Ethical and Legal Challenges in Decision-Making for an Elderly Patient: The Case of Jamilah Shah

QUESTION

Introduction: Ethical and legal problems arise in healthcare organizations when the decision-making capacity of an elderly patient is uncertain, particularly when the patient’s decisions are at odds with the rest of the family’s preferences. The scenario provided here is about this type of situation.

This performance assessment will provide you with experience in sorting through the sometimes-competing issues related to a scenario such as the one described, as well as experience in formulating actions that can help guide a healthcare organization through ethical problems that arise in caring for elderly patients.

Note: Students may rely on conversations and notes gleaned from cohort lectures and Boot Camp.

SCENARIO

You are the healthcare administrator at a local hospital. A social worker has come to you to discuss the case of Jamilah Shah, a patient who has recently been admitted to the hospital. Jamilah is a 90-year-old woman who was brought to the hospital after collapsing at the side of her bed. EKG and lab tests revealed a heart attack.

More than 40 years ago, Jamilah emigrated with her wealthy husband (now deceased) and their three sons from Turkey to the United States. Jamilah was a homemaker and learned only basic English, but her children are fluent English speakers. The children are now all in their 50s. The family retains Turkish culture and norms, including the sons acting as patriarchs for the family. Even though Jamilah is highly educated (in Turkey she was trained as a lawyer), the sons make many of the family decisions. Two of the three children are in successful careers. The remaining child, the youngest son, Bashir, owns a small market and struggles financially.

Until yesterday, the day of her admission, Jamilah resided in an extended care facility (ECF), where she has lived since her husband’s death. She reportedly has severe chronic obstructive pulmonary disease and adult-onset diabetes mellitus.

Jamilah has no advance directives on file. Because of her communication difficulties, the emergency department physician started her on anticoagulants while trying to contact her next of kin. The ECF sent paperwork to the hospital, listing Bashir as the emergency contact. Bashir was contacted and is now at the hospital with his two brothers. He has informed the care team that he is the decision maker, and he wants his mother to have a Do Not Resuscitate (DNR) order with no intervention of any kind other than comfort care.

The social worker has come to you with concerns that this decision may not reflect Jamilah’s wishes. When the social worker was visiting with Jamilah alone, Jamilah reached for her hand and said, “Please help me. I want to live.” The social worker shares concerns about the interactions observed between Jamilah and her sons, stating that the relationships seem unsupportive. The hospital’s ethics committee has not yet been involved. The social worker also reports that the emergency physician requested a cardiology consultation, which was just completed. The consultant documented that “Because the family has requested only comfort care, and due to the patient’s multiple comorbidities, the patient will be managed medically, with no intervention, and will not receive cardiac catheterization or be considered for coronary bypass surgery.” If nothing is done, Jamilah will likely die within days.

REQUIREMENTS

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The similarity report that is provided when you submit your task can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

Note: Complete these prompts by using complete sentences.

Note: The web links “Advance Directives” and “Determining Competency for Medical Decisions” found below may be used to assist you in completing this assessment.

A.    essay (suggested length of five to pages, not including attachments) analyzing the scenario by doing the following:

1.   Describe three potential ethical dilemmas presented in the scenario: one related to autonomy, one related to beneficence, and one related to non-maleficence.

a.   Analyze legal implications associated with each of the potential ethical dilemmas described.

2.   In response to Bashir’s demands for only comfort care, discuss each of the following three courses of action in the scenario as it relates to each ethical dilemma.

•   Course of action 1: follow Bashir’s wishes

•   Course of action 2: refuse to follow Bashir’s wishes

•   Course of action 3: briefly delay the decision to gather additional information and other perspectives

a.   Choose and justify the correct course of action (in response to Bashir’s demands for only comfort care).

b.   Choose one of the courses of action from part A2 that you did not justify in part A2a and explain how possible consequences show that it is not the correct course of action.

3.   Putting yourself in the role of a healthcare administrator, describe in the essay what should happen next within the scenario by doing the following:

a.   Describe two resources that could have made or could still make Jamilah’s wishes clearer.

i.   Explain how each resource could have made Jamilah’s wishes clearer.

4.   Create three policy recommendations that you could make as an administrator to help your employees and the facility’s medical staff handle similar situations in the future.

a.   Justify each policy recommendation.

B.   Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

C.   Demonstrate professional communication in the content and presentation of your submission.

ANSWER

Ethical and Legal Challenges in Decision-Making for an Elderly Patient: The Case of Jamilah Shah

Introduction

In healthcare organizations, ethical and legal dilemmas often arise when the decision-making capacity of elderly patients is uncertain, especially when their preferences conflict with their family’s wishes. This essay discusses the case of Jamilah Shah, a 90-year-old woman recently admitted to a local hospital after suffering a heart attack. Jamilah’s family, particularly her son Bashir, demands only comfort care, raising potential ethical dilemmas related to autonomy, beneficence, and non-maleficence. The legal implications of these dilemmas must also be considered. The essay further explores three courses of action, emphasizing the importance of respecting Jamilah’s wishes while ensuring her best interests are upheld. Finally, as a healthcare administrator, I will propose policy recommendations to guide similar situations in the future.

