Case Study: 90 year old admitted to the hospital
A 90 year old female, Mrs. Ruth came from home with her daughter and is admitted to hospital after sustaining a hip fracture. She has a history of chronic obstructive pulmonary disease and is on home oxygen for maintenance and moderate to severe aortic stenosis. After receiving treatment in the ER for pain and fracture stabilization, Mrs. Ruth is visited in the ER by patient registration to get as much information from her for admission. During this time Mrs. Ruth is alone and her daughter has stepped out to communicate with other family members. Mrs. Ruth tells the registration clerk that she does not have an advanced directive, but would like to be considered a DNR and the registration clerk makes notation of her wishes on her profile. Mrs. Ruth 2 hours later undergoes hemiarthroplasty (hip surgery) with an uneventful operative course.
The patient’s daughter is her primary caregiver and communicates that she has financial power-of-attorney, but it is not known whether she has formal power of attorney for personal care. Concerns have been raised to the ICU team about the possibility of elder abuse in the home by the patient’s daughter.
Unfortunately, on postoperative day 4, the patient develops delirium with respiratory failure secondary to hospital acquired pneumonia and pulmonary edema. (Fluid in the lungs) Her goals of care were not assessed pre-operatively. She is admitted to the ICU for non-invasive positive pressure ventilation for 48 hours, and then deteriorates and is intubated. After 48 hours of ventilation, it was determined that due to the severity of her underlying cardio-pulmonary status, ventilator weaning would be difficult and further ventilation would be futile.
The patient’s daughter is insistent on continuing all forms of life support, including mechanical ventilation if indicated. However, Mrs. Ruth’s delirium clears within the next 24 hours of intubation, and she is now competent, although still mechanically ventilated. She communicated to the ICU team that she preferred 1-way extubation (removal of the ventilator) and comfort care. This was communicated in writing to the ICU team, and was consistent over time with other care providers. The patient went as far to demand the extubation over the next hour, which was felt to be reasonable by the ICU team.
The patient’s daughter was informed of this decision, and stated that she could not come to the hospital for 2 hours, and in the meantime, that the patient must remain intubated.
At this point, the ICU team concurred with the patient’s wishes, and extubated her before her daughter was able to come to the hospital.
The daughter was angry at the team’s decision, and requested that the patient be re-intubated if she deteriorated. When the daughter arrived at the hospital, the patient and daughter were able to converse, and the patient did not agree to re-intubation if she deteriorated. The daughter was angry by her decision and tells her mother that she will be leaving to go home.
In a 3-4 page paper, discuss the ethical issues and incorporate answers to the questions below.
Your paper should include be formatted in APA style, 12 font, double space, and include references that are APA formatted.
Below is a list of questions to help you develop your paper to include and include necessary information to cover your basis throughout the case study.
- What are some of the ethical issues in this case?
- Apply the ethical principles you learned in the book to this case study to support your stance.
- Who should make decisions in this situation?
- Should the ICU team have extubated the patient?
- What service line or lines can you think of that the hospital offers in house that can help investigate if the daughter has power of attorney and can initiate the process for Mrs. Ruth to have a legal document in hand in the event she becomes ill again or passes away?
- After discharge, should Mrs. Ruth return to her home or consider placement? What service line can help assist her with placement?
- Are you familiar with adult protective services? Do you think a member from the hospital should give them a call with concerns?
