Example Of Clinical Case And Reflection Case Study

Type of paper: Case Study

Topic: Nursing, Patient, Decision, Medicine, Education, Doctor, Biopsy, Skills

Pages: 9

Words: 2475

Published: 2020/12/11

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Background

Decision making is an important factor that physicians assess during each patient visit with some cases calling for further evaluation of their capacity to make decisions based on their abrupt change of mental status. Cases of patients who make hasty decisions regarding treatment options as well those with previous history of capacity to make decisions are the ones physicians target for assessment. There are four aspects of abilities a patient should undergo in order to determine whether or not they can decide what the best clinical option is necessary. The first thing that needs to be assessed is the ability a patient has on understanding the information provided about a treatment option. The next aspect is their understanding and appreciation of the information provided to their situation. The third factor is their capacity of reasoning with the information provided and the last one is making a choice and expressing it. Therefore, when the physician is presented with a clinical case scenario where the patient is a 78 year old man recently diagnosed with metastatic cancer with the primary unknown, a physician has to be careful about his ability to make decisions.
The patient undertook a computed tomography (CT) scan that shows that there is a lesion in the pancreases suspected to be the primary cancer. The lesion is also the only available one for biopsy. Due to the need for pain control the patient is in need of large doses of narcotics and as a result affects his consciousness level that keeps on fluctuating. The physician is worried that the patient is confusing the tissue diagnosis required and his prognosis and that the two will not have an impact on the treatment or the outcome of the whole process. This became an issue when the patient was lucid and demanded that he wants a CT guided biopsy of the pancreas posing the question of his ability consent on the procedure (Sullivan & Youngner, 2010). Therefore, it is important that the different clinical reasoning cycle is required to aid in making a proper management decision that will not affect the right of autonomy for the patient. In western countries, the need for autonomy supersedes the need for beneficence; hence, the physician is always faced with the dilemma of making the best decision for both the well being of the patient as well as adhering to the codes of ethics. The need for a clinician to reflect on their decision making is also vital in making sure that all the decisions are not entirely based on assumptions and may possibly be full of mistakes that could be avoided. In this case, the physician was trying to avoid cases where the patient might feel that their rights are being infringed on despite their possible lack of proper mental abilities to undertake the decision.

