Ethical Dilemmas for Ethics Colloquium. AFA Conference 2014. “Danged if you do and danged if you don’t” You have a ward who is fairly stable when he/she is taking his/her medications but has a long history of medication non-compliance and of violent behavior when he/she is off his/her medication. The ward has had numerous involvements with the law associated with this and his spent considerable time in jail and in the restoration to competency unit at the Arizona State Hospital. In an effort to increase the wards medication compliance you place him/her in a level 2 behavior health residential facility where there are staff to monitor their medication compliance. While at this facility the ward cheeks their medications repeatedly and spits them out into the toilet. The ward then begins to display aggressive behavior and goes AWOL from the level 2 facility. The ward is located by the police and returned to the facility whereupon you request that the ward be placed in a level one facility to be re-stabilized on their medication. The behavioral health service provider complies but then refuses to discharge the ward back to the level 2 facility insisting instead that they be discharged directly back to the community. You appeal this decision and in response the behavioral health service provider petitions the court to have you dismissed as guardian and conservator based on the psychiatrists determination that the ward is no longer incapacitated. The “transparency” dilemma The requirement that the fiduciary provide the ward/protected person with notices and other legal filings (including accounts) results in the potential for the accounting to be left out for review by caregivers, family, etc. This resulted in family members, caregivers etc. reading the accounting and starting various forms of trouble (especially if they believed the accounting indicated there was substantial assets), including asking the protected person if they would engage them individually for services (as opposed to through the agency they worked for). The dilemma is providing such notice, and (somehow) keeping it confidential – even though the fiduciary often has little practical control over who is coming into contact with the ward/protected person and their belongings/documents.
The “quality of life” dilemma. This occurs when the ward/protected person has significant physical issues that are likely to result in their early demise. When the fiduciary is faced with very limited resources (such as with most public fiduciary cases), that are likely to run out before the ward passes, there is often a dilemma in spending on non-essentials, such as entertainment, in order to preserve the resources for the essentials (food, clothing, shelter). There are many protected persons that can/will benefit (at least emotionally) from some form of entertainment – yet, the fiduciary is sometimes loathe to allocate such funds knowing that the ward/protected person will be completely out of resources before they pass-away. This puts the fiduciary in the position of having to decide whether or not to allocate resources that will improve the current quality of life knowing that it is likely to result in a diminishment of options before the person passes. The “conflicting wishes” dilemma. What if you have a seriously mental ill ward on dialysis who has a living will stating his wishes to not have extraordinary measure taken to save his life. He no longer wants dialysis, but when you question him, and ask him if he is sure he wants to die, he tells you that he won’t die, doesn’t have kidney disease because white men never get it. Also, Jesus loves him. His attorney supports his desire to quit dialysis, which is essentially a form of life support, but you realize that he is not capable of making an informed decision about this. In fact, when asked, he states that he doesn’t want to die. Result: we had a hearing and I testified that you can’t really consent to withdraw life support, if he doesn’t believe he will die. I won.
9H
Mr. J is a 62 year old male with serious medical and mental health issues. Mr. J was appointed a guardian and conservator due to the fact that his mental illness prevented him from making or communicating responsible decisions regarding his finances and medical treatment. Mr. J also refused mental health services and medications from the local mental health center. Mr. J isolated himself from others and was estranged from his family.Mr. J was inconsistent in attending scheduled medical appointments which resulted in multiple hospitalizations and a diagnosis of kidney cancer.Fiduciary sought instruction from the Court who ordered police to assist fiduciary in escorting Mr. Johnson to his medical appointments. Mr. J’s physician recommended that he have surgery due to the fact that his kidney cancer was life threatening. Fiduciaries working with Mr. J continued to him to medical appointments and met with his physician on numerous occasions in an attempt to make sure that Mr J received the necessary medical care. Mr. J was scheduled for surgery on two separate occasions;however Mr. J refused to have surgery stating that he did not have cancer and that he did not want to be cut open. The physicians treating Mr. J also stated that they were unwilling to do surgery due to the fact that Mr. J was opposed to it even though he was told that his condition was life threatening Fiduciary also met with the hospital ethics committee who also recommended that Mr. J not have surgery due to his mental illness and his inability to care for himself in addition to his refusal to allow fiduciary or other care providers assist him post operative care. Fiduciary advised the court of Mr.J’s refusal to receive medical treatment. Mr. J died soon after that at his home.
End-of-Life Decision Making: Case 2 by Elizabeth Menkin http://www.scu.edu/ethics/practicing/focusareas/medical/conserved-patient/case2.html The public guardian has just been granted healthcare decision making power for Ms. Long, a 78 year-old woman with severe dementia, diabetes with impaired vision, and poor kidney function, recent recurrent pneumonia, and prior strokes. You are seeing her for the first time in a skilled nursing facility. She was transferred there yesterday following a four-month hospitalization. When you arrive at the skilled nursing facility to see Ms. Long, she looks very thin, and the nurse tells you that there is a large necrotic pressure sore on her sacrum. The aides are repositioning her so that the speech therapist can do her evaluation. There is an IV running fluids in the patient's left arm, and her right arm lies limp on the bed. Some of the time she seems to look at a face and track movements, but sometimes not. She does not give any answers to simple questions, either verbally or with nods or shaking her head, and does not consistently look at the person who is talking to her. She does not give any social smile in response to the speech therapist's attempts to engage her. You notice that the patient grimaces when she's moved, and cries in apparent pain when she is rolled on her back. She opens her mouth when offered a straw but does not suck on the straw. She takes a small amount of ice cream that is offered by spoon, but after two more tries by the speech therapist she pushes it away and slaps using her left hand. • What are the treatment decisions at this point? • On what basis will these decisions be made?
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