Author: Judy

This paper should be double spaced and be 4-6 pages in 12 point New Times Roman font. Include a cover page [not counted as a page] which should have student name and title of your paper. Must have at end of the paper a list of references in APA Format [not counted as a page]. No deduction if paper exceeds a page or so. But deduction of 2 points from the 25pts paper is worth if paper is less than 4 pages. The paper is to be posted in Assignment #4 drop box. Paper should be submitted in word doc. No pdf papers as I cannot post  my comments in your paper.

Paper must be submitted by last day of class. No late papers accepted after last day of class.

The final project for this course is an analysis of the legal and ethical issues involved in the below health care scenario.A 72 year old woman was admitted to the Neurological Intensive Care Unit following a cerebral hemorrhage which left her with severe brain damage and ventilator dependent. One year before this event, the patient and her husband had drawn up “living wills” with an attorney. She was diagnosed by her treating physician as being in a permanent unconscious condition. The patient’s living will specified that the patient did not want ventilator support or other artificial life support in the event of a permanent unconscious condition or terminal condition.

The patient’s husband is her legal next of kin and the person with surrogate decision-making authority. When the living will was discussed with him, he insisted that the patient had not intended for the document to be used in a situation like the present one. Further discussion with him revealed that he understood that the patient would not be able to recover any meaningful brain function but he argued that the living will did not apply because her condition was not imminently terminal. He further indicated that he did not consider his wife to be in a permanent unconscious condition.  The immediate family members (the couple’s adult children) disagreed with their father’s refusal to withdraw life support.

The treatment team allowed a week to pass to allow the husband more time to be supported in his grief and to appreciate the gravity of his wife’s situation.  Nevertheless, at the end of this time, the husband was unwilling to authorize withdrawal of life support measures consistent with the patient’s wishes as expressed in her living will.

List and discuss the three most important ethical/legal issues in this scenario [Just three]. Why are they legal /ethical issues?  Be sure and define the concepts you discuss. As a health care provider, how would you have handled this situation and why? 

Use as headings in your paper the three legal/ethics issues you pick to discuss. 

You are on the honor system not to discuss or  consult with any students or other individuals about this paper. You may use the information we have discussed in the class, the articles in the class, and the article I have furnished below but you may NOT do internet research on this topic.

Background info to get your mind going and principle article to use to evaluate the facts in the scenario. This article is more than a sufficient aid to help you determine the three most important issues and also assist you in formulating your discussions for each issue. 

Relationships: I. clinical ethics, law & risk managementDefinitions and sources of authority

In the course of practicing medicine, a range of issues may arise that lead to consultation with a medical ethicist, a lawyer, and/or a risk manager. The following discussion will outline key distinctions between these roles. Clinical ethics may be defined as:  a discipline or methodology for considering the ethical implications of medical technologies, policies, and treatments, with special attention to determining what ought to be done (or not done) in the delivery of health care.   Law may be defined as: established and enforceable social rules for conduct or non-conduct; a violation of a legal standard may create criminal or civil liability. Risk Management may be defined as: a method of reducing risk of liability through institutional policies/practices.

Many health care facilities have in-house or on-call trained ethicists to assist health care practitioners, caregivers and patients with difficult issues arising in medical care, and some facilities have formally constituted institutional ethics committees. In the hospital setting, this ethics consultation or review process dates back to at least 1992 with the formulation of accreditation requirements that mandated that hospitals establish a “mechanism” to consider clinical ethics issues.

Ethics has been described as beginning where the law ends. The moral conscience is a precursor to the development of legal rules for social order.  Ethics and law thus share the goal of creating and maintaining social good and have a symbiotic relationship as expressed in this quote:

[C]onscience is the guardian in the individual of the rules which the community has evolved for its own preservation.  William Somerset Maugham

The role of lawyers and risk managers are closely linked in many health care facilities. Indeed, in some hospitals, the administrator with the title of Risk Manager is an attorney with a clinical background. There are, however, important distinctions between law and risk management. Risk management is guided by legal parameters but has a broader institution-specific mission to reduce liability risks. It is not uncommon for a hospital policy to go beyond the minimum requirements set by a legal standard. When legal and risk management issues arise in the delivery of health care, ethics issues may also exist. Similarly, an issue originally identified as falling within the clinical ethics domain may also raise legal and risk management concerns.

