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Respecting Patient Privacy and Diversity SAEM Ethics Committee Ethics in the Trenches: A HEROs GUIDE

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Title: Respecting Patient Privacy and Diversity SAEM Ethics Committee Ethics in the Trenches: A HEROs GUIDE


1
Respecting Patient Privacy and Diversity SAEM
Ethics CommitteeEthics in the Trenches A HEROs
GUIDE

2
The Changing Face of Medicine
  • 18th Century Medicine
  • Practitioner and Patient Share Common Religion,
    Culture, and Race
  • 21st Century Medicine
  • Practitioner and Patient have different racial,
    cultural, and religious backgrounds

3
The Changing Face of Medicine
  • An increasing variety of cultures, races and
    religions are interacting within the clinical
    realm
  • Culture Religion influence healthcare behaviors
    and values
  • Multiculturalism ? Multiple Value Systems
  • The clinician therefore must negotiate between
    different value systems to form healthcare
    partnerships

4
Healthcare Disparities
  • Racial and Ethnic minority populations have worse
    healthcare outcomes than other groups
  • IOM Report Unequal Treatment found quality of
    healthcare provided to minorities is present even
    amongst persons with equal insurance status and
    access to healthcare
  • Example
  • African Americans are more likely to die from
    cardiovascular disease but are less likely than
    whites to undergo PTCA and CABG procedures
  • African Americans are less likely to be placed on
    organ recipient waiting list or undergo
    transplant even when socioeconomic and health
    status is adjusted for

5
Healthcare disparities
  • While most research efforts have focused on
    African Americans similar data exists for
  • Asian-Americans
  • Pacific Islanders
  • From this one can extrapolate that minority
    patients receive an inferior quality of care
  • If these disparities in healthcare were
    eliminated
  • Five times as many lives would be saved by
    advances in medical techniques

6
Causes of Healthcare Disparities
7
Ethical Obligations
  • Beneficence ? Provide same quality of care to all
    patients
  • Social justice ? Work to eliminate healthcare
    disparities
  • How?
  • 1) Eliminate bias
  • 2) Provide patient-centered care tailored to
    patient preferences and culturally-sensitive
  • 3) Promote diversity in the workforce

8
Eliminating Bias
  • Step 1 Eliminate Bias
  • Educate ourselves and our colleagues about
    healthcare disparities
  • Examine our practices for personal bias and
    consciously combat it
  • Offer the same treatment options to all your
    patients
  • Increase cultural competence
  • Learn the important cultural practices and values
    of the populations we serve

9
Ethics of Cultural Competence
  • Culturally competent care is a moral good that
    emerges from a commitment to patient autonomy and
    social justice
  • Essential principles
  • Acknowledge the importance of culture in peoples
    lives
  • Culture informs healthcare behaviors and values
  • Akin to the wind
  • Unable to be seen
  • But can be felt when it is directly opposed to you

10
Ethics of Cultural Competence
  • Essential principles respect cultural differences
  • Medicine has its own culture and value system
  • We cannot enforce our values on our patients
  • Minimize any negative consequences of cultural
    differences
  • Be willing to adapt your practice to accommodate
    patients needs and preferences
  • The main impediment to patient-centered care is
    physician reticence

11
Patient-Centered Care
  • Step 2 Provide Patient-Centered Care
  • Adjust your practice to meet needs, preferences
    and expectations of patients
  • Empower patients in the decision-making process
  • Encourage questions
  • Be willing to negotiate interventions and
    customary practice

12
Promote Diversity in Workforce
  • Step 3 Promote Diversity
  • Mentor trainees from diverse backgrounds
  • Encourage diversity in the department and medical
    center

13
Illustrative Case
  • 59 yo Southeast Asian Female
  • CC Chest Pain Inability to Urinate
  • Pt brought in by EMS and requests a female
    provider
  • HPI
  • 24 hours prior pt fell in kitchen
  • Shooting pain from lumbar back to right leg
  • Difficulty ambulating
  • Inability to urinate/defecate
  • 1 hour prior
  • Substernal chest pain and dyspnea

14
Case
  • PMHx
  • Parkinsons Disease (Stable)
  • MI 99 s/p angioplasty
  • Arthritis
  • GERD
  • Chronic Back Pain and Sciatica
  • Meds Norvasc, Sinemet, Cogentin, ASA, Prevacid
  • NKDA

15
Provider Preference
  • Can the patient choose their caregiver?
  • According to autonomy ? Yes
  • Should we accommodate patient preferences?
  • If possible why not?
  • The lack of accommodation might perpetuate ethnic
    disparities in healthcare and impede a healthcare
    partnership
  • Other acute medical practices do consider patient
    preferences Labor Delivery
  • Psychological harm
  • I was so embarrassed (when a male touched me), I
    wished the ground would open up and swallow me
  • In light of beneficence and non-maleficence we
    should prevent psychological harm if possible

16
Case
  • Physical Exam-
  • 36.7, 100, 140/93, 20, 100 on Room Air
  • MS
  • Spinal Tenderness L4-S1
  • Mild tenderness R Femur, No Ecchymosis
  • Decreased Knee extension secondary to back pain
  • Neuro
  • CN II-XII intact
  • Sensation Dec. R Foot to LT
  • Strength RLE 4/5, LLE 5/5
  • Motor Pill Rolling Tremor L Hand
  • Rectal exam refused

17
Refusal of Rectal Exam
  • Do patients have the choice of medical/physical
    interventions?
  • If competent ? Yes!
  • Principle of Patient Autonomy
  • Respect the patients value system and document
    the refusal and conversation
  • Consider other methods/interventions which may
    yield similar information

18
Case Presentation
  • EKG- No acute changes
  • CXR no active disease
  • V/Q Scan Low Probability
  • Labs - unremarkable
  • U/A 2 HgB, all else negative
  • Troponin lt 0.01
  • Clinician decides to admit the patient for an MRI
    of the LS spine and to complete a cardiac workup
  • Pt refuses bedpan adamantly and wants to walk to
    the bathroom
  • Nurse refuses to break with protocol chest
    pain patient must be on strict bed rest
  • Patient refuses admission

19
Bedpan Quandary
  • Do we allow the patient to leave AMA or do we
    negotiate?
  • The clinician discovers that the patient believes
    using a bed pan makes her unclean
  • However protocol requires non-ambulatory status
  • They come up with a solution ? A commode in the
    room
  • The patient agrees to the admission

20
Highlights from the Case
  • Responding to the needs of a diverse patient
    population requires
  • Effective communication
  • Example eliciting patient concepts of
    cleanliness
  • Creative thinking to find solutions
  • Example commode
  • Willingness to accommodate patient needs and
    preferences
  • Example Finding a female provider to perform
    the physical exam

21
References
  • Paasche-Orlow, M. The Ethics of Cultural
    Competence. Acad Med 2004 79(4)347-50.
  • Bostick, N., Morin, K., Benjamin, R. et. Al.
    Physicians Ethical Responsibilities in
    Addressing Racial and Ethnic Healthcare
    Disparities. JNMA 2006 98(8)1329-34.
  • Padela, A. Can You Take Care of My Mother?
    Reflections on Cultural Competency Clinical
    Accommodation. AEM 2007 14(3)275-7.
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