Response to peer discussion board-150 words-1 reference within 5 years-NURSING JOURNALS ONLY.There is a large push for evidence-based practice to become the main foundation of all clinicalpractices and clinical decision making. In order to provide the best up to date quality careevidence-based practice must be used. By the year 2020 90% of clinical decisions will besupported by accurate timely and up-to-date clinical information and will reflect the bestavailable evidence (Boswell& Cannon 2017). Though it is ideal to have evidence-base practicedriving health care practices there are many obstacles in the way of changing the culture ofhealth care practices. There are many obstacles to change such as resistance to change fromstaff available resources to support changes lack of support and training from mentors andresearch findings incompatible with the realities of their practice (Johnston Coole Feakes Whitworth Tyrell & Hardy 2016 p. 392).Working at Shands Hospital in Gainesville Florida there is most definitely a strong push forthe best quality of care through evidence-based practice. Each unit throughout the hospital hasa clinical leader. The units clinical leaders main job description is to assure the unit is clinicallyusing practices that are evidence-based. The main obstacle that I have found on my unit hasbeen research findings incompatible with the realities of their practice (Johnston et al. 2016 p.392 ). Working on such a high acuity unit in the cardiovascular intensive care unit a lot ofevidence-based hospital driven policies and practices have had to be adjusted specially to fit ourunit. Hospital wide practices have had to be adapted because certain practices do not apply tothe realities and acuity of our unit. One main example is the MEWS assessment. The modifiedearly warning score (MEWS) is an example of a physiological track and trigger system designedto identify patients at risk of clinical deterioration in order to provide a timely response torequest appropriately-trained nursing or medical staff to assess the patient and provide anyinterventions required (Harris 2013 p.432). MEWS is an extremely useful tool on floor units but on my particular unit a majority of our patient population have such a high baseline MEWScore. If following our hospital protocol for our patients MEWS we would be constantly callingphysicians and bringing them to the bedside. Our patients have extremely high acuity which isone of the reasons they are in the intensive care unit. Our physicians are aware of the acuity ofour patients and therefore the hospital wide MEW score does not really apply to our unit. Wehad to adjust the triggers of the MEW Scores of when to notify a physician. On the floor aMEWS of 4 a physician is notified and needs to come assess the patient but in the CICU thescore for when a physician has to come to bedside was adjusted to a 6. MEWS is just one ofthe many obstacles present in implementing evidence-based practices on our unit. There aremany obstacles to implementing evidence-based practices in our clinical practices but it isimperative that we adjust or policies and practices to reflect the research found in order toprovide the best quality care.Answer rating (rated one time)

Directions: Carefully read each scenario describing an ethical dilemma in health care. SelectTWOscenarios for which you will write a thorough response to not exceedONEcomplete paragraph for each. Responses will vary based on an individuals cultural upbringing ideology and educational knowledge; however you must support your position with appropriate theory and principle.In Clinical Ethics three clinical ethicists (a philosopher -Jonsen a physician -Siegler and a lawyer -Winslade) developed a method to work through difficult cases. The process can be thought of as the ethics workup similar to the History and Physical skills that all medical students use when learning how to workup a patient’s primary complaints. While this method has deep philosophical roots clinicians who use this method like the way it parallels the way they think through tough medical cases.Medical Indications- All clinical encounters include a diagnosis prognosis and treatment options and include an assessment of goals of carePatient Preferences- The patients preferences and values are central in determining the best and most respectful course of treatment.Quality of Life- The objective of all clinical encounters is to improve or at least address quality of life for the patient as experienced by the patient.Contextual Features- All clinical encounters occur in a wider social context beyond physician and patient to include family the law culture hospital policy insurance companies and other financial issues and so forth.Scenario 1At your last office staff meeting the rising cost of rent and overhead was discussed. One of your partners mentioned that he had been approached by a large pharmacy chain with an offer of space adjacent to their new pharmacy that is only one block from your current offices. The cost per square foot is half of what you are currently paying and there was a suggestion that the rent could be lowered if the volume of prescriptions from your office were substantial. Although this offer is very tempting you have reservations about the potential conflict of interest. One of your partners is pushing to explore this option. You are wondering if you could manage the conflict by refusing to engage in any reduction in rent based on prescription volume but still take the space at the reduced lease costs. Another partner feels that this arrangement will compromise her autonomy and feels that it will look as if the office is associated with the pharmacy even if it is not. Everyone agrees that the overhead costs need to be reduced. What is the right thing to do?Scenario 2You are the training director for a residency program. Recently several residents have come to you reporting that a physician frequently makes disparaging comments to residents and to patients about the work of other physicians. The physicians latest comment was to a patient in which he said he would not allow a particular physician to treat his pets. Other comments attributed to this physician involved telling the residents that a surgeon is a butcher and a psychiatrist a mindless twit. The residents have attempted to speak to him about this practice to which the physician responded