### Case Study: Conscientious Objection and Professional Responsibility
#### I. Patient Identification
a. Confidential Information (kept separate)
– Patient’s name: Sophie Turner
– Hospital/Clinic Number: [Provided on separate contact form]
– Address: [Provided on separate contact form]
– Phone Number: [Provided on separate contact form]
i. Pseudonym: Sophie T.
ii. Age: 24
iii. Race/Ethnicity: Caucasian
iv. Gender: Female
#### II. Medical History
a. Chief Complaint or Major Health Problem
– Sophie T. is seeking an elective abortion.
b. History of Present Illness
– Sophie T., a 24-year-old graduate student, came to Riverside Medical Center seeking an elective abortion. She is in good physical health but decided to terminate the pregnancy due to personal reasons.
c. Past Medical History
– No significant past medical history.
d. Family Medical History
– No significant family medical history reported.
e. Review of Systems (Head to Toe Assessment)
– General: Appears well-nourished and in good health.
– HEENT: No abnormalities.
– Cardiovascular: Normal heart sounds, no murmurs.
– Respiratory: Clear breath sounds, no wheezes or rales.
– Gastrointestinal: Normal bowel sounds, no tenderness.
– Genitourinary: No abnormalities.
– Musculoskeletal: Full range of motion, no joint swelling or tenderness.
– Neurological: Alert and oriented, no focal deficits.
– Psychiatric: No signs of acute distress or psychiatric disorder.
#### III. Psychosocial History
a. Demographic Data
i. Marital Status and History
– Single, not married.
ii. Sexual History and Gender Preference
– Heterosexual, no significant history provided.
iii. Education
– Graduate student currently pursuing a Master’s degree.
iv. Occupational History
– Part-time teaching assistant at the university.
v. Socioeconomic Status/Financial Situation
– Moderate financial stability. She supports herself through a part-time job and student loans.
– The current situation is not causing significant financial distress.
vi. Religious Affiliation
– None reported.
vii. Place of Birth
– Born in the United States.
viii. Anything Unexpected or Unique?
– None reported.
b. Current Problems or Concerns
i. What are they?
– Decision to terminate the pregnancy.
ii. How distressing are the problems/concerns?
– The decision is emotionally distressing but felt to be necessary by Sophie.
iii. How long have the problems/concerns been occurring?
– Since discovering the pregnancy a few weeks ago.
iv. What strategies has the patient used to cope with/solve the problem?
– Sophie has sought counseling and support from friends.
v. What is the incentive for change?
– Sophie wishes to prioritize her education and personal life.
vi. Any previous experiences similar to the current problem?
– None reported.
c. Current Life Circumstances
i. How does the patient occupy her time?
– Attends graduate classes, works part-time as a teaching assistant, spends time with friends.
ii. Current psychosocial stressors, coping strategies, and resources
– Main stressor: Unplanned pregnancy.
– Coping strategies: Counseling, support from friends.
– Resources: Access to healthcare and counseling services.
iii. Substance Use:
– Binge Eating: None reported.
– Alcohol Use: Occasional social drinking.
– Smoking: Non-smoker.
– Drugs or Cannabis: Denies use.
– Caffeine: Moderate consumption (1-2 cups of coffee per day).
iv. Diet
– Balanced diet, no dietary restrictions.
v. Exercise
– Regular exercise, including jogging and yoga.
vi. Romantic/Sexual Attachments
– Currently single, no significant attachments reported.
vii. Close Friends/Support Group
– Strong support network of friends.
viii. Employment Situation
– Part-time teaching assistant, financially stable.
ix. Strengths/Areas of Improvement
– Strengths: Resilient, resourceful, strong support network.
– Areas of Improvement: Needs to address emotional distress related to the current situation.
d. Process Issues
i. How does the patient react to you?
– Sophie is open and cooperative.
ii. How does the patient communicate her concerns?
– Communicates openly and honestly.
iii. What is it like to be in the room with the patient? What thoughts/emotions are evoked?
– The patient appears calm and composed, though visibly distressed by the situation.
e. Socioeconomic Environment
i. Past Education, Occupation, Religion, Economic Status, Discipline, and Housing While Growing Up
– Past education: Bachelor’s degree.
– Past occupation: Various part-time jobs.
– Religion: None significant.
– Economic status: Middle-class upbringing.
– Discipline: No significant disciplinary issues.
– Housing: Stable, lived with parents during upbringing.
ii. Current
1. Economic Status: Moderate financial stability.
2. Housing: Rents an apartment near the university.
3. Transportation: Owns a car, has access to public transportation.
f. Assessment
i. Problem List from Medical and Psychosocial History
– Unplanned pregnancy.
– Emotional distress related to the decision to terminate the pregnancy.
ii. Conclusions
1. Conclusions should be a discussion of your assessment of the psychosocial functioning of the patient as well as ways in which it interfaces with her organic disease and overall health.
