At 80, R.L. lives with his wif

At 80, R.L. lives with his wife in a retirement community. Hehas always valued his independence, but recently he has been havingtrouble caring for himself. He is having difficulty walking andmanaging his medications for diabetes, heart disease, and kidneyproblems.

His doctor diagnoses depression after noting that R.L. has lostinterest in the things he used to enjoy. Lethargic and sleepless,R.L. has difficulty maintaining his weight and talks about killinghimself with a loaded handgun. He agrees to try medication for themood disorder.

Two weeks later, before the effect of the medicine can be seen,R.L. is hospitalized for a heart attack. The heart is damaged soseverely it can’t pump enough blood to keep the kidneysworking.

Renal dialysis is necessary to keep R.L. alive, at least untilit’s clear whether the heart and kidneys will recover. Thisinvolves moving him three times a week to the dialysis unit, whereneedles are inserted into a large artery and a vein to connect himto a machine for three to four hours.

After the second treatment, R.L. demands that dialysis bestopped and asks to be allowed to die.

You are R.L.’s physician. What should you do?

R.L.’s was an actual case that presented his physicians with acommon dilemma in treating patients with serious illnesses: Haddepression rendered him incapable of making a legitimatelife-and-death decision?

When patients agree to undergo or refuse medical treatment, theyare supposed to reach the decision by a process called informedconsent. The doctor discloses information about the medicalcondition, treatment options, possible complications, and expectedoutcomes with or without treatment.

To give informed consent or refusal, the patient must be actingvoluntarily and must have the capacity to make the decision. Thatmeans the patient must be able to understand the information,appreciate its personal implications, weigh the options based onpersonal values and life goals, and communicate a decision. From anethical point of view, informed consent is based on thephilosophical principles of autonomy and beneficence. In R.L.’scase, these two principles are in conflict. First, R.L.’s prognosisis unclear, and the physician does not know if the benefits ofdialysis will outweigh the burdens. Under normal circumstances,this decision would be made by R.L., but the physician suspects thepatient’s capacity for autonomous decision making is impaired bydepression.

Depression is a mood disorder that can profoundly affect aperson’s ability to think positively, experience pleasure, orimagine a brighter future. Depressed people frequently have littleenergy, poor appetites, and disturbed sleep. They may havedifficulty concentrating, or they may be troubled by feelings ofguilt and hopelessness. Preoccupation with death is common and, insome cases, may include contemplating suicide.

Because R.L. was suicidal before his heart attack, no one wassure whether his refusal of dialysis represented an authenticexercise of his right to stop life-saving treatment or a convenientmeans to passively end his life. On the other hand, if the doctorcontinued dialysis, he would be denying R.L. the same right torefuse treatment that another patient who was not depressed wouldhave.

When patients ask to have life-sustaining treatment withheld,doctors have been taught to consider whether depression is drivingthe request, because the condition lifts in two-thirds of those whoare treated with anti-depressant medications. The presumption isthat once the problem has cleared, the patient will look attreatment decisions differently.

Recent research has challenged that presumption by showingdepressed patients don’t necessarily choose to hasten death in thefirst place and they often make the same decisions after theyrecover from depression.

Thus, depressed patients may be able to give informed consent,but doctors and loved ones must consider whether the decision torefuse medical treatment is logical, internally consistent, andconforms with past life choices and values.

In R.L.’s case, the doctor, in consultation with a psychiatrist,decided to continue the course of anti depressant medication to seeif, when it began to take effect, R.L. would change his mind abouttreatment. In the meantime, his dialysis was continued.

After five weeks, R.L. showed no improvement, and he began torefuse medications and food. His wife was asked to give consent fora feeding tube.

On conferring with the rest of the family, R.L.’s wife deniedthe doctor’s request. Her husband’s repeated refusal of dialysishad convinced the family R.L. really did want to die. In addition,R.L.’s unchanged physical condition indicated that, if he survivedto discharge, he would probably need nursing home care, a fate hehad resisted even before his depression.

