Ethical Legal Dilemma Advanced Practice Nursing Case Study II Essay

Ethical Legal Dilemma Advanced Practice Nursing Case Study II Health insurance policies have set limits on what services will be paid for with a terminally ill person in the home and these limitations may conflict with the nurse’s obligation to provide care for the terminally ill patient (Fry, Veatch & Taylor, 2011). Speaking with the family of a 59 year old male with his only history being terminal lung cancer that has metastasized to the brain, they express concern that they are beginning to have increase difficulty managing this condition. The patient is receiving hospice currently in the home, but the insurance company will not cover both hospice and respite services to assist the family. Community nurses working in the homes of dying patients often encounter many forms of ethical dilemma and they need support in this demanding situation that arises during the end of a patient’s life in the home (Karlsson et al. , 2010). The community nurse is a professional to whom the patient and family turn when they have questions or want to discuss plan of care and treatment options at a critical time in the patient’s life when personal assistance is required (Erlen, 2005). Speaking with the family (son and daughter), it is now found that the patient is now incontinent of both stool and urine and they are now limiting his intake of food and fluid in the afternoon and evening, so that their father doesn’t â€Å"lay in his own wastes throughout the night†. The patient has now developed an excoriated perineum and it appears that further skin breakdown is imminent. The patient has become increasingly weak, and has fallen several times over the last few days. He requires total care with all ADL’s and IADL’s and the family verbalizes being overwhelmed with what their father requires. The patient is receiving hospice for medication administration for agitation and pain as well. Both son and daughter are at risk of losing their jobs related to missing work in order to take care of their father. The son works day shift and the sister works afternoon shift. They have each decided to return to work and this will cause their father to be left alone for almost two hours each day. This could be a case of negligence, where there is a failure to exercise a standard of care and it can be alleged when a person fails to act when a duty exists. There are five elements required to establish a case of negligence: the existence of a legal duty to exercise reasonable care; a failure to exercise reasonable care; cause in fact of physical harm by the negligent conduct; physical harm in the form of actual damages; and proximate cause, a showing that the harm is within the scope of liability (Cornell University Law School, n. d). Negligence falls under tort law and could be criminal. According to Collins English Dictionary (2009) negligence or mal-practice is defined as any immoral, unethical misconduct or neglect of a health care professional. The patient is receiving care at home from Hospice for pain and agitation medication management, which is not sufficient. There is no absolute method to avoid lawsuits; however, prevention of this case could have occurred prior to discharge with proper education of the family of their options for care regarding their father. Detailed explanation of what care their father may need as the end of life is near, may have steered the family to make alternative arrangements for their father. Hospice will have a duty to educate the family of the possible act of negligence and it will be the duty of the hospice workers to report this act made by the family, by following their policies and procedures, which will be their best defense (Grant & Ballard, 2011). Further discussion has shed light on the possibility of Human Rights being violated, under the Affordable Car Act. This is due to the patient’s insurance declining to pay for needs at home. This law alleviates according to Gable (2011) some of the hardships forced on the public’s health for those with insufficient availability of health insurance or access to health care. The Affordable Care Act bans insurance companies from placing lifetime dollar limits on health benefits, which will prevent individuals suffering from chronic diseases from having to worry about going without treatment because of their lifetime limits and it restricts the use of annual limits and bans them completely in 2014 (U. S. Department of Health and Human Services, n. d. ). The ethical principle that will be violated here is the respect for person and the concept of deontology. Deontology means that some behaviors are our duty, whether there is benefit or not (Fry, Veatch & Taylor, 2011). The Stanford Encyclopedia of Philosophy (2012), says that deontology is within the moral theories that guide and assess our choices of what we ought to do and what type of person we should be. Again, proper education to the family, prior to discharge of this patient and by the nurses within the hospice agency could have avoided this occurring. Respect for person involves autonomy, but not all individuals are able to acting autonomously. This requires the ability to set goals and make choices, and this may be compromised at times in a person’s life. Defined by the Belmont Report, respect for persons requires that these vulnerable individuals be offered special protections during periods when they cannot act autonomously. This is also a major emphasis of the principle of justice which requires that the vulnerable be extended special protections with regard to the distribution of the benefits and burdens of research (Yale Human Subject Research Resource & Education Program, 2006). Legal reasoning is evident in two forms, legislative drafting and application of rules to cases and it involves an acceptance and spirit of working within law, which gives it some bias towards maintaining existing rules (Peterson, n. d. ). This does not always mean that law is always just and practical, and judges avoid applying rules that would result in less than desired outcomes. According to Peterson (n. d. ), legal reasoning contains many examples of efforts to changing the legal system and returning to the law making process. Coherence in legal reasoning is