A Legal And Ethical Dilemma Contributed By Alan S. Whiteman

A Legal And Ethical Dilemma contributed By Alan S Whiteman Phd Facmp

A Legal and Ethical Dilemma Contributed by Alan S. Whiteman, PhD, FACMPE, and Lisa E. Sliney, MS, LNHA, Barry University

Background: Mary Evelyn Greene, who has memory impairment, lives in a private room at Shady Brook Skilled Nursing Facility located in a beautiful suburb of a major metropolitan city. She has resided at Shady Brook for the past 18 months. Before moving into Shady Brook, Mrs. Greene lived independently in her own home with assistance from a private-duty nursing assistant and a housekeeper. She and her husband had resided together in this home for more than 50 years. Mrs. Greene is 89 years old and suffers from several health problems associated with aging. Mrs. Greene has one son, David Greene. David has the power of attorney to handle his mother’s health care and other personal affairs. David works as a trial attorney in one of the city’s largest and most prestigious law firms. He owns a large home in an upscale neighborhood and works hard to put two of his children through college and another one through medical school. His home is about an hour’s drive from his workplace and about 20 minutes from Shady Brook.

David’s wife Barbara has never been close to her mother-in-law and has not shown much interest in her care. Hence, caring for his mother has become a major responsibility for David, and he is having a difficult time dealing with her declining health and the onset of mild dementia. It is becoming increasingly more difficult for David to leave his law practice or the courtroom to deal with issues related to his mother. Mrs. Greene’s husband was a very successful land developer who left her with a substantial estate, which meets all of her financial needs.

After her husband passed away, Mrs. Greene decided to remain in her home. She was able to maintain her independence until she was 87, when she began to show signs of dementia. Shortly thereafter, David moved her to Shady Brook. David also hired a part-time “sitter” to keep her mother company because she was too weak to go out of her room on her own. Mrs. Greene seems to enjoy the sitter’s company and likes the attention she gets. Upon entering Shady Brook, Mrs. Greene became depressed over losing her independence and her home and felt a growing frustration with forgetfulness. She gradually lost her appetite, and her desire to eat continued to decline.

On the other hand, Mrs. Greene seems to enjoy the smell of certain foods. The associates monitor and document her food intake and her facial expressions when she is offered different foods. Mrs. Greene is particularly fond of Susan Brown, a certified nursing assistant (CNA), who sits with her and helps Mrs. Greene with whatever little she can eat. When this occurs, her appetite shows some improvement. Mrs. Greene also responds well to volunteers who carry out activities at the facility. Frustrated Family Member: Mrs. Greene has become too weak to eat on her own. When no one is feeding her, she leaves most of her food on the tray. Recently, she has sustained a weight loss of more than 5 pounds per week. Her plan of care needs to be reevaluated, and her situation needs immediate attention. David has been visiting his mother quite regularly. Recently, however, his visits have become less frequent, generally two to three times per week. The associates who work on Mrs. Greene’s nursing unit have reported some changes in David’s attitude. At one time he became angry with his mother, raised his voice, and spoke to her as if she were a bad child. Although no one was present in Mrs. Greene’s room at the time, the associates working at the nursing station heard David’s loud voice. When the charge nurse went into Mrs. Greene’s room to find out why David was angry, David told her that it was none of her business. On David’s subsequent visits, the associates observed that Mrs. Greene would become agitated during David’s visits. These issues were brought to the charge nurse’s attention, and they were documented in the patient’s medical record.

The Dilemma: One day David approached the charge nurse and exclaimed that his mother had expressed that she wished to die. On his next two visits, David also told the CNAs that his mother’s desire was not to eat anything so she could just die a quick death. This was the first time the CNAs had heard that Mrs. Greene had expressed a desire to die. The associates also believed that Mrs. Greene appeared to be happier when David was not there. Before the week was over, David came into the facility early in the morning on his way to work. He handed a sealed envelope to the incoming charge nurse on the day shift. The envelope was addressed to Betty Wright, Shady Brook’s administrator. David said to the charge nurse, “I have been telling you people that my mother wishes a speedy death. Tell your administrator that I will be filing a lawsuit if my mother’s wishes are not carried out.” David left without visiting his mother. Betty Wright decided to place the issue on the ethics committee’s agenda for that same afternoon. As a safeguard, Betty also notified the facility’s liability insurance carrier of the potential legal action. Meeting of the Ethics Committee: That afternoon, Betty met with members of the ethics committee: chaplain, medical director, director of nursing, charge nurse, social worker, two CNAs, and the local ombudsman.

Betty began the meeting by expressing concerns about David’s motives and the legal implications of his threats. The committee deliberates on whether or not to comply with David’s request to withhold food as well as the threat of a lawsuit, and considers the ethical principles involved, including patient autonomy, beneficence, non-maleficence, and justice.

