Review the following case and respond. In your commentary, identify, analyze and discuss the legal and ethical issues presented. Additionally, consider the four principles of ethics discussed in the first chapter and incorporate into your response. Case Study An eighty three year old man with a long history of diabetes and peripheral vascular disease is admitted to the hospital with evidence of ischemia and infection of his right lower leg. In the past, he has had a transmetatarsal amputation of the right foot and also a femoral-popliteal bypass on the right. The patient, Mr. Irving, has been meticulous in his efforts to control his diabetes and careful in the care of his feet. Unfortunately, on the day prior to his admission, he noticed purulent drainage from the amputation site on his right foot with surrounding erythema and red streaking up his leg. Over the next day, the erythema progressed up to his knee and the lower leg became swollen and warm. He called his physician who saw him later that afternoon and admitted him to the hospital with the diagnoses of cellulitis, diabetes out of control (likely secondary to his infection) and peripheral vascular disease. Mr. Irving was very concerned about the infection and felt quite ill. He was begun on intravenous antibiotics and a vascular surgeon was called in consultation. Despite aggressive therapy, Mr. Irving’s infection was barely held in check. The consulting vascular surgeon felt it likely that an above the knee amputation would be required to save Mr. Irving’s life. Mr. Irving’s primary care physician, Dr. Smith, spoke with his patient about the surgeon’s recommendations. Dr. Smith explained that the antibiotics would be continued for a few days but it seemed unlikely that the infection would respond. She agreed with the surgeon’s recommendation and urged Mr. Irving to agree to the proposed right above the knee amputation. During the discussion, at Mr. Irving’s request, his three children were present. Mr. Irving’s wife had died five years previously. After the death of his wife, he requested to be DNR. He lived alone with help from his children who were all supportive, loving, and concerned. Mr. Irving thanked Dr. Smith for her concern and understood that she and the surgeon felt it likely that he would die if he did not have the amputation. Mr. Irving made it clear, however, that he felt he had lived a long and good life, that he was tired of fighting the diabetes, and that he recognized that an above the knee amputation would likely mean that he would need to go to a nursing home. He found that an unacceptable option. Mr. Irving also expressed his feeling that he was born with two legs and two arms and “I plan to die with two legs and two arms. I know I may well die if I do not have this amputation but I will not have it done.” Mr. Irving’s children were visibly upset by their father’s response. His older son spoke with Dr. Smith and told her: “My Dad is just depressed, he must have this operation. You have to make him have it.”
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