Health Care Institutional Organization and Management

Health Care Institutional Organization and Management

Individual Paper #2

June 25, 2006

Imagine laying in a hospital intensive care unit critically injured, unconscious, yet fully aware of your surroundings but unable to interact. Imagine hearing your family discussing with the doctors your slim potential for recovery or insurance coverage running out and you can not articulate your wishes to continue treatment. In a situation like this, advanced directives provide the hospital, the staff, and your family the necessary guidance to authorize the use or withdraw of medical procedures. According to the Federal Patient Self Determination Act of 1990, advanced directives are "an individual's rights under State law to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment" and such directives will ensure that the patient's wishes are followed to either conduct procedures to save your life or no procedures to allow you to pass on. In either case, advanced directives are an extremely important step in patient health care in providing quality service to the patient and relieving the physician from liability if some people do not agree with the advanced directives.

Advance directives also assist the hospital staff in making the correct and ethical decision for the patient. In these critical situations, there are "ethical duties that physicians owe to their patients: the obligation to respect a competent patient's right to refuse medical treatment in accordance with his/her own values and beliefs...the obligation to engage in a process of communication that adequately prepares the patient to make an informed decision". The process of creating advanced directives provides the patient the communication to make an informed decision, which also allows the physician to make an ethical decision.

Though advanced directives seem fairly "cut and dry", there are some problems. Many patients who have advanced directives usually don't tell or forget to tell their doctor, many patients do not maintain their advanced directives (wills) in their medical files for reviewing by the doctors, their directives are so vague that the doctor can not follow them, or the patient's legal guardian or parent wants to proceed with a conflicting medical procedure than the patient annotated in their advanced directive. To clarify many of these situations that hospital staff or health care administrators find themselves, I propose a scenario of a physician scheduled to conduct a appendectomy on an incapacitated female (surgery on the schedule for quite some time), but the day of the surgery finds the patient's chart to say a tubal ligation with a consent form signed by the legal guardian with hand written remarks authorizing any additional procedure.

As the hospital manager, I would meet with the chief surgeon to determine the facts of the situation and to determine why the female has been scheduled for an appendectomy, an emergency procedure, and is now receiving a tubal ligation. I would also check the advanced directives of the patient consenting to the surgery and I would find the hand written statement authorizing any other procedure determined to be in the patient's interests by the patient's legal guardian. As you can see from this scenario, there are a number of legal and ethical issues involved with the treatment of this incapacitated female patient. As the hospital manager, it is my duty to ensure that my physicians act in a legal and ethical manner to provide the highest quality of health care.

To begin, I must check the patient's medical records and forms to ensure that a court approval was obtained. A court approval in needed because "any person acting on behalf of an incapacitated adult or a minor does not have the same latitude for consent as in self-treatment decisions. Decision makers [legal guardian] can not authorize...sterilization...without prior court approval." If the court approval is not in the patient's medical records, I will not be able to allow the surgery to take place until such authorization is received. Applied consent is rarely granted by courts in regards to sterilization. The reason is because parents or legal guardians do not have the authority to authorize sterilization without the patient's consent. Patient consent was not received, only the legal guardian signed the consent form.

If the legal guardian still wants to go through with the sterilization, we would need the patient's signature on the consent form. In regards to getting the patient's signature, we need to ensure that the patient is "legally competent, has the capacity to make the decision, and is informed" of the procedure and the consequences of the alternatives. If the adult is considered incompetent or incapacitated, the courts allow a legal guardian to make decisions on the patient's behalf. In this case, the legal guardian has elected sterilization for the patient and the court must decide if the procedure is legal. In the decision process, courts apply the "substituted judgment" or the "best interest" standard to determine what the patient would have wanted. In the case of minors, court authorization is needed if the minor's wishes differ from the wishes of the legal guardian or parent. In all aspects of this situation, the patient needs to be confronted, disclosed the information regarding the surgery, sign the consent form, or get the courts authorization in the absents of the patients ability to sign.

It is my responsibility to ensure the surgeon treats the patient only after proper consent is given. "The common law requirement of informed consent assures that adequate information is made available to provide an opportunity for a knowledgeable decision to consent or refuse." The decision will be left to the patient if she is a competent adult. While I am checking the paperwork and approval for the surgery, I will ask my chief of surgery to try and speak with the patient and ensure that all information regarding the sterilization was disclosed. The paperwork states an appendectomy, and I worry that the patient was briefed on the procedure and outcome of an appendectomy and not a tubil ligation. If all of the paperwork is in order and the surgical procedure was just an administrative error, then the "physician remains legally