Bioethics Case Pascasio, DC Perez, CM

Patient Profile Patient is E.M., 85/F, Roman Catholic. Patient is a diagnosed case of hypertension 5 years ago and is a chronic NSAID user due to her degenerative osteoarthritis. Patient is non-diabetic.

HPI Chief complaint: Melena HPI: 5 days PTA- patient was apparently well but started complaining of body malaise 2 days PTA- patient complained of nonradiating abdominal pain that is dull and aching in character and was relieved spontaneously. 1 day PTA- abdominal pain persisted and patient noted her stool to be black and watery in consistency and sought consult at a local clinic where patient was advised transfer to a hospital for further evaluation.

Review of systems (-) wt loss (-) anorexia (-) fever (-) blurring of vision (-) decreased hearing (-) chest pain (-) chest tightness (-) headache, nausea, vomiting (-) urinary changes, dysuria, oliguria, hematuria, (-)hematochezia (-)polyuria, polydipsia, polyphagia

Past medical history (+) hypertension, good control (-) diabetes, asthma, allergies, thyroid abnormalities, tuberculosis, goiter (-) previous surgeries/ hospitalization

family medical history (+)Hypertension – mother (-) DM, PTB, BA, goiter, cancer

Physical examination General Survey Conscious, coherent, not in cardiorespiratory distress Vital Signs:BP: 100/60 HR: 78 RR: 20 Temperature: 37.1 HEENT: pale conjunctivae, anicteric sclera, (-) neck vein engorgement, (-)tonsillpharyngeal congestion, (-) anterior neck mass Chest / Lungs: Equal chest expansion, clear breath sounds, (-) retractions, (-) crackles CVS: Adynamic precordium, normal rate, regular rhythm, (-) heaves, thrills, murmurs Abdomen: Soft, flabby, nontender, normoactive bowel sounds, (-) masses,(-) hepatomegaly, intact traube space GU / IE: not done. Skin / Extremities: Full equal pulses, pale nailbeds, (-) cyanosis, (-) clubbing, (-) edema; good skin turgor Neuro Examination: GCS 15, motor 5/5 on all extremities, equal sensory perception on all extremities

diagnosis Upper Gastrointestinal Bleed secondary to bleeding peptic ulcer disease secondary to chronic NSAID use Anemia Degenerative osteoarthritis

Course in the wards 12/28/09: patient was admitted in the ward 1/1/10: patient had melena and hematemesis 1/2/10: patient had another bout of melena and hematemesis 1/3/10: CBC revealed hemoglobin of 64 prompting infusion of 2 units of packed RBC 1/4/10: unremarkable ward day 1/5/10: EGD was performed on the patient which showed a gastric ulcer

Course in the wards 1/6/10: patients BP was at 80/50, which was intractable with fluid challenge. Patient was started on Dopamine drip 1/7/10: patients pulse was becoming faint and BP was dropping despite putting the dopamine drip to maximum. Patients BP and heart rate was 0 at 11am.

Discussion

Autonomy rational agents are involved in making informed and voluntary decisions patient has the capacity to act intentionally, with understanding, and without controlling influences "informed consent" in the physician/patient transaction regarding health care

Nonmaleficence we not intentionally create a needless harm or injury to the patient – acts of commission or omission. In common language Providing a proper standard of care one may be morally and legally blameworthy if one fails to meet the standards of due care

Nonmaleficence The legal criteria for determining negligence – the professional must have a duty to the affected party – the professional must breach that duty – the affected party must experience a harm; and – the harm must be caused by the breach of duty

Beneficence to take positive steps to prevent and to remove harm from the patient. applied both to individual patients, and to the good of society as a whole. It is sometimes held that nonmaleficence is a constant duty,

Justice giving to each that which is his due – implies the fair distribution of goods in society and requires that we look at the role of entitlement to each person an equal share to each person according to need to each person according to effort to each person according to contribution to each person according to merit to each person according to free-market exchanges

Issues Present Do not intubate, but with no DNR order – Is it a practical option? Who is the primary decision maker? – Who decides in his/ her absence? – Does being the financer equate to being the decision maker? – Educating the family of the patient regarding prognosis When is enough, enough?

Issues Present Considering issues beyond what they currently face – Justice for all – Finance as a finite resource Legal implications – Putting everything into writing – How not to get sued* Establish rapport, among other things

Issues Present Other issues…?

-END- Thank you