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References

Running head: DISCONTINUING WARFARIN The Ethical Implications of Discontinuing Warfarin Therapy in the Cognitively Impaired Patient Elizabeth Gardner Texas Woman's University Running head: DISCONTINUING WARFARIN The Ethical Implications of Discontinuing Warfarin Therapy in the Cognitively Impaired Patient Summary of the Case Study
Kathryn Mead is a 65-year-old African American female from Dallas who has been a patient in the Anticoagulation Monitoring Clinic (AMC) for 5 years. She was referred by her primary care provider for management of her warfarin therapy, which she receives due to a history of recurrent deep venous thrombosis (DVT). She is seen by the author on a monthly basis to adjust her warfarin dose, based on the results of her international normalized ratio (INR). Her other diagnoses include bipolar disorder, hypertension, bilateral degenerative joint disease of the knees, history of tubulovillious adenoma, and syphilis. She was diagnosed with Alzheimer's disease in August 2009. She also has a history of falls despite use of a walker but has had no serious injuries to date. Her medications include Detrol, amlodipine, imipramine, sertraline, topiramate, depakote, warfarin, aspirin, and hydrocodone. Mrs. Mead lives alone. Her son travels frequently but is involved in her care. A visiting nurse assists her with medications. At her last clinic visit, Mrs. Mead was confused and agitated (see Appendix A). As this was a worrisome change from her baseline functioning, the author contacted patient's geriatric provider to discuss her observations. She also expressed concern for the patient's increasing cognitive dysfunction coupled with fall risk, precluding safe warfarin use. The geriatric provider answered with a question: What if the patient wants to stay on warfarin? General Ethical Dilemma
The patient and her health care providers are faced with difficult medical and ethical choices. The patient wants to continue warfarin treatment, but her Alzheimer's disease with its attendant cognition dysfunction may prevent her from being able to take the drug safely. The Running head: DISCONTINUING WARFARIN duty of the provider is to do no harm; however, continuing warfarin treatment places the patient in harm's way. Conversely, not continuing warfarin carries serious risks of thromboembolism. There are no studies that identify the safest option. Do the dual dangers of maleficence and impaired ability to give informed consent dictate that her autonomous desires be overridden? What course of treatment will provide the most benefits and the least risk to the patient? In addition, the issue of justice simmers in the background. Her socioeconomic status as an elderly African American female places her at risk for disparate treatment. This paper will attempt to dissect these issues and formulate a safe, effective, and ethically sound treatment plan. Stakeholders in the Issue
The primary stakeholders are the patient and her family. A decision in any direction can lead to profound disability or death. Patients with similar medical predicaments are also stakeholders, as individual cases have the potential to become standardized practice. Also affected are her primary care provider and nurse, as they care for this patient regardless of the outcome. This author is affected, as she will need to deal with the ramifications of negative outcomes based on her recommendations. Secondary stakeholders are Medicare and society as a whole; an adverse outcome in any direction will be costly to the system. Background Information
Rationale for Treatment with Warfarin
Deep vein thrombosis (DVT) usually arises in the calf veins. Untreated, 20% of calf vein thrombi extend into the proximal venous system. Of these, 10% will cause fatal pulmonary embolism, and another 50% will cause pulmonary embolism or recurrent venous thrombosis (Pineo & Hull, 2005). Warfarin is highly effective for preventing recurrent venous thromboembolism (VTE) (Kearon, Kahn, Agnelli, Goldhaber, Raskob, & Comerota, 2008). This Running head: DISCONTINUING WARFARIN patient has had three episodes of DVT, with her last episode recurring two months after discontinuing therapy. In this scenario, patients require lifelong treatment with warfarin (Anderson, 2005). Risks Associated With Warfarin
