Jody Smith: Application of the Moral Model… Applying Ethical Decision Making Model

"Jody Smith Case Study: Application of Thiroux's Moral Model"

The decision making model that will be applied in this work is the Moral Model (Thiroux 1977) and the case it will be applied to is the Jody Smith case. The reason this model was chosen is because the model lends itself best to a situation, such as Smith's where an impasse has been reached between the patients values and desires and that of family and the health care team. In this case the ethical dilemma is one clearly of informed consent as Smith has been excluded from conversations associated with her prognosis and care and this is contrary to her values and her identity. Without inclusion of this communication standard Smith has very little to go on regarding her prognosis and may be seeing her situation as insurmountable not only because of the lack of information but because she has been excluded as an informed part in the process. It is likely that there may be some resentment on Smith's part regarding this exclusion from informed consent and that her recent rehabilitation from total hip replacement is stark in her memory.

"Jody Smith, a retired nurse with 3 adult children and numerous adult grandchildren, lives alone in a small rural area. Her income is limited. Two months ago, she fell and broke her left hip. After surgery for an artificial hip replacement, she was transferred to a rehabilitation center, where she had a left sided cerebrovascular accident (CVA). She was then readmitted to the acute care facility, where she has received aggressive therapy of the CVA.

Completely paralyzed on her left side, Mrs. Smith has decided that she no longer desires aggressive therapy and frequently asks the staff why she cannot die in peace. "The rehabilitation is so painful and I'll never walk again. What's the use?"

Both the doctors and her family are much more optimistic. The orthopedic surgeon is convinced that she will walk again, and the neurologist believes that she will make a full recovery and be able to return home and care for herself. Both doctors have excluded Mrs. Smith from their conversations, assuring her children that she will be "as good as new" and ignoring her requests to discontinue anticoagulant and rehabilitative therapy.

While not in a life-threatening condition, Mrs. Smith refuses to cooperate with the physical and occupational therapists and to take her medications. She also refuses to perform simple tasks, relying on staff to meet her activities of daily living. (Guido, 2010)

According to the Thiroux Moral Model (1977) the following sections will be applied to the case of Ms. Smith. Ms Smith are dealing with a dilemma concerning the desire to remove herself from any further aggressive treatment and refusing any further treatment.

Thiroux Moral Model Applied

M massage the dilemma IDENTIFY and define issues in the dilemma consider the opinions of the major players patients family members nurses physicians clergy and other interdisciplinary healthcare members as wells as their value systems

The most immediate moral and ethical dilemma associated with the care of Smith is the rational and realistic communication of Smith's prognosis to her through the inclusion of her in discussions regarding her medical care. Given that Smith is a former nurse her reluctance to continue aggressive treatment may in part be supported by the fact that someone just telling her she has a chance is not the same as being informed by her physicians of the advances and developments that make it possible for her to have a full recovery as well as her real condition, in medical terms. Smith needs very much to be included in any and all communications about her care, and not excluded as she has been. Her desire to stop care might or might not be changed by the process of communication but she is the patient, she has her own medical power of attorney and she is likely the most knowledgeable of all parties, excluding the rehab specialists and the doctors, of the specifics of care that may be needed for her prognosis of a full recovery to prevail. The ethical/moral dilemma is therefore seated plainly in the fact that she has been excluded from communications which is contrary to her history as a nurse and contrary to her rights and values as a person. Secondly, pain control management needs to be addressed more aggressively with Smith. There are alternatives to narcotic pain control that might alter her ability to be involved in a painful process of physical therapy but that would allow her greater comfort in attempting rehabilitation.

O outlines the options, Examine all options fully, including the less realistic and conflicting ones. Make 2 lists identifying the pros and cons...

This stage is designed to fully comprehend the option and alternative available, not to make final decision
Communicate fully with Smith in an attempt to give her full knowledge of the positive prognosis in hopes (King, Eckman & Moulton, 2011) that this coupled with more affective pain management will allow her to change her mind and continue with treatment (Chorney, McGrath, Finley, 2010).

Pro

Smith will make an informed decision

Smith may choose to continue treatment once she feels like she has been fully informed

Con

Smith may still choose to discontinue treatment

Awareness of the full scope and breadth and therefore difficulty of aggressiveness of the treatment may increase Smiths anxiety as feared by family and staff and may therefore sway her opinion toward ceasing care.

Reduce the aggressiveness of the rehabilitation treatment so it is more tolerable, though likely less effective and explore the pain management option more fully.

Pro

The scaled down treatment may allow Smith hope to continue treatment

The continued treatment may result in positive treatment outcome

Con

Scaled back treatment at this critical window would likely result in a reduced potential outcome

Scaled down treatment and reduced recovery affect may adversely affect Smith's ideation of the treatment outcome as not worth the effort.

Allow her decision for rejection of aggressive treatment to stand and scene treatment. Send her home on hospice care

Pro

The patients wishes would be fully realized thus supporting her identity and her right to choose

Con

Termination of care would likely result in reduced quality of life, if she were able to recover partly on her own

Support the family in stripping Smith of her medical power of attorney and force her to participate and remain at the rehabilitation facility despite her wishes.

Pro

Patients family would feel justified in their ability to continue with aggressive treatment in conjunction with the positive prognosis

Con

Patient would remain resistant and therefore difficult to treat, if this were the case and individual treatment regimens were not followed the outcome would be completely incongruent with the positive prognosis

R Resolve the dilemma review the issues and options applying basic ethical principles to each option. Decide the best option based on the views of all those concerned in the dilemma

Having reviewed several possible options I believe the first option presented involving greater communication with the patient regarding her positive prognosis and the therapeutic regimen she will be given the option to follow is the best possible solution for all involved. Protecting Smith from the information has been contrary to her identity as a former nurse and as a patient in need of true informed consent. The patient's family will also be better served if Smith is openly offered options and then either chooses to continue therapy or makes a full informed decision regarding termination of care. The wishes of health care providers and family are clearly secondary to the decision that Smith needs to make herself as she is the only one who can either successfully perform rehabilitative tasks or not and she is the one that needs to make decisions about her care, for the simple purpose of compliance or non-compliance. Protecting Smith from the information is clearly contrary to her history as a nurse and her autonomy as an individual.

A Act by applying the chosen option. This step is usually the most difficult because it requires actual implementation whereas the previous steps had allowed for only dialogue and discussion.

Set a time and meeting place for an informative discussion with the patient and possibly one or two of her family members with doctors and rehabilitation specialists. Demonstrate the course of treatment fully to Smith as well as discussing the possible outcomes of her positive prognosis. The team may also be best served if they show Smith similar examples of other patients in her situation who have fully recovered from a similar condition through rehabilitative care. Discuss the stride made in rehabilitative care since Smith was a nurse and also the narrow window of opportunity to decrease the chances of permanent atrophy. All this information should be offered to Smith in a professional and respectful way. Coercion should be avoided but Smith must also be informed that rehabilitative services are offering her the best chance for quality of life improvement after the CVA event. If she goes home without receiving any form of this care,…