence and Non-maleficence and Respect for Autonomy

by Celena Smith RN
Contextual Features
The Principles of Loyalty and Fairness

Huihui Sun RN
Patient Preferences
The Principle of Respect for Autonomy

The right of a patient to make decisions about their medical care without their health care provider trying to influence the decision (Medicinenet, 2015).
Felicia Skipper RN
by Laura McConnell RN
end of life care is a medical and ethical challenge.
medical includes: infection, anorexia-cachexia, fatigue, mental confusion, and various other problems
ethical includes: right place to care for the dying person such as home, hospice, nursing home or with family members (Mohanti, 2009)

there are six values of medical ethics:
1. autonomy--person has the right to choose or refuse treatment
2. beneficence--doctor should act in best interest of the patient
3. non maleficence--first, do no harm
4. justice--concerns distribution of health care equitbility
5. dignity-the patient and person treating the person has the right to dignity
6. truthfulness and honesty-the concept of informed consent and truth giving (Monhanti, 2009)
Prognosis was given to the family; it was clearly explained that she would remain in indefinite existence.
All care was revoked, "DNR" order was written

Palliative care was not discussed; however was probably the next move.
To assist family with other decision making, care coordination, pain and symptom management (Sudore et al., 2014)

Celena Smith
Two primary rationales have been used to justify the use of DNR order:

1. Respect for patient autonomy;
2. Reduction of futile, costly medical care.

In this case, in consideration of Mary Lou' s real situation, end-of-life care and DNR information should be discussed between family and care provide team because of patient's mental status ( confusion and disorientation).
to honor the principle of beneficence, providers should relieve suffering at the best of their ability (Runzheimer, 2015)
Felicia Skipper RN
Uses substituted judgement standard due to patient unresponsiveness (son Tom)
Rule of Double Effect :"[To] do this to the right person, to the right extent, at the right time,with the right motive, and in the right way,that is not for every one nor is it easy;wherefore goodness is both rare and laudable and noble."(Aristotle, Ethics II.9)
The patients family is respecting Ms. Warnings rights both ethically and legally to the fullest extent possible. They have been given an informed treatment plan, protecting patients dignity, safety, and comfort.
Decision made to withdraw meds,IV fluids, no treatments of any kind.They have decided that a DNR would be what would be in the patients best interest.

The main source utilized for primary background information was from our textbook Nursing Ethics : Across the curriculum and Into Practice as referenced below.
American Nurses Association. (2010). Registered nurses’roles and responsibilities in providing expert care and counseling at the end of life. Retrieved from
Aristotle. (n.d.) The Principle of double effect. Ethics II.9. Retrieved from
Billings, J., Krakauer, E. (2011).On Patient Autonomy and Physician Responsibility in End-of-Life Care Archives of Internal Medicine.171(9):849-853. doi:10.1001/archinternmed.2011.180
Butts, J.B., & Rich,K.L. (2013).Nursing ethics:Across the curriculum and into practice(3rd ed.). Burlington, MA: Jones & Bartlett.
Definition of Autonomy,patient.(2015). Retrieved from
Kindethics. (2014, June 10). Making Meaningful and Personalized Medical Decisions - Advance Directives. (Video File).Retrieved from
Mohanti, B. K. (2009). Ethics in palliative care. Indian Journal Of Palliative Care, 15(2), 89-92. doi:10.4103/0973-1075.58450
Runzheimer, J., & Larson, L. (2015). Medical ethics for dummies cheat sheet - For dummies. Retrieved from

Background References
Laura McConnell
Laura McConnell
Laura McConnell
The family had many issues to address including what they felt their mothers end of life wishes would of been. The family to me made the correct decision for their mother and the physicians explained the severity of their mothers illness so that the family could make their decision. Now facing them they need to determine where she should be for her dying days.
Laura McConnell

Patients can experience complete loss of cognitive, physical, and sensory functions effecting self autonomy after a chronic occlusive stroke (Moeller & Carpenter, 2013)

Prospects of returning to a normal life with or without treatment depends on pre-stroke function and extent of the stroke. Within the case study Mary Lou Warning suffered a chronic stroke leaving her in an unconscious state (Butts & Rich, 2013)

Leaving her family in a position to make crucial decisions regarding their mother's care.

Celena Smith
Mary Lou Warning
73 year old widow
symptoms confusion and disorientation
diagnosis occlusive stroke
medical history-none documented
her support was 5 sons & 1 daughter in various states
no end of life care discussed prior to this with the family
Patient on admission was confused and disoriented.
Nursing and physician staff should ask on admission if patient has a living will or DNR.
The next day the patient is incapacitated due to extension of stroke and unable to participate in medical decisions.
Son anxious due to issue of advanced directives/end of life care were never discussed. Patient does not have a living will or advanced directive: see importance of advanced directive in video link.

Physician has presented Tom with options to withdraw or withhold treatment.Prognosis is poor, will possibly remain unconscious (Buckley & Abell, 2009).
Staff to provide support to family and provide quality and supportive care to patient.
Social work, ethics committee, and Pastoral Care consults if needed are made.
Son Tom Warning is using appropriate standards for decision making by calling her other five children to make a decision regarding end of life care.
Decision made to withdraw meds,IV fluids, no treatments of any kind.

Ethical & Legal
Felicia Skipper RN
Felicia Skipper RN

Decisions and Directives
Celena Smith

Significant attention has been directed by social scientists, medical humanists, and clinicians to ways in which organizational culture and protocol in hospitals influence the dying experience( Weiss & Hite, 2000).