Paper For Above instruction

The core issue of this case revolves around the ethical and legal dilemmas concerning Mrs. Greene’s wishes, her capacity to make decisions, and the potential influence of her son’s motives. Specifically, it questions whether her expressed desire to die should be honored, and whether withholding food to facilitate her death aligns with ethical standards and legal boundaries. Furthermore, it examines the responsibilities of the healthcare providers in safeguarding the patient’s rights while respecting her autonomy and managing concerns about possible elder abuse or undue influence by her son.

Key facts include Mrs. Greene’s deteriorating health and mental status, her expressed desire to die, her recent weight loss and declining appetite, her positive response to certain foods and caregiving approaches, and her family dynamics, particularly her son David’s increasing frustration, anger, and threats. David, who is her durable power of attorney, appears to be exerting influence over her care, motivated perhaps by financial considerations or his own emotional distress. The healthcare team, especially the ethics committee, must navigate respecting Mrs. Greene’s rights and wishes while ensuring her safety and well-being, amid conflicting interests and potential legal repercussions.

Potential alternative solutions the ethics committee might consider include: 1) respecting Mrs. Greene’s expressed wishes and exploring her capacity to make end-of-life decisions, including advance directives or living will; 2) conducting a comprehensive capacity assessment to determine her ability to understand her condition and wishes; 3) initiating palliative or comfort care measures aimed at relieving suffering without hastening death; 4) involving legal and social services to address potential undue influence or elder abuse; 5) establishing an interdisciplinary care plan that emphasizes patient-centered approaches and safeguards her health and dignity.

The consequences of these alternatives vary: Respecting her wishes could uphold her autonomy but risks legal questions if her capacity is questionable. Conducting a capacity assessment may clarify her decision-making ability but delay action and potentially increase her distress. Focusing on palliative care aligns with beneficence and non-maleficence, potentially improving her quality of life, but might be interpreted as giving up on treatment. Addressing potential elder abuse protects her rights and safety but may strain family relationships. A patient-centered interdisciplinary approach balances ethical principles but requires careful coordination.

From the perspective of Mrs. Greene, respecting her autonomy and addressing her pain and suffering aligns with dignity and compassionate care. Conversely, if her capacity is compromised, or her wishes are influenced unduly, respecting her autonomy might lead to hastening death against her true desires. From Shady Brook’s standpoint, adhering to legal and ethical standards protects the institution from liability, ensures compliance with regulations, and promotes a reputation for ethical integrity. Ignoring potential elder abuse or undue influence could lead to legal consequences and harm residents’ trust. The best approach involves thorough assessment, open communication, and safeguarding her rights and well-being.

It is advisable for the ethics committee to recommend conducting a comprehensive capacity evaluation for Mrs. Greene to determine if she can make informed decisions regarding her end-of-life wishes. If she demonstrates decision-making capacity, her expressed desires should be seriously considered and documented in her care plan. If her capacity is impaired, palliative and comfort care should be prioritized, and legal safeguards should be employed to protect her from undue influence. Engaging legal counsel and social workers may help identify and mitigate potential elder abuse or undue influence by her son. Transparent communication with her family, especially her son, should be maintained, respecting her dignity and rights while safeguarding her health and safety.

Regarding Betty’s comment that David needs the money to educate his children, this should not influence the ethical decision-making process. Ethical principles and professional guidelines emphasize that patients’ wishes and best interests should be the primary drivers of care decisions. Personal motives of family members, even if financially motivated, are extraneous and should not be permitted to overshadow the patient’s rights and well-being.

References

• Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press.
• Brody, H. (2016). Ethics and End-of-Life Care. Annals of Internal Medicine, 165(11), 801-807.
• Cohen, J., & Earp, J. (2019). Elder Law and Ethics. Journal of Elder Abuse & Neglect, 31(2), 145-159.
• Garrard, E. (2017). Autonomy, Capacity and Informed Consent. Journal of Medical Ethics, 43(3), 199-204.
• Jonsen, A. R., Siegler, M., & Winslade, W. J. (2015). Clinical Ethics: A Guide for Clinicians (8th ed.). McGraw-Hill Education.
• Lachs, M. S., & Pillemer, K. (2018). Elder Abuse. New England Journal of Medicine, 378(5), 436-445.
• Oberle, C. D. (2017). End-of-Life Decision Making in Elderly Patients. The Journal of Ethics, 19(4), 372-379.
• Sulmasy, D. P., & Sugarman, J. (2018). Ethics and End-of-Life Care. Handbook of Clinical Ethics, 2nd ed., 543-560.
• Vladeck, B. C. (2019). Protecting the Rights of Elderly Patients. Health Affairs, 38(2), 306-312.
• Winzelberg, G. G., et al. (2015). Ethics of Withholding or Withdrawing Treatment in Elderly Patients. Journal of Medical Ethics, 41(6), 423-427.