You have now come to understand, Mrs. Smith will need life long dialysis as well as continued wound care
which could be short term or it could be long term to maintain her kidney function; more timely address her
calciphylaxis; and then deal with her other chronic issues such as diabetes and hypertension.
Time goes by, the patient continues to be on your radar from a variety of sources:
Patient reports to attending that she fell onto her stump when undergoing PT but this is contraindicated by
the PT report. Patient states she has had a difficult time participating in PT due to fatigue and lack of sleep.
Upon investigation, PT denies patient falling. PT reviewed with involved staff regarding allegations bypatient as well as needed PT treatment.
Patient having some bizarre ideas about the catheter and is getting paranoid about staff. It was explained
to her that only the catheter dressing needs to be changed by many staff and nephrologist. She may be
getting disoriented at this point noted by a few providers and staff. The BK stump looks good. Plan to return
to OR on Wed if okay with other MDs.
Patient starts refusing dialysis not every day but is erratic in being compliant. One Provider tried to speak to
her by phone but she hung up on the kidney doctor. Patient then insists on the catheter being changed.
Saying to nursing that the catheter has 3 parts and that the part that is outside needs to be replaced and
that the dressing needs to be changed regularly. She was informed her that the entire catheter is one piece
and that the end caps are the only ones that can be changed and that dressing change has already been
done. Patient refuses to accept this and is not willing to listen any further saying that no one is supporting
her. Her treatment for HD is on a three times a week course, yet she refuses on certain days but not every
ID: Nursing reports some unusual behavior. She Did not want one provider to expose her during exam
although he was trying to evaluate abscesses for proper care and treatment.
Dispute arose as patient’s brother is taking pictures of hospital staff and dialysis staff without permission.
Administration called to assist with problem. Brother has fled the campus with pictures; not answering the
phone when attempted to call him due to pictures being taken without staff permission.
Case Management: working with Skilled Nursing Facilities for clinical necessity. Pt stating that if she had
known post care needed, would not have agree to surgeries. Pt becomes very frustrated with Social
Worker with insurance approvals needed.
Stable and calm today. At the time for further care related to her stump; she does not want to proceed with
the Below the Knee Amputation debridement and closure despite recommendations. Will plan later if pt
As the director of clinical ethics, you are involved again due to this difficult patient with specificity around
Write a paper responding to the following questions which are the questions within the Four Box
1. Has the patient been informed of benefits and risks of diagnostic and treatment recommendations,
understood this information and given consent?
2. Is the patient mentally capable and legally competent or is there evidence of incapacity?
3. If mentally capable, what preferences about treatment is the patient stating?
4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for an incapacitated patient? What standards should
govern the surrogate’s decisions?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, Why?
As you answer each question, what steps would you recommend to be taken to answer the questions if noanswer found?
In addition, what can you offer to the team? What if any actions would you recommend?
INCLUDE any references used in your paper