Ethical Case Studies
Consider the ethical dilemma the health care professional faces in the selected case study. Pay particular attention to details that will help you analyze the situation using the three components of the Ethical Decision Making Model (moral awareness, moral judgment, and ethical behavior).
Note: The case study may not supply all of the information you may need for the assignment. In such cases, you should consider a variety of possibilities and infer potential conclusions. However, please be sure to identify any speculations that you make.
Reducing Hospital Readmissions
Caleb Powell was preparing the agenda for the upcoming executive leadership meeting and he shook his head ruefully. As chief executive officer for Virginia County Regional Hospital (VCRH), Caleb believes that a key piece of VCRH’s future success lies in reducing readmission rates, not only in the areas identified by federal guidelines, but across the board. A few weeks ago, he read a piece from the National Institutes of Health discussing strategies associated with reduction in readmission rates. He decided that he wanted to discuss the issue in detail with his leadership team.
Caleb’s goal is to align the hospital’s strategic planning with the goal of reducing readmissions. The stakes are high; under provisions of the Affordable Care Act, hospitals with higher than expected 30 day readmission rates for heart failure, heart attack and pneumonia are penalized with reduced payments. Historically, hospitals (including VCRH) have struggled to avoid the penalties, but Caleb believes that believes that a focused approach will allow them to be successful. He also believes that reducing readmission rates will improve patient satisfaction, which has become a key metric in measuring hospital quality.
Caleb’s initial research into this issue revealed that while many facilities were incurring the Centers for Medicare and Medicaid Services (CMS) penalties, there was still significant variability in terms of hospitals implementing successful strategies for reducing their readmission rates. However, several themes have emerged. Hospitals that established partnerships with physicians, physician groups and other local hospitals have had greater success. In addition, a clear discharge planning process and nurse driven medication reconciliation have also been associated with reducing the risk of readmissions.
At the same time, Caleb is concerned that an aggressive policy to avoid readmissions could be construed as too focused on the hospital’s bottom line and indifferent to patient needs. The last thing he wants is to create a policy that prevents patients from seeking or receiving care. Caleb hopes that this meeting will begin a productive discussion around developing strategies to improve VCRH’s performance in this area.
Caleb’s email to the executive leadership team with the agenda for the meeting included the following note:
“As we research the readmission rate issue for improvement, we need to be aware that we cannot add additional days to the patient’s initial stay. It’s a balancing act. We also cannot hinder a patient from coming back into the hospital for a readmission. I’ll be asking for your input about whether we should create a system to profile health care providers whose patients have high readmission rates.”
Old School or Out of Touch?
Corey Davidson is the new Emergency Department Director at Crosby Community Hospital. When he was hired, the hospital administrator explained that the first order of business would be for Corey to develop a system for documenting the reappraisal process for physicians applying for reappointment to the medical staff and for clinical privileges. At the time of his interviews, Corey didn’t think much of this focus, but now that he has been on the job for several months, he realizes that there was a very specific reason: Dr. Lacey.
Dr. Lacey has been practicing medicine in Crosby County longer than the hospital has existed, and has treated virtually everyone who works in the hospital. With his twinkly blue eyes and white hair, Dr. Lacey was Crosby’s very own Dr. Santa. Dr. Lacey’s reputation used to be unassailable, but unfortunately age and declining health are taking a toll on his skills. Complicating the situation is the fact that Dr. Lacey is seen as a beloved icon by anyone who didn’t actually work with him.
When Corey logs onto his email one Monday morning, he finds a request to meet with Margaret Truman, Director of Nursing. When they meet, she wastes no time in explaining what she wants to discuss.
“You’re going to have to do something about Dr. Lacey… or rather, Dr. Lasix, as the nursing staff are currently calling him”
“What’s happened?” Corey asks, somewhat nervously.
“Well, you know how we’ve been moving toward a more evidence–based approach to diagnosis and treatment in the ED” Margaret says. One of the areas where we’ve established some solid guidelines is regarding patients presenting with shortness of breath.”
Corey nods. “Yes, I remember you presented on piloting the use of the guidelines.”
