NHSFP4000 Capella Ethical Decision-making Model For Hospital Readmissions

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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.

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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 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.”

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.

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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.

Ethical Decision-Making Model

Ethical decision-making at an individual level and one's ethical behavior can be viewed in three primary steps using an ethical decision-making model.

First is one's moral awareness, recognizing the existence of an ethical dilemma. This is the pathway to establishing the need for an ethical decision. This awareness is an individual sensitivity to one's values and personal morals.

Once a personal awareness is evident, we can make a judgment in deciding what is right or wrong. This sounds simple, yet there are a number of variables driving this personal judgment. One variable is the individual differences and cognitive bias we all have based on our personal history and experiences. A second variable is the organization. This variable may be influenced from a group, organizational or cultural perspective. A code of conduct or standards of behavior may also influence our judgment.

This model, operating in a dynamic fashion, leads us to our ethical behavior; taking action to do the right thing. Is the right thing the same decision for everyone? Obviously not. We are all influenced my multiple factors in our decision-making.

This decision-making model can help us understand the pathway to our ethical decisions.

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Assessment 1 Instructions: Applying Ethical Principles –... Course Navigation ! Tutorials https://courserooma.capella.edu/webapps/blackboard/content/listCo... Support Irasema Betancourt Log Out LoriAnn Pajalich FACULTY ! Paul Jeannotte COACH 22 ! Assessment 1 Instructions: Applying Ethical Principles 1 of 3 5/7/19, 11:02 AM Assessment 1 Instructions: Applying Ethical Principles –... https://courserooma.capella.edu/webapps/blackboard/content/listCo... Develop a solution to a specific ethical dilemma faced by a health care professional by applying ethical principles. Describe the issues and a possible solution in a 3-5 page paper. Whether you are a nurse, a public health professional, a health care administrator, or in another role in the health care field, you must base your decisions on a set of ethical principles and values. Your decisions must be fair, equitable, and defensible. Each discipline has established a professional code of ethics to guide ethical behavior. In this assessment, you will practice working through an ethical dilemma as described in a case study. Your practice will help you develop a method for formulating ethical decisions. D e m o n s t r a t i o n o f P ro f i c i e n c y By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: Competency 1: Apply information literacy and library research skills to obtain scholarly information in the field of health care. Apply academic peer-reviewed journal articles relevant to an ethical problem or issue as evidence to support an analysis of the case. Competency 3: Apply ethical principles and academic standards to the study of health care. Summarize the facts in a case study and use the three components of an ethical decisionmaking model to analyze an ethical problem or issue and the factors that contributed to it. Discuss the effectiveness of the communication approaches present in a case study. Discuss the effectiveness of the approach used by a professional to deal with problems or issues involving ethical practice in a case study. Apply ethical principles to a possible solution to an ethical problem or issue described in a case study. Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others, and that is consistent with expectations for health care professionals. Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics. Write following APA style for in-text citations, quotes, and references. Instructions Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum, be sure to address each point. In addition, you are encouraged to review the performance level descriptions for each criterion to see how your work will be assessed. For this assessment, you will develop a solution to a specific ethical dilemma faced by a health care professional. In your assessment: 1. Access the Ethical Case Studies | Transcript media piece to review the case studies you may use for this assessment. 1. Select the case most closely related to your area of interest and use it to complete the assessment. 2 of 3 5/7/19, 11:02 AM Assessment 1 Instructions: Applying Ethical Principles –... https://courserooma.capella.edu/webapps/blackboard/content/listCo... SCORING GUIDE Use the scoring guide to understand how your assessment will be evaluated. VIEW SCORING GUIDE 3 of 3 " 5/7/19, 11:02 AM Running head: APPLYING ETHICAL PRINCIPLES Applying Ethical Principles Learner’s Name Capella University Developing a Health Care Perspective Applying Ethical Principles January, 2018 Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. 