Ultimately, the physician shared the family’s assessment thatR.L.’s consistent refusals indicated an authentic wish to halttreatment. He was taken off dialysis and put on comfort measures.Six days later, he died.


  • Write a 1,000-1,200 word essayusing APA style that applies the relevant aspects of the ACHE Codeof Ethics to an assigned case study.


What are the ethical questions involved when depressionimpairs seriously ill patients’ ability to makedecisions?



What are the ethicalquestions involved when depression impairs seriously ill patients’ability to make decisions?

Depression affects your decisionmaking in several ways. When we saydepression leads to poorerdecision, it means that thedecisions lead to outcomes that have less positiveimpact on your life over the long run.

The first waydepression leads to poordecisions is that depressed people tend to be moreindecisive

Psychiatric disorders can pose problemsin the assessment of decision-making capacity (DMC). This is soparticularly where psychopathology is seen as the extreme end of adimension that includes normality. Depression is an example of sucha psychiatric disorder.

Four abilities(understanding, appreciating, reasoningand ability to express a choice) are commonlyassessed when determining DMC in psychiatry and uncertainty existsabout the extent to which depression impacts capacity to maketreatment or research participation decisions.

Certain questions in thiscontext are:

  • · Depression impairperformance on tests of decision-making capacity?
  • · Does depression affectthe insight of an individual?
  • · Do patients withdepression regain DMC-Decision making capacity after thetreatment?

In this case study followinginterpretations are made.

1. The patient does not wish to receivetreatment; however, he clearly meets clinical criteria for a majordepressive episode and continues to express self-harmintent.

2. In this case, the physician’sduty of beneficence, which prioritizes treatmentof depression, conflicts with the patient’s initialautonomous desire to end his life.

The psychiatrist should explore thistension by providing appropriate education to the patient of hisdiagnosis and clinical options and exploring if the patient wouldaccept voluntary hospitalization.

3.The psychiatristhas a duty to “first do no harm.” This encompasses the imperative toensure that medical issues are not left untreated and that anytreatment plan (e.g., pharmacotherapy) will take the patient’smedical issues into consideration and will not increase the risk ofclinical harm.

4.The psychiatrist isrespecting the duty of confidentiality toward the patient and seeks hispermission prior to speaking with his wife. In some emergencysituations, there may be legal protections for gatheringclinical information without the patient’s direct consent.However, if the patient is conscious and cooperative, itwould be prudent for the physician to ask the patient forpermission to speak with his wife first.



The purpose of the Code ofEthics of the American College of Healthcare Executives is toserve as a standard of conduct for members. It contains standardsof ethical behavior for healthcare executives in their professionalrelationships. These relationships include colleagues, patients orothers served; members of the healthcare executive’s organizationand other organizations; the community; and society as awhole.The Code of Ethicsalso incorporates standards of ethical behavior governingindividual behavior, particularly when that conduct directlyrelates to the role and identity of the healthcareexecutive.The fundamentalobjectives of the healthcare management professionare

  • · to maintain or enhance the overallquality of life, dignity and well-being of every individual needinghealthcare service and
  • · to create an equitable, accessible,effective and efficient healthcare system.
  • · Healthcare executives have anobligation to act in ways that will merit the trust, confidence andrespect of healthcare professionals and the generalpublic. Therefore, healthcare executives should lead livesthat embody an exemplary system of values and ethics.

In fulfilling theircommitments and obligations to patients or others served,healthcare executives function as moral advocates andmodels.

  • · Since every management decisionaffects the health and well-being of both individuals andcommunities, healthcare executives must carefully evaluate thepossible outcomes of their decisions. In organizationsthat deliver healthcare services, they must work to safeguard andfoster the rights, interests and prerogatives of patients or othersserved.
  • The role of moral advocate requiresthat healthcare executives take actions necessary to promote suchrights, interests and prerogatives.