Managing warfarin therapy has been described a "high-wire balancing act", with success partially determined by avoidance of two equally serious clinical failures: over-anticoagulation and under-anticoagulation (McCormick, 2005, p. 14.1). The most common anticoagulation- related bleeding sites associated with warfarin with significant morbidity are gastrointestinal, genitourinary tract, and soft tissue injuries (Byeth, 2005). The most serious complication of warfarin therapy is intracranial hemorrhage (ICH), which causes 90% of the deaths and most of the permanent disability from warfarin – associated bleeding (Hart, 2009). Rates of anticoagulation-related ICH range from 0.3 to 2.0% each year. Adding aspirin therapy to warfarin doubles the risk of ICH. Patients on warfarin need to be able to take warfarin correctly and consistently, adhere to dietary recommendations, avoid certain medications, keep appointments for INR monitoring, and recognize and respond to symptoms of excessive bleeding. Alzheimer's disease consists of progressive impairment of memory, orientation, language, judgment, problem solving, and perception. The concern is that Mrs. Mead's declining cognitive function interferes with her ability to fulfill these criteria, while her history of falls puts her at risk for serious bleeding and hemorrhage. Ethics Section
The ethical duties of this author in this case study are to avoid harming the patient, provide benefits, maintain patient autonomy, and promote justice. Conflict immediately arises when attempting to reconcile the competing demands to fulfill the ethical imperatives of Running head: DISCONTINUING WARFARIN autonomy and nonmaleficence. This dilemma has been described by Miller, who stated, "In clinical bioethics, the right to autonomy of individuals is in tension with healthcare professionals' obligations to benefit patients" (1995, p. 246). The preeminence of autonomy is described by Grace (2009 p. 19) as being "one of the powerful moral principles framing Western social and political system." As such, it will be addressed first. Autonomy
The word "autonomy" is derived from the Greek word for "self-law" or "self rule" and means the moral right to choose and follow one's own plan of life and actions or the moral ability to identify and pursue our goals (Merriam-Webster online, 2009). The moral philosopher Kant (1785/1967, p. 317) asserted, "Because human beings have the ability to reason, decide and act, they should be free to make their own personal decisions without interference." This right is reinforced within the patient- provider relationship by the provider's duty of fidelity. Miller (1995,p 246 ) describes three elements of the psychological capacity of autonomy: (a) agency, recognizing that one's self has desires and intentions and acting on them; (b) independence, the absence of influences that control a person to the degree that it cannot be said he or she wants to do it; and (c) rational decision-making, which requires that one's beliefs are subject to truth and evidence, the ability to recognize commitments and act on them, change their decisions based on their beliefs, and make commitments based on their beliefs and values. When these criteria are met, the patient is able to give true, informed consent. Lo (2009, p. 77) described an assessment of informed consent by asking three questions: (a) Can the patient make decisions and communicate choices? (b) Does the patient understand the medical issues and prognosis? (c) Running head: DISCONTINUING WARFARIN Does the patient understand the plan of care, the alternatives to this plan of care, and the risks and benefits resulting from this plan of care? In Mrs. Mead's case, impending dementia may decrease her ability to give true informed consent. Swonger and Burbank (2005) observed that mental capacity may be diminished in the elderly due to the nature of disease processes as well as changes in capabilities that accompany aging. They recommend that the patient's mental competency be evaluated if this is suspected. If her ability is diminished, a proxy should be designated to assist her with decision-making. If the patient is considered competent and wants to continue warfarin, her desires need to be respected. As much as the right to autonomy is seen as a foundation in our culture, societal expectations necessitate that physicians keep the vows of Primum non nocere: "Above all, do no harm" (Soskolne & Sieswerda, 2002). There is a considerable potential for adverse outcomes when continuing warfarin in the setting of cognitive dysfunction and fall risk. A fall could result in an inter-cerebral hemorrhage or other internal bleeding. The patient may inadvertently underdose herself, which would lead to another thrombosis, while an overdose could lead to hemorrhage. She may be unable to maintain the dietary restrictions necessary to keep her INR within therapeutic range. She may not be able to recognize and respond to symptoms of excessive anticoagulation. Conversely, as discussed previously, not continuing warfarin carries a great risk of morbidity and mortality from pulmonary embolism. There are no definitive studies to help guide treatment options. Jacob, Billet, Freeman, Dinglas, and Jumquio (2009) completed a retrospective observational study of closely monitored nursing home patients with a history of falls and dementia. The indication for treatment was atrial fibrillation and the mean age was 82. Jacob et al. concluded that these patients had low rates of stroke, hemorrhage, and death. The Running head: DISCONTINUING WARFARIN results of these findings cannot be applied in this case, as Mrs. Mead lives alone without the benefit of 24-hour per day observation and assessment. Beneficence
