Case study

Please read scenario and the post that we will be responding to below and finally my post which is on the last page of this word document. Finding similarities and agreeing on new information in the (first post) ..

Prelude:
Rita is a registered nurse with advanced expertise in psychiatric ward, and she works as a
member of a multidisciplinary team looking after Treatment Resistant Depression (TRD)
patients. Rita oversees patients discharge from the hospital. Prof S, the leader of her team,
heavily relies on her reports before making discharge decisions. Mr R, one of her patients,
died by suicide when he jumped from the 8th floor of an hotel adjacent to the hospital, after
having been discharged.Mr R’s family raised several concerns about his treatment to the Coroners Court. These

included:
• Appropriateness of the qualifications of the treating nursing team and their
assessments of Mr R and role in the decision to discharge Mr R from Hospital;
• A lack of an appropriate consent process for the implantation of a Deep Brain
Stimulator1 technology (DBS) and particularly, a failure to advise Mr R that suicide
and reversible changes in mood/personality were risks associated with DBS surgery;
• Lack of communication by the clinicians with Mr R’s family;
• Post-operative DBS complications;
• Management of his physical concerns in Hospital;
• The management of his mental health;
• The death could have been avoided had his medical advice and treatment been
different.

Case:

Mr R, a twenty-seven-year-old patient, received the diagnostic of depression when aged
fifteen. When Rita first met Mr R, he self-reported more than 30 ineffective and/or poorly
tolerated medication trials and an ineffective course of electroconvulsive therapy which
have lead him to seek last recourse treatment. During their first meeting, Rita suggested to
Mr R to consider the possibility of enrolling in a new experimental DBS trial for TDR, where
she sits as co-researcher with multiple colleagues, under the leadership Prof S.
One week following Rita first meeting with Mr R, he consulted Prof S to undergo an
experimental usage of DBS targeting TRD. During the consultation, Mr R was accompanied
by his brother. Prof S advised Mr R that DBS was an experimental treatment potentially
targeting TDR symptoms. Prof S says that he advised Mr R that the potential risks of the DBS
surgery include death, permanent disabling stroke, infection of the brain or the IPG, seizure
disorder, and reversible changes in mood/personality. Mr R was also told that DBS therapy
1 DBS surgery involves implanting a thin, insulated lead into the brain (most often in the subthalamic nucleus or the globus pallidus, which are part of the basal ganglia system.) The lead is then connected via an insulated
extension to a device called an implanted pulse generator (‘IPG’). This is similar to a pacemaker. The extension runs below the skin from the head down the side of the neck behind the ear to the IPG which is usually implanted under the skin in the chest. When switched on, the IPG produces electrical impulses that are sent to the brain. The impulses can be adjusted using a patient programmer.However, retrospectively, Mr R’s brother disputes that Mr R was told about reversible changes in mood and personality.The informed consent signed by Mr R stipulated: “The doctor may [...] withdraw you fromtrial at any time if he/she considers this to be in your best interest.” The surgery wasperformed without incident one month later, it was uneventful, and Mr R’s surgical woundshealed well. Mr R had inserted bilateral stimulators within the subcallosal cingulate cortex.Thursday, one day after the surgery, Mr R indicated to Rita that he experienced someheadache, and commented “I feel like I am who I am now, but it's not the me that went intothe surgery.” These feelings of self-estrangement were experienced with suicidal thoughtsand that for the past day Mr R had thought about nothing else but ending things. Hereported wanting to make sure it was permanent and that this was the only reason he hadnot acted on his thoughts. Accordingly, Rita indicated in her records a numberof sources for the distress, including:

