resolution guidelines dealing with ethics from an arnp perspective

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Ms. Brown comes into the emergency department to secure treatment for a head injury, plus minor bruises and abrasions she reportedly received during an assault that happened about 20 hours ago. Ms. Brown is 34 years old and accompanied by her boyfriend, Roy. She indicates they were sleeping in a protected entrance to an elevator in the city parking garage when two young men began beating and kicking them. The two men took Ms. Brown’s purse, a sack of food she and Roy had accumulated, and Roy’s wallet which contained $5.00.

Ms. Brown indicates she has been homeless for more than a year. She occasionally stays in city shelters but spends most of her time roaming the city and walking to procure meals at the various programs that feed the poor. She is tall and thin, with a variety of skin lesions. She came to the hospital due to dizziness that prevented her from walking to the church, where she could eat. She and Roy occasionally work odd jobs but use the bulk of their income to support Roy’s drug habit. She is trying to get Roy to quit using.

The nurse practitioner (NP) cleans Ms. Brown’s scalp and tapes the traumatic lesion. A contusion is suspected, and the NP suggests Ms. Brown rests for a few days and goes to the neurological clinic if the dizziness worsens. Ms. Brown points out that she has no place to rest and cannot get to the clinic without public transportation. The NP realizes this but indicates it is beyond her control. Because the contusion is not definitively diagnosed, the NP must discharge Ms. Brown with follow-up orders to seek help if things get worse.

Using the Resolution Guidelines with the mnemonic ETHICAL, consider the following questions:

E—Examine what other data are needed to make informed choices.

T—Think about who should be involved in the decision-making process and who should make the ultimate decision. Should Roy be involved? What agencies are available in your community to assist Ms. Brown?

H—Humanize Reflect on all the possible options with resulting consequences and humanize them by constructing a decision tree.

I—Incorporate the ethical principles (autonomy, beneficence, nonmaleficence, veracity, confidentiality, fidelity, and justice) when appropriate. Are there any legal statutes that apply? What standards of care should be incorporated

C—Choose an option.

A—Act on your ethical choice.

L—Look back and evaluate your option to see if you need to make any other choices. This also will be a guide for the next time a similar situation arises.

1.Post an initial substantive response(min250) of to each questions as an FNP. Use Diagnostic Reasoning to answer each question.

2.Please be sure to validate your opinions and ideas with in text citations and references in APA format.

3.References and citations should conform to the APA 6th edition.

4.Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.

5..The peer postings should be at least one paragraph (approximately100 words).

6.Please be sure to validate your opinions and ideas with in text citations and references in APA 6th edition format.

Timothy’s Post:

This is a situation that will require more than the routine discharge from the clinic. According to Institute of Medicine (US) Committee on Health Care for Homeless People (1988), one of the most serious issues facing those who work with homeless people is that many standard forms of treatment assume that the patient has a home; when that is not true, treatment is extraordinarily difficult. The goal should be to enable homeless people to have access to the range of services that already exist, thereby decreasing their need for specialized services. The ultimate goal is to resolve whatever problems prevent homeless people from becoming domiciled.

E—The first step is to examine what other data might be needed to make informed choices. Questions should be asked in order to make sure the patient has his or her autonomy. According to Humanit (2010), autonomy is the principle that addresses the concept of independence. Can this patient make their own decisions and act on their own value? Is this patient alert, oriented, and capable of making competent choices with a head injury? Other questions related to family support, patient safety, and housing arrangements should be asked and answered to start the discharge process. The patient should provide answers related to police reports, insurance, and closest family support. Past medical history from the patient should be obtained as well as allergies to medications. Ms. Brown should provide the last time she had anything to eat and how many meals she has during the day. The patient should be asked about safety and how she feels at this time.

T– Multiple caregivers as well as any social workers should be involved in the process of making sure Ms. Brown receives all the information needed to get her care. The police should be notified in making sure a report has been filed in this case. The local shelter facilities should be contacted in order to have a place for Ms. Brown to be discharged to from the clinic. Ms. Brown should have the ultimate decision unless she is not able to make competent choices. Roy can be involved only if consent is given by Ms. Brown, or it would be a HIPAA violation. The agencies available in the community to assist Ms. Brown would be the Salvation Army, United Way, Good Samaritan Free Clinic, and the New Albany Homeless Shelter. These agencies help provide safe facilities that offer food, sleeping arrangements, laundry facilities, free treatment services for drug addiction, and free healthcare. Some of the local church charities offer free transportation during the day for the homeless.