Beneficence, like nonmaleficence, is central to the Hippocratic Oath. It is the obligation to provide benefits or seek the welfare of another. (Churchill, 1995). The medical benefits of continuing warfarin are the reduced probabilities of recurrence of DVT and its associated risks of thromboembolism and post-phlebitis syndrome. The patient may also experience the emotional benefit of knowing that the risk of recurrent DVT is substantially diminished. The benefits of stopping warfarin include the termination of the risk of bleeding and injuries associated with therapy, as well as the freedom from the emotional, physical, and fiscal burden of monthly appointments, dietary and medication restriction, and surveillance for signs of excess anticoagulation. Beneficence, Malefience and Ethical Theories
Deontology is the study or science of duty. (Encyclopedia Britannica Online, 2009). Deontological theory claims that actions are either good or evil, while the result or product of the action is not considered ethically important. An act has moral worth if it fulfills and obligation. As such, deodontic theory does not serve to inform us in this case. While principled motivations are necessary, the needs of this patient extend beyond virtuous intentions. Failure to determine the most medically sound solution could result in a serious negative outcome. It would be doubtful that the patient and her family would find comfort from the principled intentions of her provider if she were to suffer an intracranial hemorrhage. Conversely, the provider could have malevolent intentions but inadvertently have a good patient outcome. The theory of utilitarianism also does not help enlighten the decision. Naverson and Wellman (1970) Running head: DISCONTINUING WARFARIN describe utilitarianism as being a theory that ranks outcomes from an impersonal standpoint. Utilitarians consider that the best outcomes are those that contain the greatest amount of collective individual welfare. How can one treatment decision affect the health, happiness and freedom of the majority? In a society where health care rationing was in effect, a utilitarian might argue that continuing therapy is a waste of resources in a patient with these diagnoses, as it diverted resources from the majority. The ethics of risk versus benefit analysis was evaluated to help provide ethical clarification. Hansson (2007, para.1) defines risk as being the probability of an unwanted event which may or may not occur. He notes that this theory has been not been widely discussed, as it has been left to the arena of decision theory. He does explain that moral philosophy assesses human behavior in well-determined situations. Decision theory takes these assessments, adds the probabilities and derives assessment for behavior . This theory is not able to be utilized as there is no information about statistical probabilities in these circumstances. The ethics of justice consist of "an ethical perspective in terms of which ethical decisions are made on the basis of universal principles and rules, and in an impartial and verifiable manner with a view to ensuring the fair and equitable treatment of all people" (Botes, 2000, p. 1072). Rawls (1971) asserted that justice is the most important asset of social institutions. Beauchamp and Childress (2009) maintain that there is racial, ethnic, and gender discrimination in health care. Smedley, Stith, and Nelson (2003) discussed how, despite steady improvement in the overall health of Americans, racial and ethnic minorities still experience higher rates of morbidity and mortality than non-minorities. African- Americans have the highest rates of mortality for cancer, heart disease, cerebrovascular disease, and HIV/AIDS than any other group. Running head: DISCONTINUING WARFARIN Smedley et al. admitted that the reasons for the differences are complex but maintained that at least one of the factors is the direct and indirect consequences of discrimination. Mrs. Mead, as an elderly, cognitively impaired African American female, is at high risk for inequitable treatment. There are no data telling us exactly what therapy a middle class male Caucasian with the same risk factors would receive. Presence of family members to advocate for the patient and healthcare providers cognizant of this issue can help ensure Mrs. Mead receives thoughtful and An Alternate Way of Reasoning
