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Essay Instructions: Patient rights include the right to informed consent, which entails that patients receive adequate information to make medical decisions. But many questions can arise if patients appear to lack the capacity to understand their medical condition or options. How is capacity determined? Who decides on behalf of the patient if the patient is determined to lack capacity? How should a surrogate decide on behalf of a patient?

In this Application Assignment, you will analyze the legal and ethical issues around patient capacity and surrogate decision making by focusing on the following scenario:

An 83-year-old diabetic male, Mr. Jones, is brought in to the emergency department because of respiratory distress, by his care-giving daughter, with whom he lives. In examining him, the emergency department physician discovers that Mr. Jones has gangrene on his right foot up to his ankle.

Mr. Jones' daughter reports that her father has been diagnosed with Alzheimer's disease. A preliminary capacity assessment is consistent with mild dementia, but one of the nurses suggests that Mr. Jones' confusion might be the result of his respiratory distress, coupled with the disorienting atmosphere of the emergency department.

The clinical recommendation is to perform a below-the-knee amputation. The patient refuses this surgery, saying he has lived long enough and wants to die with his body intact. His daughter disagrees and says she wants everything done so that she can take him home as soon as possible, and says that she will sue the hospital if they do not perform the amputation. A social worker comments that the daughter might be afraid of an elder-neglect investigation if her father dies.

Mr. Jones does not have an advance directive of any kind and is not under guardianship. Assume that the applicable law in your state is the same as Sections 5, 7, and 11, of the Uniform Health-Care Decisions Act, available at http://www.law.upenn.edu/bll/archives/ulc/fnact99/1990s/uhcda93.htm

To prepare for the Application:
Review Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?40.
Also review the section of the Merck Manual on surrogate decision making, http://www.merck.com/mmhe/sec01/ch009/ch009f.html. Refer to these readings as well as to the laws as described in Sections 5, 7, and 11 of the Uniform Health-Care Decisions Act in order to identify legal and ethical issues that apply to the scenario above.
Consider the role that capacity assessment must play in health care. Why is it important? What are the consequences of not adequately assessing a patient's capacity?
Read Chapter 4, "Health Care Ethics Committee," in Legal and Ethical Issues for Health Professionals (required reading in Week 6). In what ways would a health care consultation or committee be able to address the ethical challenges in this scenario? How do you think a bioethicist would deal with this case in terms of the procedures he or she would engage in?

This is the question to be answered...in terms of the legal and ethical issue please define them and relate it to the scenario to answer the question. For eg is Malpractice is a legal aspect define it in answering the question.



To complete this Application Assignment, write a 3- to 4-page paper in which you would address the following questions:
What are the relevant legal issues at stake? What are the legal rights of the patient and his daughter?
What are the relevant ethical issues at stake?
Why does capacity assessment matter?
How might the hospital's ethics committee or ethics consultation service help in addressing this? Include a description of how an ethics consultant or committee might become involved in this case.





Please use these resources along with what you have


Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?1840. Retrieved from http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=1&sid=1&Fmt=4&clientId=70192&RQT=309&VName=PQD
Also available at http://www.nejm.org/doi/pdf/10.1056/NEJMcp074045 as a PDF document.

This article discusses legal and ethical issues that arise in the challenge of assessing a patient's capacity or competence to understand health care options and give consent.
Article: Coiera, E., & Clarke, R. (2004). e-Consent: The design and implementation of consumer consent mechanisms in an electronic environment. JAMIA: Journal of the American Medical Informatics Association, 11(2), 129?140. Retrieved from http://jamia.bmj.com.ezp.waldenulibrary.org/content/11/2/129.full.pdf


Caring Connections: What Are Advance Directives?
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3285

This website explains the meaning of advance directives and offers tips for personally developing an advance directive.
Caring Connections: Download Your State's Advance Directives
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289

This website provides access to advance directives in states across the U.S. Use this site for one of this week's Discussion options.
Merck Manual: Surrogate Decision Making
http://www.merckmanuals.com/home/sec01/ch009/ch009f.html



Hampton, T. (2008). Groups push physicians and patients to embrace electronic health records. JAMA: Journal of the American Medical Association, 299(5), 507?509. Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/299/5/507?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT



Please use APA.



This article discusses the unresolved issues, including privacy concerns, that have slowed the adoption of electronic health records by health care providers and organizations, as well as by patients.
Article: Rothstein, M. A., & Talbott, M. K. (2006). Compelled disclosure of health information: Protecting against the greatest potential threat to privacy. JAMA: Journal of the American Medical Association, 295(24), 2882?2885.
Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/295/24/2882?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT
This article examines the challenges that the electronic health record poses to patient health information privacy and confidentiality.

