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Legal and Ethical Decision Making in Person Centred Care

Ethics are the principles which determine the behaviour of a person such as if the activities conducted by the person are morally correct or not (Rae, 2018). The definition of ethics can be changed according to the field in which a particular person is working (Banks, 2016). When a person is working in the field of healthcare, it is seen as a requirement that everyone associated with the healthcare of a patient should follow ethical principles (Moore et al., 2017). In case, one or more of these ethical principles are violated, it is called the breach of ethics and there can be legal implication not only on the person but also on the organization or institution where the patient was admitted. The practical basis of a person’s action, the judgment and intentions behind them is the universal rule of ethics (Butts & Rich, 2019). On the contrary in healthcare, it is also influenced by the personal dilemma, make judgment calls and decisions that are based on values (Francis et al., 2016). Historically, the patient care was based on paternalistic care approach where the decision of medical care of the patient was decided by the doctor or the team (Naldemirci et al., 2017). In recent time, it has changed to person-centred care and ethical care is one of the components (Castro et al., 2016). The present essay aims to explore the case study for the identification and discussion of ethical and legal consideration in the case study.

In the present case scenario, Mrs. Dorris is a seventy-year-old female patient who reported to the emergency department and was accompanied by her husband Peter. She was brought to the emergency department after her fall at home before which she was reported to be happy, mobile and caring for herself as well as her husband. In the emergency department after assessment by radiograph, it was seen that she suffered from a hip fracture and it was decided that the surgical correction is required for the same. After this decision, the patient was transferred to the orthopedic department where the treatment would be undertaken without the patient being informed about the condition and treatment to be done. In the Australian healthcare system, there is the presence of a charter system according to which there are three principles (Delaney, 2018). First is the accessibility to healthcare service which is right to a good level of healthcare service as and when it is required (Delaney, 2018). Second is to enjoy the same right as everyone to have the same level of physical as well as mental health (Delaney, 2018). Third and last principle is to get culturally appropriate care which is safe as well as sensitive to the cultural background of the patient so as to ensure patient safety and good quality of care (Delaney, 2018).

In the emergency department, it was seen that the patient was becoming increasingly confused as to what was happening and it was reported that she did not have any prior cognitive dysfunction. It is the duty of the doctor to inform the patient about the condition, the treatment that would be taken and the time required to do so (Rhodes, 2020). It is the right of the patient towards the communication with the personnel in the healthcare team such that they have a say in the decision that is made regarding the care (Leboul et al., 2017).To make the decision, it is required the patient is given a chance as well as encouraged to take part in the health and medical care (Delaney, 2018).This was not done in case of Mrs. Dorris as she was not given any explanation regarding her treatment before or after the transfer to the orthopedic department.

By not informing the patient about the procedure that is being carried out, there is a violation of informed consent not being obtained properly from the patient (Akyüz et al., 2019). It is required that the caregiver obtains informed consent from the patient and it is a vital part of healthcare process (Katz et al., 2016). When the nurse was conducting an assessment in the orthopedic department, it was seen that the doctor did not inform the patient or the husband about the form or the procedure that would take place. Peter, her husband while talking to the nurse revealed that he has been increasingly losing his memories and it was not documented in the charts of the patient. It can be seen from the case study that the husband as having memory problems is not an ideal candidate to get the consent signed especially since she has the sound cognitive ability. If the surgeon felt there was the constraint of time, he should have delegated the word to a nurse who could do the work and explain everything to the patient and obtain consent (Maillot et al., 2019).

Based on the knowledge and experience, the registered nurse was able to judge the case and escalate the case to the doctor as he was in charge of the patient and the response obtained was not satisfactory (Zambas et al., 2016). Upon seeing this she did not go to the next step of escalation and informed the nursing manager and as per the duties and responsibilities of a registered nurse that would have been the appropriate step. When the nurse signed off from her duty, she did not take any necessary action for the lack of proper consent that was taken by the surgeon. The action should have been according to the nursing guidelines and hospital policies. The patient was visited by their neighbour who confirmed about the memory loss of Peter and requested if required he can provide consent. Being a medical proxy is not new but it is done in case the patient does not have the cognitive ability or not in a condition to make a decision for herself (Fetherstonhaugh et al., 2017). Health proxy or medical proxy is a person who can be considered as next of kin. In this neighbour cannot be one until the patient agrees about it. This is what the nurse should have done, that is, she should have asked Mrs. Dorris if she would like Bert to sign the consent form on her behalf. Mrs. Dorris does not have any cognitive disability and she should be solely responsible to make any medical decisions. 

