Ethical principles and Legal Implications of Ethical Dilemmas

The first potential dilemma in the case of Jamilah Shah appears where her youngest son, Bashir provided the decision for Do Not Resuscitate. Bashir as the emergency contact provided a decision that violates her mother’s autonomy. Patients with mental capabilities should make their own decisions on whether to have DNR or not. 

The second dilemma is the Jamilah’s family following the Turkish culture of males acting as the heads of decision making in the family. The decision for DNR order could not reflect the patient’s wishes, but the culture could only allow the son to provide the decision. Patients are required to be treated fairly among their family members and be supported in their decisions. 

The third dilemma was the determination of the healthcare team to provide efficient care to Jamilah being influenced by the family’s decisions. The team knew what was best for the patient, but could not provide the appropriate treatment because the family ordered their patient to have a DNR. The case scenario has three potential dilemmas such as autonomy, justice, and beneficence. 

Ethical principles and Legal Implications of Ethical Dilemmas 

The principle of autonomy is respected by enhancing patient’s freedom of choice and respecting the choices made by patients. Jamilah’s rights on choosing DNR or not was undermined by Bashir. The wishes of Jamilah were to stay alive, but her son ordered no further treatment should be provided to her apart from comfort care. The legal documentation advising on measures to be taken for patient's health is not available, therefore difficult to distinguish the ability of patients in decision making. Professionals could have assessed Jamilah's mental capacity to determine abilities to make decisions before passing the responsibility to a member of the family. However, the national league for nursing provides a statement documenting patient’s rights and expects nurses to uphold patient’s rights and advocate for those who are not able to advocate for themselves. 

The principle of justice ensures justice and fairness in healthcare and is often related to the delivery of services. The principle of justice raised dilemma of what is harmful and what is beneficial for the patient, depending on harms outweighing benefits. The patient wished to live, but the decisions of her son undermined her wish and this was not fair. The legal implication of the principle of justice recommends the most important choice and must take priority. The practitioners before adhering to Bashir’s orders were required to consult with the healthcare’s ethics committee, to put the interests of all parties into consideration. Further conflicts inclusion needed of hospital administrators, risk management personnel, and hospital's legal counsel to come up with right decision for treating Jamilah. 

Healthcare practitioners are required by the principle of beneficence to treat patients in their best interest. The principle of beneficence in the case of Jamilah required the practitioners to keep her alive according to her wishes by preventing harm, removing harm, and promoting good for her. The legal implication of the principle requires patients to be provided beneficial care. Jamilah Shah wishes to live, and the benefits of treatment in her case clearly outweigh the benefits of Bashir’s wishes, and therefore the practitioners should treat the patient and ignore the DNR order. 

Course of Action 

Additional Information Needed to Make Decisions 

The information needed in determining the course of action on Jamilah’s condition was to assess the medical condition and decide whether it was acute, chronic, critical, emergent, terminal, or reversible. The condition was chronic because she was suffering from the chronic obstructive pulmonary disease. She also had a chronic onset of diabetes mellitus. The scenario indicates that Jamilah had the problem for quite sometimes because she has been in the care facility since the death of her husband. The condition is also emergent and acute because she will likely die in case she will not be provided with medical care. 

The other information to be considered is the goals of her treatment. The goals are to cure Jamilah of her condition and relieve her pain to live a normal life. The other information to be considered is the probability of the success of treatment options. The probability of success is high because doctors will analyze thoroughly options and use the best to provide effective treatment. The information on how the patient can benefit from nursing and medical care to avoid harm is also essential (Field, Fritz, Baker, Grove & Perkins, 2014) . The patient will benefit from treatment because she will survive and the illness will be reduced by the administered care. 

Resource to ma ke Jamilah’s wish clear 

The best resource to make the patient’s wish clear is for the nurse to facilitate and participate in an interdisciplinary mechanism to resolve the conflict. The action taken should ensure whenever possible that the decision is a subject of thorough discussion between healthcare team, patient, and the designated surrogate, and the action to be taken be in accordance to the wishes of the patient. The patient’s wish in the case scenario was to stay alive, and therefore the interdisciplinary team will focus on convincing Bashir, to do away with his order of Do Not Resuscitate. Disputes regarding the patient’s wishes should be taken through the hospital’s mediation system, and the order will not be issued or reviewed until the dispute is resolved. The disputes concerning the order will be subject to a judicial review and the party challenging the order must provide convincing and clear evidence that the DNR decisions are contrary or not to the patient’s best wishes and interest. 

Why interdisciplinary mechanism would be helpful 

The interdisciplinary team will review the patient’s wishes by linking decisions on DNR to the overall treatment plan discussion. The interdisciplinary mechanism will provide clarifications about the goals of care, and aid communication between practitioners and the surrogate to reduce patient’s harm. The interdisciplinary mechanism in the DNR decision process is important in communication, advocate, and supporting patients (Burghal H & Maryyan, 2017). 

Proposing Cause of Action 

I would propose following Bashir’s wish demanding for only comfort care. Do Not Resuscitate Order was the best choice to prevent patient’s harm because she was in a critical condition and had been through much pain. 