Essay Instructions: Patient Guide to the Internet

Text Format – APA with title page and references


II. Requirements for Content – Important!
NR 448 writing assignments require the use of technical writing skills which are different from creative writing. Technical writing strives for clarity and brevity, explaining concepts and describing steps in a process with precision. Recipe for success -- stick closely to directions and do not introduce non-required material.

III. Instructions for Completing Assignment and Grading Scheme

Write a guide for patients on how to evaluate the veracity and integrity of web sites consulted for health care information. The guide should be formatted in an easy-to-read style. Remember that patients vary greatly in sophistication, reading ability and medical knowledge so use plain language. The guide consists of 2 pages.

A. Page 1 -- Evaluation Criteria for Websites

1. Guidelines for Evaluation

The first page contains the actual guidelines, giving patients criteria for ensuring that information found on the Internet is accurate and reliable; how should a layperson evaluate websites? The task is to boil down how to assess reputable websites and translate that knowledge into a form usable by patients. Assume that the patient or caretaker has basic Internet skills and can enter words in query box in a search engine like Google.



A. Format of guidelines logical and easy to read (10 points)

B. Evaluation criteria for websites clear and concise (10 points)

C. Language appropriate for laypersons (10 points)

D. Evaluation criteria accurately indicate the signs of a reliable website and the signs of a suspect website (30 points)


B. Page 2 – Website for a Specific Patient and Grading Scheme (total 70 points)

A. On the second page, create a scenario of a patient with a specific disease entity or concern who wants more information; it is not necessary to include a lot of detail about the patient but be sure that need for information is clear. (10 points)

B. Direct that patient (or caretaker of patient) to 1 carefully chosen website and steer patient away from 1 suspect website. Websites chosen are appropriate for skill level of most patients and address concern or disease.

The recommended site could be a general information site (see Course Documents under Resources tab for a start) – however, remember that most patients do not have your skill in searching databases. If a general information site is chosen, it should have valid articles that address the patient’s specific disease, condition, or situation.

C. Appropriate Website -- choose one (1) website to recommend to patient for accurate information; website likely to yield good information for skill level and needs of patient. Analysis of chosen website follows criteria established on page 1 of the paper; defend the validity of the good website chosen. (30 points)

D. Suspect Website --choose one (1) website that the patient should avoid due to high probability of faulty information and explain why this website is not recommended. The reasons for determining that this is a suspect website should be clear and use criteria established on page 1 of the paper.

Essay Instructions: Patient Guide to the WWW:
Scenario : This should have an outline of a brief scenario, then identify a patient who is seeking information about a specific disease or health condition. Be sure to include the nurse?s assessment of learning needs and the patient/family member?s readiness to learn.
Example:
Scenario for Mr. Jones
Jane Doe (your name here)
? Mr. Jones is a 54-year-old male recently diagnosed with esophageal cancer.
? His wife has accompanied him to the oncologist?s office.
? Both have a high school education.
? Mr. Jones has no interest in his diagnosis; his father died at an early age from esophageal cancer, and thinks nothing can be done.
? Mrs. Jones is greatly interested in any treatment; she has been searching on the Internet for alternative cures.
? Mrs. Jones has asked the nurse for help on how to determine what a credible website is.

Criteria : This should address at least four (4) criteria to judge information (websites) found on the Internet. The task is to explain how to assess the credibility of websites and convey this to the patient and/or care giver described in the Scenario. Concentrate on evaluation of information, not how to search. Assume that the patient or caregiver has basic Internet searching skills, a computer in the home and can enter words in the query box in a search engine such as Google, Bing, Dogpile, or Yahoo. The idea is to teach your patients how to evaluate websites (suspect and credible) as it relates to a specific illness/disease/health condition.
The format of the criteria should be logical and easy to read, e.g., a table, checklist, or Q & A. Be creative! Language should be appropriate for the educational level of the audience, i.e., the patient and/or caregiver as described in the Scenario.

Suspect Site: This should give the name and description of a suspect website. The suspect website must be related to the disease or condition identified in the scenario, but the site does not meet the criteria for a credible site, e.g., gives inaccurate information. You must provide a link to a working site. Explain why the site is suspect based on the criteria you outlined.

Credible Site: This should give the name and description of a credible website that you would recommend to the patient and/or caregiver/family member. The website must be appropriate for the general public. Avoid sites that are aimed at healthcare professionals.
The credible site must address the disease or condition identified in the scenario. You must provide a link to a working site. Explain why the site is credible based on the criteria you outlined.
b. The four headings should pertain to.
I. Scenario
II. Criteria
III. Suspect site
IV. Credible site

Essay Instructions: Patient Scenario
Addresses Learning Outcomes:
? Use knowledge of biological principles and the Scientific Method to ask and answer relevant questions about human health and disease
? Analyze information to distinguish between diseased and healthy structure and functioning.
? Analyze how internal and external factors cause disruption of healthy body function, leading to disease and disorders.