Ethical Dilemmas and Legal Implications

Autonomy

Jamilah’s autonomy is at stake, as her sons make decisions on her behalf, despite her advanced education and ability to express her wishes. Jamilah’s inability to communicate effectively raises concerns about her autonomy. Legally, patients have the right to make decisions about their healthcare if they are deemed competent. In Jamilah’s case, her communication difficulties warrant further assessment of her decision-making capacity.

Beneficence

The conflict arises between respecting Jamilah’s right to autonomy and ensuring her overall well-being. Bashir demands comfort care, which may prioritize his own emotional comfort over his mother’s wishes. Beneficence obligates healthcare providers to act in the patient’s best interest, raising questions about whether comfort care is truly in Jamilah’s best interest, given her plea to live.

Non-maleficence

The decision to provide comfort care only could potentially harm Jamilah if it denies her the opportunity to receive potentially life-saving medical interventions. The consultant’s recommendation for no intervention may align with Bashir’s wishes but raises ethical concerns about doing no harm to the patient. Legally, healthcare providers have an obligation to avoid harm to patients, which must be weighed against the family’s wishes.

Courses of Action

Follow Bashir’s Wishes

Choosing to follow Bashir’s demands for comfort care would respect his authority as the listed emergency contact. However, this course of action might not align with Jamilah’s wishes, as she expressed a desire to live when alone with the social worker. From an ethical standpoint, prioritizing autonomy and patient wishes should be paramount.

Refuse to Follow Bashir’s Wishes

Rejecting Bashir’s demands and pursuing medical interventions aligns with beneficence, aiming to promote Jamilah’s well-being and potentially save her life. However, this approach may compromise autonomy and create family conflicts, leading to potential legal challenges if the family contests the decision.

Briefly Delay the Decision

Delaying the decision allows for gathering additional information and perspectives, considering the complexity of the case. Engaging the hospital’s ethics committee would be beneficial to address the ethical concerns adequately. This approach respects both autonomy and beneficence, as it seeks to make a well-informed decision in Jamilah’s best interest.

Justification for the Chosen Course of Action

The most appropriate course of action is to briefly delay the decision to gather additional information and perspectives. This approach balances the ethical principles of autonomy and beneficence, as it recognizes Jamilah’s expressed desire to live while also allowing the family’s concerns to be considered. Engaging the ethics committee ensures a thorough and unbiased evaluation of the situation, resulting in a more informed decision that respects all stakeholders involved.

 Explanation of Why Another Course of Action is Not the Correct Choice

Refusing to follow Bashir’s wishes and pursuing medical interventions immediately may disregard Jamilah’s autonomy. If it is later revealed that Jamilah genuinely prefers comfort care, this decision would have been inappropriate and may lead to legal consequences. Respecting autonomy requires careful consideration, and the brief delay allows for a more comprehensive assessment.

Next Steps for the Healthcare Administrator

As the healthcare administrator, my priority is to ensure the best possible care for Jamilah while addressing the ethical concerns raised. To do so, the following steps should be taken:

Resources to Clarify Jamilah’s Wishes

Language Interpretation Services: Providing an interpreter fluent in Turkish would help overcome Jamilah’s communication difficulties and ensure her voice is heard, allowing for a clearer understanding of her preferences.
ii. Advance Care Planning (ACP) Conversations: Facilitating discussions between Jamilah and her healthcare providers, possibly with the involvement of a trained counselor, would enable the exploration of her values and end-of-life preferences.

Policy Recommendations

Mandatory Advance Care Planning: Implement a policy mandating that all elderly patients, particularly those with language barriers or communication difficulties, participate in advance care planning discussions. This would ensure that patient wishes are documented and respected.

Involvement of Ethics Committee: Establish a policy requiring the involvement of the hospital’s ethics committee in complex cases involving conflicts between family preferences and patient autonomy. This ensures a thorough ethical evaluation and unbiased decision-making process.

Cultural Competency Training: Provide regular training to healthcare staff on cultural competency, especially for patients from diverse backgrounds. This would enable better communication and understanding of patients’ values and preferences.

Conclusion

The case of Jamilah Shah highlights the ethical and legal complexities that can arise when the decision-making capacity of an elderly patient is uncertain, and their family’s preferences conflict with the patient’s wishes. By prioritizing autonomy, beneficence, and non-maleficence, healthcare administrators can navigate these challenges and ensure the best possible care for the patient. Engaging the ethics committee, utilizing appropriate resources, and implementing effective policies are essential to guide healthcare organizations through ethical dilemmas and promote patient-centered care.