“That’s just it — Dr. Lacey is completely unwilling to use them” Margaret says. We’ve come to terms with his unwillingness to use the electronic health record — that’s a battle we just weren’t going to win — but this is getting serious. He’s gotten it into his head that Lasix is the drug of choice for anyone who comes in with dyspnea. This goes against the guidelines we’ve assembled, but he won’t listen to a mere nurse — especially when he’s ordering meds for a patient.
“The thing is — Lasix can be an effective treatment in some cases, but it isn’t recommended as the first treatment option for a patient who has been brought into the ED. There are a number of situations where Lasix can actually be harmful. If the patient has pneumonia or dehydration, they shouldn’t be given Lasix at all. The guidelines we established specifically call for delaying the use of Lasix until a definitive diagnosis of heart failure can be confirmed by chest Xray and laboratory studies.”
A thought occurs to Corey. “Why are you coming to me today with this? Did something happen over the weekend?”
“That’s exactly why I’m here,” says Margaret. “We had a patient present Saturday night with confusion and difficulty breathing. Dr. Lacey ordered Lasix and chest xrays, but the nurse assisting him suspected sepsis. The patient had come in from a nursing home and her skin was not in good shape. Sure enough, the patient had a particularly nasty pressure sore.
“The problem is that Dr. Lacey will not listen to the nursing staff and his own skills are less than they used to be. In this case, the nurse was able to convince him to follow the guidelines, but honestly, nurses have their own work to do and it doesn’t include watching over a doctor to make sure he doesn’t actually harm anyone.”
Corey nods, glumly aware that he is going to be the person who took away Dr. Santa’s ER privileges.
Measles Making A Comeback
Piper Banks is the medical director for Open Arms, a non-profit medical clinic and wellness center serving low-income patients in an urban neighborhood. On most days, Piper loves her job and the work her clinic is able to do for people in the community, but lately there has been a problem that is beyond frustrating. This past summer, the city experienced a significant measles outbreak. Thousands of people were exposed to the measles and 78 cases were confirmed. Of the 78 cases, 73 involved unvaccinated children in the city’s East African immigrant community.
What Piper finds most troubling is not that the “herd immunity” was compromised, though that does trouble her. Worse, in her opinion, was the fact that members of the anti vaccination community were distributing fliers and talking to families in the affected community. The anti vax activists reportedly told people that the measles outbreak had been created by the government in order to pressure immigrant parents to vaccinate their children. One of Open Arms’ primary goals has been to counter the fear and misinformation that anti vaccine groups have been spreading in the community for nearly a decade. That misinformation specifically promotes the purported vaccine autism link, despite extensive research disproving those claims. This is troubling, because there is a high incidence of autism within the community and parents are justifiably concerned.
Despite her frustration, Piper hasn’t given up hope. Religious leaders and trusted health care providers in the community have been enlisted by clinic staff members to convince parents to protect their children by getting the measles mumps rubella vaccine.
At a staff meeting, Piper asks for insights to the situation. Felicia Cruz, the clinic pediatrician, expresses optimism about the situation. “Since the measles outbreak, I’ve seen several parents who’ve refused to inoculate their children come in,” she says. “They’re still nervous — very nervous, in fact — but they’re more open to believing us than I’ve ever seen.”
Nasra, an intern at the clinic who is working toward a master’s degree in public health, adds “I was recently talking with a woman who said that the imam at her mosque has been very blunt. He said If you care about your child, you must vaccinate. I think it’s important to make sure parents know how devastating these diseases are. I heard that the anti vaxers were trying to set up measles parties to deliberately expose unvaccinated children to children with measles. We need to explain to these parents that they are playing with fire.”
“I wonder how many parents would make different choices if they could actually see the effects of these diseases” says Emily, a clinic nurse. “People have forgotten how devastating these diseases used to be. They think that if they feed their children a nutritious diet, then these vaccine–preventable diseases will be mild. Sometimes I wish I could take them to the cemetery and show them all the little headstones from when we didn’t have vaccines.”
Piper is encouraged by these comments, and by the fact that the clinic has been administering almost twice as many vaccines since the measles outbreak as they had the previous year. Still, she worries about how to counter the information being spread by the anti vaccination activists and respond in an ethical way to parents who don’t want to vaccinate their children.