Ethical leadership concepts and practices

Ethical Leadership

Advance directives are a way to help people ensure that their wishes are carried out at the end of their lives, even if they are no longer in a state to communicate these wishes. Indeed, these kinds of directives exist precisely for the purpose of ensuring a person's wishes are established during a time when they are able to state these clearly and without any ambiguity (Mitty, 2012). Importantly, every person has the right to create an advance directive and to have such a directive honored at the end of his or her life. Such a directive therefore also overrides any personal desires among family members, for example, to prolong life by means of intensive or artificial methods. In the case of Mr. E, there are three important factors when considering the validity of his advance directive. First, despite his "mild" developmental delay, Mr. E had the presence of mind to understand his need for a nursing home and checked himself in without assistance from his family members. Second, Mr. E received assistance from a professional patient advocate, whose ability to clearly explain advance directives to Mr. E could be assumed. Finally, the document clearly states Mr. E's wishes. With or without family involvement, the nursing standards for advance directives does not require a family signature. What could have been done in this case, instead, was to contact the patient advocate, who was directly involved and could have given insight into Mr. E's presence of mind at the time when he made the decision to create the advance directive. Indeed, regardless of Mr. E's current state of mind, the directive was made precisely for a situation during which he would not be completely able to make rational decisions.

In this case, my role as physician would have been to first establish as clearly as I could Mr. E's ability to make advance directive decisions at the time he did so. My secondary role would have been to, finding that the directive was valid, ensure that it was honored by both medical personnel and family members.

According to the ANA Board of Directors (2010, p. 13), honoring a patient's wishes to refuse treatment at the end of his or her life is an ethical and legal requirement, regardless of any personal misgivings. Hence, as a professional, my decision should be driven by Mr. E's wishes at a time when he was able to make such a decision. Even if his current state of mind is such that he could not make rational, sound decisions, this is not the driver of my professional conduct in this case.

As for family involvement, this is not something that can or should be ignored. Indeed, the ANA code of ethics includes family as strong determinants for the creation of a living will and/or advance directive. Hence, I do not believe that it was a mistake to contact Mr. Y or to involve Ms. H in making decisions regarding further steps of care for Mr. E. I do believe, however, that it was a mistake to not mention Mr. E's advance directive to either Mr. Y or Ms. H. Clearly, their lack of bringing up the subject of the directive implies that they were unaware of its existence and that they were no involved in Mr. E's decision at the time. I believe that a more ethical protocol would have been to contact the patient advocate involved and ask questions relating to the conditions that would have excluded the family from Mr. E's directive decisions.

In the case of Mr. Y, the most ethical decision he might have made in this case was to ask whether Mr. E expressed any wishes regarding his care in the event that he was unable to make such decisions. Mr. Y's appointment as medical power of attorney gives him the ethical responsibility to ensure that his brother's wishes are carried out. Hence, I do not believe it was ethical for him to authorize the use of a respirator for his brother.

There are several factors complicating the decision making process for Mr. E. First, his developmental challenges might have impacted his ability to make sound decisions regarding his care in the event of life-threatening conditions. Further, the fact that there was no clear family involvement in the decisions made might indicate that Mr. E did not truly understand the gravity of the advance directive. Finally, Mr. E's appointment of his brother as medical power of attorney without clearly informing him of the advance directive begs questions regarding his state of mind at the time.

The main HIPAA violation that occurred in the case of Mr. E is the fact that his brother, as medical power of attorney, did not receive full disclosure of his brother's advance directive (Pathfinder, 2010). Indeed, even without input from the patient advocate involved at the time, the brother could have provided insight into Mr. E's ability to make decisions of the kind. This could have provided important insight into the decisions to be made by the medical personnel working with Mr. E.