To better understand the significant overlap among these disciplines in the health care setting, consider the sources of authority and expression for each.

Ethical norms may be derived from:Law Institutional policies/practices Policies of professional organizations Professional standards of care, fiduciary obligations

Note: If a health care facility is also a religious facility, it may adhere to religious tenets. In general, however, clinical ethics is predominantly a secular professional analytic approach to clinical issues and choices.

Law may be derived from:Federal and state constitutions (fundamental laws of a nation or state establishing the role of government in relation to the governed) Federal and state statutes (laws written or enacted by elected officials in legislative bodies, and in some states, such as Washington and California, laws created by a majority of voters through an initiative process)   Federal and state regulations (written by government agencies as permitted by statutory delegation, having the force and effect of law consistent with the enabling legislation) Federal and state case law (written published opinions of appellate-level courts regarding decisions in individual lawsuits) City or town ordinances, when relevant

Risk Management may be derived from law, professional standards and individual institution’s mission and public relations strategies and is expressed through institutional policies and practices.

B.     Conceptual Models 

Another way to consider the relationship among the three disciplines is through conceptual models: LinearDistinctionsIntercommectdness

II. Orientation to law for non-lawyersPotential legal actions against health care providers

There are two primary types of potential civil actions against health care providers for injuries resulting from health care:  (1) lack of informed consent, and (2) violation of the standard of care. Medical treatment and malpractice laws are specific to each state.

1. Informed Consent. Before a health care provider delivers care, ethical and legal standards require that the patient provide informed consent. If the patient cannot provide informed consent, then, for most treatments, a legally authorized surrogate decision-maker may do so.  In an emergency situation when the patient is not legally competent to give informed consent and no surrogate decision-maker is readily available, the law implies consent on behalf of the patient, assuming that the patient would consent to treatment if he or she were capable of doing so.   

Information that must be conveyed to and consented to by the patient includes: the treatment’s nature and character and anticipated results, alternative treatments (including non-treatment), and the potential risks and benefits of treatment and alternatives. The information must be presented in a form that the patient can comprehend (i.e., in a language and at a level which the patient can understand) and that the consent must be voluntary given. An injured patient may bring an informed consent action against a provider who fails to obtain the patient’s informed consent in accordance with state law.

From a clinical ethics perspective, informed consent is a communication process, and should not simply be treated as a required form for the patient’s signature. Similarly, the legal concept of informed consent refers to a state of mind, i.e., understanding the information provided to make an informed choice.  Health care facilities and providers use consent forms to document the communication process. From a provider’s perspective, a signed consent form can be valuable evidence the communication occurred and legal protection in defending against a patient’s claim of a lack of informed consent.  Initiatives at the federal level (i.e., the Affordable Care Act) and state level (e.g., Revised Code of Washington § 7.70.060)  reflect approaches that support shared decision-making and the use of patient decision aids in order to ensure the provision of complete information for medical decision-making.

2. Failure to follow standard of care. A patient who is injured during medical treatment may also be able to bring a successful claim against a health care provider if the patient can prove that the injury resulted from the provider’s failure to follow the accepted standard of care. The duty of care generally requires that the provider use reasonably expected knowledge and judgment in the treatment of the patient, and typically would also require the adept use of the facilities at hand and options for treatment.  The standard of care emerges from a variety of sources, including professional publications, interactions of professional leaders, presentations and exchanges at professional meetings, and among networks of colleagues. Experts are hired by the litigating parties to assist the court in determining the applicable standard of care.