1 Comment [A1]: You effectively used the APA Style Paper Template at the Assessment 1 Resources area – Resources. APPLYING ETHICAL PRINCIPLES 2 Applying Ethical Principles Health care professionals often face ethical problems during their practice that require them to use their moral values and principles when making decisions. The four fundamental principles of health care ethics—autonomy, beneficence, nomaleficence, and justice—act as yardsticks for fair and ethical decision-making. These ethical principles are widely accepted in the field of health care. Medical practitioners and health care administrators often use these principles to make decisions when faced with complex situations involving patients. Overview of the Case Study Betsy is a dedicated pediatric nurse known for the care and concern she shows her patients. Her neighbor and friend, Alice, lives with her husband and 4-year-old daughter, Shirley. Alice and her husband are followers of Christian Science, a belief that advocates spiritual healing and discourages most types of medical intervention. One day, when visiting Alice and Shirley, Betsy sees Shirley experience what seems like a seizure. The child suddenly becomes unresponsive and has a brief staring spell, with her eyes rolling upward. The episode lasts for 20 seconds, during which she seems completely unaware of her surroundings. While Shirley is having the seizure, Alice sits by her side and prays but takes no other action. Betsy is concerned about the little girl’s condition and probes her friend for details. Alice tells Betsy that Shirley used to have around 15–20 such episodes a day until a few months ago; this has now reduced to about 12. Alice attributes the improvement in Shirley’s health to her prayers and faith. However, this does not help Betsy feel comfortable about Shirley’s condition. She is almost certain that Shirley has epilepsy, which, if not treated on time, could have profound health implications. At the very least, she thinks Alice should have Shirley’s symptoms accurately diagnosed. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Comment [A2]: Remember to add an APA citation to the case study. Note: Each paragraph discussing the case study should have an APA citation. APPLYING ETHICAL PRINCIPLES 3 Understanding the gravity of the situation, Betsy sets up a meeting with Shirley’s parents and Dr. Campbell, director of the neurology department at her hospital. She treats this meeting as an intervention, and both she and Dr. Campbell express their concern for Shirley’s health. They stress on the fact that the improvement in Shirley’s symptoms does not necessarily mean she will be cured. They empathize with Alice and her husband’s reluctance on account of their religious faith but reiterate the importance of getting Shirley’s symptoms diagnosed. To prove their point, they present studies that describe how seizures can be indicative of illnesses such as epilepsy, which could negatively affect her cognition and behavior. Shirley’s parents are grateful that Betsy and Dr. Campbell are concerned about their daughter’s health but remain resolute about going against their faith. They believe that prayer will cure her. Betsy is faced with an ethical dilemma of whether she should respect the parents’ religious beliefs and not intervene in the matter or perform her moral obligation as a health care professional. Analysis of Ethical Issues in the Case Study In the case study, the main factor that led to Betsy’s ethical dilemma is Shirley’s parents’ refusal of medical assistance for their daughter owing to their Christian Science beliefs. When Betsy notices Shirley’s seizures, she thinks it is her duty to make sure Shirley receives medical attention. As she respects the religious faith and belief of Shirley’s parents, she decides to explain the risks that seizures could involve. She also includes Dr. Campbell in the conversation so that he could provide an objective opinion to make them understand the need for medical intervention. However, Shirley’s parents are certain that prayer will cure her seizures. Considering that their attitude could result in serious health implication for Shirley, Betsy is concerned about the little girl receiving appropriate medical attention (Baumrucker, et al., 2017). Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Comment [A3]: Sub-headers, like these used here, are helpful in alerting the reader about topic changes. APPLYING ETHICAL PRINCIPLES 4 Using the Ethical Decision-Making Model to Analyze the Case Study The three components of the ethical decision-making model—moral awareness, moral judgment, and ethical behavior—can help analyze the ethical issue outlined in the case study. Whereas moral awareness is knowledge of the existence of an ethical dilemma, moral judgment involves choosing between the right and wrong actions when posed with such a dilemma. Both moral awareness and moral judgment lead to ethical behavior. Ethical behavior is taking the right action to resolve a dilemma. Betsy’s moral awareness is reflected by the fact that she recognizes the circumstances surrounding Shirley’s condition. Her moral judgment is reflected by her decision to try to convince Shirley’s parents to get Shirley medical help because she believed that it was the right thing to do. Betsy’s ethical behavior constitutes the action she takes to resolve the dilemma. This, in turn, depends on her personal judgment and the four principles of health care ethics (autonomy, beneficence, nonmaleficence, and justice) she should abide by as a health care professional. Effectiveness of Communication Approaches in the Case Study Comment [A4]: You effectively used the 3 components of an ethical decision-making model to analyze this ethical issue. Listening plays an important role in patient–physician communication. By listening to Alice, Betsy learns of the frequency of Shirley’s seizures and the reduction in their occurrence. She also learns that Alice and her husband believe that this reduction is due to their prayers and faith in Christian Science. Therefore, active listening helps Betsy understand the situation better. Betsy is aware that if she decides to get medical help for Shirley without the consent of Shirley’s parents, she would be violating their right to informed consent and overstepping her boundaries as a health care professional. So, she decides to present them with the information they need to make an informed decision. She maintains an open communication with Shirley’s parents while explaining the impact of seizures on their daughter’s health. She stresses the Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Comment [A5]: This section shows your good critical thinking regarding communication approaches to use! APPLYING ETHICAL PRINCIPLES 5 importance of immediate diagnosis of Shirley’s seizures. Thus, by being respectful of Shirley’s parents’ emotions and providing them with complete information about the problem, Betsy communicates the situation