As per code of ethics TheHealthcare Executive’s Responsibilities to Patients or OthersServedThe healthcare executive shall, within the scope of his or herauthority:

  • · Work to ensure the existence of aprocess to evaluate the quality of care or servicerendered;
  • · Avoid practicing or facilitatingdiscrimination and institute safeguards to prevent discriminatoryorganizational practices;
  • · Work to ensure the existence of aprocess that will advise patients or others served of the rights,opportunities, responsibilities and risks regarding availablehealthcare services;
  • · Work to ensure that there is aprocess in place to facilitate the resolution of conflicts that mayarise when values of patients and their families differ from thoseof employees and physicians;
  • · Demonstrate zero tolerance for anyabuse of power that compromises patients or othersserved;
  • · Work to provide a process thatensures the autonomy and self-determination of patients or othersserved;
  • · Work to ensure the existence ofprocedures that will safeguard the confidentiality and privacy ofpatients or others served; and
  • · Work to ensure the existence of anongoing process and procedures to review, develop and consistentlyimplement evidence-based clinical practices throughout theorganization.

· Statement of theIssue

End-of-life decision making andcare are important aspects of the delivery of patient-centeredhealthcare.

Medical interventions haveshaped the dying process, giving us options that canimpact when, where and how we die. Intervening during the dyingprocess with medical care can sustain lives, even when there islittle or no hope for recovery or a meaningful existence. However,such actions may be inconsistent with patient preferences andfoster unwarranted variations in end-of-life practicepatterns.

In response, patients ornext of kin should exercise control over decisions regarding use ofmedical interventions that may prolong existence rather than allowthe natural progression of the dying process. The traditional valueto preserve life by all possible means is now being weighed againstpatient-centered, quality-of-life considerations based onevidence-based care and a shared decision-makingprocess.


The American College of HealthcareExecutives (ACHE) expects healthcare executives to be committed tothe compassionate and competent care of dying patients,including addressing the ethical dilemmas surrounding death anddying. Additionally, executives should promote publicdialogue that will lead to an awareness and understanding ofend-of-life issues and policies

In this casestudy

when a dilemma arose betweenthe patient`s demand and physician`s role , considering the mentalcapacity of patient, wife was given the right to arrive at adecision. But later when patient responded totreatment, patients decision were also respected to arrive at aconclusion

ACHE encourages all healthcareexecutives to play a significant role in addressing thisissue by:Ensuring EthicalEnd-of-Life Decision Making

  • · Healthcare executives and theirorganizations should ensure the patient’s (or, when lackingdecision-making capacity, the authorized surrogate’s)self-determination regarding end-of-life decision making.Generally, informed adult patients or their surrogate have theethical and legal right to accept or refuse any recommendedtreatments based on the ethical principle of autonomy. Suchdecision making should include an open, truthful discussionregarding the patient’s situation and evidence-driven healthcareoptions.
  • · The healthcare executive shouldensure patient or surrogate decisions are appropriately documentedand respected.
  • · When there is a disagreement oruncertainty regarding treatments for patients, healthcare providersshould respond with empathy and thoughtful exploration of allpossibilities, including palliative care with the appropriatedecision maker. Healthcare executives should ensure there are clearguidelines, including a process to address care-managementdisagreements (such as, situations when the patient or surrogate isdesiring non-beneficial treatments), as well as provide support tohealthcare professionals, patients and/or surrogates responsiblefor making treatment choices.

Developing and ImplementingEnd-of-Life Organizational Guidelines

  • · Healthcare executives should ensureappropriate end-of-life care and decision-making policies andprocedures are developed and implemented, includingdo-not-resuscitate orders, withholding and withdrawinglife-sustaining treatment, medical futility issues and organdonation. Such guidelines should be regularly reviewed.
  • · When developing and implementingguidelines, healthcare executives should encouragecooperation and understanding among the clinical staff,members of the governing body and executive management.Executives should ensure appropriate methods for raising awarenessand staff education are provided regarding end-of-life ethicaldilemmas, including how to access organizational ethicsresources.
  • · If organizational policies limitspecific end-of-life options for patients and families orsurrogates, healthcare executives have a responsibility to ensurethat procedures are in place to provide full disclosure of suchlimitations.