Many states measure the provider’s actions against a national standard of care (rather than a local one) but with accommodation for practice limitations, such as the reasonable availability of medical facilities, services, equipment and the like. States may also apply different standards to specialists and to general practitioners. As an example of a statutory description of the standard of care, Washington State currently specifies that a health care provider must “exercise that degree of care, skill, and learning expected of a reasonably prudent health care provider at that time in the profession or class to which he belongs, in the State of Washington, acting in the same or similar circumstances.”   

    III.            Common clinical ethics issues: medical decision-making and provider-patient communication

There are a number of common ethical issues that also implicate legal and risk management issues. Briefly discussed below are common issues that concern medical decision-making and provider-patient communication.

If a patient is capable of providing informed consent, then the patient’s choices about treatment, including non-treatment, should be followed. This is an established and enforceable legal standard and also consistent with the ethical principle of respecting the autonomy of the patient. The next two sections (Surrogate decision-making; Advance directives) discuss how this principle is respected from a legal perspective if a patient lacks capacity, temporarily or permanently, to make medical decisions. The third section briefly introduces the issue of provider-patient communication, and highlights a contemporary dilemma raised in decisions regarding the disclosure of medical error to patients.

            A.  Surrogate decision-making

The determination as to whether a patient has the capacity to provide informed consent is generally a professional judgment made and documented by the treating health care provider. The provider can make a determination of temporary or permanent incapacity, and that determination should be linked to a specific decision. The legal term competency (or incompetency) may be used to describe a judicial determination of decision-making capacity. The designation of a specific surrogate decision-maker may either be authorized by court order or is specified in state statutes.

If a court has determined that a patient is incompetent, a health care provider must obtain informed consent from the court-appointed decision-maker. For example, where a guardian has been appointed by the court in a guardianship action, a health care provider would seek the informed consent of the guardian, provided that the relevant court order covers personal or health care decision-making.

If, however, a physician determines that a patient lacks the capacity to provide informed consent, for example, due to dementia or lack of consciousness, or because the patient is a minor and the minor is legally proscribed from consenting, then a legally authorized surrogate decision-maker may be able to provide consent on the patient’s behalf.  Most states have specific laws that delineate, in order of priority, who can be a legally authorized surrogate decision-maker for another person. While these laws may vary, they generally assume that legal relatives are the most appropriate surrogate decision-makers. If, however, a patient has previously, while capable of consenting, selected a person to act as her decision-maker and executed a legal document known as a durable power of attorney for health care or health care proxy, then that designated individual should provide informed consent.

In Washington State, a statute specifies the order of priority of authorized decision-makers as follows: guardian, holder of durable power of attorney; spouse or state registered partner; adult children; parents; and adult brothers and sisters. If the patient is a minor, other consent provisions may apply, such as: court authorization for a person with whom the child is in out-of-home placement; the person(s) that the child’s parent(s) have given a signed authorization to provide consent; or, a competent adult who represents that s/he is a relative responsible for the child’s care and signs a sworn declaration stating so.  Health care providers are required to make reasonable efforts to locate a person in the highest possible category to provide informed consent. If there are two or more persons in the same category, e.g., adult children, then the medical treatment decision must be unanimous among those persons.  A surrogate decision-maker is required to make the choice she believes the patient would have wanted, which may not be the choice the decision-maker would have chosen for herself in the same circumstance. This decision-making standard is known as substituted judgment. If the surrogate is unable to ascertain what the patient would have wanted, then the surrogate may consent to medical treatment or non-treatment based on what is in the patient’s best interest.

Laws on surrogate decision-making are slowly catching up with social changes. Non-married couples (whether heterosexual or same sex) have not traditionally been recognized in state law as legally authorized surrogate decision-makers. This lack of recognition has left providers in a difficult legal position, encouraging them to defer to the decision-making of a distant relative over a spouse-equivalent unless the relative concurs. Washington law, for example, now recognizes spouses and domestic partners registered with the state as having the same priority status.   

