VHA Intensive Ethics Advisory Committee Training

 

 

 

 

Question 1 (30 points)
This is a theoretical case taken from VHA Intensive Ethics Advisory Committee Training, 1998, as presented by Arthur R. Derse MD, JD. An 87-year-old woman widowed for six years, who is otherwise healthy, was visiting another city and abruptly became ill. She was seen in the emergency department of the local VA and admitted to the on-call physician. The on-call physician (who has not previously seen her) made the diagnosis of bowel obstruction arid made arrangements for a surgeon to evaluate her. The surgeon recommended surgery and obtained her consent for surgery. The surgeon expects an uneventful recovery. She is told that she will be on a ventilator for a short time after surgery. The patient tells the surgeon that is OK as long as it is for a short time. She tells the surgeon that she does not want to be dependent upon machines. She was asked upon admission whether she had an advance directive. She replied that she has a living will and a power of attorney for health care which names her daughter (who does not live in the area) as her health care agent. The patient undergoes surgery, which is successful in treating the underlying problem and does not show any malignant causes, but in the recovery room she has a cardiopulmonary arrest and is resuscitated. She is transferred to the ICU in the care of the on-call physician. The physician attempts to wean her gradually from the ventilator, but this is unsuccessful. Three days later, she has regained consciousness but is still intubated. Though she cannot speak because of the ventilator, she is able to write and asks that the tube be removed. The attending physician tells her that she is dependent upon the ventilator and the patient needs to remain on the ventilator until she can breathe on her own. She writes that she understands that she may die, but she does not want to be on machines. Her only children — a daughter and son — – have arrived. She repeats her wish to them that she wants the tube removed. She writes to her daughter that “I don’t want to die, but we all have to die sometime, and I don’t want to have to live on a machine. I know that whatever the outcome, God will take care of me.” Her daughter tells the physician that her mother is adamant that she be off of machines and she respects her mother’s wishes, even if she cannot breathe on her own. She says this is consistent with her previously expressed wishes and her religious beliefs. Her son tells the physician that he disagrees with his sister — since his mother does not have a terminal condition, he can not see why she should not be forced to put up with the ventilator until she can be weaned from it. He feels that she is being shortsighted, and she will be thankful to have been kept on the ventilator when she is finally able to be weaned. Describe the criteria for giving “legal” consent. Were all elements met in this case? In other words, did the patient demonstrate decision-making capacity? Explain. (Minimum of 1 page including in-text citations and references in proper APA format

Question 2 (10 points)
Based on case study above: Is this patient requesting to be euthanized or for her physician to assist in her suicide (PAS)? In your answer describe how the two terms differ. (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

Question 3 (10 points)
A managed care group may want to market their organization as being “the best” or “a leader” in providing certain services/ treatment. How can this type or marketing effect quality of care and utilization of services, hence costs? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

Question 4 (10 points)
According to Darr, MCO enrollees can be described as either light/moderate users or heavy users. What are some of the strategies that management uses to turn “heavy” users into light/ moderate users? In your personal opinion, what positives or negatives may result? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

Question 5 (15 points)
Describe the constraints/challenges that physicians experience as being service providers affiliated with a Managed Care Organization. (Minimum 2 paragraphs including in-text citations and references in proper APA format)

Question 6 (5 points)
Give a very brief “real-life” example/instance where drugs/ medical treatment/services were microallocated. And give a “real-life” example of macroallocation. (Do not include the examples provided in the text.) (Minimum 1 paragraph including in-text citations and references in proper APA format)

question 7
Read the case of Karen Ann Quinlan (p. 248-249). Explain why this is a case involving medical futility. (Include in your an answer the definition of medical futility). Darr (2011, p. 218) writes, “[the] futility theory has quantitative and qualitative aspects.” What is meant by these terms? Present arguments for each as it relates to this case. (Minimum 2 paragraphs including in-text citations and references in proper APA format)

 

 

 

 

 

Sample Solution

The Strangely Troubled Life of Digby Mackworth Dolben

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Famous achievement arrived behind schedule in life to Robert Bridges—not excessively he much minded. At the point when the columnists at long last slid on his home in the late spring of 1913, he reacted first with lack of concern—and afterward not in the slightest degree, leaving their pleading thumps unanswered. One may presume he had figured out how to abhor the press from Tennyson, whose excellent presentation as artist and sage had troubled the Victorians of Bridges’ age with an understanding of the job whose aged enchantment they would never entirely overlook, anyway much they would come to despise the stunt—yet Bridges’ own hold was profoundly felt and actually gained.

