Pontifical and Royal

UNIVERSITY OF SANTO TOMAS

The Catholic University of the Philippines

THE GRADUATE SCHOOL

Thomas Aquinas Research Complex Espaa, Manila

BIOETHICAL CASE STUDY

In partial fulfilment On the requirements in NRS 602 (BIOETHICS)

Submitted to:

Submitted by: Leo V. Brigino, RPh, RN, MHAc Elvira Q. Lozano, RM, RN, MANc John Henry O. Valencia, RN, RM, MANc

I am in love with a child I havent yet met - Mandy Harrison

Case Number Six:

R.F., a 36-year old G3P2 was admitted because of septicemia, preterm pregnancy, 28 weeks not in labor. Inspite of massive antibiotics, she deteriorated. A cesarean section was suggested but no consent was available. On the 3rd hospital day she went into cardio-respiratory arrest, was resuscitated and was maintained on vasopressors. On the 4th hospital day she had uterine contractions. 3 hours later she became cyanotic, with signs of fetal distress. An emergency cesarean section was done delivering a pale, baby boy with slow heart rate and no respiration.

20 hours later R.F. expired. What ethical issues are present in this case?

Case Number Six | Bioethical Case Study

PART I: Gather and Assess the Facts

What is the patients current medical status? Are there other contributing medical conditions? What is the Dx? Prognosis? How reliable are these? What are the risks and side effects of Tx? What benefits will Tx provide?

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I.

MEDICAL FACTS

MATERNAl First Day: Septicaemia Pre-term Pregnancy Third Day: Cardio Respiratory Arrest Fourth Day: Cyanotic (ARDS as a Complication) Pre-term Labour

CHILD Fourth Day: Pre-term Infant 2-3 APGAR Score

MATERNAL FACTS FIRST DAY: What is Septicaemia? Sometimes referred to as bacteraemia, is a syndrome that results from an acute invasion of the bloodstream by certain microorganisms or their toxic products. Patients are given a diagnosis of sepsis when they develop clinical signs of infections or systemic inflammation.

Three Stages of SEPSIS: SEPSIS When an infection reaches the bloodstream and causes inflammation throughout the body.

SEVERE SEPSIS

Occurs when infection disrupts blood flow to the brain or kidneys, leading to organ failure. Blood clots cause gangrene (tissue death) in the arms, legs, fingers, and toes.

SEPTIC SHOCK

When blood pressure drops significantly. This can lead to respiratory, heart, or organ failure and death.

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Assessment of patients with SEPSIS reveals: Fever Hypothermia Heart rate >90 beats per minute (bpm) Fast respiratory rate Altered mental status (confusion/coma) Edema (swelling) High blood glucose without diabetes Low blood pressure Low urine output Absent bowel sounds

T General Symptoms

Laboratory Findings

High creatinine Coagulation abnormalities Low platelets High bilirubin High white count Low white count Immature white blood cells in the circulation

TREATMENTS: Sepsis should be treated as a medical emergency. In other words, sepsis should be treated as quickly and efficiently as possible as soon as it has been identified. This means rapid administration of antibiotics and fluids. A 2006 study showed that the risk of death from sepsis increases by 7.6% with every hour that passes before treatment begins. Antibiotics

Antibiotics (usually more than one type) are prescribed by the physician based on the type of infection that is causing the illness. The first antibiotics are usually broad-spectrum, which means the antibiotic is effective against several of the more common bacteria. The antibiotics are given by intravenous in order to ensure they get into the blood system quickly and efficiently.

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IVF

Antibiotics alone wont treat sepsis; fluids are also needed. The body needs extra fluids to help keep the blood pressure from dropping dangerously low, throwing the patient into shock. Giving the fluids by IV allows the health care staff to track how much fluid is being administered and to control the type of fluid the patient is getting. Ensuring the body has enough fluids helps the organs do their work and may reduce damage from sepsis. Supportive Management

THIRD DAY Septic Shock The patient suffered from Cardio-Respiratory Arrest indicative of Septic Shock. Treatment Modality includes that of Tx for Sepsis and giving of VASOPRESSORS. Physicians prescribe vasopressor to patients who are in shock and whose blood pressures have dropped dangerously low. The vasopressors act by constricting or tightening up the blood vessels, forcing the blood pressure to go up. FOURTH DAY

Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a rapidly developing, life-threatening condition in which the lung is injured to the point where it can't properly do its job of moving air in and out of the blood

Foetal risk must be considered when pharmacological therapy is administered. Adequate maternal oxygen saturation is essential for foetal wellbeing. Excessive alkalosis can have adverse effects on placental perfusion.

Case Number Six | Bioethical Case Study

TREATMENT:

There is no specific treatment for ARDS. The goal is to support breathing and allow the patient's lungs to heal. This involves the use of a breathing machine (mechanical ventilator) and supplemental oxygen.