The American Nurses Association (ANA, 2009) code of ethics states that nurses must practice with compassion and respect for the inherent dignity, worth, and uniqueness of every human being. In addition, nurses must promote, advocate for, and strive to protect the health, safety, and rights of each patient (ANA). In Jean Watson's caring theory, nurses provide a supportive, protective, and/or corrective physical, socio-cultural, and spiritual environment (Cara, 2003). The ethical provision for these directives is fulfilled in this case analysis. The individual risk versus benefit analysis acknowledges the inherent uniqueness of Mrs. Mead. The role of the author in conferring with patient and healthcare providers fulfills the need of the patient for an advocate to protect her health, safety and rights. Finally, the author creates a protective environment by developing a patient safety net to minimize harm and maximize benefits of therapy. Legal Issues
The FDA's Adverse Event Reporting System determined that warfarin is one of the top 10 drugs that reported the largest number of severe unfavorable events from 1990 to 2005. Wysowski, Nourjah, and Swartz (2007) found the following: Running head: DISCONTINUING WARFARIN From U.S. death certificates, anticoagulants ranked first in 2003 and 2004 in the number of total mentions of deaths for drugs causing adverse effects in therapeutic use. Data from hospital emergency departments for 1999 through 2003 indicated that warfarin was associated with about 29,000 visits for bleeding complications per year, and it was among the drugs with the most visits. (p. 1414) McCormick (2005) stated the negative information about warfarin has given lawyers ammunition to initiate litigation for medical malpractice and professional negligence. The Internet abounds with advertisements for "warfarin lawyers" willing to assist clients who perceive they have been injured while on this therapy. In 2008, there were 18 cases regarding either complications, failure to monitor properly, or inappropriate indications related to the use of warfarin (McCormick). Bungard, Ghalie, Teo, McAlister, and Tsuyuki (2000) found the plaintiffs won the majority of the cases, with some of the settlements for more than 1 million dollars. Concern about litigation influences physicians' prescribing patterns. Bungard et al. describes fear of litigation as a reason for physicians to under-prescribe warfarin in patients who could benefit from this therapy. Lo (2009) believes that healthcare providers are held more accountable for their actions than their omissions, causing them to be reluctant to prescribe the more risky therapies. The following case from the Journal of Family practice identifies part of the solution. Susman (2009) discussed the case of a 37-year-old man with a history of stroke due to a hypercoaguable state who was placed on warfarin. Therapy was discontinued several years later when his hypercoaguable state had resolved. He then had another large stroke, for which he received a 3.1 million dollar settlement. Susman's comment was "by documenting a careful discussion of benefits and harms and consulting with experts, a date in court can sometimes be avoided" (p. 385). In this case, fulfilling ethical duty to provide fully informed Running head: DISCONTINUING WARFARIN consent also provides the best legal prevention. Wysowski et al. suggested other ways for healthcare providers to prevent legal liability. He recommends establishing, maintaining, and documenting communication with family and other healthcare providers. He also advises monitoring patients to ensure they keep appointments in clinics and that the results of blood tests are in therapeutic range. Personal Decision
This author supports the continued use of warfarin, but with qualifications. The reason for her support is that thrombosis is almost certain to reoccur without treatment. In contrast, the available literature suggests that the risk of death from internal bleeding is less of a threat. Mrs. Mead has indicated she wants to continue therapy. She has been able to keep appointments. Her INR results have been within range for 13 of 16 visits (see Appendix B). She has a home health nurse to set up and monitor her medication use. The qualifications would be that Ms. Meads receive neuropsychiatric testing to determine the stage of her Alzheimer's disease and start drug therapy if indicated. This author also recommends surgical consultation to determine if the patient is a candidate for placement of an inferior vena cava (IVC) filter. This author recommends that aspirin therapy be discontinued. A proxy decision maker (presumably her son) should be identified now due to the progressive nature of Alzheimer's disease, and