where law makes sense as a whole, and is a form of supportive rationality (Bertea, 2009). The coherence part of legal reasoning may be weaker than the logical part. Coherence of a set of legal norms is made by there being a realization of some common value or some common principle (Dickson, 2010). Logic in legal reasoning is the reasoning involved in interpreting constitutions, statutes, regulations, balancing fundamental principles, adopting and modifying legal rules, while applying those rules to cases and evaluating evidence, prior to making decisions (Walker, 2007). Case law is the legal principles embodied in judicial decisions that are derived from applying areas of law to the facts of individual cases. Case law is a dynamic and constantly developing body of law, where each case contains part of the facts of the controversy and an explanation of how the judge arrived at a conclusion (The Free Dictionary by Farlex). Lastly is legal analysis, which requires proving each element of a rule to be true or false and it refers to a statement by a court, judicial officer, or legal expert as to the legality or illegality of an action, condition, or intent (Connelly, n. d. ). The function of ethical reasoning revolved around the fact that much of human behavior has consequences for the welfare of others. People can act toward others in such a way as to increase or decrease the quality of their lives and we are capable of helping or harming. We are empathetic and therefore can recognize when we are doing one or the other. The role of ethical reasoning is to decipher acts that either enhances the well-being of others and those that harm or diminish the well-being of others. Developing one’s ethical reasoning abilities is crucial because there is in human nature a strong tendency toward egotism, prejudice, self-justification, and self-deception which has sociocentric influences (Elder & Paul, 2011). The problem of pseudo-ethics is that one cannot develop as ethical persons if we cannot face the fact that everyone is prone to egotism and prejudice. Flaws in human thinking are the cause of much human suffering and only developing fair-mindedness, honesty, integrity, self-knowledge, and deep concern for the welfare of others can provide foundations for sound ethical reasoning (Paul & Elder, 2009). According to Paul and Elder (2009), ethical reasoning involves doing what is right while avoiding selfish desires and to live an ethical life, is to develop command over our native egocentric tendencies. The elements of ethical reasoning include awareness, independent problem solving, supported problem solving, and decision and outcome evaluation, while effective ethical reasoning requires sensitivity, problem solving skills, and the motivation and determination to act on decisions (Kenny et al. , 2007). The logic of ethical reasoning involves moral theory derived from meta-ethics and evolutionary ethics. The fundamental problem is that evolutionary ethics is a scientifically based theory while meta-ethics is a philosophically based and logic related to human behavior is cannot convey the complexity of human experience, so moral terminology such as good and moral have evolved from billions of social issues over centuries of time that are related to human behavior (Bromberg, 2011). The advantages and disadvantages of ethical reasoning start with the fact that ethical reasoning assumes that everyone will make choices that will cause no harm. This would mean that an ethical society will prohibit unethical actions, but ethical reasoning excludes actions that are based on spiritual or social customs and does not persecute any specific group for their beliefs. Ethical reasoning is meant to determine actions that are in the best interest of everyone, but the course of action is not always clear-cut. Ethical reasoning is simple, all things are not equal, and determining the true ethical route can be difficult and subjective (Mayers, n. d. ). Summary Some cultures continue to practice rituals that are illegal in other counties. Those things that are ethically acceptable in one culture, many times aren’t with other cultures. Laws are based on rules within cultures. Rules are things that citizens must obey in order to prevent persecution by governing authority. Ethical reasoning is based on what people believe is morally right or wrong, whereas legal reasoning is based rules made within cultures. Many times things that are illegal coincide with things that are believed to be unethical within a culture; however, an illegal act by a health care practitioner is always unethical, but an unethical act is not necessarily illegal. Ethics involves standards of behavior and the concept of right and wrong, over that which is legal in a given situation. Moral values are formed through the influence of the family, culture, and society and form one’s ethical reasoning basis (Judson & Harrison, 2012). I feel any ethical decision model must involve individual employees, as well as their supervisors in order to be effective. Shared decision making, between health care professionals, is vital to arrive at what best meets the employee’s needs. I think an ethical reasoning tool needs to involve the employee and the supervisor so the problem can be addressed. The use of an integrative model can develop confidence and justification in making ethical decisions. Preferences and values come into effect during the process of an integrated ethical decision making model and principles of patient-centeredness and shared-decision making must be integrated (Sestini, 2010). An integrated model of ethical reasoning highlights the integration between ethics and decision making, where ethics is a tool that brings positive aspects of the reasoning process. The model is composed of three major elements: the ethical component; the decision making component; and the contextual component (Grundstein-Amado, 1991). Park (2012), reviewed available structured ethical reasoning and decision-making models and developed an integrated model consisting of six steps: 1. the identification of an ethical problem 2. the collection of additional information to identify the problem and develop solutions 3. the development of alternatives for analysis and comparison 4. the selection of the