It's also very important to treat the underlying cause of the ARDS. For example, if there is a bacterial infection such as in the case of R.F, antibiotics will be prescribed.

Preterm Labour

Preterm labour is defined by WHO as Onset of labour prior to the completion of 37 weeks of gestation, in a pregnancy beyond 20 wks of gestation.

The period of viability varies in different countries from 20 to 28 wks.

RISK FACTORS

Previous history of induced or spontaneous abortion or preterm delivery. Multiple gestations Smoking habits Low socio economic and nutritional status. Maternal stress Infection

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INFECTION

Infection (is implicated as the etiological factor in 40-50% of cases of preterm labour at early gestations (<30 weeks).) Infection induces intraamniotic inflammatory response involving the activation of a no. of cytokines and chemokines.

INTRAPARTUM MANAGEMENT

Monitoring: Fetal hypoxia and acidosis may increase the risk of intraventricular hemorrhage. The preterm fetus should be monitored closely for signs of hypoxia during labour, preferably by continuous electronic fetal monitoring.

Antibiotic prophylaxis Delivery: Delivery must be conducted in the presence of expert neonatologist capable of dealing with complications of prematurity. Caesarian section: only for obstetric indications.

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NEWBORN FACTS

FOURTH DAY Pre-Term Infant ( 28 weeks) A neonate born before the 37 weeks gestation. High Risk for complications because the systems are immature.

LBW less than 2500grams Minimal crease in the soles and palms Absence of sucking, gag and cough reflex Weak grasp reflex Square window sign Scarfs sign Admission in NICU Maintain Airway. If neonates respiratory effort is poor, an ET Tube maybe inserted and mech.

ASSESSMENT

MANAGEMENT

Ventilation can be started Monitor Vital Signs Maintain Heat and O2 Concentration May administer: Colfoscent Palmitate or Beractant

2-3 APGAR Score

INTERPRETATION 0 3 POOR 4 7 FAIR 7 10 GOOD Infant requires resuscitation Gently stimulate infants back by rubbing; Administer O2 to Infant No intervention is required except to support infants spontaneous Effort

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II.

PATIENTs PREFERENCE Is the patient competent? Does she understand the need for medical care, options that are available and probable result of such option? Have all the Tx alternatives and their possible consequences been discussed with the patient?

INFORMED CONSENT Provides the patient a fully informed and complete control over his health care, which includes what is done to his mind and his body. Patient has a right to CLEAR explanation, in LAY persons Term: a) All proposed procedures, whether Dx or Therapeutic including the identity of the person who will perform the procedure b) Possibilities of any risks involved as well as mortality c) Problems related to recuperation

REQUISITES of Informed Consent: a) Specific as to the proposed Intervention: Applicable only on the specific intervention for which the pt. Agreed and does not include any Tx that may yield the same effect b) Voluntary: Consent was not coerced or forced. As a Pt. Advocate, Nurses must inform the patient that she is making a decision and not merely signing a hospital form c) Informed: The pt. has the capacity to make the consent (sound mind and Legal age)

PRESUMED or IMPLIED CONSENT The Patients consent is presumed and need not to be obtained during emergency cases when the patients are unconscious or incompetent and the surrogate decision maker is unavailable.

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This is based on the principle of BENEFICENCE when the health care providers are OBLIGED to act on the patients behalf when the life of the later is at stake.

III.

LEGAL, ADMINISTRATIVE AND EXTERNAL FACTORS Are there laws that apply to this situation? Are there potential liability that might be present with respect to the hospital and to the providers?

House Bill no. 261 / Senate Bill No. 812

AN ACT DECLARING THE RIGHTS AND OBLIGATIONS OF PATIENTS AND ESTABLISHING A GRIEVANCE MECHANISM FOR VIOLATIONS THEREOF AND FOR OTHER PURPOSES

Section 1. Short Title. -This Act shall he known as the Magna Carta of Patients Rights and Obligations.

Title III; Section 4; Subparagraph 2a states that: in emergency cases, when the patient is at imminent risk of physical injury, decline or death if treatment is withheld or postponed. In such cases, the physician can perform any diagnostic or treatment procedure as good practice of medicine dictates without such consent

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Furthermore; Title III; Section 4; Subparagraph 2 states that: Informed consent shall be obtained from a patient concerned if he is of legal age and of sound mind. In case the patient is incapable of giving consent and third party consent is required, the following persons, in the order of priority stated hereunder, may give consent:

i. ii. iii. iv. v.

spouse; son or daughter of legal age; either parent; brother or sister of legal age, or guardian

If a patient is a minor, consent shall be obtained from his parents or legal guardian. If next of kin, parents or legal guardians refuse to give consent to a medical or surgical procedure necessary to save the life or limb of a minor or a patient incapable of giving consent, courts, upon the petition of the physician or any person interested in the welfare of the patient, in a summary proceeding, may issue an order giving consent.