advance directives should be completed. The patient needs to continue receiving home health nursing services. Her ability to safely continue warfarin should be reassessed every 6 months or whenever there is a change in her condition. Warfarin therapy has the power to both extend life and to shorten it and requires careful monitoring to realize its benefits and curtail negative outcomes. This ability creates medical and Running head: DISCONTINUING WARFARIN ethical dilemmas in situations where warfarin is strongly indicated, but the risks of adverse events are also great. The risks and benefits of warfarin therapy were examined through the ethical lenses of nonmaleficence, beneficence, autonomy, and in consideration of the principle of equitable care. A plan was developed to address safety concerns. With this in place, this author believes that the most medically and ethically sound decision at this time is to continue warfarin Running head: DISCONTINUING WARFARIN References
American Nurses Association. (2009). Code of ethics. Retrieved November 3, 2009, from Anderson, D. (2005). Duration of anticoagulation therapy in venous thromboembolic disease. In A. E. Ansell, L. B. Oertel, & A. K. Wittkowsky (Eds.), Managing oral anticoagulation therapy (pp. 42.1–42.6). St. Louis, Missouri: Wolters Kluwer Health. Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press. 2000). A comparison between the ethics of justice and the ethics of care. Journal of Advanced Nursing, 32(5), 1071–1075. Retrieved from Bungard, T. J., Ghalie, W. A., Teo, K. K., McAlister, F. A., & Tsuyuki, R. T. (2000). Why do patients with atrial fibrillation not receive warfarin? Archives of Internal Medicine, 160, Byeth, R. J. (2005). Assessing risk factors for bleeding. In A. E. Ansell, L. B.Oertel, & A. K. Wittkowsky (Eds.), Managing oral anticoagulation therapy (pp. 32.1–32.5). St. Louis, MO: Wolters Kluwer Health. Cara, C. (2003). A pragmatic view of Jean Watson's caring theory. International Association for Human Caring Journal, 7(3), 51–61. Retrieved from Running head: DISCONTINUING WARFARIN Encyclopedia Britannica online. (2009). Deontology. Retrieved from Churchill, L.R (1995). Beneficence. Encyclopedia of bioethics (3rd ed) pp.269-273. New York: Macmillan. Grace, P. J. (2009). Nursing ethics and professional responsibility in advanced practice. Sudbury, MA: Jones and Bartlett. Hart, R. G. (2009). Risk of intracerebral hemorrhage in patients treated with warfarin. Retrieved Hansson, S. (2007) Risk, The Stanford Encyclopedia of Philosophy (Winter 2008 Edition), Edward N. Zalta (ed ) Retrieved from Jacobs, L., Billett, H., Freeman, K., Dinglas, C., & Jumaquio, L. (2009). Anticoagulation for stroke prevention in elderly patients with atrial fibrillation, including those with falls and/or early-stage dementia: A single-center, retrospective, observational study. The American Journal of Geriatric Pharmacotherapy, 7(3), 159–166. Retrieved from Running head: DISCONTINUING WARFARIN b6209dd1fd4791d5712d. Kant, I. (1967). Foundations of the metaphysics of morals. In A. I. Melden (Ed.), Ethical theories: A book of readings (pp. 317–366). Englewood Cliff, NJ: Prentice- Hall. (Original work published in 1785) Kearon, C., Kahn, S., Agnelli, G., Goldhaber, S., Raskob, G., & Comerota, A. (2008). Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 133(6 S), 454s–545s. Retrieved from http://ezproxy.twu.edu:2124/sites/entrez. Lo, B. (2009). Resolving ethical dilemmas: A guide for clinicians (4th ed.), Philadelphia: Lippincott Williams & Wilkins. McCormick,W. P. ( 2005). Medical-legal implications of anticoagulation therapy. In A. E. Ansell, L. B.Oertel, & A. K. Wittkowsky (Eds.). (2005). Managing oral anticoagulation therapy (pp. 14.1–14.7). St. Louis, MO: Wolters Kluwer Health. Miller, B. L. (1995). Autonomy. Encyclopedia of bioethics (3rd ed., pp. 246–251). New York: Macmillan. Retrieved from acd2583&version=1.0 Merriam-Webster online. (2009). Definition of autonomy. Retrieved from Running head: DISCONTINUING WARFARIN Naverson , J. and Wellman,C. (1970) Utilitarianism and moral norms. The Journal of Value Inquiry, 4(4) pp. 273-286. DOI 10.1007/BF00137937 Pineo, G. F., & Hull, R. D. (2005). Prevention and treatment of venous thromboembolism. In A. E. Ansell, L. B. Oertel, & A. K. Wittkowsky (Eds.), Managing oral anticoagulation therapy (pp. 20:1–20:22). St. Louis, MO: Wolters Kluwer Health. Rawls, J. (1971). A theory of justice. Cambridge, MA: The Belknar Press of Harvard University Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Retrieved fr Soskolne, C. L., & Sieswerda, L. E. (2002). Nonmaleficence. Encyclopedia of public health (pp. 826–827). New York: Macmillan. Retrieved November 16, 2009, from acd2583&version=1.0 Susman, J. L. (2009). Discontinued anticoagulant blamed for stroke.