In the present case of Mrs. Dorris, it was seen that there were a few ethical violations conducted by registered nurse responsible for the care of the patient as well as doctor and the surgeon responsible for the care. In the emergency department assessment of the altered condition of the patient was not evaluated and she was not informed about her condition before transfer. The surgeon got a blank consent form signed from the husband who had memory problems without completely informing him or Mrs. Dorris what is going to happen. The registered nurse is concerned did escalate the issue but did not do it completely and she registered off duty without making sure that there is a resolution to the issue (Gill et al., 2016).

In the field of healthcare, there are four major principles of healthcare or biomedical ethics which are considered to be the cornerstone of healthcare and they are autonomy, beneficence, non-maleficence and justice (Teays, 2019). All the four principles of ethics were seen to be violated at some of the other points in the case of Mrs. Dorris. The first principle of ethics is that of autonomy which means that one respect others and if a person is capable of making the decision for himself or herself is given the right to make medical as well as healthcare decisions (Osamor & Grady, 2018). It is the right of each and everyone to have dignity and part of it is to make sure that a person is given the right to making the decision which might be according to the patient in the best interest (Zürcher et al., 2019). Mrs. Dorris was not informed about her condition in the emergency department what the line of treatment is going to be which did not give her any chance of making choice for herself, therefore, violating autonomy. Also, this was violated when the patient being cognitively sound did not sign the consent form herself. The consent form is an important part of the healthcare which is obtained after the complete procedure is explained to the patient by the doctor including any adverse events that might be expected (Gligorov, 2018).

The second principle of ethics in healthcare is beneficence. According to this principle of beneficence, it is the duty and responsibility of the doctor as well as everyone in the healthcare team should work in such a manner that it would only bring positive changes in the health of the patient (Veatch & Guidry-Grimes, 2019). This is violated when the complete assessment of the patient is done and a blank consent is obtained from Peter, her husband and neither of them is aware of the procedure, how long the procedure will take, recovery time required or the expected risks. The third principle of bioethics is non-maleficence. It means to do no harm to the patient which does not only includes giving wrong treatment but it has other corollary principles. They are to have risk mitigation, to make sure that the patient is not a risk to others in a community and the work is done in such a way that resources are not wasted (Veatch & Guidry-Grimes, 2019). The outcome of the patient should be positive such that there is no direct or indirect intended or unintended harm to the patient. In the present case of Mrs. Dorris, it is seen that nurse escalated the problem but it did not see it thoroughly which accounts for non-maleficence.

The last principle of bioethics is that of justice towards the patient. It is required that a healthcare professional always treats all the patients in the same way such that they are all treated with just, equally and fairly (Pozgar, 2019). Three principles of bioethics were violated in the case of Mrs. Dorris by the doctor were autonomy, non-maleficence and justice. When Mrs. Dorris was brought to the orthopedic ward she was not informed about the operation and neither was her carer and a blank consent form was signed by her husband. This violated her autonomy in making the decision for herself.The surgeon who was supposed to perform the corrective operation delegated the work to a junior doctor without fully assessing the strengths and weaknesses of the doctor such that whether he would be able to perform the operation properly. This was done by the doctor due to personal and leisurely reasons. This was a violation of non-maleficence as had the operation been performed by the surgeon as planned it would have improved the outcome of the surgery. This can be considered as intent to harm as the sub-standard treatment was given to the patient it would not be led to a further restriction in the movement of the patient post-operative. The registered nurse attempted to resolve the issue of consent that was not obtained but she did notfollow through. The nurse could have let the patient decide if she would want the neighbour Bert to be proxy for her medical decision and sign the consent form for her.

Whenever there is suspicion of medical negligence it is required that it is proven if the healthcare professional, as well as healthcare facility, is responsible for the violation, substandard practice and there is resultant harm (Hurwitz, 2018). The cause of harm should be because of the malpractice and harm is not far or rather it is proximate.

In conclusion, in the current practice of person-centred care, it is required that the patient is involved in the care process of the self when the patient has complete cognitive abilities. In the present essay, it is discussed how ethical principles are violated. When a person is working in the field of healthcare it is seen as a requirement that everyone associated with the healthcare of a patient should follow ethical principles. These violations can cause legal repercussions on the healthcare professionals and healthcare facility where the treatment was being undertaken. In the present case, it was seen that the patient's autonomy was violated along with other principles of bioethics which resulted in healthcare and medical negligence as it resulted in proximal harm for the patient.