H– The next step would be to reflect on all the possible options with resulting consequences. According to Humanit (2010), all health care practitioners are constrained by the principles of professionalism in honoring and upholding the interests and well-being of their patients. This embodies the concept of the fiduciary relationship; work performed that always and without exception favors the client and not the professional performing the work. The responsibility for maintaining these high professional standards rests exclusively with the party holding the position of trust, power, and authority. The client is in the weak and vulnerable position entirely due to the client’s real or perceived unmet needs, with these needs not being able to be ameliorated by the client on his or her own. Health care professionals have a duty of care that extends to the patient, professional colleagues, and to society as a whole. Any individual professional who neither understands nor accepts this duty is at risk for acting malevolently and violating the fiduciary principle of honoring and protecting the patient. The goal should be to enable homeless people to have access to the range of services that already exist, thereby decreasing their need for specialized services. The ultimate goal is to resolve whatever problems prevent homeless people from becoming domiciled.

I-Autonomy is the principle that addresses the concept of independence. Make sure Ms. Brown is capable of making competent choices in order that she does not harm herself or others. Nonmaleficence is the concept of not causing harm to others. According to Humanit (2010), beneficence reflects the counselor’s responsibility to contribute to the welfare of the client. Fidelity involves the notions of loyalty, faithfulness, and honoring commitments. Ms. Brown needs to understand that her health and safety is the top priority before being discharged from the clinic.

C-The next step is to choose an option which would be to discharge Ms. Brown to the New Albany Homeless Shelter where she can get the help she needs for follow up. If Ms. Brown has a change and needs further emergency medical treatment, the facility can take her to the Emergency Department which is nearby. The facility can also offer Roy some assistance in getting treatment for his drug addiction. This would be a great choice for Ms. Brown and Roy.

A-The next step would be to act on the choice. Ms. Brown would be discharged from the clinic with instructions to follow up with a neurological clinic. Transportation would be arranged by the New Albany Homeless Shelter through the nearest church facility. Ms. Brown would also have instructions to go to the nearest Emergency Department if any new symptoms occur.

L– The last step would be to look back and evaluate the choices made to make sure the patient received the best possible options. According to Institute of Medicine (US) Committee on Health Care for Homeless People (1988), the goal should be to enable homeless people to have access to the range of services that already exist, thereby decreasing their need for specialized services. The ultimate goal is to resolve whatever problems prevent homeless people from becoming domiciled.

References

Institute of Medicine (US) Committee on Health Care for Homeless People. Homelessness, Health, and Human Needs. Washington (DC): National Academies Press (US); 1988. 5, Health Care Services for Homeless People. Available from: https://www.ncbi.nlm.nih.gov/books/NBK218235/

J. C. Humanit (2010). Beneficence and the professional’s moral imperative. Journal of chiropractic humanities, 16(1), 44-6. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC33428…

April’s Post:

Case Study Overview and Local Resources

This case presents a number of medical and ethical decision-making concerns. Working as an emergency department (ED) nurse for the past 13 years, I have encountered many similar situations and, in most cases, there is not a straightforward answer. Unfortunately, the rural area where I live has very limited resources when it comes to helping those who are homeless. Our hospital/clinic has a social worker who is available during daytime hours on the weekdays, but no one available after hours. The ED does have cab and hotel vouchers what we can give patients if they need them; however, we do not have a homeless mission or half-way house in the community. In fact, the closest shelter is over 200 miles away, which can be particularly problematic in the winter when the temperature is below zero and patients have nowhere to go. Typically, we can assist them in staying at a hotel overnight, but there is not much more we can do. It has been acknowledged as a huge deficit in our area.

ETHICAL Mnemonic

The ETHICAL mnemonic can be a useful tool in helping to evaluate such situations. When Examining what other data is needed to make informed choices, I believe the most important thing is to assess Ms. Brown’s decision-making capacity. The capacity to make one’s own decisions is a key part of the ethical principle of autonomy and is an integral part of every provider-patient interaction. The patient’s capacity is best assessed by using open-ended questions during the interview process. Once it has been determined that Ms. Brown demonstrates adequate decision-making capacity, she can be deemed capable of making decisions related to her care. The patient should be educated about the providers concerns, including the differential diagnoses, and the treatment options (Karlawish, 2017).

