Unit 3: Option Two--during the week of 25 February:

Nurs 505A: Forum 03-A Nurs 505A: Forum 03-B Nurs 505A: Forum 03-C Chan Craven Fox Ebuen Gelyana Person Sanchez Akahori Antonio Bosch Kemp Mealer Peacock Rodriguez Blaschka Dawson Greco Jacobs Miner Mohun Smith Nurs 505B: Forum 03-A Nurs 505B: Forum 03-B Nurs 505B: Forum 03-C Dingel-Stewart Halliday LaCoste Lewis Liebelt Rogers Sork Bondi Cooper Doolan Hansra McManus Moreno Wood Adams Ancelloti-Mendez Edwards Krenn Locke Mangunlay Russell Steele Each group has a case scenario below. These are real-life ethical dilemmas which actually occurred in clinical practice, in which an inappropriate request was made. The point of this assignment is to get you thinking about how you will handle such problems as they occur in practice. Many providers seem to have adopted a philosophy of care, ranging from "I just give the patient anything they want" to "They can do it my way or get another provider." Some clinicians consider the signing of a prescription as the signal that the encounter has been successfully completed. All of these approaches represent "philosophies of care." Of course in the middle of this continuum are the providers who try to handle such problems on a case-by-case basis. And, it is important to realize that not all patient requests are necessarily inappropriate. As always, it's important to listen to one's patients and think before acting.   Those in the group who are choosing Option Two are to work within their group's forum. Discuss: What are the clinical indications in favor of honoring the request? What are the ethical considerations involved with honoring the request? One Strategy For Solving A Moral Problem: http://www.accessexcellence.org/21st/SER/BE/teachingd.html What alternatives do you think you can offer the patient? What do you think are the ethical consequences of these alternatives ? Don't tell us yet whether you're going to honor this patient's request!   Start posting as early as you can so discussions can be forthcoming and maximized. It's perfectly fine in your workgroups to post sentence fragments, and discuss back and forth. Eventually one person from the group should post the group's final analysis. Do consider each of the "Strategies for Solving" (define, collect, identify, reflect and prioritize). It's OK to group-hop and see what others have been up to. The Group in Forum 03-A Ms. Gonzalez is a 50 y/o obese Hispanic female with NIDDM and very mild COPD.  She has no other apparent physical complaints.   She has a longstanding history of drug abuse and is well-known to the clinic as being very demanding.  Until recently, she has been a patient of Dr. Kostyra.  Dr. Kostyra is no longer with the practice, so Ms. Gonzalez's care has been transferred to Dr. Rabinowitz.  She is in today for her establishment H/P and he finds her condition stable and does not find any new medical problems.   At the conclusion of the visit, she hands the doctor a DMV form to fill out for a disability parking placard renewal.  He asks her to come to the office to discuss it.  Based on his thorough review of the chart and H/P, he informs her that based on DMV criteria he does not believe her to qualify for the placard.  Ms. Gonzalez becomes very irritated. "I don't get it!," she exclaims.  "Dr. Kostyra has given me one for the past five years." Dr. Rabinowitz reviews the chart again to see if he missed something.  Indeed, in last year's visit, Dr. Kostyra wrote in the assessment and plan, "Wants DMV placard renewed -- done." The Group in Forum 03-B Paige, an extremely pleasant 19 y/o African-American college sophomore, comes to see you in clinic at Student Health at Stanford.  It's almost finals week, she admits she's been up for the past three nights studying and hasn't been eating or drinking much except for coffee and Snickers bars!  But her throat has been "killing her" since last night.  Her tonsils seem swollen to her, and her mom's an LVN (and she herself is a premed and volunteers at the Child Study Center) and she's not sure but she thinks she saw some white patches in the back of her throat.  She's doubly concerned because her nose is runny and she feels so run down… .  She talked to the Advice Nurse last night who told her to take it easy, most likely this is a virus.  But she can't risk having strep during finals!  And unfortunately this clinic doesn't do rapid strep testing… it's Friday, if we do a culture tonight, it won't be ready for 24 hrs, then another day for the prescription… and if she has strep she'll have to miss volunteering at the Child Center, there's nobody to cover for her!  Mom said another lady at work was given Zithromax for the "exact same thing" and that cleared it up in a day!!  Can't she please have some?  Pt is afeb VSS non-toxic appearing; pharynx mildly injected, + postnasal drip. The Group in Forum 03-C Mr. Williams, an extremely belligerent 46 y/o patient of Dr. Rivers, has been seen in clinic weekly by Dr. Rivers for sciatica and migraine headaches.  He is in the reception area screaming that he wants to talk to his doctor NOW because he's run out of Vicodin and is in a great deal of pain. 200 pills every other week and all he has to do is come up and ask.  He is very upset when the triage nurse informs him that Dr. Rivers is on medical leave and he'll have to speak with one of the Urgent Care doctors tonight.  "Why can't I just have my pills!" he demands.  "You're just discriminating against me." During Week 6 (4-10 March): Each individual who's chosen Option Two should come to a conclusion regarding what you're going to do for your patient in the case study for your group. State in your own words what you consider your "philosophy of care" to be, and how it applies to your case. There are no hard and fast "philosophies of care." Take another look at: What Are The Origins For The Principles Guiding Physicians? http://www.accessexcellence.org/21st/SER/BE/teachingb.html Deferring the patient to your attending physician is NOT an option here! Let us know how you will explain your denial to the patient--and how you will explain it to Patient Services when they come to you with the patient's complaint that you wouldn't honor your patient's request. Post as early as possible so that your colleagues can comment and discuss. During Week 6 (4-10 March): Have a lively discussion with each other about what each of you posted in your group for Unit III--whether you chose Option One or Option Two.   At end of Week 6 (10 Mar): Submit Midsemester Course Feedback.

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