MEDICAL ETHICAL LEGAL Cornelia AKUHN

CASE 1 A patient admitted with headache, worsening with due time. Patient on appropriate analgesic drugs but headache still persists. After 3 hours following admission, patient has a cardiorespiratory arrest, resuscitation successful and urgent CT scan dine which shows massive cerebral bleed. Patient taken for an urgent surgery and evacuation done. Extraventricular drain is inserted and patient taken to intensive care post operatively. 2 hours post operatively patient has a lot of blood draining from the EVD.

Repeat CT scan done shows a re bleed and tonsillar herniation present Repeat CT scan done shows a re bleed and tonsillar herniation present. Neurosurgical review –no need for surgery, conservative management. Next day remains unresponsive still intubated and ventilated off sedation. Neurosurgical review recommend brain stem function test to be done. In the following few days, discussions held with all clinical items and patent family but family maintains aggressive management to carry on despite all features suggestive of brain stem death being present.

What next? Hospital ethics committee consult done How is the meeting decision be carried out??

Case 2 A baby( full term ) is born with anal orifice atresia, patent ductus arteriosus and hydrochephalus Mother contacted for need for surgery but says she does not want any intervention on the baby and baby should be allowed to die peacefully Medical team feels failure to carry out the surgery is negligence and baby has a very good chance of survival since all presenting complains are reversible Hospital ethics committee consult is done What next

Case 3 Baby X,4 year old is admitted in the hospital following road traffic accident where he has lost a lot of blood. Patient is tachypnec,tachycardic and hypotensive. Very pale, hemogram results show the baby had a hemoglobin level of 5 g/dl. Patient is intubated and on mechanical ventilation with a GCS of 5t/15. Parents contacted for blood transfusion consent but declines. Heamatinics are commenced but no much change. Day 3 organs stable ,patient extubated and commenced on oxygen therapy via mask and repeat Hb is 4g/dl. Parents still decline transfusion Hb day 4, is 3,5g/dl ,patient dyspneac requiring reintubation but parents still decline transfusion.

Case 4 Ms Y presents to the hospital with abdominal pain. Ct abdomen done shows the patient has abdominal aortic aneurysm. She is informed by the surgical team that the way to fix her problem is through surgical intervention and the rate of survival is 50/50. The patient is a model and declines the surgery with the reason of it will a scar on the abdomen that will compromise her carrer. Despite various rediscussions by various surgeons, she maintains her decision. The surgeons decide to do the surgery with put her consent, she is sedated and taken to theatre and surgery done successfully. She survives and is discharged

She later opens a case against the hospital Is this an ethical legal case Why Was the decision made justified?

What do you do now? Ethical consult-how do you think the decision tree will be?

Schummans ‘four boxes’ approach Medical indications Beneficence and non maleficence What is the patients medical problem Is the problem acute or chronic, critical, urgent emergent or reversible What are the goals of treatment What are the probabilities of success What are the plans in case of therapeutic failure In sum how can this patient be benefited by medical and nursing care and how can harm be avoided Patient preferences Respect for patient autonomy Is the patient mentally capable and legally competent Is there evidence of capacity If competent what is the patient stating about preferences for treatment has the patient been informed of benefits and risks, understood this information and given? If incapacitated who is the appropriate surrogate? Is the surrogate using appropriate standards of decision making Has the patient expressed prior preferences Is the patient unwilling or unable to cooperate with medical treatment? If so why In sum is the patient’s right to choose being respected to the extent possible in ethics and law Quality of life Beneficience, non maleficence and respect for patient autonomy What are the prospects, with or without treatment for a return to normal life? What physical, mental and social beneficits is the patient likely to experience if treatment succeeds? Are there biases that might prejudice the provider evaluation of patient quality of life? Is the patients present or future condition such as his or her continued life might be judged as undesirable? Is there any plan and rationale to forgo treatment? Are there plans for comfort and palliative care? Contextual features Loyalty and fairness Are there family issues that might influence treatment decisions? Are there provider(nurse, doctor) issues that might influence treatment decisions? Are there financial and economic factors? Are there religious and cultural factors? Are there limits on confidentiality? Are there problems of allocation of resources? How does the law affect treatment decisions? Is clinical research or teaching involved? Is there conflict of interest on the part of the providers or the institution?

Medical legal cases are common in hospital setups and need to set up a hospital ethical team is vital. This has now incorporated as a mandatory working committee in a hospital under the joint commission of health care standards effective from July 2017. So what is the role of the nurse in medical legal cases

Summary and conclusion Forensic nursing is covered in nursing syllabus but never examined so no key focus of this is present Nurse should be a key member in medical legal and ethical teams in the hospital.