Clinical reasoning

Clinical reasoning is an important aspect of treatment procedure that happens automatically. The process happens cognitively that helps the clinician make a diagnosis of the underlying problem as well as aid in the strategic management of the problem. The process of clinical reasoning starts with hypothesizing followed by hypothesis testing, re-analysis and then the differential diagnosis follows. This cycle helps a clinician make a decision on the diagnosis as well as what management is needed for the patient. Therefore, in the case of the 78 year old man diagnosed with cancer, the main issue presenting a problem was deciding whether he was in a good mental state to decide the best treatment option for him (Grisso & Appelbaum, 2003).
The physician in this case was faced with a decision that focused on the ability of the patient to make a decision. According to the physician’s hypothesizing, the patient was not in a perfect condition to make the right decision regarding the different options required to come to the best conclusion. Therefore, the clinician had to apply different assessment approaches to determine the ability of the patient to make a decision as well as sign the consent for the biopsy. According to the physician, the large doses of narcotics given to the patient to manage pain were causing an abrupt change in the mental abilities of the patient caused by his medication. Therefore, the physician and the nurses took on a directed clinical interview for the patient where different aspects of the patients decision making capacity was tested to determine whether he could make any clinical decision. The physician undertook the tests to determine whether the current level of the patient’s functioning were possibly going to improve. The main aim is for the clinician to test the hypothesis that the patient is having a problem comprehending the different aspects of his diagnosis and as a result may impair his ability to make a clear decision on the consent for a biopsy. This is due to the fact that the patient thinks that the CT scan is a procedure that would help the biopsy process and speed up the treatment. Therefore, the physician ordered the directed clinical interview tests to determine the mental capability of the patient through a series of ancillary tests (Roth, Meisel & Lidz, 2002).
It is important to note that the fact that the patient may lack the ability to make the main decision and consenting to the biopsy does not necessarily mean that the patient’s overall decision making is impaired. The main concern is on his ability to process and understand the relevance and significance of the information provided to the health problem facing them. This was the case with the 78 year old patient who was having a problem determining exactly and processing the different aspects of his health problem to the information given by the physician as well as the CT scan results. In this case, the major problem facing the physician was the need to make a decision that would be best for the patient (Drane, 2007). Here the call for patient autonomy is up most as compared to the call for beneficence that can be offered by other people including the doctor and other family members. The fact that the patient is an adult with no history of psychiatric problems only makes it difficult to overlook the need for autonomy. This comes with the belief that they can make their own decisions that can be for the better or for the worse. It is only from the results of the clinician assessments that the physician can rule out the right of autonomy for the patient (Wellington, 2007).
The physician also used the structured assessment tool to help identify the mental abilities of the patient and then determine the best course of action. Here, the focus was on evaluation of his capacities with the use of the Aid to Capacity Evaluation (ACE). This tool is used together with the MacArthur Competence Assessment Tool (MacCAT). The main tool used in assessing the patient was the ACE as it is easier to administer in a span of five to ten minutes structured in a more clinically oriented way (Millers & Bolla, 2009).
In the case study, the main problem was the lack of comprehension by the patient to the need for biopsy and its importance in the process of diagnosis. According to the patient, what was really happening was that he confused the relevance of the biopsy on diagnosis to the course of treatment. Therefore, this called for the assessment of the mental abilities of the patient to give his consent to the biopsy (Higgs, 2008). This was a dilemma for the physician considering that the patient was under medication of large amounts of narcotics that led to a fluctuation of his consciousness levels. Some of the goals and course of actions that the physicians and the nurses in the case study should have followed would have been to ensure that at the end of the assessment, the patient and his family understood the need for the biopsy. It is difficult to ensure that beneficence is adhered to in a country where the most important code of ethics is autonomy of the patient. However, considering that this was a life threatening diseases, the main goal would have been to save the life of the patient (Millar, 2011). Therefore, the best course of action that would have been undertaken should have been management of the doses of narcotics to a minimum possible level that would allow for the patient to comprehend the weight of the biopsy in the diagnosis process. Here, nurses and the physicians should have placed more focus on making the patient understand and even seek for the absolution of the autonomy of the patient. The fact that his wife refused to consent for the biopsy means that she was also not in a proper position to make the best decisions for the husband. This was not necessarily due to her lack of mental abilities, but maybe she lacked proper knowledge of the need for the biopsy in helping prolong her husband’s life (Beattie, Check & Gibson, 2010). Therefore, the new course of action would have been more effective, in judging the ability of the wife to make sound decision regarding the issue considering she lacked the proper knowledge on cancer diagnosis and the choice of the treatment options arising from the biopsy (Etchells, Sharpe, Elliott & Singer, 2009). The pros of this approach include a prolonged life for the patient who died only a few weeks after the diagnosis. With the biopsy, the patient had a better chance of undergoing therapy that would have increased his life span. The other pro of this alternative is in creating an environment where the patient understands the importance of valuing the medical opinion of the doctor. As much as the focus is always placed on the patient autonomy as per different codes of ethics and the nursing standards, there is a need for some situations to focus on beneficence rather than autonomy. However, the problem with the approach is on the ethical codes of ethics and nursing standards that call on the physicians and nurses to ensure that autonomy is respected at all times (Buchanan & Brock, 2005).
In the same regards, some of the assumptions that arose during the decision making process included the fact that the patient always makes the right decision as they are grownups. This is not always the case, and this led to the decision to give the wife the last say in regards to the biopsy (Vaske 2013). When hypothesizing about a case presented by a patient, one is faced by different issues and when in a case like this one, the patient is not capable of comprehending the weight of his disease. Therefore, right from the beginning, this was a major issue that may have had an impact on the final decision. The other assumption was that the legal right of the wife gave her the ability to make the right decision while it is evident that her lack of professional knowledge inhibited her final decision. She lacked the knowledge to aid her and make her understand the value of a biopsy to the health of her husband (Cheek & Gibson, 1996).

