Please help... Ethics Case Study: "Barney Says No"

[yarr0w]

Hi, I'm wiredpsyche, a newbie Nursing student. One of my classes is Health Ethics, in which our group have been assigned to a case study where we'll make an analysis of ethical issues and possible alternate courses of action. Our case study is "Barney Says No":

Almeda was an eighty-four year old woman who lived in a retiring life with no family and few friends. She suffered from a disabling stroke three years ago and has been confined to bed in a nursing home. Almeda has lost decisional capacity and left no advanced directives. Barney, her long time friend, has been her unofficial surrogate decision-maker. Almeda has developed a Stage IV sacral decubitis, now colonized with multiple resistant staphylococcus aureus and pneumonia with heart failure. Now she is on the intensive care unit.

For two weeks, Almeda has been on the ventilator and is being fed with a gastric feeding tube. During this time, she has been treated with high dose cardiovascular drugs and Vancomycisn antibiotic. There has been no progress in the heart failure or pneumonia. Although stoic, Almeda shows clear signs of pain when moved about for care.

The nurses and attending physicians have approached Barney on the numerous occasions to raise the question about stopping aggressive curative treatment and moving toward palliative care. Barney has always insisted that he sees more potential in Almeda's condition. When asked what the right goalfor Almeda ought to be, he answered, "it would be good if she could sit up and watch a little television." Almeda's renal function has now become seriously impaired and requires renal dialysis, the nursing staff asked for a meeting with the attending physician and Barney to discuss treatment redirection from curative to palliative care.~

We have been told to place the case study in a US setting. I live in Asia (Philippines), and study in a university with a meager library, so I would be very grateful if you can guide me regarding this case. :plsebeg: Here are some of the things that I think might be relevant to the case:

• Barney is Almeda's unofficial substitute decision-maker. I feel that his current role is a 'consultant' regarding decisions made for Almeda's treatment, providing a 'vague sense' of autonomy in Almeda's case. Is there any protocol/precisely defined standards for the choice of surrogate decision-makers? And if Barney becomes the 'official'/valid surrogate decision-maker, will his role be somewhat limited because he is just a long-time friend instead of nearest kin?

• Are there any relevant US laws regarding medical treatment in nursing homes and in particular, decision-making for incompetent patients (those who have lost their decisional capacity)?

• Why is it that the nursing staff asked to discuss about treatment direction (from aggressive curative treatment to palliative care) with the prospect of renal dialysis, instead of earlier when Almeda has been on the ventilator and gastric feeding tube? We've discussed in class that ventilators is a major life-supporting treatment, its withdrawal is important enough to warrant serious decision-making.

Thank you for taking the time to read and I would be really grateful for any comment. :redpinkhe I'm a beginning Nursing student, so this case study just boggles my mind.

[Daytonite, BSN, RN]

what i would see done from my experiences and since barney is almeda's unofficial substitute decision-maker is the facility managers would have the lawyers or social service people go to court and file for the appointment of a legal guardian for almeda since barney is not acting in a realistic manner with regard to her care. it would force him to prove to a judge that he is capable and willing to be her official guardian and leave it to a judge to decide who should be making almeda's medical decisions. particularly since her care is becoming extremely complex now and the idea of life sustaining procedures is now at issue. i can't tell you how many times i saw this happen. i saw it done when family members would argue over what would be done for their mother and father and couldn't come to a decision while mom or dad laid in bed waiting for something to be done. there are people who the courts have who are willing to come forward as interested and compassionate citizens and perform this service when friends or family are not able to or don't want the responsibility to do make important medical decisions for their relatives or friends.

[yarr0w]

Thank you so much for the helpful reply. :loveya:

I never knew that appointing an incompetent patient's legal guardian / surrogate decision-maker would involve going to court. This would make the decision-making a formal/legal responsibility, so it could not be contested, I think.

It's really hard to make major medical decisions -- Almeda's case is just a theoretical one, but I'm getting somewhat confused about its (ethical) implications. :imbar

[Daytonite, BSN, RN]

i worked at a large city hospital (won't name the city) where we got indigent patients all the time who were very ill, had no homes and no family and often no friends, or at least they never showed up. if they did, they often slept right in the rooms with the patients because they had nowhere else to go! anyway, if a patient got very ill to the point that decisions about care had to be made (medical procedures, surgery, consents needed signing, etc.) a legal guardian was needed if the patient wasn't able to make the decision. we had a social service professional who was assigned to each nursing unit to help with this. they would file any paperwork with the courts for guardianships, start paperwork for patients to get welfare or get moved to government supported facilities, advise patients who had problems with medical insurance, etc. what a job they had. it required having a master's degree and state license in social work. you would be surprised at how many "barney's" back off once official court documents have to be signed. the court document is the final commitment. some people just don't want to make that final commitment--like getting married. unfortunately, in our healthcare world we have to have signatures on consents. poor almeda just lies in limbo and withers away if barney doesn't step up to the plate and make a commitment to her.