Medical ethics and the bureaucracy of healthcare

Pressure Ulcers/Case Study

Bedsores are also known as pressure ulcers. They are lesions that are primarily caused when soft tissues are pressed against bone for a long period of time, restricting blood flow to the area. These often occur when a patient is immobile or reclining in a recovery bed for a long period of time. They are common on the hips, elbows, knees, ankles and even the back of the head. Current research shows that they are exacerbated by other conditions like diabetes, perspiration, incontinence, infection, or medications that impair the circulatory system. Pressure ulcers are particularly serious in older patients — particularly those in a wheel chair or in cases in which the patient does not move or exercise. Bedsores are often fatal, even when treated aggressively and are one of the leading causes of death from complications in many developed countries — second only to adverse drug reactions (Preventing and Treating Pressure Ulcers, 2009).

Pressure ulcers are best treated through preventative care — turning the patient regularly so blood flow is not compromised, using catheters or impermeable dressings to keep the bed sheets dry, and shifting patients who are paralyzed on a regular basis or using pressure-distribute mattresses. Additionally, higher levels of Vitamin C seem to have an effect on those who develop bedsores, and in their healing (Preventing Pressure, 2011; Meschino, 2011).

Ironically, even though Medicare/Medicaid do not reimburse, or do not reimburse fully for pressure ulcers, more than 2.5 million people in the United States develop the sores. Within acute care, the incidence is up to 38% and in long-term care 24%. There is a far higher rate of pressure ulcers within intensive care units, likely due to immune compromised individuals, with 8-40% of patients developing the sores (Pressure Ulcers in America, 2001). In fact, the Centers for Medicare and Medicaid Services announced as far back as 2008 that it would no longer reimburse hospital for treating pressure ulcers because they are, in the view of the agency, preventable. Refuting this notion, however, are several academic papers and professional medical societies. This view holds that there are clinical circumstances in which pressure ulcers are unavoidable, even with excellent multidisciplinary care. Because the skin is the body’s largest organ, many diseases overwhelm the skin and even best practices cannot prevent pressure ulcers 100% of the time (WOCN Society, 2009).

Scenario – The situation involves a patient admitted to the hospital from a skilled nursing facility because of severe dehydration. Both the nursing facility and hospital often cross-refer patients, and there is a close relationship between the two facilities. Within a few days after admission, the hospital staff notices a pressure ulcer and claims that the sore was caused by the nursing facility. The nursing facility claims that there was no documentation of any skin issues prior to discharge and that the hospital is to blame. Besides the clear moral and ethical issues, there is also an issue of payment from Medicare, which classifies bedsores as “never events.” Thus, there are several arguments surrounding this type of event.

Practical Issues – The gist of the argument goes beyond healthcare management and into medical ethics and the bureaucracy of healthcare. Medicare Part A is hospital insurance that helps cover care in hospitals and skilled nursing facilities. In general, it covers inpatient care and inpatient rehabilitation costs. Medicare Part B covers medically necessary services: doctors’, medical equipment, home health care and services or supplies that treat a medical condition. Medicare Part D is specifically for Prescription Drug Coverage and once enrolled covers costs based on co-payments, a yearly deductible, the costs of the medication and the pharmacy used. In any case, the pharmaceuticals will be less expensive than they would be without coverage (

Further, there is not a great deal of research available on the timing it takes a pressure ulcer to appear. There are a number of factors that affect the issue: predisposition, actual health status, nutrition, severity of injury or surgery, pharmacological profile, weight/size/body dimensions, and more. Based on what research is available, findings indicate that pressure ulcers are likely to develop between the first hour and 4-6 hours after sustained loading onto the tissues (Gefen, 2008). Thus, in this case, it is more likely that the pressure ulcers developed after the patient was transferred to the hospital — but possible that the final day of care at the nursing facility contributed to the event. However, based on the charting that the skin sores were not noticeable for 24-48 hours, there is a higher probability that the patient did not receive enough preventative care at the hospital.

Ethical – The conundrum here is considerable; the patient is likely aged and on a fixed income based on information gleaned.: Within the framework of the ethical care model, we find that there are some medical ethical paradigms that would seem to say we prevent consternation for Mrs. Smith by recoding the infection so it will be covered: 1) Beneficence — At the core of medical ethics is the value of beneficence, which provides the primary goal and rationale of medicine and healthcare — the core of the Hippocratic Oath — “as to disease, make a habit of two things- help, or at least do no harm. 2) Veracity — In medical ethics, veracity is part of the relationship of trust between the healthcare professional and the patient. Honesty and truth in what the healthcare professional shares with the patient are now expected — and the relationship is reciprocal — the healthcare professional expects the patient to be honest and truthful about concerns, attitudes, and information regarding the physical or mental symptoms in question. The patient did not cause the infection, so why should they suffer? 3) Non-maleficence — The principle of non-maleficence not only asserts an obligation not to harm intentionally, but an additional obligation to use any and all appropriate treatments available to cure the illness. (Benjamin & Curtis, 2010).

Legal – Medicare will typically not pay or cover any “preventable” condition or mistake resulting from a hospital stay. In this patient’s case, they would not pay for the drugs, treatment, or extra days in care that were strictly based on the pressure sores. This was designed to make hospitals and healthcare facilities more accountable, but would inconvenience the patient (Medicare Will Not; 2007). Medicare and Medicaid specifically note that pressure sores will not be covered because they result in higher payments to the hospital even if the hospital caused the condition (Medicare Nonpayment, 2012).

Analysis- Based on the research, it does not appear that, in this case, there were strong predispositions toward pressure ulcers at the skilled care facility. Dehydration, however, could have contributed to the problem because if the tissues have no fluid, there is greater chance for abrasion. However, upon admittance to the hospital, we can only assume that they patient was given fluids. There is no mention, though, of the actual location of the sores or the protocol for turning the patient.

In this case it looks like the hospital will have to absorb the costs of the pressure ulcer care. The Administrator should immediately convene a committee to write standardized, best-practices, care sheet for potential pressure ulcer conditions. This would obviously focus on the elderly, and would require a protocol to prevent the sores, alleviate the causes (sheets, etc.), and if sores are noticed, aggressively treat them before they become serious. To make the situation more congenial and ultimately more meaningful to the potential future patient, the committee could be a joint group between the hospital and care facility — sharing knowledge and communication to strengthen the relationship and avoid unnecessary blame.


Coverage Information retrieved from

Medicare Nonpayment for Hospital Acquired Conditions. (2012). National Conference of State Legislatures. Retrieved from:

Medicare Will Not Pay for Hospital Mistakes and Infections. (2007, August 20).

Medicalnewstoday. Retrieved from:

Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. (2001).

Advanced Skin and Wound Care. 14 (4): 208-15.

Preventing and Treating Pressure Ulcers. (2009). UCan Health. Retrieved from:

Preventing Pressure Ulcers in Hospitals. (2011). Agency for Healthcare Research and Quality.

Retrieved from:

Benjamin, M., & Curtis, J. (2010). Ethics in Nursing – Cases, Principles, reasoning. New York:

Gefen, A. (2008). How Much Time Does it Take to Get a Pressure Ulcer? Ostomy Wound

Management. 54 (10) 26-35. Retrieved from:

Meschino, J. (2011). Vitamin C — Ascorbic Acid. Meschino Health. Retrieved from:

Wound Ostomy and Continence Nurses Society. (March 24, 2009). Position Paper — Avoidable

versus Unavoidable Pressure Ulcers. Retrieved from:

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