Retrieved November 16, 2009, from Swonger, A. K., & Burbank, P. M. (2005). Drug therapy and the elderly. Boston: Bartlett and ,, & (2007). Bleeding complications with warfarin use: A prevalent adverse effect resulting in regulatory action. Archives of Internal Medicine, 167(13), 1414–1419. Retrieved from http://ezproxy.twu.edu:2124/sites/entrez Running head: DISCONTINUING WARFARIN Running head: DISCONTINUING WARFARIN Appendix A
Patient Clinic Data Running head: DISCONTINUING WARFARIN Anticoagulation Management Clinic
Progress Note
Pt expressing irritation and is agitated today: "Those Medicaid people told me you gave me the wrong medicine. And they kept asking me the same thing over and over again! They told me to have you fill this form out for me." Form is a two-page document that apparently originated from pharmacy. Discusses risks of addiction when using Lortab, and requires patient's signature. She is unable to tell me purpose of form or which medication was thought to have been prescribed incorrectly. Meds not with her. Pt is ambulating slowly with walker. INR today - therapeutic @ 2.3 suggests she is taking the correct strength of warfarin, will not change dose. Pt knows location of geriatric clinic on the second floor. Arranged for her to see geriatric social worker now for assistance with form, Medicaid issues. RTC 1 month. Emailed PCP with concerns about patient's confusion, mental status seems worse, question if warfarin is still a safe option for her. Elizabeth Gardner, RN, FNP Running head: DISCONTINUING WARFARIN Appendix B
Patient Flow Sheet Running head: DISCONTINUING WARFARIN Anticoagulation Management Clinic
Patient Flow Sheet Patient: Kathryn Mead Indication: Recurrent DVT Comments
Swelling R leg 2 "Just feel sick" Running head: DISCONTINUING WARFARIN Anticoagulation Management Clinic
Patient Flow Sheet Running head: DISCONTINUING WARFARIN Appendix C
Case Consultation- Worksheet A Running head: DISCONTINUING WARFARIN Case Consultation
Step 1: Personal Responses
This patient seems to have declining cognitive function. She is on warfarin. Is she becoming too cognitively impaired to safely be on warfarin? Step 2: Facts of the Case
1. Deep vein thrombosis has the potential to kill. 2. Warfarin is effective in preventing deep vein thrombosis. 3. Warfarin also has the potential to cause internal bleeding and with it, serious injury or death. 4. Warfarin therapy requires careful monitoring to prevent side effects. 5. This patient has risk factors that preclude her from taking this medication safely. She is cognitively impaired due to Alzheimer's disease. Her psychiatric medications may be contributing to the dysfunction. She is at risk to fall and hemorrhage. Step 3a: Clinical/Psychosocial Issues Influencing Decision
Desires of patient and family member. Level of confusion and dementia. Ability to give informed consent. Gait instability/fall risk. Stability of INRs. Presence of support systems. Desire of primary care provider. Availability of alternative regimen. Running head: DISCONTINUING WARFARIN Step 3b: Initial Plan Step 2: Facts of the Case
Assess capacity to give informed consent. Discuss risks versus benefits of treatment with patient, son, and PCP. Determine patient and son's desires and concerns. Assess and confirm support systems. Determine frequency and intensity of falls. Step 4: Policies & Ethical Code Directive
Nonmaleficence – do no harm- avoid interventions that may bring harm to patient. Beneficence – provide benefits and promote welfare of patient. Maintain autonomy. Follow anticoagulation clinic policy and procedures: Consult with supervising MD in complicated cases. Step 5: Ethical Principles Analysis
The absolute risk versus benefit status is not known. Ethical justifications to continue warfarin: Nonmalefience: Stopping warfarin will most likely precipitate a recurrence of
