Question

Marguerite M., an 89-year-old widow, is admitted into the cardiac intensive care unit in Chicago’s Memorial Hospital at 3:00 A.M. on a Sunday morning with a massive heart attack (myocardial infarction). Her internist, Dr. K., who is also a close family friend, has ordered an angiogram to determine the status of Marguerite’s infarction (heart attack). Dr. K. knows that the angiogram and resulting treatment need to be done within the first six hours after an infarction in order to be effective. Therefore, the procedure is going to be done as soon as the on-call surgical team can set up the angiography room. The radiologist, who lives thirty minutes from the hospital, must also be in the hospital before the procedure can begin. At 4:30 A.M. the team is ready to have Marguerite, who is barely conscious, transferred from the intensive care unit (ICU) to the surgical suite. Coincidentally, at 4:30 A.M. Sarah W., an unconscious 45-year-old woman, is brought in by ambulance with a massive heart attack. The emergency room (ER) physicians, after conferring with her physician by phone, conclude that she will need a balloon angiography (dilating an obstructed blood vessel by threading a balloon-tipped catheter into the vessel) to save her life. When they call the surgical department to have the on-call angiography team brought in, they are told that the room is already set up for Dr. K.’s patient. They do not have another team or surgical room for Sarah. A decision is made that because Sarah needs the balloon angiography in order to survive, they will use the angiography team for her. Dr. K. is called at home and told that his patient, Marguerite, will not be able to have the angiogram. The hospital is going to use the angiography team for Sarah, because she is younger than Marguerite and has a greater chance for recovery. Unfortunately, it took longer than expected to stabilize Sarah before and after the procedure and the six-hour “window” when the procedure could be performed on Marguerite passed. Marguerite expired (died) the following morning. Do you believe that this case presents a legal or an ethical problem, or both? What do you believe should be the criteria for a physician to use when having to choose a solution that will benefit one patient at the expense of another? How can Dr. K. justify this decision when speaking to the family of Marguerite M.? What options does a member of the angiography team or a caregiver for Marguerite have if he or she disagrees with this decision? Why is the ability to determine when death has occurred so critical in today’s healthcare environment?

Answer 1

• Ethics are related to human principles and rights.Law is legal standardised issues.

The following issue can become an ethical issue because of delay in the delivery of the care.But it can become a legal issue if the clients family put uos case against that.

• In the presented case Ms Marguerite M is 89 year old and can undergo angiogram within 6 hours but the other case that is Ms Sarah 45 year who came with massive attack needs immediate attention.By considering the 2 cases if we prioratize Ms Sarah needs immediate treatment so the doctor can give the treeatment to the patient who needs immediate care.And if we think of time factor 6 hours are there to do angiogram for Ms Marguerite.Thinking that the doctor might have opted to treat Ms Sarah.
• Dr K can justify his decision by explaining regarding the prioty based care to the family members.Ms Sarah came with massive attack who needs immediate care that is immediate ballon angioplasty should be done to save her life but Ms Marguerite need not angiogram immediately and she is also 89 year old the priority goes to treat Ms Sarah.When we compare the recovery c also chances of good recovery will be more for Sarah when compared to Marguerite.The unexpected thing is the procedure for Sarah took long time in order to stabilize the condition.
• Angiogram is a therapeutic as well as diagnostic procedure for myocardial infarction.This procedure helps us to detect any norrowing of blockage of arteries.In some cases treatment need to be started based on the report of the angiogram.

Initially we can treat the patients with aspirin 150-300 mg in suspected cases of myocardial; infaction.

Another treatmen is starting the fibrinolytic therapy which includes the following

-tissue plasminogen activator

-streptokinase

But these drugs are not used in all the cases.

The common indications are

-chest pain lasting for atleast 30 minutes.

who came to hospital within 4 hours of onset of signs and symptoms

-ST segment elevation in ECG.

-who are aged less than 75.

Contraindications:

-known cerebrovascular issues.

-any trauma

-malignancy

-uncontrolled hypertension

-intracranial haemorrhages

-dementia.

-prior use of anticoagulants.

Based on the indications and contraindications they can start the fibrinolytic therapy.

• Here in this scenario Ms Marguerite had already posted for angiogram since there is another case the doctor preferred to treat Ms Sarah since the chances for recovery is more.Because o fthis decision the life of patien is lost.So proper decion making is not only the measure even the follow up of the other case and even making an alternate management for Marguerite is also important or some measure might have taken to refer the client ot some other area where they can make arrangements for the angiogram.Other option is they might have planned to do the procedure immediately after finishing angiogram to Ms Sarah.

Since the technology is improved and all facilities are avialable for the patient care even the health care system it is easy to initiate the emergency management for a client.But in some cases the severity may not be able to determine which make the health care profesionals to face the challanges.