to them in an effective manner. During the discussion with Shirley’s parents, both Betsy and Dr. Campbell are empathetic toward Alice and her husband’s reluctance to get the necessary medical help for their daughter on account of their religious faith. Betsy seems to have involved Dr. Campbell so that he could share his objective expert opinion based on his experience in dealing with patients who have similar symptoms. She probably thought that Shirley’s parents would change their decision if Dr. Campbell reiterated that Shirley could develop severe cognitive problems (such as learning difficulties and memory deficits) or behavioral problems (such as irritability, anxiety, hyperactivity, and mood swings) if her seizures are neglected. However, they were unable to convince Shirley’s parents to get Shirley medically diagnosed. Although Betsy followed a systematic approach while dealing with the issue at hand, it seems to have been ineffective as Shirley’s parents continued to stand by their faith in prayer. However, listening patiently to patients’ problems and showing empathy and genuine care while communicating with them are some lessons that health care professionals can take back from this case study. Resolving the Ethical Dilemma by Applying Ethical Principles The four ethical principles of autonomy, beneficence, nonmaleficence, and justice are often employed to resolve ethical dilemmas related to health care. Autonomy refers to accepting and understanding patients’ values, beneficence refers to acting for the welfare of patients, nonmaleficence refers to not doing harm to the patient, and justice refers to treating patients fairly without bias. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. APPLYING ETHICAL PRINCIPLES 6 The ethical dilemma that Betsy faces in this case involves three of the four basic principles of medical ethics. In the case study, the ethical dilemma is caused by the conflict between the principles of autonomy on the one hand and beneficence and nonmaleficence on the other. Betsy preserves the autonomy of Shirley’s parents by respecting their religious beliefs and not coercing them to get the girl correctly diagnosed. She further ropes in Dr. Campbell to try to explain to them the importance of getting an accurate diagnosis. Approaching Child Protective Services—a social service agency run by the government to counsel and support children and their families and promote child welfare—could be considered by Betsy as an ethical means to resolve the dilemma. As Betsy is obligated to help Shirley get medical care (beneficence) and prevent any harm that might be caused from ignoring her seizures (nonmaleficence), she could seek intervention from Child Protective Services. Although involving Child Protective Services could result in overriding the ethical principle of autonomy, Betsy might have to take this decision keeping Shirley’s best interests in mind (Baumrucker et al., 2017). Conclusion The four principles of health care ethics can be applied by health care professionals to analyze and resolve ethical dilemmas. In the case study, Betsy has to decide between respecting Shirley’s parents’ religious beliefs and performing her moral obligation as a health care professional by helping Shirley seek medical care. The proposed solution involves upholding the principles of autonomy, beneficence, and nonmaleficence to resolve Betsy’s ethical dilemma. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Comment [A6]: You provided a clear plan on how to address this issue. Also, the proposed solution is based on ethical principles. APPLYING ETHICAL PRINCIPLES 7 References Baumrucker, S. J., Easterday, J., Stolick, M., McCall-Burton, M., Adkins, R. W., Winiger, D., & Cook, C. (2017). Ethics roundtable: Parental autonomy and the minor patient. American Comment [A7]: Your paper is wellresearched with the inclusion of recently published academic journal article! It is a best practice to use articles published in the last 35 years. Journal of Hospice & Palliative Medicine, 34(3), 287–292. Retrieved from http://journals.sagepub.com.library.capella.edu/doi/pdf/10.1177/1049909115608812 Capella University (2018). NHS-FP4000 Exemplar Sample Ethical Case Study. Retrieved from Capella Website: xxx. Copyright ©2018 Capella University. Copy and distribution of this document are prohibited. Comment [A8]: NOTE: This case study was created exclusively for the purpose of this exemplar and was not reproduced from any source. Replace this with the citation from the case study you use.
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Ethical Dilemma in Medical Practices

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Ethical Dilemma in Medical Practices
In any profession, ethical issues lead to a dilemma. Ethical dilemmas come when a person
has to decide on specific actions of others on whether they are right or wrong (Lo, 2012). In this case,
one must consider the moral awareness, moral, and ethical behavior in order to drive to the desired
solution. The paper will address the ethical dilemma and dictate on how to solve the problem using
ethical principles.
The case study of focus revolves on the ignorant behavior of physicians in their actions. The
case involves Dr. Lacey is a senior an aging doctor in Crosby hospital that has been operating for
several years. Among the staff, he is the oldest and most experienced in the institution. Corey role
was to develop a system that gives the clinicians privileges. Additionally, the new system would aid in
issues such as staff reappointment. The system increased the privileges on Dr. Lacey where he would
make the right decisions without consultation. Unfortunately, Dr. Lacey does not listen or discuss
with the other medical staff especially nurses. Dr. Lacer treats all instances of breathing issues with a
single type of medicine. In this case, he uses the Lasix drug. Unfortunately, the drug can be harmful
to some patients hence making the nurses approach the doctor with evidence of the implicatio...

Really helped me to better understand my coursework. Super recommended.


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