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Question: Disucss the Case Study of Tom. Answer: Summary of family distress Tom is a 55-year-old man hospitalized with advanced lung cancer and multiple metastases. He is under morphine/midazolam syringe driver that he heavily contested. His daughter Carina, who claims to have power of attorney, wants the morphine withdrawn, something better to be administered and everything to be done to save him. Jimmys son disputes the power of attorney claims and argues that Toms wife Cec is the sole guardian and that his father did an advanced care paper. Although not sure of this, he believes that this would override the guardian issue. Main issues Several ethical dilemmas and medical issues arise in the provision of palliative care for Tom. The main issue in this case relates to the treatment of patients under palliative care. The first overriding issue is respecting the rights of patients. The autonomy pillar of medical ethics argues that the patient has a right to refuse or choose any given type of treatment. In the case of John, the administration of morphine/ midazolam syringe driver was done against his contestation of the treatment raising ethical concerns regarding failure to respect his right to choose or refuse treatment. Another key issue is the place of the power of attorney and its place in the provision of palliative care. The power of attorney regarding palliative care is a legal document in which the patient appoints someone to make decisions for him/her regarding medication, surgery or any other medical procedures. By claiming to have power of attorney, Carina has the authority to make decisions for her father. She has a right to stop any medication and demand treatment for her father, but she must act in the best interest of the patient. Given her authority, Carina makes demands, which I must consider as a nurse, including stopping the morphine treatment and introducing a better treatment and doing whatever is possible to save her father. Nevertheless, the legality of the power of attorney claims is questionable since Jimmy raises a dispute concerning the same. An ethical dilemma that arises here is determination of the validity of the Carinas power of attorney authority and considering conflicting information from the family members. Clearly, this conflict raises concerns regarding the validity of the power of attorney in this case. Moreover, Tom raises another ethical issue concerning enduring guardianship and provision of palliative care treatment. The Guardianship Act 1987 (NSW) makes it possible for a patient to appoint an enduring guardian to make decisions for him/her in the event of incapacitation. The authority of the guardian continues even when the patient is incapacitated (New South Wales Government 2016). In the case of Tom, an ethical dilemma arises when Jimmy claims that his father signed advance documentation granting his wife enduring guardianship authority. Finally, the palliative care medical team comprises physicians, nurse practitioners, nurses, social workers, chaplains and other medical practitioners. This multidisciplinary team works closely with patients and their families to provide the best care for the patient. The NFR, not for CPR and not for ICU admission are important and necessary orders in the provision of healthcare in Australia (Sidhu, Dunkley and Egan, 2007). The purpose of these orders is to support the autonomy of the patient while preventing the implementation of non-beneficial medical interventions (Yuen, Reid and Fetters, 2011). These signed notes from the team raises a range of ethical dilemmas in making decisions regarding provision of palliative care for Tom. Establish Decision-making goals A better understanding of the medical ethic would play a critical role in making decisions and providing adequate care for the terminally ill patients (Hallenbeck, 2006). My first goal would be to determine consent in providing treatment for Tom. It is important to attain informed consent before commencing the provision of palliative care for Tom. The patient has a legal right to make treatment decisions and must make consent for the decisions involving the provision of his/her medical care. In case of Tom, there was a clear violation of his right to informed consent given that morphine was administered regardless of his protestation. It is important to determine the capacity of the patient to make informed decisions. When the patient is incapacitated, a substitute decision maker, probably the immediate family member assumes the authority and responsibility of making the treatment decision on their behalf (Australian Government 2016). The Guardianship and Management of Property Act19 91(ACT) for each state and territory provides guidelines and outlines providing alternative or substitute decision maker in the event the patient is incapable to make treatment decisions. Regardless of the decision maker, the law requires that the person be provided with adequate information and support to make appropriate decisions concerning their treatment (Lamba et al., 2013). In provision of palliative care, informed consent should entail information concerning the benefits, risks and consequences of a given treatment intervention. It is important to determine whether Tom was given adequate information concerning the importance of morphine administration in order for him to offer informed consent regarding treatment. My second goal would be to establish the validity of the power of attorney. It is important for me to establish exactly under what