Justification of proposed cause of action 

Many studies show that 18 t0 20% older patients admitted to hospitals for cardiac arrest leave the hospital to arrive after deciding for Do Not Resuscitate. The Do Not Resuscitate order would prevent Jamilah from treatment risks such as chronic coma and decreased consciousness levels. Having an effective DNR does not create room for guesswork, and allows death without intervention, and is reversible at any time. The DNR would be appropriate after assessing benefits versus treatment burdens and effectively provide comfort and symptom palliation. 

Comparison of following Bashir’s wishes against refusing to follow Bashir’s wishes 

Following Bashir’s wishes would help minimize patient’s harm, but not following his wishes would increase patient’s harm in the long-run. Treatment was Jamilah’s wish, but her condition could not be cured, therefore, it is better to choose treatment objective that would enhance her dignity and prevent unnecessary suffering from needless treatment. Many patients with advanced conditions experience psychological and physiological symptoms affecting the quality of life, and 50% of them are not cured and experience poor survival rate after cardiopulmonary arrest (Burghal H & Maryyan, 2017) . 

Policy Recommendations 

Nurses should be involved in DNR order discussions. Physicians responsible for DNR discussions provide inadequate information preventing individuals from making informed decisions. The existing policy does not consult nurses in the DNR discussion process and should be allowed to initiate the DNR discussions because of their know-how about patient and patience advocacy duty (Lachman, 2010) . Including nursing interventions in the DNR process will help eliminate partial DNR orders and the late discussion timing. 

DNR discussions should frequently be provided, and patient's choice regarding resuscitation should not be neglected. The communication between physicians and patients among hospitalized patients about CPR choice is inadequate, and the seriously ill patients lack opportunities to discuss treatment options with their physicians. The DNR discussions occur too late and are usually few days before death. The challenge and burdens of making decisions are transferred to family members who are likely unfamiliar with the CPR procedures (Yuen, Reid & Fetters, 2011) . The family members usually have inaccurate information about the prognosis of their patients, and often overestimate life-sustaining treatments. 

The DNR discussions should aim at satisfying criteria for informed consent. Most physicians do not discuss the chances of survival after CPR, and when discussions exist, they are vague and in qualitative terms. Education about risks and benefits of CPR should be provided because the majority of the public have unrealistic high expectations of success rates and or failure depending on how the results are portrayed in the mass media. Providing informed consent will help patients, and their surrogates make informed decisions (Yuen, Reid & Fetters, 2011) . 

References 

Burghal H, M., & Maryyan, M. (2017). Do Not Resuscitate (DNR) Argumentative Essay. Clinical & Medical Biochemistry , 03 (02). doi: 10.4172/2471-2663.1000136 

Field, R. A., Fritz, Z., Baker, A., Grove, A., & Perkins, G. D. (2014). A systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions. Resuscitation , 85 (11), 1418-1431. 

Lachman, V. (2010). Do-not-resuscitate orders: nurse's role requires moral courage. Medsurg Nurs , 19 (4), 249-51. 

Yuen, J. K., Reid, M. C., & Fetters, M. D. (2011). Hospital do-not-resuscitate orders: why they have failed and how to fix them. Journal of general internal medicine , 26 (7), 791-797. 

The course of action 1: Follow Bashir's wishes
Medical Indications ( Beneficence and Nonmaleficence)  Jamilah’s condition is chronic because the scenario states that she had chronic adult onset diabetes mellitus and chronic obstructive pulmonary disease.  The treatment goals are to relieve her pain and cure her condition.  The medical problems are not indicated to prevent patient’s harm  The probability of success of treatment options is high because practitioners will use their skills to the best.  The patient will benefit from medical and nursing care by not succumbing to her illness.	Patient Preferences ( Respect for Autonomy)  The patient has been informed of risks and benefits, understood the information and was given consent. She chose to live.  The patient is not mentally capable and legally competent, and there is evidence of incapacity.  Not applicable. The patient does not state preference of treatment because she is mentally incapable.  If incapacitated, the patient has expressed a preference to live.  The appropriate surrogate is Bashir, her younger son.  The patient is unable to cooperate with medical treatment because of difficulties in her communication.
Quality of Life ( Respect for anatomy, Beneficence, and Nonmaleficence)  The prospects of Jamilah returning to normal life with or without treatment are few. Jamilah might still experience physical, mental, and social deficits even after the success of treatment such as high stress, vulnerability, and progressive poor health outcomes. Personal and social functions as well as symptoms, prognosis, and performance must be considered.  The quality of life on patients who cannot express themselves can be judged based on best interest standard.  Biases might prejudice the evaluation of patient’s quality of life when the provider makes decisions based on age and disabilities only.  The ethical issues that arise when improving the patient’s quality of life are issues regarding justice, autonomy, and beneficence.	Contextual Features ( Justice and Fairness)  There are no interprofessional, professional, or business interests that might create conflicts of interest in Jamilah’s treatment.  There are family members such as Bashir, with interest in clinical decisions.  There are no limits imposed on patient confidentiality by legitimate interests of third parties.  There are no financial factors creating conflicts of interest.  There are no problems of allocation of scarce health resources impacting clinical decisions.  There are no religious issues impacting clinical decisions.  The legal issues that might impact clinical decisions are whether to honor Bashir’s wish or not.  There are no considerations of clinical education and research to impact clinical decisions.  There are no issues of public health and safety.  There are no conflicts of interest affecting clinical decisions and patient welfare.