by saying he only speaks the truth adding that patients and residents have a right to know. The residents report the comments appear to be unwarranted and they seem to be scaring the patients. Is this physician behaving unethically? Should physicians question the work of their colleagues? How should this be done?Scenario 3You are nearing the end of your practice career and many of your patients are older. Several of them have developed mild dementia and youve been discussing their wishes should they continue to lose mental capacity. The other day an elderly gentleman arrived for his appointment with his middle-aged son who reported that his father is becoming increasingly forgetful. The son would like to have his father moved to a facility rather than continue to live on his own. While examining your patient you note he has multiple bruises on his upper arms that suggest he has been grabbed by someones hand. When you discuss with him the idea of moving to an assisted living facility he becomes very upset and says his son wants to get his hands on his money and that is why he wants him to move from his own home. The patients Mini Mental Status examination is within the normal limits and he reports that his multiple bruises are the result of a friend grabbing his arm while they were out walking. You would like to respect your patients autonomy to make his own decisions but have some concerns that he may be at risk. You are not sure what the ethical principles are and approach your colleague for advice. What advice would you give to this colleague if you were approached?Scenario 4You have been treating a 24-year-old man for many years in your family practice. He has an anxiety disorder and had some trouble with substance abuse in his teens but has been doing well and attending university. After his last visit for a minor injury you noted that a prescription pad was missing. A few weeks later you received a call from a pharmacy asking you to verify a prescription for Lorazepam 1mg bid 300 tablets and acetaminophen with codeine 300 tabs written for this patient. You report that this is a forgery and ask the pharmacy not to fill it. Your colleague urges you to report this to the police and states this is allowed under the Health Information Act. You are very angry with the betrayal of trust with your patient but you have never reported a patient to the police and wonder what you should do. The CMA code of ethics advises you to keep patients personal health information private and only consent to release to a third party with consent or as provided for by the law such as when the maintenance of confidentiality would result in a significant risk of substantial harm. You are wondering if your patient has a substance abuse problem and whether he could be selling this medication. You have called the patient to come in for an appointment but he has refused. Should you notify the police?Scenario 5A patient has rheumatoid arthritis for which she should be taking drugs to control the disease and prevent further joint damage. However she tells the doctor that she has stopped because she does not like the look of the side effects listed on the leaflet in the packet and would like a treatment she found on the internet. The doctor disagrees with her preferred treatment. What issues does this raise? How should the doctor handle this scenario?Scenario 6A newly hired nurse is being given orientation and training in the hospital by a senior member of the nursing staff. Assigned to a medical -surgical unit the nurse receives instructions on procedures. The nurse is instructed to push Heparin IV through a tube in the person’s arm. The nurse when being trained in nursing program was instructed not to do so such a thing as it could have serious consequences. When the newly hired questioned the procedure that nurse was told by the senior nurse: Look that is how we do it here missy. We are understaffed and do not have the time to do it intravenously. If you want to work here that is how you will do it too. What should the response of the new nurse be to this situation? Why?Scenario 7John a 32 year-old lawyer had worried for several years about developing Huntington’s chorea a neurological disorder that appears in a person’s 30s or 40s resulting in uncontrollable twitching and contractions and progressive irreversible dementia. It typically leads to death in about 10 years. John’s mother died from this disease. Huntington’s is autosomal dominant and children of an affected person have a 50% chance of inheriting the condition. John had indicated to many people that he would prefer to die rather than endure the progression of the illness. He was anxious drank heavily and had intermittent depression for which he saw a psychiatrist. Nevertheless he was a productive lawyer. John first noticed facial twitching 3 months ago and 2 neurologists independently confirmed a diagnosis of Huntington’s. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused John reassured him that he did not plan to attempt suicide any time soon. But when he went home he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife who did not yet know about his diagnosis found him unconscious and rushed him to the emergency room without removing the note. How much weight should Johns preferences (especially his attempt to end his life) carry in managing his emergency and subsequent clinical care? Scenario 8Mrs. Jones has signed a donor card indicating that she is willing to donate her body to science without notifying her husband and son. She gets into an accident and it is determined she is brain dead. The family doctor who is on call that afternoon reviews the chart and determines that she would be perfect for medical students to practice the removal of organs for transplantation purposes. The doctor then talks to the family to discuss the procedure and to confirm their consent. They both oppose the procedure and refuse to allow their doctor to move forward. The doctor points out that Mrs. Jones could be helping hundreds of people by educating the medical students and that technically consent has already been provided. The husband understands how beneficial the educational experience is but is too emotional to allow them to continue. The son a medical student refuses because he knows the bodies are not treated with dignity. If you were the doctor how would you proceed? Why?