• Mr R was experiencing severe pain as a feature of his brain surgery. This was not well
controlled as his DBS device which had only recently been reactivated and was not
yet functioning at optimal levels.
Rita’s impression was that Mr R presented with a mixture of dysphoric/depressive and
hypomanic symptoms. She suspected the DBS stimulation may be contributing to
hypomania.
The following morning, Mr R was seen by Prof S who increased his DBS voltages. That
afternoon, Rita noted Mr R was “very upset and agitated.” He was upset that his voltages
weren’t “tweaked earlier”. Rita explained that he might not necessarily be adjusted every
day. Mr R admitted that his TDR’s symptoms were not too bad yet but was anxious for
further adjustment. He was unsure if the DBS or the stress was causing his mood problems.
The weekend things were stable. However, the brother of Mr R left a voice message to Rita
at work, informing her “I don’t recognise my brother since the surgery. He
uncharacteristically seems so impulsive and appears always changing his mind”.
When assessing Mr R on Monday his primary complaint to Rita was a "twisting" pain in his
head. Mr R associated the pain with increased stimulation and the morning dose of
medications. He told Rita he had a return of agitated mood over the weekend, experience of
self-estrangement and suicidal thoughts. Rita wrote in her report that the suicidal thoughts
were a result of the pain Mr R was experiencing.
Given the severe adverse affects, removal of the device was prescribed by the treating team
based on the belief that no therapeutic benefit would accrue from further treatment.
Despite absence of any benefit from the trial and the severity of suicidality, Mr R formally
refused, opposed, and resisted the device removal.
Tuesday, Rita noted that Mr R had a better day but his pain remained troublesome. He had
no agitation or suicidal thoughts. Mr R remained fixated on his postoperative course /
device settings. Rita noted improvement in mood although there were some remaining
issues:
• sensitivity to stimulation (agitation, mood changes);
• uncertainty regarding his discharge location (currently expressing clear preference to
live independently in Sydney rather than with his brother).
Eight days after surgery, Rita reviewed Mr R and noted his mood was improved and he had
no suicidal thoughts, which according to her demonstrated stability from a mood
perspective. He described one brief episode of mood deterioration two days prior, however
this was not associated with suicidal thoughts. Rita developed a plan for discharge with Mr
R, and discussed this with his brother who insisted it was premature to discharge his brother
from the Hospital, despite Mr R stating he was happy with his mood. Rita’s report was sent
to Prof S. Mr R was discharged that very same day.Two days later, Mr R’s brother dropped Mr R off at the front of the Hospital and saw him go
inside the administration area. Mr R did not go to the Hospital but instead checked into the
Summit Apartments, an adjacent hotel to the Hospital. This occurred at approximately
10:20am. Around 11h30, Mr R’s brother received a text message from Mr R. This text
message suggests that:
• Mr R’s main concern was his pain;
• Mr R considered he was put back on TRD’s medication without appropriate
supervision and proper pain control;
• The treating team did not believe him or properly listen to him;
• If the possibility of such pain had been explained to him, he may not have had the
operation; and
• His death could have been prevented had his medical advice and treatment been
different.
Just after 11.30am, an eyewitness reported seeing Mr R jumped from the balcony of his
room (8th floor).

 Please find similarities between the above post and mine (below) and write a response on what was interesting or what i may hace missed also agree on what the person is saying. Find similarities between both posts and agree . Respond to above post not the one below as that’s my post!The central ethical question posed by this case is related to the premature discharge of Mr R post deep brain stimulation surgery, resulting in his death.There were many ethical dilemmas leading up to the discharge and subsequent death of Mr R. To begin, Professor S was not completely transparent during his consultation with Mr R. Professor S addressed many side effects associated with the insertion of the deep brain stimulation device but failed to mention the chance of severe pain and suicidal thoughts (Burkhard et al 2004). This could be considered professional negligence under Tort Law (LI) as the patient was not fully informed to provide informed consent to the procedure, and as stated in his last message he may not have consented to the treatment had he known these risks. Improper pain management is evident through Rita’s reports and patient’s statements.Doctors came to the decision that the DBS device was not of any benefit to the patient, and as a result it was prescribed for removal. Although Mr R signed consent documents prior to the initial surgery that clearly stated that doctors would seek removal of the device if considered in the patient’s best interest, Mr R refused and the device was not removed. A patient’s autonomy in decision-making for their own health care is one of the principles of bio-ethics (Beauchamp & Childress 2018). This scenario is problematic as it is a tussle between the ethical side of health care in regards to a patient’s autonomy, consent and rights to decision making, and the other side being the obligation of beneficence from the doctors. In this case, the doctors were aware that the stimulation from the DBS was causing feelings of suicidality which had the real potential to cause harm to Mr R. Practicing the principle of beneficence in this case would mean removal of the device, therefore removing harm and acting in the patient’s best interest by ceasing the suicidal thoughts related to the DBS device (MDHPN 2012). It can be argued that as a result of the device, Mr R’s reported mood changes, impulsivity of decision making and change in personality could have inhibited his ability to make an autonomous, informed decision regarding the removal of the DBS device. In this case, Mr R’s decision to keep the DBS device was enabling potential serious harm to himself, as evident in Rita’s reports of severe suicidal thoughts. If the doctors were unable to advocate and collaborate with Mr R in negotiations regarding the removal of the device, other avenues should have been sought to ensure the minimalisation of any potential harm caused by side effects of this device.It is understood that Mr R had multiple relapses of mood and suicidality during his hospital admission after the DBS surgery. During his last few days in hospital, Mr R informed Rita of these feelings along with problems with his pain, which she recorded in her report. Rita was under the assumption that Mr R’s suicidal thoughts were caused by his pain levels, not considering it to be a side effect of the DBS device. Although considered ‘stable’ by Rita, Mr R’s moods had a common theme of coming and going, enough for cause for concern upon discharge. As part of Tort Law, clinicians have a duty of care to patients, and this can be questioned in the discharge of Mr R.

While Mr R could not be forced to take medical advice and have the DBS device removed, he was discharged prematurely with reoccurring mood instability and without proper pain management.

