VHA Intensive Ethics Advisory Committee Training
This is a theoretical case taken from VHA Intensive Ethics Advisory Committee Training, 1998, as presented by Arthur R. Derse MD, JD. An 87-year-old woman widowed for six years, who is otherwise healthy, was visiting another city and abruptly became ill. She was seen in the emergency department of the local VA and admitted to the on-call physician. The on-call physician (who has not previously seen her) made the diagnosis of bowel obstruction arid made arrangements for a surgeon to evaluate her. The surgeon recommended surgery and obtained her consent for surgery. The surgeon expects an uneventful recovery. She is told that she will be on a ventilator for a short time after surgery. The patient tells the surgeon that is OK as long as it is for a short time. She tells the surgeon that she does not want to be dependent upon machines. She was asked upon admission whether she had an advance directive. She replied that she has a living will and a power of attorney for health care which names her daughter (who does not live in the area) as her health care agent. The patient undergoes surgery, which is successful in treating the underlying problem and does not show any malignant causes, but in the recovery room she has a cardiopulmonary arrest and is resuscitated. She is transferred to the ICU in the care of the on-call physician. The physician attempts to wean her gradually from the ventilator, but this is unsuccessful. Three days later, she has regained consciousness but is still intubated. Though she cannot speak because of the ventilator, she is able to write and asks that the tube be removed. The attending physician tells her that she is dependent upon the ventilator and the patient needs to remain on the ventilator until she can breathe on her own. She writes that she understands that she may die, but she does not want to be on machines. Her only children — a daughter and son — – have arrived. She repeats her wish to them that she wants the tube removed. She writes to her daughter that “I don’t want to die, but we all have to die sometime, and I don’t want to have to live on a machine. I know that whatever the outcome, God will take care of me.” Her daughter tells the physician that her mother is adamant that she be off of machines and she respects her mother’s wishes, even if she cannot breathe on her own. She says this is consistent with her previously expressed wishes and her religious beliefs. Her son tells the physician that he disagrees with his sister — since his mother does not have a terminal condition, he cannot see why she should not be forced to put up with the ventilator until she can be weaned from it. He feels that she is being shortsighted, and she will be thankful to have been kept on the ventilator when she is finally able to be weaned. Describe the criteria for giving “legal” consent. Were all elements met in this case? In other words, did the patient demonstrate decision-making capacity? Explain. (Minimum of 1 page including in-text citations and references in proper APA format)
2. Based on case study above: Is this patient requesting to be euthanized or for her physician to Help in her suicide (PAS)? In your answer describe how the two terms differ. (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
3. A managed care group may want to market their organization as being “the best” or “a leader” in providing certain services/ treatment. How can this type or marketing effect quality of care and utilization of services, hence costs? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
4. According to Darr, MCO enrollees can be described as either light/moderate users or heavy users. What are some of the strategies that management uses to turn “heavy” users into light/ moderate users? In your personal opinion, what positives or negatives may result? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
5. Describe the constraints/challenges that physicians experience as being service providers affiliated with a Managed Care Organization. (Minimum 2 paragraphs including in-text citations and references in proper APA format)
6. Give a very brief “real-life” example/instance where drugs/ medical treatment/services were microallocated. And give a “real-life” example of macroallocation. (Do not include the examples provided in the text.) (Minimum 1 paragraph including in-text citations and references in proper APA format)
7. Read the case of Karen Ann Quinlan (p. 248-249). Explain why this is a case involving medical futility. (Include in your answer the definition of medical futility). Darr (2011, p. 218) writes, “[the] futility theory has quantitative and qualitative aspects.” What is meant by these terms? Present arguments for each as it relates to this case. (Minimum 2 paragraphs including in-text citations and references in proper APA format)
8. Having just completed this class, what do you now know that you did not know before? VHA Intensive Ethics Advisory Committee Training
Training for the VHA’s Intensive Ethics Advisory Committee