References for Mrs. Doris Ethics Case Study

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Banks, S. (2016). Everyday ethics in professional life: Social work as ethics work. Ethics and Social Welfare10(1), 35-52. https://doi.org/10.1080/17496535.2015.1126623.

Butts, J. B., & Rich, K. L. (2019). Nursing ethics. Jones & Bartlett Learning.

Castro, E. M., Van Regenmortel, T., Vanhaecht, K., Sermeus, W., & Van Hecke, A. (2016). Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Education and Counseling99(12), 1923-1939. https://doi.org/10.1016/j.pec.2016.07.026.

Delaney, L. J. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian25(1), 119-123. https://doi.org/10.1016/j.colegn.2017.02.005.

Fetherstonhaugh, D., McAuliffe, L., Bauer, M., & Shanley, C. (2017). Decision-making on behalf of people living with dementia: how do surrogate decision-makers decide?. Journal of Medical Ethics43(1), 35-40. http://dx.doi.org/10.1136/medethics-2015-103301.

Francis, K. B., Howard, C., Howard, I. S., Gummerum, M., Ganis, G., Anderson, G., &Terbeck, S. (2016). Virtual morality: Transitioning from moral judgment to moral action?. PloS One11(10), e0164374. https://doi.org/10.1371/journal.pone.0164374.

Gill, F. J., Leslie, G. D., & Marshall, A. P. (2016). The impact of implementation of family‐initiated escalation of care for the deteriorating patient in hospital: A systematic review. Worldviews on Evidence‐Based Nursing13(4), 303-313. https://doi.org/10.1111/wvn.12168.

Gligorov, N. (2018). Telling the truth about pain: Informed consent and the role of expectation in pain intensity. AJOB Neuroscience9(3), 173-182. https://doi.org/10.1080/21507740.2018.1496163.

Hurwitz, B. (2018). Clinical Guidelines and the Law: Negligence, Discretion, and Judgement. CRC Press.

Katz, A. L., Webb, S. A., & Committee on bioethics. (2016). Informed consent in decision-making in pediatric practice. Pediatrics138(2). https://doi.org/10.1542/peds.2016-1485.

Leboul, D., Aubry, R., Peter, J. M., Royer, V., Richard, J. F., & Guirimand, F. (2017). Palliative sedation challenging the professional competency of health care providers and staff: A qualitative focus group and personal written narrative study. BMC Palliative Care16(1), 25. https://doi.org/10.1186/s12904-017-0198-8.

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Moore, L., Britten, N., Lydahl, D., Naldemirci, Ö., Elam, M., & Wolf, A. (2017). Barriers and facilitators to the implementation of person‐centred care in different healthcare contexts. Scandinavian Journal Of Caring Sciences31(4), 662-673. https://doi.org/10.1111/scs.12376.

Naldemirci, Ö., Wolf, A., Elam, M., Lydahl, D., Moore, L., & Britten, N. (2017). Deliberate and emergent strategies for implementing person-centred care: A qualitative interview study with researchers, professionals and patients. BMC Health Services Research17(1), 1-10. https://doi.org/10.1186/s12913-017-2470-2.

Osamor, P. E., & Grady, C. (2018). Autonomy and couples’ joint decision-making in healthcare. BMC Medical Ethics19(1), 3. https://doi.org/10.1186/s12910-017-0241-6.

Pozgar, G. D. (2019). Legal and ethical issues for health professionals. Jones & Bartlett Learning.

Rae, S. (2018). Moral choices: An introduction to ethics. Zondervan Academic.

Rhodes, R. (2020). The Trusted Doctor: Medical Ethics and Professionalism. Oxford University Press.

Teays, W. (2019). Applied ethics: Principles and perspectives. In Doctors and Torture (pp. 131-147). Springer, Cham. https://doi.org/10.1007/978-3-030-22517-9_9.

Veatch, R. M., & Guidry-Grimes, L. K. (2019). The basics of bioethics. Routledge.

Zambas, S. I., Smythe, E. A., & Koziol-Mclain, J. (2016). The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study. International Journal of Qualitative Studies on Health And Well-Being11(1), 32090. https://doi.org/10.3402/qhw.v11.32090.

Zürcher, T., Elger, B., & Trachsel, M. (2019). The notion of free will and its ethical relevance for decision-making capacity. BMC Medical Ethics20(1), 31. https://doi.org/10.1186/s12910-019-0371-0.

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