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PART II: Identify the values in CONFLICT

This is a case of conflict between patients AUTONOMY (informed Consent) and BENEFICENCE. This is also a Conflict between patients RIGHTS (right to Informed Consent and Right to LIFE) and some major Bioethical Principles (Non-Malificence, Paternalism, Double Effect and Solidarity)

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AUTONOMY VS. BENEFICENCE

I.

Autonomy: autos (Self) and nomos (governance) A form of personal liberty, where the individual is free to choose and implement ones own decision, free from deceit, constraint or coercion. The concept of autonomy means that individuals are to be permitted personal liberty to determine their own actions. Characteristics: Free action Authenticity Effective Deliberation Moral Reflection

Four Basic Elements: Autonomous person: a) Is RESPECTED b) Must be able to DETERMINE personal goals c) Has the capacity to DECIDE on a plan of action d) Has the FREEDOM to act upon choices

Liberty Limiting PRINCIPLES: a) Harm principle b) Principle of Paternalism c) Offense principle d) Principle of Legal Moralism e) Social welfare principle

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II.

Beneficence Means to do good, to provide a benefit, and contribute to the welfare of others. The goal of the health care provider should be that would benefit the patient and take positive step to remove or prevent harm to the patient. Three MAJOR components: a) We ought to do or promote good b) We ought to prevent evil c) Remove evil

PATIENTS RIGHTS VS NON-MALIFICENCE, PATERNALISM, DOUBLE EFFECT AND SOLIDARITY

I.

NON MALEFICENCE The principle is based on the persons rigorous effort to avoid injuring another individual. Do no harm and protect from harm those who cannot protect themselves such as: children, mentally incapacitated and unconscious patients. This principle affirms the need for PROFESSIONAL COMPETENCE Non maleficence is related to following HUMAN RIGHTS: a) Right not to be KILLED b) Right not to have body injury or pain inflicted to oneself c) Right not to have ones confidence revealed to others

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NOTE: The main difference of non-maleficence and beneficence is that in non-maleficence, one must accept substantial risk to ones safety in order not to cause harm to others, whereas acceptance of EVEN MODERATE RISK is not generally required to benefit others in beneficence

The PRINCIPLE of indirect or DOUBLE EFFECT justifies some actions as non violations of the principle of Non-Maleficence.

II.

DOUBLE EFFECT / TWOFOLD EFFECT

Applied when the human act has both good and bad effect, To be judged as morally good, an action should meet the following criteria: a) The action must be morally good and must not be evil in itself. Or the action must be neutral. b) The good effect must be willed and the bad effect merely allowed. c) The good effect must not come from an evil action but must come from the initial action itself directly. d) The good effect must have greater effect than the bad effect. There should be a proportionately grave reason to justify the effect.

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III.

PATERNALISM The act of being fatherly to someone, as if the latter were ones own offspring. With regard to RFs Safety, paternalism may either be restricted or extended. In the medical context; PERSONAL PATERNALISM is one in which an individual decides on the basis of ones best knowledge of what is good for another person.

STANDARD OF BEST INTEREST Pertains to health care providers making decisions about a clients health care when they are unable to make informed decisions about their own care. This is base on the principle of PATERNALISM and AUTONOMY

IV.

SOLIDARITY

Means to be one with others. In the provision of healthcare it is most important for the provider to be in solidarity with the patient when seeking always the latter best interest.

In our country, this is the most IMPORTANT PRINCIPLE while dealing with the poor, the uneducated, the disadvantaged and the marginalized.

They are the least provided with adequate healthcare, they are the ones most in need of the concerned healthcare provider.

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PART III: Alternative Course of ACTION

The HEAD of the MEDICAL TEAM should have informed the Medico-Legal officer of the hospital in order for the officer to file for a COURT ORDER GIVING CONSENT to the physician to do the Caesarean Section prior to the third day of RFs hospitalization; in that way the surgeon will be free to any criminal and civil liabilities on the patient.

But since getting an ORDER might take long due to the process and submission of exhibits, the

ATTENDING PHYSICIAN can still perform any treatment by the virtue of PATERNALISM and under the House Bill no. 261 / Senate Bill No. 812, provided that the action that will be done will be for the best interest of the PATIENT.

Furthermore, if the Attending Physician informed the Medico-Legal officer, there will be exhibits and proper process and right person to defend the medical team in case the relatives of the patient will file a civil or criminal case against the hospital and the medical staffs.

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PART IV: IMPLEMENTATION and Follow Up

After getting a COURT ORDER GIVING CONSENT, The attending physician can call for a Junta Medica or Medical Team Meeting in order for them to discuss the perceived patients condition and standard course of action as well as plans of actions to save the life of the patients.

In that way, the entire team member will be informed and will have the same GOAL and that is to save the LIFE of both MOTHER AND CHILD!

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