The course of action 2: Refuse to follow Bashir's wishes
Medical Indications ( Beneficence and Nonmaleficence)  Jamilah’s condition is chronic because the scenario states that she had chronic adult onset diabetes mellitus and chronic obstructive pulmonary disease.  The treatment goals are to relieve her pain and cure her condition.  The medical problems are not indicated to prevent patient’s harm  The probability of success of treatment options is high because practitioners will use their skills to the best.  The patient will benefit from medical and nursing care by not succumbing to her illness.	Patient Preferences ( Respect for Autonomy)  The patient has been informed of risks and benefits, understood the information and was given consent. She chose to live.  The patient is not mentally capable and legally competent, and there is evidence of incapacity.  Not applicable. The patient does not state preference of treatment because she is mentally incapable.  If damaged, the patient has expressed a preference to live.  The appropriate surrogate is Bashir, her younger son.  The patient is unable to cooperate with medical treatment because of difficulties in her communication.
Quality of Life ( Respect for anatomy, Beneficence, and Nonmaleficence)  The prospects of Jamilah returning to normal life with or without treatment are few. Jamilah might still experience physical, mental, and social deficits even after the success of treatment such as high stress, vulnerability, and progressive poor health outcomes. Personal and social functions as well as symptoms, prognosis, and performance must be considered.  The quality of life on patients who cannot express themselves can be judged based on best interest standard.  Biases might prejudice the evaluation of patient’s quality of life when the provider makes decisions based on age and disabilities only.  The ethical issues that arise when improving the patient’s quality of life are issues regarding justice, autonomy, and beneficence.	Contextual Features ( Justice and Fairness)  There are no interprofessional, professional, or business interests that might create conflicts of interest in Jamilah’s treatment.  There are family members such as Bashir, with interest in clinical decisions.  There are no limits imposed on patient confidentiality by legitimate interests of third parties.  There are no financial factors creating conflicts of interest.  There are no problems of allocation of scarce health resources impacting clinical decisions.  There are no religious issues impacting clinical decisions.  The legal issues that might impact clinical decisions are whether to honor Bashir’s wish or not.  There are no considerations of clinical education and research to impact clinical decisions.  There are no issues of public health and safety.  There are no conflicts of interest affecting clinical decisions and patient welfare.

the course of action 3: Briefly delay the decision to gather additional information and other perspectives
Medical Indications ( Beneficence and Nonmaleficence)  Jamilah’s condition is chronic because the scenario states that she had chronic adult onset diabetes mellitus and chronic obstructive pulmonary disease.  The treatment goals are to relieve her pain and cure her condition.  The medical problems are not indicated to prevent patient’s harm  The probability of success of treatment options is high because practitioners will use their skills to the best.  The patient will benefit from medical and nursing care by not succumbing to her illness.	Patient Preferences ( Respect for Autonomy)  The patient has been informed of risks and benefits, understood the information and was given consent. She chose to live.  The patient is not mentally capable and legally competent, and there is evidence of incapacity.  Not applicable. The patient does not state preference of treatment because she is mentally incapable.  If incapacitated, the patient has expressed a preference to live.  The appropriate surrogate is Bashir, her younger son.  The patient is unable to cooperate with medical treatment because of difficulties in her communication.
Quality of Life ( Respect for anatomy, Beneficence, and Nonmaleficence)  The prospects of Jamilah returning to normal life with or without treatment are few. Jamilah might still experience physical, mental, and social deficits even after the success of treatment such as high stress, vulnerability, and progressive poor health outcomes. Personal and social functions as well as symptoms, prognosis, and performance must be considered.  The quality of life on patients who cannot express themselves can be judged based on best interest standard.  Biases might prejudice the evaluation of patient’s quality of life when the provider makes decisions based on age and disabilities only.  The ethical issues that arise when improving the patient’s quality of life are issues regarding justice, autonomy, and beneficence.	Contextual Features ( Justice and Fairness)  There are no interprofessional, professional, or business interests that might create conflicts of interest in Jamilah’s treatment.  There are family members such as Bashir, with interest in clinical decisions.  There are no limits imposed on patient confidentiality by legitimate interests of third parties.  There are no financial factors creating conflicts of interest.  There are no problems of allocation of scarce health resources impacting clinical decisions.  There are no religious issues impacting clinical decisions.  The legal issues that might impact clinical decisions are whether to honor Bashir’s wish or not.  There are no considerations of clinical education and research to impact clinical decisions.  There are no issues of public health and safety.  There are no conflicts of interest affecting clinical decisions and patient welfare.