Medical Ethics: Ron’s Hypertension Case Study

Introduction

An eighteen year old is brought to the Emergency Department of a reputable hospital from a motor vehicle accident. The young man had his seat belt on at the time of the accident and he was driving. The patient’s name is Ron. He is awake, alert, and oriented. Initial complaint by the patient to the hospital personnel is chest pain. Vital signs stable with HR 98, B/P 140/90, and repatriations 20. No other apparent injuries. Parents concerned about the recovery of their son remain at his bedside. The emergency room physician notifies the Trauma service and cardiovascular surgical services to come and see the patient for complaint of chest pain. Dr. Cardio sees the patient and decides he needs a CAT scan to rule out Aortic Trauma due to the patient’s complaint of chest pain following a traumatic motor vehicle accident.

The CT scan reveals that the patient needs to go to surgery for a Torn Aorta. The cardiac surgeon determines the best approach for this type of injury is by the EndoVascular Approach. Informed consent is obtained by the surgeon from both the patient and parents in the emergency department. Patient is taken to surgery and receives a stent graft to repair the Aorta. From there the patient goes to critical care. Subsequently, following his operation, the patient develops uncontrolled hypertension. There is no previous medical history or family hereditary link to substantiate the continued blood pressure problems. Patient is thereafter placed on four different intravenous blood pressure medications at maximal doses with no change in status. No record of previous medical consultation for the patient’s continued high blood pressure from the cardiac surgeon exists.

Nurse at the patient’s bedside continued to ask Dr. Cardio if he wanted to get a consult as well as his thoughts on the continued blood pressure problems. Dr. Cardio continued to state the patient would be fine. Patient is then transferred to the ward at the ground floor on multiple PO medications for his blood pressure, all at maximal allowable doses. While on the floor the patient was sent to radiology for evaluation of renal artery steno-sis which is known to cause hypertension in the young population. Nurse from the floor went with the patient to radiology because of his status kept worsening. Respirations elevated patient’s color from the nipple line dusky and also stated that he was having trouble with breathing.

Trauma service had rounded on the patient and wrote orders to discharge if okay with Dr. Cardio. Dr. Cardio agreed to this after patient arrived back from radiology. The nurse practitioner with the patient at floor ward becomes very uncomfortable with the discharge order and recommends to the trauma service stating that the patient seemed to be worsening and should not go home.

Parents had gone home and came back wondering where their son was and became distraught. The parents stopped a physician/nurse and asked for help. Family explained that they did not know or understand what was going on and why their son did not seem to be getting better and in fact he was worse. After the family had given their perspective, physician guided the nurse to take the family to radiology. Dr. B went to investigate. Dr. B understands that after a repair of a torn aorta, a patient develops hypertension. He understands that the patient probably developed iatrogenic coarctation. This can be done by taking the blood pressure of the upper and lower extremities, and compare the difference. The patient’s difference was 60 mm HG. Physician B called Dr. Cardio to discuss case and urged CT scan with contrast to complete the diagnosis. Ensuing discussion led to the patient being taken back to the operating room for an emergent open repair of his aorta.

The ethical dilemma for Dr. B with respect to the condition of the patient is whether he should step in and speak with Dr. Cardio about the patient’s status and how to manage his current diagnosis, or let it continue down the road the way it is going? Calling up a colleague from the same service as well as organizing competing groups to let them know that a different approach should be taken is not routinely done.

Using the analytical method of serious decisions to make very good proxies nervous will be demonstrated for this case study to ensure that all areas of concern are covered and that the best outcome will be for the patient in question. Even though there are many different ways to examine all the factors for a case study, this appears to be the most thorough.

Stakeholders

• 18 year old patient
• Parents of the patient
• Dr. Cardio and Dr. B
• Organization
• CV outcomes
• Nursing staff from the OR
• Nursing staff from ICU and Floor
• Nurse Practitioners
• Trauma Staff

Decisional authority

• Patient
• Parents
• Surgeon of the patient, Dr. Cardio

The patient is not in control of his medical condition at the time of being admitted at the hospital. Parents have entrusted the hospital staff with the task of treating their son. The hospital administration should take a disciplinary action against Dr. Cardio being a surgeon for his reckless actions. It is the duty of the management to ensure that the entire staff is harmonized in purpose and duty. They should be trained on the best practices in health care in order to prevent health hazards.

Medical Indication

The patient’s condition is fixable

The initial medical condition includes the stubborn chest pains incurred during the motor accident. CT scan reveals a torn aorta that is subsequently treated through the recommended Endo Vascular Approach. The patient’s doctor, Dr Cardio, recommends the procedure as the most effective approach to treat the injury. The situation appears manageable.