When Thinking about who should be involved in the decision-making process, once deemed to have adequate decision-making capacity Ms. Brown should be the primary decision maker when it comes to her health and treatment. By respecting her autonomy, the provider acknowledges that the patient has the right to make decisions regarding her care—and ultimately her life—even when these decisions do not align with the provider’s views or recommendations. As to whether or not Roy is involved in the decision-making process, this again is dependent on Ms. Brown’s wishes. Patients often prefer that their family members are included in decision-making and often take their family’s opinions into account (Sedig, 2016).

The third step, Humanize options, allows for the consideration of all options and the consequences of these options. In this scenario, one option would be to do a CT of Ms. Brown’s head to rule out any potentially dangerous or life-threatening head injury. This may negate the worry that the patient may need follow up as neurologically normal patients who has a normal head CT are at low risk for subsequent neurologic deterioration. One possible consequence to ordering a CT is the radiation exposure to the patient (Evans & Whitlow, 2018). Another option would be to admit patient for observation, although with her mild symptoms, being 20 hours out from injury, and a presumably negative CT, she technically may not meet criteria for admission (Andrade et al., 2011). Another option would be to discharge the patient, as the NP had done in the scenario, telling her to follow up with the neurology clinic as needed if symptoms worsen. This may be unrealistic for the patient, as she is likely to be uninsured. Because the majority of homeless individuals are uninsured, most utilize the emergency department as their primary source of medical care. For this patient, telling her to return to the emergency department for follow up may be more feasible as the ED does not demand payment up front or require a referral (Morris & Gordon, 2006). Of course, the risk of discharging Ms. Brown is that she may not follow up as recommended, even if her symptoms worsen.

We can Incorporate ethical principles, first beginning with autonomy as discussed earlier when determining the capacity to make decisions. In letting Ms. Brown decide amongst the various options presented, we are also allowing her to exercise autonomy. When considering options for treating Ms. Brown, the provider practices beneficence by considering the harms and benefits of each choice and ultimately doing what is in the patient’s best interest. Confidentiality should be exercised as always, while providing patient care (Dunphy et al., 2015). When working in the ED, one legal obligation is to provide care in accordance with The Emergency Medical Treatment and Labor Act (EMTALA). EMTALA requires that any individual who presents to an ED must receive a medical screening exam. Furthermore, this examination and treatment cannot be delayed in order to ask about insurance or payment. The case study scenario does not state if Ms. Brown has insurance or if she is uninsured, but either way the law requires that she receive a medical screening exam. Also, necessary treatments should not be withheld if she is unable to pay for them (American College of Emergency Physicians, 2018).

If I were the NP treating Ms. Brown in the ED, I would present the afore mentioned options to her and if she is agreeable, I would Choose to do a CT scan of her head to rule out any underlying dangerous injury. I feel this is in the best interest of the patient, as she may have limited access to further care and there is no guarantee that she will be able to follow up as recommended. Additionally, a negative scan can negate the need for admission for observation (Evans & Whitlow, 2018). If Ms. Brown agrees to a CT scan, I would Act by ordering one to be done in the ED during her visit. Looking back, I don’t think I would change my actions. In the rural ED where I work as a nurse, many of the providers would do the same thing as primary care and follow up appointments are often difficult to come by. This way, at least we can attempt to provide the best care to our patients during the time that they are actually present in our facility.

References

American College of Emergency Physicians. (2018). EMTALA Fact Sheet. Retrieved from https://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/#sm.0001paia6e7bpcxjw6g1qp1ookeni

Andrade, A. F., Paiva, W. S., Soares, M. S., De Amorium, R. L. O., Tavares, W. M., & Teixeira, M. J. (2011). Classification and management of mild head trauma. International Journal of General Medicine, 4, 175-179.

Dunphy, L. M., Winland-Brown, J. E., O’Porter, B., & Thomas, D. J. (2015). Primary Care The Art and Science of Advanced Practice Nursing (4th ed). [VitalSource Bookshelf Version].

Evans, R. W. & Whitlow, C. T. (2018, March 5). Acute mild traumatic brain injury (concussion) in adults. Retrieved from https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults

Karlawish, J. (2017, September 20). Assessment of decision-making capacity in adults. Retrieved from https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults

Morris, D. M. & Gordon, J. A. (2006). The Role of the emergency department in the care of homeless and disadvantaged populations. Emergency Medicine Clinics of North America, 24, 839-848.

Sedig, L. (2016). What’s the Role of Autonomy in Patient- and Family-Centered Care When Patients and Family Members Don’t Agree? AMA Journal of Ethics, 18, 12-17.

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