Ethical and Legal Predicaments in Home Health Care for Terminally Ill Patients

The utilization of health insurance policies to establish the extent of coverage for terminally ill patients in their residence has the potential to generate ethical and legal predicaments for advanced practice nurses. These policies frequently impose restrictions on reimbursable services, which can clash with the nurse's obligation to offer care for the terminally ill patient (Fry, Veatch & Taylor, 2011). In this particular case study, a male aged 59 is enduring terminal lung cancer that has metastasized to his brain. His family expresses concern regarding their capacity to handle his deteriorating condition.

Currently, the patient is receiving hospice care at home. However, the insurance company is not providing coverage for both hospice and respite services that could help the family. Nurses working in the homes of dying patients often face ethical dilemmas and require support during this challenging time (Karlsson et al., 2010). The community nurse plays a crucial role as a professional who can answer questions and discuss care and treatment options for the patient when personal assistance is needed (Erlen, 2005).

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During a conversation with the patient's family (son and daughter), it was discovered that the patient is presently dealing with incontinence issues for both stool and urine. In order to avoid the patient being exposed to his waste at night, they have begun limiting his food and drink intake in the afternoon and evening. Consequently, this has caused irritation in the patient's perineum, increasing the risk of further skin damage. Furthermore, the patient's strength has been declining, leading to multiple recent falls.

The family is facing challenges in fulfilling their father's requirements for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Additionally, they have concerns about job stability as they devote time to his care. The son has daytime employment while the sister works in the afternoon, resulting in their father being left unattended for approximately two hours every day.

This could be a case of negligence, where there is a failure to exercise a standard of care and it can be alleged when a person fails to act when a duty exists. There are five elements required to establish a case of negligence: the existence of a legal duty to exercise reasonable care; a failure to exercise reasonable care; cause in fact of physical harm by the negligent conduct; physical harm in the form of actual damages; and proximate cause, a showing that the harm is within the scope of liability (Cornell University Law School, n. d).

Negligence is a form of wrongdoing that falls within the realm of tort law and can also be considered a criminal offense. According to Collins English Dictionary (2009), negligence or malpractice refers to any immoral, unethical misconduct, or neglect displayed by a healthcare professional. Currently, the patient is receiving inadequate pain and agitation medication management at home from Hospice. Although it is impossible to completely eliminate the risk of lawsuits, this specific situation could have been prevented if the family had received proper education regarding their father's care options prior to his discharge.

The family may have decided to make alternative arrangements for their father as his end of life approaches due to a detailed explanation of the care he may require. Hospice workers will have a responsibility to inform the family about the potential negligence and follow their policies and procedures in reporting it, which will serve as their strongest defense. Additionally, further discourse has raised concerns about the violation of Human Rights under the Affordable Care Act, as the patient's insurance refuses to cover the necessary expenses for home care.

Gable (2011) states that the Affordable Care Act was implemented to address the issues faced by individuals with limited access to health insurance or healthcare. The law prohibits insurance companies from imposing lifetime dollar limits on health benefits, thus ensuring that those with chronic illnesses do not have to concern themselves with depleting their lifetime limits and being unable to receive necessary treatment. Moreover, the legislation restricts the usage of annual caps and aims to completely eliminate them by 2014 (U.S. Department of Health and Human Services, n.d.).

The violation of the ethical principle of respect for person and the concept of deontology occurs in this situation, where certain behaviors are considered our duty regardless of benefit. Deontology is a moral theory that guides our choices and shapes our character. According to the Stanford Encyclopedia of Philosophy (2012), this theory explains that certain actions should be undertaken irrespective of their consequences. If the family and nurses at the hospice agency had provided proper education to the patient before discharge, this situation could have been avoided.

Respect for persons includes autonomy, but some individuals may not have the ability to act autonomously. According to the Belmont Report, respect for persons means that vulnerable individuals who cannot act autonomously should be given special protections. This aligns with the principle of justice, which calls for special protections for vulnerable individuals in the distribution of research benefits and burdens (Yale Human Subject Research Resource & Education Program, 2006).

Legal reasoning can be observed in two ways: through legislative drafting and the application of rules to cases. It requires an acceptance of and adherence to the law, which inevitably leads to a preference for maintaining existing rules (Peterson, n. d.). However, this does not imply that the law is always fair and practical. Judges often refrain from applying rules that would yield unfavorable outcomes. Peterson (n. d.) argues that legal reasoning includes numerous attempts to modify the legal system and reinstate the process of creating laws.

Coherence in legal reasoning is the concept that the law as a whole should make sense, and it is a type of rationality that supports this idea (Bertea, 2009). The logical aspect of legal reasoning may be stronger than the coherence aspect. The coherence of a group of legal norms exists when there is a realization of a shared value or principle (Dickson, 2010). Legal reasoning involves the use of logic to interpret constitutions, statutes, and regulations, as well as to balance fundamental principles and adopt or modify legal rules. This reasoning is applied to cases and evidence evaluation prior to making decisions (Walker, 2007).