Ensuring Available End-of-LifeCare Support for Patients, Families and StaffMembers

  • · In the care of patients at the end oflife, executives should support the development and availability ofeffective resources such as palliative care and hospice programsfor patients and families to preserve psychological, social andspiritual well-being.
  • · Executives should ensure effectivesupport programs, such as ethics committees and employeeassistance, are available to staff members to address ethicalconflicts and moral distress that frequently surround end-of-lifedecision making and patient care.

Promoting Community End-of-LifeDiscussion

  • · Executives should heighten awarenessof ethical issues, including the patient or surrogate’s right tochoose treatment, through facility and community information forumsthat promote open discussion among patients and their families,attorneys, clergy, journalists, physicians, other healthcareprofessionals and the public. By raising and openly discussingethics issues, healthcare executives will aid the staff and thepublic in understanding the importance of thinking aboutend-of-life issues and the organization’s interest in ensuringpatient-centered care.
  • · Healthcare executives should fosterreasoned, compassionate, patient-centered decision making thatconsiders the rights, preferences and values of patients and staffmembers. While interpretation of these principles will vary bylocal custom and law, healthcare executives have a responsibilityto ensure their organization operates with respect for the inherentworth, rights and human dignity of every individual.
  • ACHE expects healthcare executives willpromote ethical end-of-life decision making with the use of advanceplanning documents and end-of-life organizationalguidelines.
  • Executives should ensure end-of-lifecare support resources are available for patients, families andstaff members. Lastly, healthcare executives should serve as acommunity resource in end-of-life discussions.

Autonomous DecisionMaking

  • Persons have a right to put forwardtheir end-of-life treatment preferences. The Federal PatientSelf-Determination Act (PSDA)
  • The person’s right toautonomously voice their end-of-life treatment choices has to berespected ethically considering the use of advance treatments andtheir prognosis. This right of autonomy has somelimitations, and hence faces an ethical dilemma. The healthcareprofessional should respect the patient’s autonomy whileconsidering its limitation and carry out their duties to benefit thepatient without doing harm.


Patients autonomous decisionmaking is considered and hence patient was withdrawn from lifesaving treatment.

Ethical Theories Involved inEnd-of-Life Care

Depressed patients lackappreciation

  • Several of the articles highlightedappreciation as the component of capacity lacking indepressed individuals.
  • In simple terms, the transitionfrom simply understanding the medical facts, to actual applicationof those facts by an individual to their own situation, can beimpaired in the depressed individual.
  • When depression was seen to impaira patient’s ‘ability to comprehend the consequences of achoice’, again indicating that appreciative ability is atstake in depressive illness.


  • Elliot (1997) addressed thecapacity of depressed individuals from a different perspective,drawing moral responsibility into the picture.
  • Whilst accepting DMC couldbe influenced by both cognitive and emotional factors, hepinpointed two criteria required for accountability that arepotentially compromised in depressed patients; namely,decisional authenticity and a minimallevel of concern regarding one’s own welfare.
  • Lack of ‘decisionalauthenticity’ refers to the fact that depressedindividuals may not make decisions that reflect their ‘true’autonomous self. Equally, they may not possess a minimal level ofconcern for their own welfare, without which any claim of DMC isjeopardized.

Emotion, cognition andcapacity

  • All the clinical ethical literaturerecognizes interplay between cognition, emotion and DMC. Thewidespread view is that capacity assessment must take into accountboth cognitive and emotional factors.
  • ‘Depressivehelplessness produces anunderestimation of one’s possible effectiveness in the face ofserious illness. Guilt andworthlessness may make one believethat suffering and death are deserved.
  • Anhedoniamay make it impossible to imagine that life will offer anypleasures for which it is worth enduring … illness. Depressivehopelessness can make it impossibleto imagine that life will ever offer a better balance of pleasureand pain that it does at present.’

Impression: This case studyoutlines how the patients autonomy is respected even when decisionmaking ability was altered, keeping in view the principle ofbeneficience and non-malificience.


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