circumstances the power of attorney in NSW apply and if it is valid in Toms case. According to the Powers of Attorney Act 2003,(NSW),the attorney, who is appointed by the principle in writing, is only allowed to make any financial transactions and decisions with the principles money,assets,real estate or shares among others. The Act does not provide for the attorney making any personal decisions concerning the principle, which includes medical or health care decisions. Consequently, Carina in this case is not allowed to decide the medical fate of her father and therefore as a nurse, I am not allowed to act as per instruction. My third goal would be to determine the validity of the issues regarding the enduring guardianship that were raised by Jimmy. Jimmy claims that Tom did appoint his wife Cec as his enduring guardian, and that in this capacity, her decision should be considered in Toms administration of treatment. The Guardianship Act 1987 (NSW), allows for a person in their right capacity to appoint an enduring guardian, who has legal authority to make decisions regarding health and lifestyle on behalf of that person. This may include the type of health care the person receives, where they may live and agreeing to medical treatment among others. This means that the case of Tom,Cec can make decisions on the palliative care to be administered to Tom, including treatment. However, her capacity as Toms guardian,Cec is required to consider Toms past wishes and views. She is also required to consider the views of the medical practitioners and important people in Toms life before making any decisions. She is Toms substitute decision maker and I should by all means work in consultation with her towards restoring Toms condition. My fourth goal would be to determine the validity of the issue regarding the advance care paper also raised by Jimmy. According to The Common Law of NSW, Advance Care Directives are accepted and legally binding. The NSW Supreme Court confirmed this in 2009.Advance care directives are instructions given by a person while in their right capacity about their desired future medical care. In the event that a person is not able to make medical decisions on their own, doctors, health care professionals and family members are required to act as per the patients advance care directives.In this case of Tom,his advance care directive should be consulted as a guide in the administration of treatment. It amounts to upholding the patients rights to consent or refuse medical treatment even at the point of death(Advance Care Planning 2015). My filth goal is on how to address the NFR, not for CPR and not for ICU admission instructions made by the medical registrar with consulting team. Often times, Cardiopulmonary resuscitation(CPR) is administered as a default treatment to patients whose heart stops beating, in the absence of a withhold order( Waldron et al,2016).For Tom, the instruction, not for CPR,was rightly administered. This is the case for Not for resuscitation(NFR),which in most countries is used bar the use of CPR on patients in cases where it will be of no help or where the patient refuses.ICU is administered to patients who are seriously ill, whose body fails to function normally. For example chronic respiratory failure, infections and renal failure among others. Tom did not qualify for ICU admission since his body could still support the various function at this particular time. Therefore, the instructions were all valid. Select a course of action Based on findings of the decision making goals, first I will not withdraw the administration of morphine treatment to introduce a better treatment as requested by Carina, who is only an attoney.Instead I will require to be served with the advance care paper that Tom had signed in order to honor his right to choose his medical treatment and care. The advance care directive will also serve to unite the family in decision making. Secondly, together with other medical practitioners; we will take Cec, Toms wife, through all the available medical options for Tom and give her an opportunity to decide on the best way forward References Australian Government, 2016. 10. Review of State and Territory Legislation: informed consent to medical treatment. [Online]. Accessed 3 May 2017 https://www.alrc.gov.au/publications/10-review-state-and-territory-legislation/informed-consent-medical-treatment Guardianship and Management of Property Act1991(ACT) ss 32B, 32D;Mental Health Act2009(SA) ss 56, 57. Hallenbeck, J., 2006. A Palliative Ethic of Care: Clinical Wisdom at Lifes End. Lamba, S., Bonanni, M., Courage, C.A., Nagurka, R. and Zalenski, R.J., 2013. When a patient declines curative care: management of a ruptured aortic aneurysm.Western Journal of Emergency Medicine,14(5), p.555-558 New South Wales Government, 2016. Guardianship Act 1987 No 257. [Online]. Accessed 3 May 2017. https://www.legislation.nsw.gov.au/#/view/act/1987/257 Sidhu, N.S., Dunkley, M.E. and Egan, M.J., 2007. " Not-for-resuscitation" orders in Australian public hospitals: policies, standardised order forms and patient information leaflets.Medical journal of Australia,186(2), p.72-75 Waldron, N, Johnson, C, Saul, P, Waldron, H, Chong, J, Hill, A, Hayes, B 2016, 'Development of a video-based education and process change intervention to improve advance cardiopulmonary resuscitation decision-making', BMC Health Services Research, 16, pp. 1-10. Yuen, J.K., Reid, M.C. and Fetters, M.D., 2011. Hospital do-not-resuscitate orders: why they have failed and how to fix them.Journal of general internal medicine,26(7), pp.791-797.