[Verified Answer]: Debbie R. Faulk and Arlene H. Morris J. E. is

Debbie R. Faulk and Arlene H. Morris J. E. is the chief nursing officer (CNO) of a midsized regional hospital. One evening an older person was found unresponsive at a nearby long-term care facility, placed on ventilator support, and transferred to J. E.’s hospital. This person is awake and alert and has end-stage chronic obstructive pulmonary disease and severe rheumatoid arthritis with little likelihood of being weaned from the vent. Due to the patient’s long-term chronic diseases and limited prognosis secondary to the illnesses, the lifetime Medicare reserve days are nearly exhausted. J. E. has been informed that the prior long-term care facility has no beds for readmission and that other hospitals or long-term care facilities in the geographic area are reluctant to accept transfer of this patient. Additionally, there is no family willing to care for the patient at home; the only living family members are two stepchildren who live in another state. They have requested that the patient be transferred to a facility that provides ventilator care. The physician assigned to provide care said, “The most humane plan of care is to take the patient off the vent and allow a peaceful death through comfort care after extubation.” It is anticipated that discontinuation of ventilator support will result in death, likely within a week. J. E. believes there are only two options: extubation as suggested by the hospital physician or continuing care for the patient with the ventilator until death. The stepchildren call the case manager, who refers the call to J. E. The stepchildren are informed about the patient’s status and the two options. J. E. tells the stepchildren that the physicians are concerned the patient has no quality of life. Although J. E. requests consent to extubate, the stepchildren would not consent, stating they wanted to wait until December 26 to decide. When J. E. asks why they desire to wait and possibly prolong suffering, the stepchildren reply that they do not want to associate the memory of the patient’s death with a holiday. The stepchildren ask how to get someone else appointed to make decisions. J. E. had been informed by the case manager that if a state agency appointed a legal guardian, the stepchildren could not have a say in funeral arrangements. J. E. relays this information to the stepchildren, who are upset about no input regarding the funeral, but they ask no other questions. The stepchildren later call back and consent over the phone to withdraw life support and request to be informed when the patient dies. J. E. is concerned about the phone consent and decides that a consent form would be worded as follows: “We, ________ (name) and ________ (name), understand that if the ventilator is removed, death will likely occur soon, but this is in the best interest of ________ (name of patient).” This consent form is sent electronically to the stepchildren, who sign the form and return it. J. E. then asks the case manager and the primary nurse to sign as witnesses on the form. However, the case manager says that the signing had not been witnessed and asks J. E. if a notary should have been involved and a hard copy of the form sent by mail. J. E. replies that electronic consent forms are part of the healthcare world as long as two people are present. The case manager and primary nurse express concern that the consent could have been coerced and actually provide for the physician to end the patient’s life. J. E. asks another case manager and nurse to sign as witnesses for the consent form, and they agree. However, the patient’s case manager and other nurses on the patient’s unit begin discussing possible legal and ethical implications of these actions and ask if a line had been crossed. Morris & Faulk, 2012 Case Study Questions 1. What factors initially contributed to the development of this situation? 2. Do you believe there were other options besides the two presented? Explain your thoughts. 3. Describe the ethical concerns for each of the following: The patient The family members The primary nurse The case manager J. E. The physician(s) The case manager and nurse who signed as witnesses The hospital as an organization The healthcare delivery system 4. Describe the legal implications for each of those listed in question 3. 5. Who was the advocate for this patient? 6. Was a consideration related to the patient’s condition not discussed? 7. What would you have done if you were J. E.?