HCAD 635 Decision Authority

Do we know whether the resident is capable of making his own health care decisions?

In the given case study to make the decisions related to healthcare when the patient is at the stage where the end of life care is considered as the primary and ethical issue which is bound with Mr. Parker. As the daughter of Mr. Parker does not wish for palliative care. But she is also not involved in primary care as the patient is 88 years old and is in the wheelchair having an end-stage of Alzheimer's and is on spoon feed. In such a situation, Mr. Parker has not any ability to make the decision. This would result in the cognitive impairment that the patients having Alzheimer's disease might not be able to have the capability of decision making that gives the informed consent for the medical treatment(Santurri E, 1982). This might affect the choice and ability to make appropriate decisions. As the progression of Alzheimer's disease, the patient slowly requires others, among which usually are the family members who play a vital role in assisting, and they ultimately take over the medical decision. In this case, Mr. Parker is unable to make decisions regarding his health issue, so her daughter takes the decisions. She involved in all the decisions which are associated with the care of her father.  

Moreover, the individuals tend to presumed to be competent to make the healthcare decision.so the ethical presumption indicates that the individual should be capable and are entitled to take some vital decisions about the wellbeing and healthcare in the context of medical principle. However, the obligations that are meaningful to involve the competent person in decision making who, in such case, is the daughter of Mr. Parker. So instead to alone focus on the autonomy in the broader context. This also includes and identifies the ethical obligation to Mr. Parker, who is vulnerable and is unable to participate expressively in deciding on his health care.

As, in the given case study, there is not the apparent wish of Mr. Parker that what he wants and what his values are. But the only thing which indicates his wish was that he refuses to eat. However, the case study also not indicate the values of Mr. Parker. The reason for this is that Mr. Parker is unable to talk and spend most of his time sleeping in a wheelchair. This shows that he has lacked all the interests and even refused to eat as well. He is so feeble that he only needs to feed by spoon.

Are there any known wishes from Mr. Parker?  What would he want?  What are his values?

As the substitute decision making commonly refers to the decision taken by the third party on behalf of others who have to lack the decision-making capacity. However, to identify the substitute decision-maker is informal, and it also reflects the best characteristics of custom. As. Mr. Parker had not appointed anyone on his behalf and is nor incapable. So the responsibility is on his daughter, who is looking at him (Back AL, 2005).

However, in the case when Mr. Parker is unable to decide so her daughter is his substitute decision-maker. As Mr. Parker was once able to decide on healthcare, have lost the ability to decide due to his disease. This capacity loss seems to be permanent, and Mr. Parker loses his developmental disabilities. This is due to the age or the developmental stage, which is acquired to have the ability that is meaningful in participation in the decision about healthcare. Furthermore, the presented case has indicated that the previous decision-making capacity had been disoriented, and it is also not clear the patient has a temporary or more profound health issue. So in this regard, the competent and Mr. Parker's daughter becomes the substitute decision-maker concerning healthcare. So this extends the personal authority for the aspect that his life to his daughter.

Furthermore, the associated challenges of the substitute decision making are considered as the more apparent and are the move away from the transmitted decisions to a more challenging context. So, in this regard, the following three types of decisions have been distinguished, which are:

  • Transmitted decisions
  • Hypothetical judgment
  • Guardian judgment 

Mr. Parker has not communicated any of his wishes nor the values. So the hypothetical judgment has been formed by his daughter, who is now the substitute decision-maker because Mr. Parker is not capable to explicitly express. So in this situation, the substitute decision-maker agrees with the assessment but on the thing that she wants her father to be alive and that specific assessment about to fit Mr. Parker's beliefs and values.

However, the most challenging and difficult decision by his daughter, who is the so-called guardian judgment. His daughter has no direct knowledge about Mr. Parker's wish or the values. Moreover, the presented case indicates that the daughter believes that she is accurately presenting her father's wish concerning pain medication (DW., 1992). This is only based on the long and withstanding relationship with his father and due to having the intimate knowledge of his father's action in the past regarding healthcare issues as there is no other option or any other family member to describe the collateral evidence to the claim of the daughter that his father would not truly want any of the changing the plan of care to palliation.

Is his daughter the substitute decision-maker?  Can she, in this role, demand treatment and expect that you comply?

As the team from the director of nursing had approached the daughter when her father refused to eat and fells that his refusal is genuine. So the alternate option which they offer to Mr. Parker's daughter was to change the plan of care to the palliation. But in response to such a proposal, Mr. Parker's daughter refuses and claims that "you cannot kill my father, I want everything to keep him alive. Furthermore, from the legal and ethical perspective, the situation is where the situation is considered defensible that could place the limit on the authority that is under the substitution decision-maker who is the daughter who represents the faithful representation of the known wish or preference. So it is significant to identify the authority of the substitute decision-maker concerning the fact that the decision making is not the power for the family. In the given case, the daughter had presented and insisted that the father had not given the palliation care, so the care provider does not provide theaccuracy of the statement by the daughter. 

Also, the situation unfolds the fact that the care provider has become more convinced, which is inappropriate due to the current situation of Mr. Parker. The team was aware of the patient's discomfort condition and also considered the moral distress that has been evoked. But in such a case, the daughter of Mr. Parker is fully aware and continues to believe that she is truly representing her father's views and insists not to go for palliation(Forrow L, 1993).

On the other side, care providers are intended to be cautious about the act which they have to do for the reservation, and they know about the substitute decision-makers who are appeared to be harmful, which is represented in this case. In such settings, there is seen a clear obligation that on behalf of a care provider who communicates the concerns to the director of nursing and has a difference of opinion or the disagreements regarding the best of their interest of Mr. Parker. So to resort the unilateral decision making off to dismiss the substitute decision-maker (daughter) is not equally and ethically defensible. But if the concern is serious about the decision of substitute, it becomes imperative that there requires a need for the third party involved who could assist with the conflict resolution or to the mediation. If the differences have not been satisfactorily resolved in a way that the first and the foremost wish is to protect the vulnerable patient, care providers such as director of nursing have to explore the options in the facility of healthcare, city, and province or to the territory to the legitimately challenge the associated authority of the substitute decision-maker (daughter) and/or to recognize the category of the substitute decision-maker, for instance, public trustee.

Finally, in such practice, the daughter should obey the director of nursing due to the vulnerable condition of his father, who is refusing to eat. Definitely, director of nursing in the context of ethics, they might describe the threshold as the difference that they are willing to cooperate but not agree on the given direction by the substitute decision-makers. Moreover, they also transfer the professionals to consider the transfer of care after they secure the appropriate protection for Mr. Parker. In such a case, the option is to provide the care and provide the transfer of care to some other medical colleagues.  





Back AL, A. R. (2005). Dealing with conflict in caring for the seriously ill: "it was just out of the question." Journal of the American Medical Association; 293: 1374-81.

DW., B. (1992). What is the moral basis of the authority of family members to act as surrogates for incompetent patients? The Journal of Clinical Ethics; 3: 121-3.

Forrow, L, A. R. (1993). Preventive ethics: Expanding the horizons of clinical ethics. The Journal of Clinical Ethics; 4: 287-94.

Santurri, E, W. W. (1982). Substituted judgment and the terminally-ill incompetent. Thought; 57: 484–501.


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