Ethical Dilemma in Healthcare: Case Scenario of ER Scene 1

The case scenario involves an 83-year-old diabetic patient with respiratory distress and gangrene. The patient refused amputation, but his daughter insisted on surgery. The healthcare administrator faced an ethical dilemma in upholding the patient's autonomy while ensuring beneficence, non-malfeasance, and stewardship. Surrogate decision makers can make decisions on behalf of the patient when they lack competency. The healthcare administrator should have performed a thorough mental state assessment, checked the credibility of the surrogate, and involved a proxy surrogate in the decision.

August 30, 2
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1
Incident in the
ER Scene 1

August 30, 20242
Case Scenario: ER Scene 1
 The case scenario involves an Emergency Room situation
with an 83 year old diabetic patient
 The patient was presented to the ER with signs of
respiratory distress
 The patient has a history of diabetes
 He was accompanied by his daughter
 Patient’s daughter also informed that the patient had
Alzheimer’s
 ER staff’s assessment revealed that the patient showed
signs of dementia, but that could be attributed to the
confusion and stress caused by the respiratory distress
syndrome as well as the environment of the ER.

August 30, 20243
Case Scenario: ER Scene 1
(continued…)
 Physical examination revealed that the patient had
gangrene on his right foot
 The gangrene was found to have spread to his
ankle
 Below the knee amputation was recommended for
the patient
 The patient however refused amputation
 The social worker was informed by the patient that
he did not want the amputation as he wanted to
die with his body intact and that he had lived long
enough

August 30, 20244
Problem situation:
 Patient’s daughter however insisted upon the surgery as she
wanted her father to recover
 A surgery was performed on the patient upon his daughter’s
insistence
 A complete state checkup was not performed on the patient to
understand if the patient has the capacity to make his care related
decisions
 The medical report from nurse revealed that the patient had mild
dementia which might be due to his respiratory distress and
environmental stress
 The patient’s daughter was afraid of an elder neglect investigation
 The social worker expressed concerns that the daughter might have
failed to provided proper care to the patient since she did not seek
care for the open wound but instead on the respiratory condition

August 30, 20245
Problem Situation
(continued…)
 Healthcare administration has the responsibility to ensure
the following aspects for the patient:
 Autonomy of patient’s decision
 Beneficence: the requirement to promote the wellbeing of the
patient
 Non-malfeasance: preventing any harm to the patient
 Stewardship: preserving the wellbeing of patient
 Justice: fair and equitable treatment for patient.
 Patient’s refusal for surgery could result in his death and
thus violate the code of beneficence, non-malfeasance and
stewardship
 Following the patient wish however could result in the
violation of patient’s autonomy

August 30, 20246
Who decides on behalf of the
patient if the patient is
determined to lack competence?
 Surrogate Decision makers can make decisions on
behalf of the patient.
 Surrogate decision makers can include:
 A family member
 Primary caregiver
 Spouse
 Guardian
 Adult son or daughter
 Adult sibling
 Adult grandchild
 Close friend
 Guardian of patient’s property or estate

August 30, 20247
Surrogate Decision Maker
(continued…)
 They can also be referred to as healthcare proxy
 Their responsibility is to advocate for patients who
lacks the competence to take care of themselves or
make decisions related to their healthcare
 The surrogate can have the power of attorney to
make decisions on behalf of the patient
 The surrogate should be a trusted person
 An advanced directive should also be filed in
situations where surrogates have to make care
related decisions and an alternative healthcare
agent should also be identified in the document.

August 30, 20248
How should a surrogate decision maker
proceed on behalf of the patient?
 To make decision on behalf of the
patient, the surrogate decision the
following factors should be considered
by the surrogate:
 A power of attorney
 The best interest of the patient
 Ensuring that the decisions respects the
wishes of the patient

August 30, 20249
How can the healthcare
administrator ensure that the
patient’s autonomy is ensured
and competency established?
 To ensure patient’s autonomy, the following factors
needs to be considered by the healthcare
administrator:
 Supporting the patient to make their own care related
decisions
 Thorough checkup of patient’s mental condition to assess
their ability to make decisions
 Delegating the responsibility of making decisions to the
surrogate if the patient lacks the cognitive ability/competency
 Checking the credibility of the surrogate in their ability to
consider the best interest of the patient
 Ensuring the surrogate has the legal and moral right to make
decisions on behalf of the patient

August 30, 202410
How do the facility’s standards
and regulations affect how
competency is determined?
 HIPAA policy
 Filing advance directive
 Signing power of attorney form (DPA/HC)
 Identifying a proxy surrogate
 Hospital Policies
 Checking the mental state of the patient
 Performing risk assessment
 Verifying the credibility of the surrogate
 Ensuring that the decisions are in the best interest of the patient
 Code of Ethics
 Autonomy
 Beneficence
 Non-malfeasance
 Stewardship
 Justice

August 30, 202411
What the healthcare administrators
should have done in the case scenario:
 Perform a thorough mental state assessment on the
patient
 Check the credibility of the surrogate and investigate
why the surrogate failed to seek care for open wound
 Involving a proxy surrogate in the decision
 Filing an advanced directive
 Checking for power of attorney from the surrogate
 Considering the patient’s wish in the care decision
 Deliberating the decision to amputate until the
patient regained mental lucidity

August 30, 202412
Conclusion
 Surrogate decision makers can make clinical decisions on
behalf of the patient
 This is applicable when the patient does not have the capacity
or competency to make decisions
 Mental state exam is necessary to ensure the patient lacks
competency
 The surrogate must have a power of attorney
 Best interest of the patient needs to be considered
 HIPPA guidelines should be followed
 Hospital policies should focus on assessing the credibility of
the surrogate, perform risk assessment for the patient and
ensure the decisions of the surrogate is in the best interest for
the patient.

August 30, 202413
References:
 Ginsberg, M. D. (2014). Informed Consent and the Differential Diagnosis:
How the Law Can Overestimate Patient Autonomy and Compromise
Health Care. Wayne L. Rev., 60, 349.
 Laureate Education (Producer). (2015). Incident in the ER: Scene 1 [Video
file]. Baltimore, MD: Author.
 MedlinePlus. (2015). Mental status testing. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/003326.htm
 Teitelbaum J., &Pozgar G. (2015). Law, ethics, and policy in healthcare
administration (Custom ed.). Burlington: Jones & Bartlett Learning.
 Torke, A. M., Sachs, G. A., Helft, P. R., Montz, K., Hui, S. L., Slaven, J. E., &
Callahan, C. M. (2014). Scope and outcomes of surrogate decision making
among hospitalized older adults. JAMA internal medicine, 174(3), 370-377.
 Watson, A., Sheridan, B., Rodriguez, M., & Seifi, A. (2015). Biologically-
related or emotionally-connected: who would be the better surrogate
decision-maker?. Medicine, Health Care and Philosophy, 18(1), 147-148.

August 30, 202414
Questions
 What was the moral/ethical dilemma
that was faced by the healthcare
administrator in this case?
 Was the patient have competence to
make autonomous decision?
 What could the healthcare administrator
have done to uphold the ethical code of
practice?

August 30, 202415
Thank you