Parental decision-making and minor children. A parent may not be permitted in certain situations to consent to non-treatment of his or her minor child, particularly where the decision would significantly impact and perhaps result in death if the minor child did not receive treatment. Examples include parents who refuse medical treatment on behalf of their minor children because of the parents’ social or religious views, such as Jehovah’s Witnesses and Christian Scientists.  The decision-making standard that generally applies to minor patients in such cases is known as the best interest standard.  The substituted judgment standard may not apply because the minor patient never had decision-making capacity and therefore substituted judgment based on the minor’s informed choices is not able to be determined. It is important to note that minors may have greater authority to direct their own care depending on their age, maturity, nature of medical treatment or non-treatment, and may have authority to consent to specific types of treatment. For example, in Washington State, a minor may provide his or her own informed consent for treatment of mental health conditions, sexually transmitted diseases, and birth control, among others. Depending on the specific facts, a health care provider working with the provider’s institutional representatives could potentially legally provide treatment of a minor under implied consent for emergency with documentation of that determination,   assume temporary protective custody of the child under child neglect laws, or if the situation is non-urgent, the provider could seek a court order to authorize treatment.

B.  Advance directives

The term advance directive refers to several different types of legal documents that may be used by a patient while competent to record future wishes in the event the patient lacks decision-making capacity.   The choice and meaning of specific advance directive terminology is dependent on state law. Generally, a living will expresses a person’s desires concerning medical treatment in the event of incapacity due to terminal illness or permanent unconsciousness. A durable power of attorney for health care or health care proxy appoints a legal decision-maker for health care decisions in the event of incapacity. An advance health care directive or health care directive may combine the functions of a living will and durable power of attorney for health care into one document in one state, but may be equivalent to a living will in another state. The Physician Orders for Life Sustaining Treatment (POLST) form is a document that is signed by a physician and patient which summarizes the patient’s wishes concerning medical treatment at the end of life, such as resuscitation, antibiotics, other medical interventions and artificial feeding, and translates them into medical orders that follow patients regardless of care setting. It is especially helpful in effectuating a patient’s wishes outside the hospital setting, for example, in a nursing care facility or emergency medical response context.  This relatively new approach is available in about a dozen states, although the programs may operate under different names: POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and COLST (Clinician Orders for Life-Sustaining Treatment).  The simple one page treatment orders follow patients regardless of care setting. Thus it differs from an advance directive because it is written up by the clinician in consultation with the patient and is a portable, actionable medical order.  The POLST form is intended to complement other forms of advance directives. For example, Washington State recognizes the following types of advance directives: the health care directive (living will), the durable power of attorney for health care, and the POLST form. Washington also recognizes another legal document known as a mental health advance directive, which can be prepared by individuals with mental illness who fluctuate between capacity and incapacity for use during times when they are incapacitated.

State laws may also differ on the conditions that can be covered by an individual in an advance directive, the procedural requirements to ensure that the document is effective (such as the number of required witnesses) and the conditions under which it can be implemented (such as invalidity during pregnancy).

Advance directives can be very helpful in choosing appropriate treatment based upon the patient’s expressed wishes. There are situations, however, in which the advance directive’s veracity is questioned or in which a legally authorized surrogate believes the advance directive does not apply to the particular care decision at issue. Such conflicts implicate clinical ethics, law and risk management.

C. Provider-patient communications: disclosing medical error

Honest communication to patients by health care providers is an ethical imperative. Excellent communication eliminates or reduces the likelihood of misunderstandings and conflict in the health care setting, and also may affect the likelihood that a patient will sue.