best alternatives and justification 5. the development of diverse, practical ways to implement ethical decisions and actions 6. the evaluation of effects and development of strategies to prevent a similar occurrence. The best ethical reasoning should be determined by putting efforts from all health care professionals involved and although it will not guarantee ethically right or good decisions, it will likely improve a process and outcomes of clinical ethical decisions (Park, 2012). Applying this model to the situation of 59 year old male with his only history being terminal lung cancer that has metastasized to the brain. Applying the chosen model: 1. the identification of an ethical problem: They have each decided to return to work and this will cause their father to be left alone for almost two hours each day. 2. the collection of additional information to identify the problem and develop solutions: families concerns: Increased difficulty managing this condition Patient is receiving hospice but the insurance company will not cover both hospice and respite services to assist the family. patient is now incontinent of both stool and urine and they are now limiting his intake of food and fluid in the afternoon and evening patient has now developed an excoriated perineum The patient has become increasingly weak, and has fallen several times over the last few days. requires total care with all ADL’s and IADL’s and the family verbalizes being overwhelmed 7. Both son and daughter are at risk of losing their jobs related to missing work in order to take care of their father. 3. the development of alternatives for analysis and comparison: this would involve the family’s input into the situation. Possible another family member could be available for the two hours. There could be a possibility to withdrawal from hospice and pursuing home health care to be used for respite services. 4. the selection of the best alternatives and justification: Again this would have to involve the family’s input to see what best meets their needs, as well as their father’s needs. Justification to the family regarding their father being left alone for two hours at a time, as well as withholding fluids and food from him can be done through education. 5. the development of diverse, practical ways to implement ethical decisions and actions: Deontology means that some behaviors are our duty, whether there is benefit or not (Fry, Veatch & Taylor, 2011). This is also a major emphasis of the principle of justice which requires that the vulnerable be extended special protections with regard to the distribution of the benefits and burdens of research (Yale Human Subject Research Resource & Education Program, 2006). As a case manager, I need to work with family on awareness, independent problem solving, supported problem solving, and decision and outcome evaluation. 6. the evaluation of effects and development of strategies to prevent a similar occurrence: this would be done post intervention, and then determination could be made of whether the end result was effective. Evaluating the effects of the interventions will allow the health care professional to adapt future encounters with similar situations. Recommendations Further research revealed the U. S. Department of Health & Human Services said federal hospice investigations have increased drastically over the last few years. A Medicare oversight report in 2009, found nearly a third of hospice patients were not getting services of treatment in care plans, nor were they getting visits providers had promised to provide (Bloomberg News, 2011). This would lead to the first recommendation to the family. It can be recommended that they ask the visiting hospice to review the overall care plan with them. The case manager needs to ask for a copy of the care plan, so it can be reviewed with the family. Once the care plan is reviewed, services being received can be reviewed to match what is promised to take place. A second recommendation to the given situation includes involvement of the case manager. The case manager needs to ask the family to discuss options with the patient and consider his preferences as well as special physical, emotional and psychosocial needs. A final recommendation is that the case manager assist the family to evaluate how much support can be provided by other family members and friends. For help determining the best option, they may need to talk with the health care team. Caring for their father, according to research, may have left them no time for self-care; drained them of energy and enthusiasm; and affected interactions with other family and friends (Joad et. al, 2011). References Bertea, S. (2009). The argument from coherence. Available at http://ivr-enc. info/index. php? title=The_Argument_from_Coherence Bloomberg News. (2011). Hospice care grows as do patient negligence concerns. Retrieved from http://www. ltlmagazine. com/news-item/hospice-care-grows-do-patient-negligence-concerns Bromberg, S. E. (2011). The evolution of ethics: An introduction to cybernetic ethics. Retrieved from http://www. evolutionaryethics. com Collins English Dictionary (2009). Negligence. Retrieved from http://dictionary. reference. com/browse/malpractice. Connelly, A. (n. d. ). Legal analysis and reasoning from precedent. Retrieved from http://www. law. uky. edu/files/docs/clinic/legal_analysis. pdf Cornell University Law School. (n. d. ). Negligence. Retrieved from http://www. law. cornell. edu/wex/negligence Dickson, J. (2010). Interpretation and coherence in legal reasoning. In The Stanford Encyclopedia of Philosophy online. Retrieved from http://plato. stanford. edu/archives/spr2010/entries/legal-reas-interpret/>. Elder, L. & Paul, R. (2011). Ethical reasoning essential to education. Retrieved from www. criticalthinking. org Erlen, J. (2005). When patients and families disagree. Orthopedic Nursing, 24(4), 279–282. Fry, S. , Veatch, R. , & Taylor, C. (2011). Case studies in nursing ethics (4th ed. ). Sudbury, MA: Jones & Barlett Learning. Gable, L. (2011). The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights. Journal of Law, Medicine & Ethics. 39(3), 340-354. doi:10. 1111/j. 1748-720X. 2011. 00604 Grant, P. D. , & Ballard, D. C. (2011). 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