Repair needs to happen before he sustains irreversible heart failure

However, the condition of the patient worsens, the nurses are concerned but the other employees discharge him in order to attend to the next patient. A complete diagnosis reveals that the patient requires emergency open repair of the damaged aorta in order to prevent irreversible heart failure. This calls for the concerted efforts of Dr. Cardio and Dr. B as well as the nurses and the trauma staff in order to arrest the situation.

Values

• Patient has high value on life
• Family is upset and wants to know why he is not better
• Staff taking care of patient want him to get better
• Current provider appears to not value why patient is not getting better
• Program Director wants the level of care consistent

Goals

Have patient walk out of hospital cured

Patients should only be discharged after receiving proper medication. The procedure should correspond to professional guidelines in order to prevent complications.

Have patient and family happy with outcome

The patient should be cured before being discharged. The family of the patient should also be properly informed about the medication condition of their son. Both parties should be effectively consulted before undertaking serious medical procedures such as the invasive techniques applied to the young man when admitted at the emergency department after the accident.

Have staff happy with outcome

Organizational goals at the transplant facility should be balanced with the aspirations of its employees and physicians as equal partners and stakeholders in provision of health care. The staff should therefore be properly motivated through reward systems that recognize their individual and mutual contributions in provision of health care. The outcome of their work should be publicly acknowledged and appreciated. Decision making process should incorporate protocols that are all-inclusive and consultative.

Plans

Take patient back to operating room and repair problem

The patient should be treated again in order to repair the aorta based on the subsequent diagnosis by Dr. B. Iatrogenic co-arctation that develops the previous repair of the damaged aorta should be urgently addressed.

Improve communication between groups of same service

The management at the transplant facility should seek to improve communication between competing groups through interactive sessions. The best approach in responding to controversial issues as well as giving feedback to the administration should be clearly outlined. Patients should be exempted from work based differences according to the Hippocratic Oath by the entire hospital staff.

Reconcile competing groups in the same service to provide consistent care

Norms

• Legal – provide safe and proper care to patients
• Ethical – Do no harm, cause no harm, prevent harm
• Moral – acting on the right thing to do for the patient
• Organizational – Following the mission and vision statement by implementing the established best practice while professionally and collegially mastering relationships between employees and physicians
• Financial – providing cost effective, quality care with decreasing liability
• Medical Norms – relatively new procedure, using care givers with expertise for collaborative patient care. Technology continues to advance at a rapid rate and the institution’s goal is to stay on the cutting edge for the patient and community. Constantly striving to cut costs and decrease hospital stays for the patient and community. The hospital management should strive to ensure parents do not seek legal redress as a result of professional negligence of its medical staff. This could comprise its reputation consequently limiting its prospects of achieving organizational goals. The competing groups at the hospital need to be trained to upload the highest standards and ethics in their profession so as to prevent causing harm to their patient. They should pursue the welfare of their patient first in order to achieve their aspirations satisfactorily. The management should therefore fast-track reforms meant to establish the best practices at the hospital for its employees and doctors for the purpose of achieving professional standards and organizational goals in provision of health care. Care givers should seek to reduce liabilities while attending to patients in order to ensure quick recovery with affordable health care. The cost of accessing medication should not be a tall order to resident patients meant to benefit the neighboring community.

Analytical Method: Serious Decisions Make Very Good Proxies Nervous

Stakeholders

The patient-wanted to die?

The patient got involved in the accident while driving and suffered cardiovascular complications. The patient, Ron was awake, alert and focused at the time of the unfortunate accident. The patient accident was therefore not a deliberate action, neither was it a result of reckless driving. The patient regards life with high esteem and expects the best from the medication at the transplant hospital. The young man therefore responds to the medical examination and subsequently complains of persistent chest pains immediately after being admitted at the hospital. The family is equally concerned about the wellbeing of their beloved son.

The family-wants meaning from their son’s actions

The parents to the patient also want to get a medical report from the hospital as regards to their son’s condition. The family is actually disappointed when the patient’s conditions in the hands of the hospital care givers and physicians. The manner in which the patient is discharged contradicts ethical and professional standards. Competing groups at the hospital do not help the situation and the patient becomes a victim of a dichotomy of issues brought about by the accident and reckless hospital staff. The trauma staff appears to contradict the nurses.

Doctors appear to be victims of high-handedness at the hospital often ignoring their subordinates especially the nurses. The patient is therefore caught between the two competing groups and suffers medical negligence. The family is therefore justified in demanding for an explanation to the scenario in view of the worsening condition of their son. Dr. B interested in the situation confirms the diagnosis was not complete and procedures taken to resolve the problem previously inconclusive. The earlier diagnosis and treatment by fellow physician, Dr. Cardio requires the augmentation of Dr. B. The problem lies in the approach to be taken in order to resolve the crisis without infringing on the rights of the employees and physicians. However, the welfare of the patient comes first.

