Biostatistics assignment for epidemiology course lecture

1. SALALE UNIVERSITY COLLEGE
OF HEALTH SCIENCE
Ethicolegal Basis of Nursing
Topic :Ethical Case Analysis on
Narrative story of my experience
SUBMITTED TO : MATHEWOS M. (MSc. Assistance
professor)
Submitted by kedir Mohammed
2023/2/7 1

2. Introduction
Making ethical decisions in clinical practice is about doctors selecting the “right”
choices. These “right” choices go beyond the appropriate use of current scientific
knowledge, clinical reasoning and contextualization, to the particular needs of the
patient. To preserve professional integrity, decision making needs to be consistent
with the goals of medicine.
The primary goals of medicine include the curing of disease, relief of suffering,
improvement in functional status, as well as education and counseling. Secondary
goals are training of healthcare professionals, research and clinical/professional
governance.

3. cont.…
• Every clinical encounter has an ethical dimension and in the
majority of situations where patients and doctors have shared
targets that are consistent with these goals of medicine, problems
do not arise.
• A defining responsibility of a practicing physician is to make
decisions on patient care in different settings. These decisions
involve more than selecting the appropriate treatment or
intervention.

4. cont.…
The practice of medicine is rooted in a covenant of trust among
patients, healthcare professionals, and society. The ethics of
medicine must seek to balance the healthcare professional’s
responsibility to each patient and the professional, collective
obligation to all who need medical care.
C The critically ill patients develop acute illness which needs
immediate medical rescue for example sepsis, shock, pre arrest
condition, multi organ failure and major trauma, poisoning or
cardiopulmonary arrest along with above mentioned background
seeks admission in ICU and later on develop certain ethical
dilemmas.

5. Dilemmas concerning resource scarcity and allocation of resources
2.Case description
one day, in my duty at ICU I face situations like that:
A 25-year old man is brought to Emergency Department by his family and
diagnosed with penetrated chest trauma by physician after assessment, which is
fighting injury. He has respiratory distress(pso2=88),severe chest pain, Bp=125/80
HH/m( norma)l, pulse rate=90b/min (in normal range), RR=12.br/mnThe patient
condition is conscious. , chest radiograph(CXR) show fracture of diaphragmatic
bone.
At emergency department woud is dressed, Iv fluid was started and catheter was
done.

6. Cont...
• Then the patient was transferred to operation room and the
surgeon was consulted, then the surgeon examine the patient and
find blood accumulation in abdominal cavity then he decided to
do laparotomy for the patient and after consent the operation
was done. Type of procedure done for the patient are:- Bilateral
Chet tube and laparotomy. Post operation vital signs BP and pulse
is in normal range RR=14, pso2=88 of oxygen on oxygen pso2=95
and he is fully recovered from anesthesia, then The surgeon
admitted him to Icu for ICU management.
•

7. Cont....
As a chance we have only two bed and both beds are occupied and they are critical they
need icu management.
One patient is a 65- years old male known diabetic patient diagnosed with chronic foot ulcer
and amputation was done for him he is critical, and semiconscious and his Bp=110/70 ,
pr=60m/bt, RR=14, pso2=88b/m on oxygen RBS is between 80-100ml/dl.
The other patient is 35 years old female diagnosed with congestive heart diseases. She has fast
breathing and she used assessory muscle for breathing and also she has grade 3 abdominal
distension and bilateral pitting edema and she is conscious, Bp=90/60mm/hg, pr=132b/mn,
RR=34br/mn
The surgeon decide to transfer a 65 years old diabetic patient to surgical ward to open bed
for new admition.
But the patient family didn't accepte the decission.
Full information about the patient the condition, prognosis, indications of the transfer is not
provided for patient family.

8. 3.Ethical Dilemma
To transfer critical patient from ICU to surgical
ward or not to transfer?

9. 4. Analysis of the ethical dilemma
4.1 Medical indications
• This is 65 years old man known chronic diabetic foot ulcer patient
and amputation was done for him(left leg up to knee), he was in
semiconscious and his Rbs is less than 100ml/dl and he has
respiratory distress (Pso2<90b/min) on oxygen. The patient
medical condition is deteriorated/critical.
• The other patient is 25 years old male diagnosed with penetrated
chest trauma and he is conscious, post opp vital sign
Bp=130/85mm/Hg, pr= 94 b/m,Rr=12, pso2=90 on oxygen he is
critical but when compared to the above patient he is stable. If he
treated he will have good prognosis than this patient.