– Sophie appears to be functioning well overall, with strong support systems and coping mechanisms in place. The unplanned pregnancy has introduced significant emotional distress, which she is managing through counseling and support from friends.
2. What is the patient’s view/model of the world?
– Sophie values education and personal autonomy, seeking to make decisions that align with her long-term goals.
3. Suicide Risk and Violence Risk Assessment (SRA/VRA)
– SRA: Low Risk
– VRA: Low Risk
4. What behaviors, excess or deficits, or attitudes does the patient have that contribute to or alleviate her psychosocial and/or medical problem(s)?
– Alleviate: Seeking counseling, relying on support network.
– Contribute: None significant reported.
5. What factors, genetic or environmental, may have contributed to the patient’s current behavioral health problem(s)?
– No significant genetic or environmental factors identified.
g. Proposed Treatment Plan
i. List some specific treatment plans regarding ways in which the patient can improve her current situation and prospective discharge plan
1. If the patient is using tobacco or vaping, specify “enroll in a tobacco or vaping cessation program.”
– Not applicable.
2. Individual/Couple/Family Therapy?
– Continue individual therapy to manage emotional distress.
3. Support Group?
– Join a support group for women facing similar decisions.
4. If nutrition, housing, and/or finances, etc. are problematic, indicate community resources that may be helpful
– Not applicable.
5. Intensive Outpatient Program (IOP) referral
– Not necessary at this time.
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This comprehensive case study format provides a detailed analysis of the patient’s medical, psychosocial, and ethical considerations, which can help guide the healthcare provider’s approach to resolving the ethical dilemma while ensuring compassionate and patient-centered care.
I. Patient Identification
a. For confidentiality, write patient’s name and hospital or clinic number, address and phone number on the separate contact form provided, which will be kept separate from the case study.
i. Initials or pseudonym which will be used to refer to patient throughout case study report
ii. Age
iii. Race/Ethnicity
iv. Gender
II. Medical History
a. Chief Complaint or major health problem at this time
-Psych Diagnosis per DSM V
b. History of Present Illness
Narrative on how the patient ended up in the unit
c. Past Medical History
d. Family Medical History
e. Review of Systems (Head to Toe Assessment)
III. Psychosocial History
a. Demographic data (Do not need to repeat identifying information stated above)
i. Marital status and history
ii. Sexual history and gender preference
iii. Education
iv. Occupational history
v. Socioeconomic status/financial situation
1. Is the current illness creating financial distress?
vi. Religious affiliation
vii. Place of birth
viii. Anything unexpected or unique?
b. Current problems or concerns
i. What are they?
How distressing are the problems/concerns
i. How long has the problems/concerns been occurring?
ii. What strategies has the patient used to cope with/solve the problem?
iii. What is the incentive for change?
iv. Any previous experiences similar to current problem?
c. Current life circumstances
i. How does patient occupy his/her time?
ii. Include current psychosocial stressors, coping strategies, and resources
iii. Substance use:
1. Binge eating
2. Alcohol use
3. Smoking
4. Drugs or cannabis
5. Caffeine
iv. Diet
v. Exercise
vi. Romantic/sexual attachments
vii. Close friends/support group
viii. Employment situation
ix. Strengths/areas of improvement
d. Process Issues
i. How does patient react to you?
ii. How does patient communicate his/her concerns (e.g. openly, honestly, avoids expressing feelings)?
iii. What is it like to be in the room with patient? What thoughts/emotions are evoked?
e. Socioeconomic Environment
i. Past education, occupation, religion, economic status, discipline, and housing while growing up
ii. Current
1. economic status
2. housing
3. transportation
f. Assessment
i. Problem list from medical and psychosocial history
ii. Conclusions
1. Conclusions should be a discussion of your assessment of the psychosocial functioning of patient as well as ways in which it interfaces with his/her organic disease and overall health. If this is not readily derived from the information collected, formulated answers to the following questions will complete this section.
2. What is patient’s view/model of the world?
3. Suicide Risk and Violence Risk Assessment (SRA/VRA)
SRA (Low, Medium or High Risk)
VRA (Low, Medium or High Risk)
4. What behaviors, excess or deficits or attitudes does patient have that contribute to or alleviate his/her psychosocial and/or medical problem(s)?
5. What factors, genetic or environmental, may have contributed to patient’s current behavioral health problem(s)?
g. Proposed Treatment Plan
i. List some specific treatment plan regarding ways in which patient can improve current situation and prospective discharge plan
1. If patient is using tobacco or vaping specify “enroll in a tobacco or vaping cessation program.”
2. Individual/couple/family therapy?
3. Support Group?
4. If nutrition, housing, and/or finances, etc. are problematic, indicate community resources that may be helpful
5. Intensive Outpatient Program (IOP) referral
5.1 Name Clinic/Facility
5.2 Name of Healthcare Provider
5.3 Time & Place of IOP Appointments
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