Family Involvement:

Typically patients DNR decision proactively, family members are often asked to act as surrogate decision-makers and decide on the patient’s behalf (Eliott & Olver, 2008).

Ensuring that patients and families receive and understand all relevant medical information is highly important through the admission to the end of life.

In this case, since Mary Lou Warning is widow, her five sons and one daughter who live in various states should be asked to act as surrogate decision-makers.

Healthcare Providers Involvement

Physicians play the most significant part in the DNR decision-making process, often initiating
discussions with the patient’s family—and possibly dominating the discussion( Khalaileh, 2014).

Nurses spend most of their time beside patients, and through effective communication with their patients and their families can play an important role in discerning their beliefs, values and wishes with regard to the ethical conclusions ( Park, Kim, & Kim, 2011).

In this case, the whole health care team including physicians, nurses, and social workers should communicate with each other effectively.
Healthcare Cost Avoidance:
Palliative care unit which accept the patients near the end-of-life in hospitals is associated with significant reductions in per diem costs and total costs, and can generate substantial savings to the health system ( Jung, Kim, Heo, & Baek, 2012).
Religious and Cultural Consideration:
Religion and spirituality also play a key role in a number of diverse domains including coping with serious illness, medical decision making, mental health, and quality of life (Ford, Downey, Engelberg, Back, &Curtis, 2012).
Care of the religious patient close to death is enormously complex especially when balancing religious obligations, the role of the rabbi, medical procedures, and personal preferences ( Loike et al., 2010)

In Mary Lou Warning's case, we didn't get the information about her religion and spirituality, however, health care providers should discuss this concern with family members to make sure respect their religious and cultural needs.
1. What is the best time for making do-not-resuscitate decisions?
2. What situations indicate that patients need DNR or palliative care?
3. How many values of medical ethics in end-of-life care? Which one you think play the most important role in your practice of caring end-of-life patients?
4. Whose responsibility to choose life and death?
5. In your own view, how do religion and culture affect the DNR decision?
In this case, due to the patient's age, medical diagnosis, and disease prognosis, and current condition, palliative care would be good for patient and her family.
Huihui Sun RN
Celena Jones,RN
Huihui Sun RN

American Nurses Association. (2010).
Registered nurses’ roles and responsibilities in providing expert care and counseling at the end of life.
Retrieved from
Aristotle. (n.d.) The Principle of double effect.
Ethics II.9
. Retrieved from

Billings, J., Krakauer, E. (2011). On patient autonomy and physician responsibility in end-of-life care.
Archives of Internal Medicine. 171
(9), 849-853. doi:10.1001/archinternmed.2011.180

Butts, J. & Rich, K. (2013).
Nursing ethics: Across the curriculum and into practice.
Burlington,MA: Jones & Bartlett Learning.

Definition of Autonomy, patient. (2015). Retrieved from

Eliott, J., & Olver, I. (2008). Choosing between life and death: Patient and family perceptions of decision not to resuscitate the terminally cancer patient.
Bioethics, 22(
3), 179–189. doi:10.1111/j.1467-8519.2007.00620.x

Ford, D. W., Downey, L., Engelbeerg, R., Back, A. L., Curtis, J. R. (2012). Discussing religion and spirituality is an advanced communication skill: An exploratory structural equation model of physician trainee self-ratings.
Journal of Palliative Medicine, 15
(1), 63-70. doi: 10.1089/jpm.2011.0168

Jung, H., Kim., Heo, D. S., & Baek, S. K. (2012). Health economics of a palliative care unit for terminal cancer patients: A retrospective cohort study.
Support Care Cancer, 20
(1), 29–37. doi: 10.1007/s00520-010-1047-y

Khalaileh, M. A. (2014). Jordanian critical care nurses’ attitudes toward and experiences of do not resuscitate orders.
International Journal of Palliative Nursing, 20
(8), 403-408.

Kindethics. (2014, June 10). Making Meaningful and Personalized Medical Decisions - Advance Directives. (Video File). Retrieved from

Loike, J., Gillick, M., Mayer, S., Prager, K., Simon, J. R., Steiberg, A.,... Fischbach, R. (2010). The critical role of religion: Caring for the dying patient from an Orthodox Jewish perspective.
Journal of Palliative Medicine, 13
(10), 1268-1271. doi: 10.1089/jpm.2010.0088

Moeller, D., & Carpenter, C. (2013). Factors affecting quality of life for people who have experienced a stroke. International
Journal of Therapy and Rehabilitation, 20
(4), 207-216. Retrieved from
Mohanti, B. K. (2009). Ethics in palliative care. Indian
Journal of Palliative Care, 15(
2), 89-92. doi:10.4103/0973-1075.58450

Park, Y., Kim, J., & Kim, K. (2011). Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
Nursing Ethics, 18(
6), 802–813. doi: 10.1177/0969733011410093

Runzheimer, J., & Larson, L. (2015).
Medical ethics for dummies cheat sheet - For dummies.
Retrieved from

Sudore, R., Casarett, D., Smith, D., Richardson, D., Ersek, M. (2014). Family involvement at the end of life and receipt of quality care.
Journal of Pain and Symptom Management. 48(
6), 1108-1116. doi:10.1016/j.jpainsymman.2014.04.001

Weiss, G. L., & Hite, C. A. (2000). The do-not-resuscitate decision: The context, process, and consequences of DNR orders.
Death Studies, 24(
4), 307-323. Retrieved from

References Continued
Celena Smith
Felicia Skipper RN
Huihui Sun RN
Full transcript