10. cont.…
• The goal of transfer is to make free bed for new admission. This
decision makes further injury or increase its risk (maleficence)
• If he transferred to surgical ward he will get more critical than
before and will be die. If the patient stay in ICU, he can get
macanical ventilator for airway support and he may improved and
survive for some period of time.

11. 4.2. Patients preferences
• Since the patient is semiconscious the family members has
responsibilities to make discussion and they want to stay at ICU
for treatment until the end. In this case the right to make their
own decision for the patient is not respected (autonomy) and
also Without telling Full information about the patient
condition, discontinuation of ICU management, prognosis,
indications of the transfer is not provided for patient family. In
this case veracity(truth telling) for patient or patient family is
not respected.

12. .Patients preferences cont..
• Intensive care unit should be provided in a non prejudicial manner
that preserves and protects patient free will, choice, and human
rights. The first duty of a doctor must be to ensure the wellbeing of
patients and to protect them from harm(non maleficence)• Nurses
must protect and promote the health and wellbeing of those in
your care, their families and careers (Code of conduct). Provision 1
in the Code of Ethics for Nurses with Interpretive Statements reads

13. 4.3. Quality of life
• This patient one leg is amputated up to knee he can't fully engage him self he
depend on Others for Physical Needs because of the severity of the disease.
• The patients had poor and declining cognitive and/or physical function. The patients
also had declining ability to communicate .The patient has Low Chances of
Meaningful Recovery Patients were described by the physician.
• If he stay at ICU, he will relief of symptoms and can stay for longer periods even if he
has poor prognosis. A continuous icu management for this patient does not cure that
much because of the severity of the disease and age
• But if we transfer him or discontinue Icu management, his medical condition will be
worsened and the patient may die in short period of time.

14. Quality of life cont.…
• In this case the physician may find the “(clinically non-beneficial
interventions”) treatment to be futile or nonbeneficial. Based on the
life expectancy, age, prognosis and productivity of the patient the
physician decided to transfer the patient.
If the physician feels the therapy is futile, then he or she is not
obligated to provide any therapy that would be considered futile,
harmful, or nonbeneficial.(13)
Medical perspective has acceptable ,But this is not ethically
acceptable.

15. 4.4. Contextual feature
Principles of Justice and Fairness included
In this case due to lack of enough icu bed or allocation of th
resource, the patient is forced to surgical ward to open bed for new
admission. In this case fair, equitable, and appropriate distribution of
health-care resourcesis not respected the patient.
In this case the surgeon depend On medical dimension or clinical
ethics which says A subordinate consideration is giving priority to patients who
have a better chance of survival and a reasonable life expectancy.
Legally it is not right transferring an existing critical patient to make room for a new
one is not in the existing patient’s interest, so ethically we can not do it.

16. Contextual feature cont…
• There is a consensus among clinical ethics scholars, that in this
situation, maximizing benefits is the dominant value in making a
decision [4].
• Maximizing benefits can be viewed in 2 different ways; in lives
saved or in life-years saved; they differ in that the first is non-
utilitarian while the second is utilitarian. A subordinate
consideration is giving priority to patients who have a better
chance of survival and a reasonable life expectancy.

17. Contextual feature cont.…
• The other 2 considerations are promoting and rewarding
instrumental value (benefit to others) and the acuity of illness.
Health-care workers (physicians, nurses.) and research
participants have instrumental value as their work benefits others;
among them those actively contributing are of more value than
those who have made their contributions. The need to prioritize
the sickest and the youngest is also a recognized value when these
are aligned with the dominant value of maximizing benefits.(6,7)

18. My reflections
• health care providers(physician and nurse) of ICU department have to discuss
and foreward to hospital management about the issues and factors of this
issue like bed ,patient monitor and machanical ventilator.
• Physician and nurse of ICU department have to preper them self early to
prevent such a previous problems for the coming admission.
• once we are responsible, we have the same duty to help that we have to all our
patients. They are all equal. We cannot discriminate between them except on
basis of need.
• Health care providers have to respect the right patient to treat until the end
once we have accepted and refer the new patient going to bee admitted to
other hospital because he is not critical compare to other patient

19. My reflections cont.…
• Hospital management have to increase the number of bed and
other equipment needed for icu to Avoiding the need for capacity
transfers by increasing the number of ICU beds.
• Health care providers have to discuss the patient’s condition with
his family with the goal of discontinuing life-sustaining
interventions. These discussions should be done with sensitivity,
compassion and empathy. Palliative care should be provided to
alleviate his symptoms and to support the family until his death
and beyond in their bereavement. In this case this is not done the
communication between health care provider is poor.

20. 2023/2/7 Prepared by Ethiopia,Dereje & Kedir 20