1. This is a theoretical case taken from VHA Intensive Ethics Advisory Committee Training, 1998, as presented by Arthur R. Derse MD, JD. An 87-year-old woman widowed for six years, who is otherwise healthy, was visiting another city and abruptly became ill. She was seen in the emergency department of the local VA and admitted to the on-call physician. The on-call physician (who has not previously seen her) made the diagnosis of bowel obstruction arid made arrangements for a surgeon to evaluate her. The surgeon recommended surgery and obtained her consent for surgery. The surgeon expects an uneventful recovery. She is told that she will be on a ventilator for a short time after surgery. The patient tells the surgeon that is OK as long as it is for a short time. She tells the surgeon that she does not want to be dependent upon machines. She was asked upon admission whether she had an advance directive. She replied that she has a living will and a power of attorney for health care which names her daughter (who does not live in the area) as her health care agent. The patient undergoes surgery, which is successful in treating the underlying problem and does not show any malignant causes, but in the recovery room she has a cardiopulmonary arrest and is resuscitated. She is transferred to the ICU in the care of the on-call physician. The physician attempts to wean her gradually from the ventilator, but this is unsuccessful. Three days later, she has regained consciousness but is still intubated. Though she cannot speak because of the ventilator, she is able to write and asks that the tube be removed. The attending physician tells her that she is dependent upon the ventilator and the patient needs to remain on the ventilator until she can breathe on her own. She writes that she understands that she may die, but she does not want to be on machines. Her only children — a daughter and son — – have arrived. She repeats her wish to them that she wants the tube removed. She writes to her daughter that “I don’t want to die, but we all have to die sometime, and I don’t want to have to live on a machine. I know that whatever the outcome, God will take care of me.” Her daughter tells the physician that her mother is adamant that she be off of machines and she respects her mother’s wishes, even if she cannot breathe on her own. She says this is consistent with her previously expressed wishes and her religious beliefs. Her son tells the physician that he disagrees with his sister — since his mother does not have a terminal condition, he can not see why she should not be forced to put up with the ventilator until she can be weaned from it. He feels that she is being shortsighted, and she will be thankful to have been kept on the ventilator when she is finally able to be weaned. Describe the criteria for giving “legal” consent. Were all elements met in this case? In other words, did the patient demonstrate decision-making capacity? Explain. (Minimum of 1 page including in-text citations and references in proper APA format)
2. Based on case study above: Is this patient requesting to be euthanized or for her physician to assist in her suicide (PAS)? In your answer describe how the two terms differ. (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
3. A managed care group may want to market their organization as being “the best” or “a leader” in providing certain services/ treatment. How can this type or marketing effect quality of care and utilization of services, hence costs? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
4. According to Darr, MCO enrollees can be described as either light/moderate users or heavy users. What are some of the strategies that management uses to turn “heavy” users into light/ moderate users? In your personal opinion, what positives or negatives may result? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)
5. Describe the constraints/challenges that physicians experience as being service providers affiliated with a Managed Care Organization. (Minimum 2 paragraphs including in-text citations and references in proper APA format)
6. Give a very brief “real-life” example/instance where drugs/ medical treatment/services were microallocated. And give a “real-life” example of macroallocation. (Do not include the examples provided in the text.) (Minimum 1 paragraph including in-text citations and references in proper APA format)
7. Read the case of Karen Ann Quinlan (p. 248-249). Explain why this is a case involving medical futility. (Include in your an answer the definition of medical futility). Darr(2011, p. 218) writes, “[the] futility theory has quantitative and qualitative aspects.” What is meant by these terms? Present arguments for each as it relates to this case. (Minimum 2 paragraphs including in-text citations and references in proper APA format)
Reference:
Darr, K. (2011). Ethics in Health Services
Management. (Fifth Edition).
Baltimore, MD: Health
Professions Press, Inc.
Expert Solution Preview
Introduction:
In the field of medical education, the responsibility of a professor involves designing and conducting lectures, evaluating student performance, and providing feedback through examinations and assignments. In this context, this article provides answers to various questions related to medical ethics and managed care organizations, including criteria for legal consent, the difference between euthanasia and physician-assisted suicide, the impact of marketing on quality of care and service utilization, strategies of managing “heavy” users, constraints/challenges faced by physicians affiliated with Managed Care Organizations, real-life examples of microallocation and macroallocation, and the case of Karen Ann Quinlan related to medical futility.
1. Criteria for Legal Consent:
Legal consent in medical practice requires that the following elements are met: (a) the patient must be competent and must have decision-making capacity to make an informed decision, (b) the physician must disclose relevant information about the medical condition, the proposed treatment, the benefits and risks, and any alternative options, (c) the patient must understand the information provided and ask questions as needed, (d) the patient must voluntarily give consent without coercion or duress, (e) the patient’s consent must apply to the specific treatment or procedure, and (f) the patient must be legally capable of giving consent, which may involve considerations such as age, mental capacity, and guardianship (Darr, 2011).