He was conceived in 1844 into a well off group of the Kentish upper class, and in that capacity he had no need of ever living by his pen. He adored verse yet contemplated medication, accepting a doctor’s training would ground his scholarly endeavors in what a regular companion would later call “an information on men.” He proposed to resign at forty years old to an existence of composing, however he found after all that a little information on men goes far, and following a genuine ailment, he chose to pack in his primary care physician’s unit in front of calendar. Raised as he had been among a clan of rentiers, whose discretionary benefit was noble by time and the plausibility of heraldry, he had a specific glory of way, which his prosperity as a school rower had just strengthened. Genuinely forcing, he was in his later years compared to Olympian Zeus, with white richness of facial hair, and fingernails that had been solidified into claws by his reluctance to wash in water that was definitely not cold. In the event that he appeared to be imperious from a separation, he was well-meaning among his companions: his nobility stayed limited to the space of writing, where it was ironized by the practically all out lack of concern with which his work was freely gotten.

He had secretly printed his sonnets in little releases, grimly structured however luxuriously made, and expensive. His capricious distributing program was a piece of a progressively broad restoration of enthusiasm for the specialty customs of bookmaking that was then noticeable all around. Experts, people of good taste, and savants chased slows down and lofts for overlooked fortunes and dismissed magnum opuses; and little presses jumped up to create new volumes that could be retired with equity among those vellum ties in the private nightfall of any velvet-curtained investigation. Scaffolds’ own books were of this species, imprinted on carefully assembled paper and set in the out of date type that a companion had found at the Clarendon Press in Oxford under a time of residue. Their extremely constrained impressions would in general rat, they were even productive, yet the interest for them was not very good that any covetous distributers came calling. What’s more, he developed old right now: by a few, however never in style, even as the design swung from the overripeness of the 1890s to the tainted balance that denoted the century’s end.

A detail from a page of the 1890 version of Robert Bridges’ Growth of Love: the book was sold by the Bodley Head in London, a newish classicist bookshop whose confined premises turned into a Bohemian asylum, and whose proprietors were soon to dispatch the distributing program that would deliver the shameful Yellow Book. The Bodley Head touted The Growth of Love as being “choicely imprinted in Fell’s Old English sort on Whatman’s handcrafted paper, by Mr. Daniel, at his Private Press; constrained to 100 duplicates.”

Be that as it may, before long Bridges ended up in another position. A manager at the Oxford University Press plumped for his consideration in the “Oxford Poets” arrangement: the outcome, distributed in 1912, assembled just because into a reasonable volume the product of Bridges’ forlorn and solid craftsmanship; and in its first year, it sold a shocking 27,000 duplicates. On this growing influx of support, he would be named Poet Laureate. At 69 years old, Robert Bridges was well known.

On the off chance that he had felt that his eighth decade on Earth would manage the cost of him honorable rest, he had been mixed up. It brought just a war, and as the Imperial Poet, it tumbled to him to summon the dreams as youngsters went to butcher by the millions. At the point when the war was finished, he abandoned urban work to The Testament of Beauty, a book-length sonnet in which he spread out his way of thinking of life. It was anything but a Christian way of thinking. Despite the fact that he never joined the modest number of beset open skeptics, he had by the end totally disposed of the strict excitement of his childhood and found in its place a gentle kind of agnostic otherworldliness formed by the works of Plato and Lucretius. Yet, he had once been Christian, and he had once been enthusiastic—and regardless of whether the experience had neglected to outfit him with any enduring confidence, it had in any event given him long lasting companions.

As a kid, Bridges encountered the intensity of a strain of sentimental Christianity exceptional to his time. The heading of the Church of England was then intensely questioned from beneath by evangelicals who pushed for protestant gravity, and from above by a development that tried to accentuate the Anglican Communion’s offer in the medieval conventions of the Catholic Church. In Oxford during the 1830s, these high church Anglicans had pounded their religious philosophy into a fine gold leaf: they were amazed by the magnificence of their work however neglected to see that it was excessively delicate to endure the minister challenge it welcomed. Where fragile religious philosophy fizzled, intense style would have a preliminary. As doctrinal focuses retreated away from plain sight, the high church Anglicans started to enjoy a preference for display and custom shared by their Pre-Raphaelite peers. They longed for jeweled cups and samite robes, the sweet-smelling fog of incense, and now and again the furious hints of the scourge.

Extensions fell in with the high church set at school. As young men, they had no chance to test their extreme soul, zero chance to strike it against the hard surfaces of life, to watch the flashes and see whether its front line developed sharp or dull—however they were sincere in their dream. In later years, their ways separated. A few, similar to Bridges, lost their enthusiasm and woke up from the fantasy, while others submerged themselves all the more profoundly in it, floating consistently towards the Catholic church. Be that as it may, before this occurred, Bridges met two significant companions. They shared his affection for verse, an energy which would tolerate significantly after strict excitement stopped to offer any shared belief. For similarly as Bridges was forsaking his high church second thoughts, these two companions were arranging, autonomously of each other, to join the Church of Rome. The two of them kicked the bucket youthful, however decades separated; and in mature age, Bridges thought back on them, flush with his own startling achievement, recalling the artistic sustenance that these kinships had given him in his young desire and in his moderately aged lack of definition. As Europe sleepwalked towards the Great War, this old Victorian neo-agnostic assembled the old compositions of his two seriously Christian companions for production.

