NSG/426 Week 5: Ethical and Legal Case Resolution, sample paper

A Signed Order Against Intubation and a Son Who Says "Do Everything": An Ethical and Legal Case Resolution

[Student Name]

University of Phoenix

NSG/426: Integrity in Practice: Ethic and Legal Considerations

Week 5 Assignment

[Instructor Name]

[Date]

The patient, family and hospital are a composite written for a model paper. No real patient is described.

The Facts

A composite 79-year-old retired railroad worker with severe chronic obstructive pulmonary disease, on home oxygen, arrived by ambulance at the emergency department in hypercapnic respiratory failure. He was drowsy and could not speak in sentences. Six months earlier, after a long discussion with his primary care nurse practitioner, he had signed a POLST (Physician Orders for Life-Sustaining Treatment) form stating that he did not want CPR or a breathing tube, while accepting hospital treatment and noninvasive ventilation. His health care power of attorney named his daughter as his agent. She was on a flight home from overseas and could not be reached for several hours. His son, who lived nearby, arrived and told the team to "do everything," saying his father "didn't really mean it" and could not have understood what he signed. The emergency physician began noninvasive ventilation, which the POLST allowed. Over two hours, the patient's condition worsened, and the question of intubation became urgent. The team had a clear written decision from the patient, a distressed son who wanted it set aside and very little time.

The Conflict

The conflict is between respecting the patient's documented refusal of intubation and responding to the son's demand for full treatment, under time pressure, while the legally designated decision maker was unavailable.

Ethical Analysis

Respect for autonomy. The patient made an informed decision while capable, after discussion with his clinician, and documented it in a medical order. Respecting autonomy means honoring decisions a person made about future care when he can no longer speak for himself (Beauchamp & Childress, 2019).

Beneficence and nonmaleficence. Intubation might prolong life, but in severe COPD it carries risks of prolonged ventilation, failure to wean and death in the intensive care unit, and the patient had judged that burden unacceptable. Noninvasive ventilation, comfort measures and treatment of reversible causes offered benefit within his stated limits.

Justice and respect for the family. The son's distress is real and deserves compassion, but respect for persons does not hand a relative the authority to override a patient's clear wishes because he disagrees with them.

Evidence supports the value of documents like POLST. Hickman et al. (2010), studying nursing facility residents, found that residents with POLST forms indicating comfort measures were less likely to receive unwanted life-sustaining treatments than residents with traditional advance directives alone, which suggests that POLST orders help ensure patients' preferences are honored. Silveira et al. (2010), studying older adults who died, found that most who needed decisions at the end of life lacked capacity, that those who had prepared advance directives usually received care consistent with their preferences and that advance directives mattered because surrogates otherwise had to guess.

Legal Analysis

The Patient Self-Determination Act requires hospitals participating in Medicare and Medicaid to inform patients of their rights to make decisions about medical care, including the right to refuse treatment and to prepare advance directives, and to document whether a patient has one (Patient Self-Determination Act of 1990, 1990). State law governs POLST forms and health care agents. In the composite state, as in most, a POLST is a valid medical order that travels with the patient and is followed by emergency and hospital clinicians. A health care agent may make decisions consistent with the patient's known wishes; a relative who is not the agent has no legal authority to override the POLST. The son was not the designated agent, and the agent was unavailable.

Options

The team considered three options. First, intubate to satisfy the son until the daughter arrived. Second, follow the POLST: continue noninvasive ventilation and maximal treatment within its limits, and do not intubate. Third, delay decisions by keeping the patient on noninvasive ventilation and reassessing as the daughter traveled, which would effectively follow the POLST unless a new authority emerged.

Resolution

The team followed the POLST. The nurse's role was central. She confirmed the POLST form's validity and date, showed it to the physician and the son, and asked the charge nurse to request an urgent palliative care consultation and the on-call chaplain. She stayed with the son, listened to his fear and grief and explained that his father had made this decision with his nurse practitioner six months earlier and had written it down so his family would not have to carry it. The palliative care physician met with the son, confirmed that the patient's goals were documented and that noninvasive ventilation and treatment for the exacerbation would continue, and explained that intubation would go against his father's instructions. The team reached the daughter by the airline's message service. Her reply, received an hour later, confirmed that her father had repeatedly said he did not want a breathing tube. The patient continued on noninvasive ventilation, improved partially over the next day and, with his daughter present, chose to transition to comfort-focused care at home with hospice.

Defending the Resolution Against the Strongest Objection

The strongest objection is that the patient might have changed his mind or not fully understood the form, as the son claimed, and that intubation is reversible while death is not. The response is that the form was completed after a documented discussion with his clinician, that there was no evidence he had revoked it and that intubation is not simply reversible in severe COPD, where it may lead to prolonged ventilation he explicitly refused. Setting aside a clear, recent, documented decision on the basis of a relative's disagreement would make every advance directive vulnerable to whoever arrives first at the bedside. The ethics committee would have been called if the agent had disagreed with the POLST, but she did not.

Conclusion

A patient's documented refusal of intubation conflicted with his son's demand for full treatment while his designated agent was unreachable. Ethically, respect for autonomy, supported by beneficence and nonmaleficence as the patient himself defined them, pointed to following his wishes. Legally, the POLST was a valid order and the son lacked authority to override it. The nurse advocated for the patient, supported the son, mobilized palliative care and the chaplain and helped reach the agent, and the resolution honored the patient's decision while treating his family with compassion.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Hickman, S. E., Nelson, C. A., Perrin, N. A., Moss, A. H., Hammes, B. J., & Tolle, S. W. (2010). A comparison of methods to communicate treatment preferences in nursing facilities: Traditional practices versus the physician orders for life-sustaining treatment program. Journal of the American Geriatrics Society, 58(7), 1241-1248. https://doi.org/10.1111/j.1532-5415.2010.02955.x

Patient Self-Determination Act of 1990, Pub. L. No. 101-508, §§ 4206, 4751, 104 Stat. 1388 (1990).

Silveira, M. J., Kim, S. Y. H., & Langa, K. M. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218. https://doi.org/10.1056/NEJMsa0907901