Presented by Arthur R. Derse, MD, JD, this is a theoretical case taken from the VHA Intensive Ethics Advisory Committee Training in 1998, as presented by Dr. Derse. She was visiting another city when she suddenly became ill. She had been widowed for six years and had otherwise been in good health until she visited this city. She was taken to the emergency department of the local Veterans Administration hospital and admitted to the care of the on-call physician. The on-call physician (who had never seen her before) diagnosed her with bowel obstruction and made arrangements for her to be evaluated by a surgeon as a result of his findings. Surgery was recommended by the surgeon, who obtained her consent before performing the procedure. The surgeon anticipates that the patient will have a smooth recovery. She is informed that she will be placed on a ventilator for a short period of time following surgery. The patient informs the surgeon that he or she is fine as long as it is only for a short period of time. In her conversation with the surgeon, she expresses her desire not to be reliant on machines. She was asked if she had an advance directive when she was admitted to the hospital. As a result of this, she has a living will and a health care power of attorney, both of which name her daughter as her health care agent (despite the fact that she does not live in the area). The patient undergoes surgery, which is successful in treating the underlying problem and does not reveal any malignant causes; however, while in the recovery room, she suffers a cardiopulmonary arrest and is resuscitated by emergency personnel. She is transported to the intensive care unit, where she is under the care of the on-call physician. The physician attempts to wean her off the ventilator gradually, but this is ultimately unsuccessful. Despite the fact that she has regained consciousness three days after being unconscious, she is still intubated. Despite the fact that she is unable to speak due to the ventilator, she is able to write and has requested that the tube be removed. In addition, the attending physician informs her that she is reliant on a ventilator and that she must remain on the ventilator until she is able to breathe for herself independently. According to her letter, she is aware that she may die, but she does not wish to be dependent on machines. Her two children – a daughter and a son – have finally arrived to see her. She expresses to them her desire to have the tube removed on a second occasion. “I don’t want to die, but we all have to die at some point, and I don’t want to be reliant on a machine to live my life,” she writes in a letter to her daughter. “I am confident that God will provide for me, no matter what happens.” It is her daughter who informs the physician that her mother is adamant that she be taken off of machines, and she is willing to comply with her mother’s wishes even though she is unable to breathe on her own. She claims that this is in accordance with her previously stated wishes as well as her religious beliefs. When her son meets with the doctor, he expresses his disagreement with his sister, stating that because his mother does not have a terminal illness, he does not see why she should not be forced to endure the ventilator until she is able to be weaned off of it. He believes that she is being shortsighted, and that she will be grateful to have been kept on the ventilator until she is able to be weaned when the time is right. Describe the conditions under which “legal” consent can be given. Were all of the requirements met in this instance? To put it another way, did the patient demonstrate the ability to make decisions? Explain. It should be no more than one page long, including in-text citations and references in the proper APA format.
2. In light of the preceding case study: Is this patient requesting to be euthanized, or is she requesting that her physician Help her in her suicide? Explain the differences between the two terms in your response. The paper should be no more than 2 paragraphs long, including in-text citations and references in proper APA format.
3. A managed care organization may wish to position their organization as “the best” or “a leader” in the provision of specific services or treatments to their patients. What impact does this type of marketing have on the quality of care and the utilization of services, and therefore on the cost of care? The paper should be no more than 2 paragraphs long, including in-text citations and references in proper APA format.
(4) According to Darr, MCO enrollments can be divided into two categories: light/moderate users and heavy users, respectively. What are some of the strategies that management employs in order to convert “heavy” users into light or moderate ones? What potential benefits or drawbacks do you see as a result, in your opinion? The paper should be no more than 2 paragraphs long, including in-text citations and references in proper APA format.
Provide an example of the constraints and challenges that physicians face as service providers affiliated with a Managed Care Organization. (At least two paragraphs, including in-text citations and references in proper APA format)
6. Describe a very brief “real-life” example or instance in which drugs, medical treatment, or services were microallocated in a very brief manner. In addition, provide a “real-world” example of macroallocation. Do not include any of the examples that are provided within the text. 1 paragraph, including in-text citations and references in proper APA format (minimum of 1 paragraph).
7. Go over the case of Karen Ann Quinlan with your group (p. 248-249). Explain why this is a case of medical futility in this particular instance. (Be sure to include the definition of medical futility in your response). As Darr (2011) puts it, “[the] futility theory has both quantitative and qualitative aspects.” What exactly are these phrases referring to? Provide supporting arguments for each as they pertain to this case. (At least two paragraphs, including in-text citations and references in proper APA format)
Eighth, having just finished this course, what have you gained knowledge of that you didn’t have before? Training for the VHA’s Intensive Ethics Advisory Committee