It was not just an activity in sentimentality—one of these companions was Gerard Hopkins, who had passed on as a bombed Jesuit cleric in 1889. Extensions’ 1918 version of the Poems of Gerard Manley Hopkins uncovered in time that Hopkins’ hindered life had been a chrysalid state from whose confined dividers an expansive winged writer would rise beyond all detectable inhibitions air. Scaffolds’ tribute to the next writerly companion of his childhood, distributed seven years sooner, could barely be anything besides immaterial in correlation. In any case, The Poems of Digby Mackworth Dolben has its very own inquisitive enthusiasm. The sonnets themselves are uninterested, best case scenario the juvenilia of a craftsman Portrayal of a Desert

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It is hard to frame a right thought of a desert without having seen one. It is an immense plain of sands and stones, scattered with piles of different sizes and statures, as a rule without streets or havens. They some of the time have springs of water, which burst forward, and make verdant spots.

The most exceptional of deserts is the Sahara. This is a huge plain, yet a little raised over the degree of the sea, and secured with sand and rock, with a blend of shells, and seems like the bowl of a vanished ocean.

In the midst of the desert, there are springs of water which burst forward and make verdant spots, called desert springs. There are thirty-two of these that contain wellsprings, and date and palm trees; twenty of them are possessed. They fill in as halting spots for the parades, and frequently contain towns.

Were it not for these, no person could cross this misuse of consuming sand. So savage, now and again, is the consuming breeze that the searing warmth evaporates the water of these springs, and afterward much of the time, the most heartbreaking outcomes follow.

In 1805, a train comprising of 2,000 people and 1,800 camels, not discovering water at the typical resting place, kicked the bucket of thirst, the two men and creatures. Tempests of wind are more horrendous right now on the sea. Huge floods and billows of red sand are raised and moved forward, covering everything in its way, and it is said that entire clans have accordingly been gobbled up.

The circumstance of such is shocking, and concedes to no asset. Many die, casualties of the most terrible thirst. It is then that the estimation of some water is really felt.

To be parched in a desert, without water, presented to the consuming sun, without cover, is the most awful circumstance that an individual can be set in, and probably the best enduring that a person can continue; the tongue and lips swell; an empty sound is heard in the ears, which welcomes on deafness, and the cerebrum seems to develop thick and aggravated.

Assuming, sadly, any one falls wiped out and about, the individual in question should either persevere through the weariness of going on a camel, (which is problematic even to solid individuals,) or the person must be deserted on the sand, with no help, and remain so until a moderate passing comes to alleviate the person in question.

condition paper, article about existence, voyaging expositionwhose guarantee had been foiled by an early passing. In any case, Bridges presented them with a long diary that portrays Dolben’s oddly upset existence with downplayed ability. Henry James was charmed by the story and composed that it was “wonderfully and gently, in truth just impeccably, done.”

Robert Bridges and Digby Dolben met in the mid 1860s at Eton, at that point as now the most celebrated of England’s state funded schools. Scaffolds was more seasoned and heartier than Dolben and as a removed cousin, felt an obligation to care for him. The two were drawn together by comparable tendencies and a mutual point of view, being resolved, imaginative, and “horrendously genuine.” Bridges acquainted Dolben with his hover of high church companions; Dolben took to them, and in a little while, he exceeded them all in his energy for the reason. He crossed himself at suppers, read inappropriate strict tracts, and in the end made prohibited journeys to counsel with specific clerics on the possibility of his godlike soul. To his companions, he appeared to be fantastic, disconnected, other-common, even pious: to the director he was a fomenter, hazardously confused.

“My memories of Mackworth Dolben are of a youthful priest of medieval occasions. . . . In appearance he was tall and slight, with a composition of straightforward paleness. He had great highlights, and fine dull despairing eyes. Do you recall Doré’s image of a youthful priest sitting in sanctuary among a great deal of more established men, and looking unfortunately into opening? He was somewhat similar to that.”

After Bridges went up to Oxford, Dolben’s whimsies expanded. He turned into a fledgling in the English Order of St. Benedict, marked his letters Dominic, and was outfitted with a priest’s propensity which he wore in broad daylight, getting a kick out of the incitement, wearing it on one event through the avenues of Birmingham, strolling shoeless, encompassed by a horde. Increasingly more he appeared to live in dreams, wanting to touch off his companions with coals of his enthusiasm and arranging the formation of a spiritualist Anglo-Catholic Brotherhood at their very own religious community foundation. In the interim, his wellbeing disintegrated. He left Eton for good, and lived between diseases with a progression of private guides whom his folks trusted would raise his Greek and Latin to Oxford sta

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