Mr. Smith is 60 years old. He was diagnosed with a prostate cancer five years ago. Over the past few days, Mr. Smith has been feeling weak and increasingly tired and has also been suffering from a headache that did not respond to over-the-counter medications. He scheduled an appointment with his physician.
His physician performed a physical examination and recommended a battery of laboratory tests and imaging procedures.

The table below shows Reference values in the right-hand column. These values reflect the normal range of values for patients without disease or illness. The center column reflects the resulting values for medical test results obtained for Mr. Smith.
Take note whether Mr. Smith?s values are within normal limits.
Mr. Smith Reference Values
K+ 2.6 mmol/L 3.8-4.9mmol/L
Hb (Hemoglobin) 7.5 g/dL 13.8 to 18.2 g/dL
Hct (Hematocrit) 20.4% 45-52%
Platelet Count 49x109/L 150-400x109/L

After receiving Mr. Smith?s test results, his physician admits him to the hospital. Hospital staff treated him and discharged him.
The following week, Mr. Smith returns to his physician with the same complaint of weakness and a new complaint of shortness of breath. His blood pressure is 160/100 mmHg. MRI reveals metastasis of prostate cancer to osseous tissue. Abdominal CT shows obstruction of intestine due to nodular enlargement of adrenal glands.

Laboratory results from Mr. Smith?s second hospital admission and medical tests show following findings:

Mr. Smith Reference Values
K+ 2.6 mmol/L 3.8-4.9mmol/L
Hb 7.3 g/dl 13.8 to 18.2 g/dL
Hct 20.4% 45-52%
Platelet Count 20x109/L 150-400x109/L
HCO3 38 mmol/l 22-26 mmol/L
Urinary K+ 70 mmol/L/24 hr 25-120 mmol/L/24 hr
Blood Glucose 460 mg/dl 64.8-104.4 mg/dL
Serum Aldosterone 1 ng/dl
24 hour Urinary Aldosterone 8.4 mcg/24 hr 2.3-21.0 mcg/24 hr
Renin 2.1 ng/ml/hr 0.65-5.0 ng/ml/hr
ACTH (Adrenocorticotropic Hormone) 1082 pg/ml 9-46 pg/ml
Cortisol 155.5 microg/dL 0-25 microg/dL

CONCLUSION AND DIAGNOSIS
Laboratory findings, MRI and CT confirmed metastatic prostate adenocarcinoma, hypertension and refractory hypokalemia due to ectopic ACTH production. High levels of circulating cortisol caused continuous activation of mineralocorticoid receptors resulting in hypokalemia, metabolic alkalosis and hypertension.

After reading provided scenario, answer the following questions:
1. What are the components of physical examination? Describe each component. (See Module 1, Commentary, Topic 8. Disease Categories, Part B. Steps in Diagnosis)
2. Mr. Smith?s blood pressure was 160/100 mmHg. How does a medical provider take or measure blood pressure? What do the top (numerator) and bottom (denominator) numbers mean in the biological sense? What is the significance the size of these two numbers? Is Mr. Smith?s blood pressure within normal range? Explain how you concluded whether Mr. Smith?s blood pressure is/is not within normal range.
3. Based on the data provided, what laboratory tests were performed and what samples were taken from the patient? Select one of the laboratory tests ordered for Mr. Smith and discuss why Mr. Smith?s physician might have ordered the test and the information she might have expected to obtain from that particular test.
4. Compare Mr. Smith?s values with reference values and indicate whether MR. Smith?s values are below, above, or within normal range (compare Mr. Smith?s values with the Reference values) for each laboratory tests in the table above from the second set of tests.
5. What imaging procedures did Mr. Smith undergo? Discuss the distinctions and similarities between the two different imaging approaches. What were the results of imaging procedures in Mr. Smith?s case?
6. Select one of the medical terms from the CONCLUSION and DIAGNOSIS section above and define what it means. Also, discuss, in your own words and based on what you can gather about Mr. Smith?s condition, how the laboratory or imaging tests helped with drawing a conclusion or making the diagnosis. In your own words, discuss how medical providers use the scientific method to come to work through the examination and diagnosis of a patient.
You should write a short paper addressing all six questions. IMPORTANT REMINDERS: content, clarity and originality of responses written in your own words. Good writing practices, including the use of correct grammar, sentence and paragraph structure, and punctuation, and presence of logical reasoning.
Cite all sources in APA format within your answer text as well as full citations in APA format at the end of the paper.