One of the more contentious issues that has arisen in the context of communication is whether providers should disclose medical errors to patients, and if so, how and when to do so. Disclosure of medical error creates a potential conflict among clinical ethics, law and risk management. Despite a professional ethical commitment to honest communication, providers cite a fear of litigation as a reason for non-disclosure. Specifically, the fear is that those statements will stimulate malpractice lawsuits or otherwise be used in support of a claim against the provider.  An increase in malpractice claims could then negatively affect the provider’s claims history and malpractice insurance coverage.  

There is some evidence in closed systems (one institution, one state with one malpractice insurer) that an apology coupled with disclosure and prompt payment may decrease either the likelihood or amount of legal claim.  In addition, a number of state legislatures have recently acted to protect provider apologies, or provider apologies coupled with disclosures, from being used by a patient as evidence of a provider’s liability in any ensuing malpractice litigation. It is currently too early to know whether these legal protections will have any impact on the size or frequency of medical malpractice claims. For this reason and others, it is advisable to involve risk management and legal counsel in decision-making regarding error disclosure.

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Notes on Readings for Review #4:  The readings for this section are extensive so you need to pace yourself accordingly; start early! (You have additional time for this section-almost three weeks; that should give you sufficient time to get through the readings.)  This section deals with the role of the Islamic revival in revolutionary changes, state building, domestic transformations, democracy, human rights, and foreign policy, as well as its role in shaping Muslim transnational dynamics, from the Iranian Islamic revolution in 1979 to the “Arab Spring” in 2011 and beyond.  The chapters from Mandaville’s book provide considerable, systematic information and analysis on how Muslim politics has manifested itself via socio-political movements, political parties, and attempts at state building and governance. These important chapters need your particular attention in your review. The Iranian revolution in 1979 had a profound impact on Iran and Muslim world relations with the US and the West, as well as significant implications for global politics since 1979. Abrahamian provides a sweeping account of the Iranian Islamic revolution and formation of an Islamic state and its significance. Beeman reflects on difficult relations between the US and Iran, Milani analyses the dynamics of the rivalry between the two important Muslim states, Iran and Saudi Arabia, while Hunter addresses the impact of US policy towards Iran on emerging intra Islamic tensions and conflict.   Vali Nasr’s article deals with the rise of Shi’i Islam, especially after the downfall of Saddam Hussein.  Kayaoglu, addresses the role of Islam in Qatar’s foreign policy. Two articles on Turkey by Pandya and Karaahmetoglu, discusses the role of Islam in domestic and foreign policy of Turkey, a key regional player and the major US ally in the region. The remainder of the readings in this section is devoted to the revolutionary and the democratic upheaval in the Arab/Muslim world. The chapter by Abou El Fadl addresses the connection between human rights and Islam. The article on “Is Islam an Obstacle to Democracy?” to provides a platform for several leading scholars (including among others, Robert Kaplan, Reza Aslan, Richard Bulliet, and Omid Safi) debate this question. Two Chapters by Esposito/Sonn/Voll, and the articles by Patterson, Marc Lynch, Oliver Roy, and Salloukh, address the role of Islamic politics in impacting democratization dynamics and challenges, including sectarianism, in the Arab Spring and beyond.   The readings in this sections end with two conceptually oriented works by Noah Feldman on the significance of Sharia, and Shadi Hamid, on what he calls, “Islamic Exceptionalism”.               In the Required video section,  the BBC award winning documentary on Iran looks at the Iranian revolution, Ambassador Bill Luers (in his lecture at FIU) looks at the Iranian Nuclear Deal. Vali Nasr discusses the origin and the evolution of Shia-Sunni sectarian divide in the Muslim world. Two lectures by Gause and Milani provide a very good outline of the new regional rivalry between Iran and Saudi Arabia and its regional and international implications, while Makdisi reflects on the historical and contemporary dynamics of sectarianism.

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i will attach an old example of the outline

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The Assignment: Assessing and Treating Clients with Dementia

The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.