Beauchamp, T. Childress, J. 2018 Principles of biomedical ethics, 4th edition, Oxford University Press, New York

Medical Dictionary for the Health Professions and Nursing (MDHPN) 2012, Beneficence, viewed May 20 2022, <https://medical-dictionary.thefreedictionary.com/beneficence>

Burkhard, P. Vingerhoets, J. Berney, A. Bogousslavsky, J. Villemure, J. Ghika, J. 2004, Suicide after successful deep brain stimulation for movement disorders, Neurology, pp. 2170–2172

Law Insider (LI), Professional Negligence, <https://www.lawinsider.com/dictionary/professional-negligence>

Please find similarities between the above post and mine (below) and write a response on what was interesting or what i may hace missed also agree on what the person is saying. Find similarities between both posts and agree . Respond to above post not the one below as that’s my post!In this case study of Mr. R, who is admitted for Treatment-Resistant Depression (TDR), several ethical issues including disregard for patient autonomy, negligence on part of health professionals involved in the care of Mr. R, and going against several healthcare codes of ethics, are observed.Rita and Professor S were justified from a utilitarian perspective to recommend Mr. R through the DBS trial operation for TDR since they genuinely wanted to help him in the situation he was in. Mr. R's autonomy was violated when Rita, the registered nurse, Professor S and team had advised the trial procedure without warning him of the underlying anguish and repercussions of the treatment, which could have prevented the suicide tragedy.  According to Skar (2010), autonomy is contingent on the patient receiving the necessary information and knowledge to make their own decisions.

The deontological viewpoint holds that treating a patient is an aim in itself. This also shows that patients can make reasoned judgments using their autonomy and free will. Mr. R's decision to have the procedure was influenced by Rita's assumption and giving of inconclusive information. Rita failed to assess the risks, benefits, and repercussions of her conduct and suppressed critical information that would have influenced Mr. R's decision (Girdler, Tarpada & Morris 2018). If Rita had informed Mr R on the potential side effects of the treatment this could have been a different outcome for him, as he and his family would have been informed and make a decision accordingly.In this case, Rita went against the code of ethics put in place by the Australian code of ethics when she did not give enough information to Mr. R or Mr. R’s family in relation to the treatment and discharge planning (New Code of Ethics in Effect for Nurses and Midwives, 2018). The ICN code of ethics 1.3 states that “individuals and families receive, accurate and sufficient information, on which to base care and treatments on”. Mabire et al. (2017) mentions that the Transitional care model incorporates “advance practice nurse conducting the hospital assessment for planning, involving the multidisciplinary team in discharge, completing a pre-discharge assessment and post-discharge follow up, and involving family and caregivers”. Unfortunately, Mr. R’s family was not involved in discharge planning, even though they had expressed concerns. Prior to discharge, a mental health assessment was not completed even when Mr. R presented with psychiatric symptoms. Therefore, collaboratively agreeing on a discharge plan between the family and healthcare team, and a mental assessment could have had a better outcome for Mr. R.

The decision to deny patient autonomy is not ethically justified from a bioethical stance. On admission, a mental status examination would be required to ascertain whether or not mental capacity was intact. Mr. R did, however, give Prof S permission to withdraw him from the DBS trial if there were any difficulties or concerns .I believe Rita and Professor S had the best interest at heart for Mr R but made poor judgement in the process.

References

Government of Australia 2014. Mental Health Act 2014.Available at: <NSW Mental Health Act – Mental Health Coordinating Council (mhcc.org.au) Mental Health Act 2014> [accessed 24 May 2022]

Girdler, S, Girdler, J, Tarpada, S, & Morris, M. 2018. Nonmaleficence in medical training: Balancing patient care and efficient education. Indian Journal of Medical Ethics, 01-05.

Chukwuneke, FN 2015, ‘Medical incidents in developing countries: A few case studies from Nigeria’, Nigerian Journal of Clinical practice, vol. 18, pp. S20-S24.

International Council of Nurses 2021, The ICN Code of Ethics for Nurses, International Council of Nurses, Geneva, viewed 31 January 2022, <https://www.icn.ch/system/files/2021-10/ICN_Code-of-Ethics_EN_Web_0.pdf>.

Mabire, C, Dwyer, A, Garnier, A & Pellet, J 2017, ‘Meta-analysis of the effectiveness of nursing discharge planning interventions for older inpatients discharged home’, Journal of Advanced Nursing, vol. 74, no. 4, pp. 788-799.

New codes of ethics in effect for nurses and midwives. 2018. Available at:  <https://www.nursingmidwiferyboard.gov.au/news/2018-03-01-new-codes-of-ethics-in-effect.aspx?> [accessed 24 May 2022]

Nursing and Midwifery Board of Australia. 2008. Code of Ethics for Nurses in Australia. Available at: <Nursing and Midwifery Board of Australia - Home (nursingmidwiferyboard.gov.au)> [accessed 25 May 2022]

Skar, R 2010, ‘The meaning of autonomy in nursing practice’, Journal of Clinical Nursing, vol. 19, no. 15-16, pp. 2226-2234.

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