thromboembolism with its attendant risks of pulmonary embolism and death. Beneficence: Continuing warfarin therapy will prevent recurrent thromboembolism and post
phlebitis syndrome. Autonomy: Patient may want to continue warfarin. To discontinue warfarin would be a
violation of patient's autonomy. Her decision-making capacity, a function of her autonomy, may be impaired because of cognitive dysfunction. Running head: DISCONTINUING WARFARIN Ethical justifications to stop therapy:
Nonmaleficence: Will prevent adverse bleeding events.
Beneficence: Patient no longer has to fear falling, have blood tests, close monitoring, or follow
dietary restraints. Justice: Patient is at risk for disparity of care due to socioeconomic status regardless of
Step 6: Possible Legal Issues
The patient and family need to be clearly informed of the risks versus benefits of this therapy. If not, the clinic could be considered liable for adverse outcome. Running head: DISCONTINUING WARFARIN Appendix D
Case Consultation: Worksheet B Running head: DISCONTINUING WARFARIN Case Consultation: Worksheet B
Plan & Implementation Strategy Refer for formal neuropsychiatric testing to assess level of dementia. Discuss with PCP: Is patient a candidate for Alzheimer's drug? Assess and verify support systems (i.e., RN for medication assistance). Monitor level of compliance: Is patient able to keep appointments, and are her INRs stable? Stop aspirin due to increased bleed risk. Consider alternate therapies: Low dose/low intensity warfarin - does not prevent DVT. Low molecule weight heparin (enoxparin): Very expensive, patient needs to be able to inject herself twice daily , which she is unable to do. Placement of Inferior Vena Cava filter (surgery consult). Formally reassess plan every 6 months or if change in condition. Running head: DISCONTINUING WARFARIN Write down how your plan: Advances Clinical/Psychosocial Interests: (a) informs family and other healthcare providers of the clinical issues, identifies the need for increased patient assistance, and evaluates which option will be safest for patient. (b) identifies other treatment options. (c) addresses major patient safety issues: The core purpose of this assessment is to reduce adverse patient outcomes. This is done by analyzing the risk versus benefits of therapy and formulating interventions to minimize harm and maximize benefit. (d) adheres to agency policies and professional ethics codes: No specific agency policy exists for cases like this. The general agency policy of consulting with the patient's primary care provider and the Anticoagulation Management Clinic supervising physician in the event of complicated cases has been fulfilled. Completion of a risk versus benefit analysis fulfills the ANA code of ethics that requires nurses to protect the health, safety, and rights of the patient. (e) minimizes harm and maximizes other ethical principles to the extent possible for the client and relevant others: It minimizes harm by creating a safety net of ongoing support and assessment while allowing the patient to realize the benefits of therapy. (f) allows you to operate within the law: Risks and benefits are thoroughly discussed with primary stakeholders, and results are well documented, reducing the possibility of successful litigation in the event of an adverse outcome.

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Survey Results & analysis for Global survey of models of preclinical TB drug testing This report contains a detailed statistical analysis of the results to the survey titled Global survey of models of preclinical TB drug testing . The results analysis includes answers from all respondents who took the survey (30 completed responses were received to the survey up to this time)