Examine Case Study: An Elderly Iranian Man w/ Alzheimer’s Disease

You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point there will be three decisions. I will choose one out of the three and give the outcome. At each decision point these are the thoughts to ponder:

Decision #1

Which decision did you select?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

***Also include how ethical considerations might impact your treatment plan and communication with clients. ***

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

2. Write paper addressing all section listed based on the decision tree.

Case Study: An Elderly Iranian Man with Alzheimer’s Disease

BACKGROUND

Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.

According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”

Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.

SUBJECTIVE

During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

MENTAL STATUS EXAM

Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis:  Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

Decisions Made and Outcomes (Needed to formulate the paper) (Must use and formulate paper based off of the chosen decision. Then tell why the other two decision were not a good choice with in-text citations noted for each.)

Choices for Decision 1: Select what the PMHNP should do:Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks Begin Aricept (donepezil) 5 mg orally at BEDTIME Begin Razadyne (galantamine) 4 mg orally BID

Decision Choice Chosen:  Begin Aricept (donepezil) 5 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: RESULTS OF DECISION POINT ONE:Client returns to clinic in four weeksThe client is accompanied by his son who reports that his father is “no better” from this medication He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviorsYou continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Choices for Decision 2: Select what the PMHNP should do: Increase Aricept to 10 mg orally at BEDTIME Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

Decision Choice Chosen:  Increase Aricept to 10 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: RESULTS OF DECISION POINT TWO:Client returns to clinic in four weeksClient’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious

Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:  Continue Aricept 10 mg orally at BEDTIME Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME Discontinue Aricept and begin Namenda 5 mg orally daily

Decision Choice Chosen:  Continue Aricept 10 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: Guidance to Student

RESULT FROM CHOOSING TO MAINTAIN CURRENT DOSE OF ARICEPT 10 mg ORALLY AT BEDTIME

Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

***Write on each decision. Make sure that in each decision choice that you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 References . Please use in-text citations for each section of each decision.  Don’t forget the ethical considerations for this assignment. Make it a section by itself.***

***Also please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***

Please use the following format when formulating the paragraphs for each section. Don’t forget the intext citations. Remember to use at least 7 references.

Introduction

Decision #1

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Decision #2

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Decision #3

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Ethical Considerations

Conclusion

References

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Week 4 Assignment CLC – EBP Identification of Clinical Question

This is a Collaborative Learning Community (CLC) assignment.

State your topic in the form of a foreground question and a problem statement of 250-500 words. Provide an initial reference list of a minimum of five resources your CLC group has consulted during the selection process.

Refer to the “CLC Assignment: Evidence-Based Practice (EBP) Project Student Guide” for additional guidance.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

You are not required to submit this assignment to Turnitin.

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Create a 500 to 900-word entry in your Strategic Management Research Journal. You will use information from this entry in your presentation due in Week 5. Respond to the following prompts in your journal entry: Describe the role of strategic planning in achieving a competitive advantage.   Assess Caterpillar Inc. to determine whether their top focus is accounting profitability, shareholder value creation, or economic value creation.  Assess whether Caterpillar Inc. leverages the appropriate value and cost drivers for their business strategy.  Analyze the strengths and weaknesses of Caterpillar Inc’s competitive advantages. Evaluate the influence of ethics, social responsibility, and legal considerations on strategic planning.   Discuss the value of corporate social responsibility (CSR), and determine if Caterpillar Inc.’s CSR meets those values.  Analyze the role of ethics and social responsibility in developing Caterpillar Inc.’s strategic plan while considering stakeholder needs and agenda.  Use at least two scholarly sources. Be sure to use Rothaermel, F. T. (2018). Strategic management: Concepts (4th ed). New York, NY: McGraw-Hill as one of the two scholarly sources.  Use the APA formatting for the title page, headings, in-text citations, and reference list. 

Submit your assignment.

