Dnr Ethical Dilemmas
Ethical conflict: The conflict is whether it is ethical to remove ventilation and treatment from a patient due to their health status and assumed survival from treatment and may be deemed futile without their consent.
Medical Indications: The primary medical problems the patient has come in with are rib fractures causing a partial flail chest and a subdural hematoma stemming from a fall. Her treatment consists of ventilator support and supportive care until her ribs heal and she recovers from the trauma, which trauma doctors have indicated may not occur.
Patient Preferences: The patient has not been involved in the decisions regarding her current treatment, and did not have a DNR in place or an advance directive in place regarding situations such as this. The family who had been acting as surrogates, were ready to stop treatment and place a DNR based on the prognosis given about the patient. As of now no one has fully assessed the patient's decision making capacity or asked the patient about her preferences, despite her regaining consciousness and her improved mental state.
Quality of Life: Without the ventilator support the patient will die, and with support the patient would live but she may not recover to her good health prior to admission as her flail chest is impeding her recover and …show more content…
if kept alive may need ventilator support for the rest of her life. However, it is uncertain whether patient deems her current quality of life unacceptable.
Contextual Features:
The ethical considerations here stem from whether her prognosis is one of strict futility and whether the use of surrogates is appropriate here with the possible re-emergence of autonomy as the patient has regained consciousness and is able to communicate.
The trauma team insists that this is a case of futility, but the situations where unilateral withdrawal of treatment are no occurring here (intervention is not rational pathophysiologically, cardiac arrest after hypoxia, or when the intervention has already failed the patient) so the team must get support from the decision makers, which may be the surrogates or the patient if she is deemed to have decision making
capacity.
Case Analysis/Recommendation:
As the patient has regained consciousness the patient's decision making capacity should be assessed and if she is deemed to have decision making capacity she should be informed of the expected outcomes of her treatment and asked if she wants the DNR that her family had placed when she was unconscious. If the patient, if deemed to have decision making capacity, and she does not consent to having her ventilation support removed, as her goals of care and life may be met in her current state or even by bare existence. In general her patient goals should be determined while she is conscious and has apparent insight so that her and the care teams' values may align. If she does not have decision making capacity or at some point loses her capacity then her family should be used as surrogates and if they still feel support should be withdrawn due to her expected outcomes then ventilation support could be removed.
Medical Indications: The primary medical problems the patient has come in with are rib fractures causing a partial flail chest and a subdural hematoma stemming from a fall. Her treatment consists of ventilator support and supportive care until her ribs heal and she recovers from the trauma, which trauma doctors have indicated may not occur.
Patient Preferences: The patient has not been involved in the decisions regarding her current treatment, and did not have a DNR in place or an advance directive in place regarding situations such as this. The family who had been acting as surrogates, were ready to stop treatment and place a DNR based on the prognosis given about the patient. As of now no one has fully assessed the patient's decision making capacity or asked the patient about her preferences, despite her regaining consciousness and her improved mental state.
Quality of Life: Without the ventilator support the patient will die, and with support the patient would live but she may not recover to her good health prior to admission as her flail chest is impeding her recover and …show more content…
if kept alive may need ventilator support for the rest of her life. However, it is uncertain whether patient deems her current quality of life unacceptable.
Contextual Features:
The ethical considerations here stem from whether her prognosis is one of strict futility and whether the use of surrogates is appropriate here with the possible re-emergence of autonomy as the patient has regained consciousness and is able to communicate.
The trauma team insists that this is a case of futility, but the situations where unilateral withdrawal of treatment are no occurring here (intervention is not rational pathophysiologically, cardiac arrest after hypoxia, or when the intervention has already failed the patient) so the team must get support from the decision makers, which may be the surrogates or the patient if she is deemed to have decision making
capacity.
Case Analysis/Recommendation:
As the patient has regained consciousness the patient's decision making capacity should be assessed and if she is deemed to have decision making capacity she should be informed of the expected outcomes of her treatment and asked if she wants the DNR that her family had placed when she was unconscious. If the patient, if deemed to have decision making capacity, and she does not consent to having her ventilation support removed, as her goals of care and life may be met in her current state or even by bare existence. In general her patient goals should be determined while she is conscious and has apparent insight so that her and the care teams' values may align. If she does not have decision making capacity or at some point loses her capacity then her family should be used as surrogates and if they still feel support should be withdrawn due to her expected outcomes then ventilation support could be removed.