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1. This is a theoretical case taken from VHA Intensive Ethics Advisory Committee Training, 1998, as presented by Arthur R. Derse MD, JD. An 87-year-old woman widowed for six years, who is otherwise healthy, was visiting another city and abruptly became ill. She was seen in the emergency department of the local VA and admitted to the on-call physician. The on-call physician (who has not previously seen her) made the diagnosis of bowel obstruction arid made arrangements for a surgeon to evaluate her. The surgeon recommended surgery and obtained her consent for surgery. The surgeon expects an uneventful recovery. She is told that she will be on a ventilator for a short time after surgery. The patient tells the surgeon that is OK as long as it is for a short time. She tells the surgeon that she does not want to be dependent upon machines. She was asked upon admission whether she had an advance directive. She replied that she has a living will and a power of attorney for health care which names her daughter (who does not live in the area) as her health care agent. The patient undergoes surgery, which is successful in treating the underlying problem and does not show any malignant causes, but in the recovery room she has a cardiopulmonary arrest and is resuscitated. She is transferred to the ICU in the care of the on-call physician. The physician attempts to wean her gradually from the ventilator, but this is unsuccessful. Three days later, she has regained consciousness but is still intubated. Though she cannot speak because of the ventilator, she is able to write and asks that the tube be removed. The attending physician tells her that she is dependent upon the ventilator and the patient needs to remain on the ventilator until she can breathe on her own. She writes that she understands that she may die, but she does not want to be on machines. Her only children -- a daughter and son -- - have arrived. She repeats her wish to them that she wants the tube removed. She writes to her daughter that "I don't want to die, but we all have to die sometime, and I don't want to have to live on a machine. I know that whatever the outcome, God will take care of me." Her daughter tells the physician that her mother is adamant that she be off of machines and she respects her mother's wishes, even if she cannot breathe on her own. She says this is consistent with her previously expressed wishes and her religious beliefs. Her son tells the physician that he disagrees with his sister -- since his mother does not have a terminal condition, he can not see why she should not be forced to put up with the ventilator until she can be weaned from it. He feels that she is being shortsighted, and she will be thankful to have been kept on the ventilator when she is finally able to be weaned. Describe the criteria for giving "legal" consent. Were all elements met in this case? In other words, did the patient demonstrate decision-making capacity? Explain. (Minimum of 1 page including in-text citations and references in proper APA format)

2. Based on case study above: Is this patient requesting to be euthanized or for her physician to assist in her suicide (PAS)? In your answer describe how the two terms differ. (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

3.

A managed care group may want to market their organization as being "the best" or "a leader" in providing certain services/ treatment. How can this type or marketing effect quality of care and utilization of services, hence costs? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

4. According to Darr, MCO enrollees can be described as either light/moderate users or heavy users. What are some of the strategies that management uses to turn "heavy" users into light/ moderate users? In your personal opinion, what positives or negatives may result? (Minimum of 2 paragraphs including in-text citations and references in proper APA format)

5. Describe the constraints/challenges that physicians experience as being service providers affiliated with a Managed Care Organization. (Minimum 2 paragraphs including in-text citations and references in proper APA format)

6. Give a very brief "real-life" example/instance where drugs/ medical treatment/services were microallocated. And give a "real-life" example of macroallocation. (Do not include the examples provided in the text.) (Minimum 1 paragraph including in-text citations and references in proper APA format)

7. Read the case of Karen Ann Quinlan (p. 248-249). Explain why this is a case involving medical futility. (Include in your an answer the definition of medical futility). Darr (2011, p. 218) writes, "[the] futility theory has quantitative and qualitative aspects." What is meant by these terms? Present arguments for each as it relates to this case. (Minimum 2 paragraphs including in-text citations and references in proper APA format)

Reference:

Darr, K. (2011). Ethics in Health Services
Management. (Fifth Edition).
Baltimore, MD: Health
Professions Press, Inc.

8. Having just completed this class, what do you now know that you did not know before?