• IOPO coordinator-wants organs for transplant to others.
• The surgeon-also wants organs for transplant to others and reputation building?
• The surgical resident-wants the surgical experience.
• ICU physician-supports organ donation and needs the bed for the next patient.
• The scrub technologist and the circulating nurse-do not want to participate but it is part of the job.
• Transplant recipients-have a chance at an almost normal and longer life.
• Hospital-gains reputation as transplant facility.

The hospital has a moral, ethical and professional responsibility to upload the highest medical standards as the transplant facility. The manner in which the hospital staff has handled the boy’s condition contravenes its professional and organizational goals. The patient’s condition keeps worsening in the hands of the care givers at the transplant facility with uncontrolled hypertension. The best they do is to issue opposing prescriptions and decisions to a patient as competing groups. The worst happens when one department discharges the patient without proper consultation of stakeholders. It appears the patient is simply discharged in order to admit another without taking note of his condition. The reputation of the hospital as a transplant facility is therefore severely compromised as a result of competition between the rival groups.

Decisional authority

The family, especially the mother, who is making all the decisions

The family is concerned about the welfare of their son after the motor accident. The legitimate concerns by the mother about the impromptu discharge of their son from the ward need to be addressed conclusively. Moral and ethical considerations in the medical profession also need to be followed in order carry out successful organ transplantation and repair. Organizational goals of the hospital should be reconciled with patient’s wellbeing professionally through initiatives that must resolve issues between competing groups. There should be sustainable communication between the rival groups for the sake of the patients whose wellbeing should supersede their work-based differences. Decision making should therefore be consultative and all-inclusive. Parents were consulted according to hospital protocols but when the trauma service recommends his discharge singlehandedly, the boy is sent home without parent’s notification.

The patient is incapable of making decisions

The patient is sick, complains of persistent chest pains but the medication receives appears to be wanting. The parents concerned with their son’s recovery remain at his bedside when admitted from the motor vehicle accident. The informed consent allows doctors at the emergency department to perform the Endo Vascular Approach in order to repair the Aorta. The patient is therefore unable to make independent decisions due to his condition unless his parents liaise with care givers at the hospital consistently.

Medical Indications

• Prolonged chest pain
• Uncontrolled hypertension-continued blood pressure.
• The patient does not respond to four different intravenous blood pressure medications performed at maximal doses.
• The patient continues to suffer from high blood pressure even after being transferred to a ground floor ward for multiple PO medications at maximum allowable doses.
• Evaluation of renal artery stenosis known to cause hypertension in the young population through radiological procedures reveals nothing.
• Elevated respiration causes patient’s color to turn from nipple line dusky.
• Patient also suffers breathing difficulties.

Conclusion

The organization should address the medical condition of the patient effectively in order to restore public confidence in the transplant facility. Decisions should follow best practices in medicine. Facilities and staff at the emergency department should be upgraded in order to prevent future complications. Effective communication protocols should be adopted through a regimen that allows staff at all levels to give and receive feedback between management and employees. There is a need for reconciliation of the competing groups at the hospital for the sake of the patient’s welfare and sustainability of the organization with respect to their objectives. Provision of health care should adhere to established norms. Procedures must be safe and correctly applied to patients. There should be no harm, serious side effects or life-time complications after medication. As such, hospital management needs to enhance effective relationships between staff in provision of health care. Hospital reputation should therefore supersede expectation for higher profit.

The moral lies in helping patients recover within the shortest time possible through quality health care which is equally cost effective. Medical norms required to upgrade the facility beyond its current shortcomings include the need to employ expertise in collaborative patient care. This also requires that the hospital should remain on the cutting edge in adopting latest medical technology in provision of health care to patients and the surrounding community. The technology is particularly relevant in the application of invasive techniques during surgery at the emergency department. Transplantation requires matching of organs between recipients and donors. Transplantation technologies need to correspond to the latest research in order meet dynamic medical challenges. The reputation of the hospital depends on the surgical experience, the technology and the facilities. Above all, concerted efforts by the employees, physicians and the management at the transplant hospital are important in maintaining its reputation.

Action plan

Dr. Cardio lacks basic ethics in the medical profession. The hospital management should ensure that Dr. Cardio is disciplined if not dismissed for professional misconduct and negligence. The hospital staff should be in engaged in team building initiatives for consultation and decision making purposes towards solving their problems. The diagnosis by Dr. B as well as his new approach in resolving the conflict at the hospital should be adopted as a forerunner to better decision making and problem solving. The medical procedure should be fast tracked towards established standards in health care. Concerted effort and consultation should guide the the decision making process.