Case law refers to the legal principles found in judicial decisions that result from the application of various areas of law to specific cases. This body of law is constantly evolving and each case involves a set of facts and a judge's explanation of their decision. Legal analysis involves proving the validity or invalidity of each element of a rule, and it includes statements made by courts, judicial officers, or legal experts regarding the legality or illegality of an action, condition, or intent.

Ethical reasoning is centered on acknowledging the potential impact of our actions on others, as they possess the ability to either enhance or detrimentally affect their quality of life. By employing empathy, we are able to determine whether our actions serve to benefit or harm others. The objective of ethical reasoning is to differentiate between acts that promote the well-being of others and those that undermine or damage it.

Developing one's ethical reasoning abilities is crucial because there is in human nature a strong tendency toward egotism, prejudice, self-justification, and self-deception which has sociocentric influences (Elder & Paul, 2011). The problem of pseudo-ethics is that one cannot develop as ethical persons if we cannot face the fact that everyone is prone to egotism and prejudice. Flaws in human thinking are the cause of much human suffering and only developing fair-mindedness, honesty, integrity, self-knowledge, and deep concern for the welfare of others can provide foundations for sound ethical reasoning (Paul & Elder, 2009).

According to Paul and Elder (2009), ethical reasoning entails the act of doing what is morally correct while consciously avoiding selfish desires. To lead an ethical life, one must strive to overcome one's inherent tendency towards egocentrism. The components of ethical reasoning comprise of awareness, independent problem solving, supported problem solving, and decision and outcome evaluation. On the other hand, the effectiveness of ethical reasoning demands sensitivity, problem-solving abilities, as well as the motivation and determination to follow through with decisions (Kenny et al., 2007). The rationality behind ethical reasoning is based on moral theory derived from meta-ethics and evolutionary ethics.

The core issue is that evolutionary ethics, a scientifically grounded theory, and meta-ethics, a philosophy-based and logic-centered approach to human behavior, cannot adequately capture the intricate nature of human experience. Consequently, terms like "good" and "moral" have emerged from countless societal concerns spanning centuries. These terms are intertwined with human conduct (Bromberg, 2011). The merits and drawbacks of ethical reasoning revolve around its presumption that individuals will consistently make choices that do not cause harm.

An ethical society will not permit unethical actions, but it does not condemn actions based on spiritual or social customs or target any particular group for their beliefs. Ethical reasoning aims to identify actions that benefit everyone, but deciding the appropriate course of action is not always straightforward. Ethical reasoning is a complex and subjective process, as not all situations are equal, making it difficult to determine the truly ethical path (Mayers, n. d.). In summary, certain cultures still engage in rituals that are considered illegal in other countries.

Ethical and legal perspectives vary between cultures, resulting in the establishment of laws that define acceptable conduct. Ethical reasoning is influenced by individual moral beliefs, while legal reasoning is derived from cultural norms. Frequently, actions deemed illegal also carry moral consequences. Nevertheless, it is important to acknowledge that an illicit act committed by a healthcare professional is always unethical, whereas an unethical act may not be unlawful.

Ethics encompasses standards of behavior and the capacity to discern between right and wrong, surpassing mere legality in a given circumstance. The establishment of personal moral principles is influenced by family, culture, and society, which form the foundation for ethical deliberation (Judson & Harrison, 2012). I argue that an effective ethical decision model should incorporate both individual employees and their supervisors. Collaborative decision-making among healthcare professionals is crucial to adequately address the needs of employees.

I believe that an ethical reasoning tool should include both the employee and the supervisor in order to effectively address the problem at hand. Utilizing an integrative model can help build confidence and provide justification for making ethical decisions. The process of using an integrated ethical decision-making model incorporates individual preferences and values. It is essential to integrate principles of patient-centeredness and shared-decision making into this model (Sestini, 2010). By doing so, an integrated model of ethical reasoning emphasizes the connection between ethics and decision making, with ethics serving as a helpful instrument in enhancing the reasoning process.

The model consists of three main elements: the ethical component, the decision-making component, and the contextual component (Grundstein-Amado, 1991). Park (2012) reviewed existing structured models for ethical reasoning and decision-making and created a unified model with six steps: 1. Identifying an ethical problem, 2. Collecting additional information for problem identification and solution development, 3. Generating alternatives for analysis and comparison, 4. Selecting the best alternatives and providing justification, 5.

The text discusses the importance of developing various practical methods to implement ethical decisions and actions. It also emphasizes the significance of evaluating the effects and creating strategies to prevent similar incidents. The author suggests that the best ethical reasoning can be achieved by involving all healthcare professionals, although it does not guarantee morally correct decisions. However, it is likely to enhance the process and outcomes of clinical ethical decisions (Park, 2012). To apply this model, let's consider the case of a 59-year-old male with a history of terminal lung cancer that has spread to his brain. We will apply the chosen model by following these steps: 1.