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The City Manager has contacted you regarding the following issues concerning various governmental departments and external stakeholders:

In the past year, citizen, department, and outside stakeholder complaints have been filed against the Department of Health administrators. Such complaints cited unprofessional leadership, unethical practices, insufficient customer and patient care, poor fire and emergency response time, and inability to implement change and resolve conflict within and amongst subordinates and staff. The Department of Health is composed of the following agencies:

Social Services,

Fire and Emergency Management, and

Human Services.

The School Board has a collaborative relationship with various government departments. In the last two (2) months, the School Board has charged department directors with failure to work collaboratively with the School Board on its efforts to:

Meet federal mandates regarding reformation of new policy issues that will impact the leadership of the Department of Redevelopment and Housing, the State Department of Education, and the State Department of Housing and Urban Development.

Support the academic leadership of secondary school principals by providing specific student data from the Department of Juvenile Relations, in an attempt to improve student retention and performance toward increase graduation rates.

Note:   You may create and / or make all necessary assumptions needed for the completion of this assignment.

Use the basic outline below to draft your paper. Organize your responses to each question (except Question 5) under the following section headings:

Public Leadership in a Health Environment (for Question 1)

Public Leadership in an Educational Environment (for Question 2)

Public  Leadership in Government Operations (for Question 3)

Improving Public Leadership Styles (for Question 4)

3 Pages

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Ashford 5: – Week 4 – Assignment

Organizational Skills Assessment

Think about the skills you have gained through coursework, personal experiences, and previous employment that will help you be effective in organizations. Prepare a written list of the skills you possess in each of the following categories: (a) work-content skills, (b) personal attributes (such as communication and self-management), and (c) technology. Following each skill listed, explain how the skill might help you in your current career or in the career you intend to pursue.  
 

The paper must be formatted according to APA style. For information regarding APA samples and tutorials, visit the Ashford Writing Center, within the Learning Resources tab on the left navigation toolbar.
 

TIP: You will also incorporate information from this paper into the Final Portfolio due in Week Five of this course.

Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment. 

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Submit Team summary on the discussion on the differences between vCJD and CJD

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 SCI 250 Week 1 Cell Division Template

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Identifying A Clinical Question

Write a 1000-1500 word essay addressing each of the following points/questions. Be sure to completely answer all the questions for each bullet point. There should be three main sections, one for each bullet below. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least five (5) sources using citations in your essay. Make sure to cite using the APA writing style for the essay. The cover page and reference page in correct APA do not count towards the minimum word amount. Review the rubric criteria for this assignment.

Identify a clinical question related to your work environment, write the question in PICOT format and perform a literature search on the identified topic. 

Purpose 

To enable the student to identify a clinical question related to a specified area of practice and use medical and nursing databases to find research articles that will provide evidence to validate nursing interventions regarding a specific area of nursing practice.

Review the Application Case Study for Chapter 3: Finding Relevant Evidence to Answer Clinical Questions as a guide for your literature search. 

Guidelines  Identify a clinical question related to your area of clinical practice and write the clinical foreground question in PICOT format utilizing the worksheet tool provided as a guide. Describe why this is a clinical problem or an opportunity for improving health outcomes in your area of clinical practice. Perform a literature search and select five research articles on your topic utilizing the databases highlighted in Chapter 3 of the textbook (Melnyk and Finout-Overholt, 2015).  Identify the article that best supports nursing interventions for your topic. Explain why this article best supports your topic as you compare the article to the other four found in the literature search.

Assignment Expectations:

Length: 1000 – 1500 words
Structure: Include a title page and reference page in APA format. These do not count towards the minimum word count for this assignment. Your essay must include an introduction and a conclusion.
References: Use appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of five (5) scholarly sources are required for this assignment to support the topic.
Rubric: This assignment uses a rubric for scoring. Please review it as part of your assignment preparation and again prior to submission to ensure you have addressed its criteria at the highest level.
Format: Save your assignment as a Microsoft Word document (.doc or .docx) or a PDF document (.pdf)
File name: Name your saved file according to your first initial, last name, and the assignment number (for example RHall Assignment 1.docx)

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