Reflective practice

In the clinical setting, nurses and physicians are always faced with difficult decisions to make. It is not about what their experience and professional knowledge guides them to do during different situation. However, it is about coming to a conclusion based on different factors that guide him or her to make certain decisions (Fitzgerald 1994). For example, in the case study discussed above, as a nurse or a medical practitioner, the need for a biopsy is vital, but many aspects needs to be taken into consideration. Therefore, according to Gibbs Reflective cycle, there is a need to understand the initial experience where I felt that the patient was in a lot of pain and this prompted the need for narcotics and further tests (Gibbs, 1988). However, the question was not only on the need for making decisions to conduct tests, a biopsy calls for patient consent and it is common knowledge in the medical field that the patient needs to be mentally stable to sign it. Therefore, this poses the question of the relevance of this step, if the nurses and other health professionals understand the importance of the tests. In this case, I was feeling that the patient should agree to the biopsy as per my view as a health professional. However, I also knew that the patient had his own right to autonomy and those resulted in mixed feelings on my part. I wanted to help the patient understand the importance of the biopsy to his life, but I was in no position to force him as it is against the codes of ethics.
During this experience, I got to see both the good and the bad side of the health care professional and the nurse’s role in the whole process. I liked that the need for autonomy was always the priority. I would not want someone I rarely know to make such a major decision in my life. Therefore, it is paramount that the decision is left to the patient. I also got to understand that the value of life is not based on how long one lives and how a decision is made, but by when the decision is made. The wife came to the decision after extensive discussion with the doctor and nurses. However, I understood her decision as she knew her husband and loved him, but as pee the pain he was going through, she knew that consenting to the decision would only hurt him worse when it was over and he did not feel better. I also saw and appreciated the role of health practice in helping a patient pass on with minimal pain (Beauchamp & Childress, 2009). On the other hand, I did not like the fact that autonomy takes away the role of a nurse or a physician to perform their duty to the need.
Autonomy is good, but it limits the responsibilities of the physician to try their best to save the life of a patient. Therefore, in an effort to analyze the whole experience, I come up with questions on the relevance of autonomy when the decision by the patient can be life threatening while the beneficence can help restore the health of a patient. This is a serious issue that is tough to bridge. It is a thin thread that can be fatal for both parties. It calls on a need for a different approach for different cases. I feel that I could have put in more effort to ensure that beneficence applied more to the case over the right of beneficence. I should have put more effort on convincing the wife to work on biopsy rather than refusing it (Bowden, 2003). However, in future, I would like that the balance between the beneficence and autonomy to be evaluated regarding individual cases. This way, it will give the health professionals a bigger control of the final decision in regards to treatment over the autonomy when the condition is life threatening (Williamson, 2009).

References

Beattie, J., Check, J., & Gibson, T. (2010). Nurses and Medications: Developing your
Professional Practice Unpublished manuscript printed by Document Services. Underdale:
South Australia.
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. 4th ed. New York: Oxford University Press.
Bowden, S. D. (2003). Enhancing Your Professional Nursing Practice Through Critical
Reflection. Abu Dhabi NURSE, 28, 1-4.
Buchanan, A. E., & Brock, D. W. (2005). Deciding for others: the ethics of surrogate decision making. Cambridge: Cambridge University Press.
Cheek, J., & Gibson, T. (1996). The discursive construction of the role of the nurse in medication
administration: an exploration of the literature. Nursing Inquiry, 3(2), 83-90.
Drane, J. F. (2007). Competency to give an informed consent. A model for making clinical assessments. JAMA, 252:925–7.
Etchells, E., Sharpe, G., Elliott, C., & Singer, P. A. (2009). Bioethics for clinicians: 3. Capacity. CMAJ, 155:657–61.
Fitzgerald. (1994). In Reflective practice in nursing: the growth of the professional
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Grisso, T., & Appelbaum, P. S. (2003). Assessing competence to consent to treatment: a guide
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Higgs, J. (2008). Clinical Reasoning in the Health Professions. London: Elsevier Health
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Majette, G. R. (2009). An AIDS patient's right to refuse lifesustaining treatment. Am Fam Physician, 58:2161–4.
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Millar, C. (2011). "Critical Reflection for Educators of Adults: Getting a Grip on the Scripts for
Professional Action." Studies in Continuing Education 13, (1) 15-23.
Millers, D. L., & Bolla, L. R. (2009). Patient values: the guide to medical decision making. Clin Geriatr Med, 14:813–29.
Roth, L. H, Meisel, A. & Lidz, C. W. (2002). Tests of competency to consent to treatment. Am J Psychiatry, 134:279–84.
Sullivan, M. D. & Youngner, S.J.(2010). Depression, competence, and the right to refuse lifesaving medical treatment. Am J Psychiatry. 1994;151:971–8.
Vaske, J. M. (2013). Defining, Teaching, and Evaluating Critical Thinking Skills in Adult
Education. Educational specialist thesis, Drake University.
Wellington, B. (2007)."Orientations to Reflective Practice." Educational Research 38, (3) 307-
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Williamson, A. (2009). "Reflection in Adult Learning with Particular Reference to Learning-in-
Action." Australian Journal of Adult and Community Education 37, (2)93-99.

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