The ethical problem identified is that the decision to return to work by each family member will result in the father being left alone for nearly two hours daily. Additional information collected includes the family's concerns, such as increased difficulty in managing the father's condition. It is mentioned that the patient is currently receiving hospice care, but the insurance company does not cover both hospice and respite services, which could assist the family. The patient has become incontinent of both stool and urine, leading to restrictions on food and fluid intake in the afternoon and evening. Additionally, the patient has developed an excoriated perineum.

The patient's condition has deteriorated, resulting in increased weakness and multiple falls. They now require complete assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs), which is overwhelming for the family. Both the son and daughter are at risk of losing their jobs due to their absence from work while caring for their father. It is crucial to assess and compare various options, taking into account the family's input. There is a potential that another family member could be available for a two-hour period. Furthermore, there is an alternative choice of opting out from hospice care and selecting home health care instead.

Respite services are used for providing temporary relief. The selection of the best alternatives and justification would require the involvement of the family to determine what meets their needs and their father's needs. Educating the family about leaving their father alone for two hours at a time and withholding fluids and food can provide justification. Deontology, which means that certain behaviors are our duty regardless of benefits, can guide the development of diverse and practical ways to implement ethical decisions and actions (Fry, Veatch & Taylor, 2011).

The principle of justice emphasizes the need for special protections for the vulnerable in research distribution (Yale Human Subject Research Resource & Education Program, 2006). As a case manager, I am responsible for working with families on awareness, independent problem solving, supported problem solving, and decision and outcome evaluation. This includes evaluating the effects of interventions and developing strategies to prevent similar occurrences post-intervention to determine effectiveness.

Evaluating the effects of interventions enables healthcare professionals to modify future encounters in similar situations. Further research suggests that federal hospice investigations in the United States have significantly increased in recent years, according to the U.S. Department of Health & Human Services. A Medicare oversight report conducted in 2009 revealed that nearly one-third of hospice patients were not receiving planned services or promised visits from providers (Bloomberg News, 2011). Consequently, the first recommendation to the family is based on this finding.

A potential recommendation is for them to consult the visiting hospice to assess and evaluate the comprehensive care plan together. The case manager should request a duplicate of the care plan to discuss it with the family. By examining the care plan, they can assess whether the services being provided align with what was promised. Another suggestion in this scenario is for the case manager to partake in the process. The case manager should encourage the family to engage in a conversation with the patient, taking into account their preferences and specific physical, emotional, and psychosocial requirements.

It is recommended that the case manager assist the family in assessing the level of support that can be provided by other family members and friends. It may be necessary for them to consult with the healthcare team to determine the best course of action. Research has shown that caring for their father has hindered their ability to take care of themselves, drained their energy and enthusiasm, and affected their relationships with other family and friends (Joad et. al, 2011).

References: Bertea, S. (2009). The argument from coherence. Available at http://ivr-enc. info/index. php? title=The_Argument_from_Coherence Bloomberg News. (2011).

Hospice care is expanding, but concerns about patient negligence are also increasing. (Bromberg, 2011) Cybernetic ethics describes the evolution of ethics. (Bromberg, 2011) Negligence is defined as malpractice. (Collins English Dictionary, 2009) Legal analysis and reasoning from precedent are important in understanding negligence. (Connelly) Cornell University Law School provides information on negligence. (Cornell University Law School)

Retrieved from http://www. law. cornell. edu/wex/negligence Dickson, J. (2010). Interpretation and coherence in legal reasoning. In The Stanford Encyclopedia of Philosophy online. Retrieved from http://plato. stanford. edu/archives/spr2010/entries/legal-reas-interpret/. Elder, L. & Paul, R. (2011). Ethical reasoning essential to education. Retrieved from www. criticalthinking.org Erlen, J. (2005). When patients and families disagree. Orthopedic Nursing, 24(4), 279–282. Fry, S., Veatch, R., & Taylor, C. (2011). Case studies in nursing ethics (4th ed.). Sudbury, MA: Jones & Barlett Learning. Gable, L.

(2011). The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights. Journal of Law, Medicine & Ethics. 39(3), 340-354. doi:10. 1111/j. 1748-720X. 2011. 00604 Grant, P. D., & Ballard, D. C. (2011). Law for nurse leaders: A comprehensive reference. New York, NY: Springer Publishing Company.

Grundstein-Amado, R. (1991). An integrative model of clinical-ethical decision making. Theoretical Medicine, 12(2), 157-170. Retrieved from http://link. springer. com/article/10. 1007%2FBF00489796 Joad, K, Mayamol, T. C. & Chaturvedi, M. (2011). What does the informal caregiver