In the case presented, the patient had previously completed a living will and a power of attorney for health care, which named her daughter as her healthcare agent. However, it is unclear whether the patient had decision-making capacity at the time of the surgery and whether the physician disclosed relevant information about the postoperative measures, such as the use of a ventilator. Moreover, the subsequent cardiopulmonary arrest and requirement for intubation further complicate the case. Therefore, it is vital to consider the patient’s autonomy and the family’s involvement in making medical decisions that respect her wishes.
2. Euthanasia vs. Physician-Assisted Suicide:
In the presented case, the patient is requesting the removal of the ventilator and expressing her desire not to be dependent on machines. Euthanasia typically involves the administration of drugs or measures to intentionally end a patient’s life, whereas physician-assisted suicide involves the provision of lethal drugs to a patient who self-administers them to end their life. The key difference is that in euthanasia, the physician takes an active role in ending the patient’s life, whereas in physician-assisted suicide, the patient takes the final act (Darr, 2011).
However, in the presented case, the patient is not explicitly requesting euthanasia or physician-assisted suicide, but rather expressing her wish to be removed from the ventilator. Therefore, it is crucial to clarify the patient’s desires and determine the appropriate course of action.
3. Impact of Marketing on Quality of Care and Service Utilization:
Managed care organizations may use marketing strategies to position themselves as the best or a leader in providing specific services or treatments. However, such marketing efforts may result in a focus on select care areas or services, which may cause unintended consequences, such as overutilization of services or treatments that are marketed as superior or effective, leading to increased costs and reduced quality of care (Darr, 2011).
4. Strategies for Managing “Heavy” Users:
Managed care organizations may use various strategies to manage “heavy” users, including care coordination, disease management programs, case management, utilization management, and provider network management. These strategies aim to identify high-risk patients, coordinate care, reduce unnecessary utilization, promote preventive care, and manage chronic conditions (Darr, 2011).
However, some of these strategies may also pose ethical and practical challenges, such as patient resistance to care coordination or disease management, restricted access to care providers, and prioritization of cost-saving measures over quality of care.
5. Constraints/Challenges Faced by Physicians Affiliated with Managed Care Organizations:
Physicians affiliated with managed care organizations may face various constraints and challenges, such as limited autonomy in clinical decision-making, restricted access to care providers or treatments, financial incentives that may compromise patient care, and performance metrics that may not fully reflect patient needs (Darr, 2011).
Moreover, managed care organizations may face ethical issues related to balancing cost-containment measures with quality of care, managing conflicts of interest, and maintaining transparency and accountability in decision-making.
6. Real-Life Examples of Microallocation and Macroallocation:
Microallocation refers to the allocation of resources, such as drugs or medical treatments, at the individual patient level, based on clinical needs, preferences, and available resources. For example, a physician may use a clinical decision support system to determine the appropriate medication dosage for a patient based on their weight, age, and medical condition (Darr, 2011).
Macroallocation, on the other hand, refers to the allocation of resources at the community or population level, based on broader considerations, such as epidemiological data, cost-effectiveness, and social values. For example, a public health agency may prioritize funding for preventive services or vaccination programs based on the disease burden and socioeconomic factors in a given population (Darr, 2011).
7. Karen Ann Quinlan Case and Medical Futility:
The Karen Ann Quinlan case was a landmark case that raised issues related to medical futility, which refers to situations where further medical interventions are unlikely to provide any meaningful benefit to the patient. In this case, Karen Ann Quinlan was in a vegetative state and was being kept alive by a ventilator. Her family requested that the ventilator be removed, but the hospital refused, citing concerns about legal liability (Darr, 2011).
The quantitative aspect of medical futility involves considerations about the effectiveness of the medical interventions, such as survival rates or morbidity, while the qualitative aspect involves considerations about the patient’s values, preferences, and quality of life. In this case, the decision to remove the ventilator was based on the qualitative aspect, as it reflected the patient’s expressed wishes and ensured a compassionate end-of-life care. However, the case also raised concerns about legal and ethical aspects of end-of-life care, including the role of caregivers, the limits of medical interventions, and the need for advanced care planning (Darr, 2011).
Conclusion:
Medical education encompasses various aspects of ethics and management related to healthcare delivery, ranging from legal consent and medical futility to managed care organizations and resource allocation. As a medical professor, it is essential to provide students with a comprehensive understanding of these issues, including their ethical, legal, and practical implications, to prepare them for the evolving healthcare landscape.
