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Ethics, Decision Making and Dilemmas

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Ethics, Decision Making and Dilemmas thanks to Dr .Ryan Liebscher, April 2010 * Onehospice * I ask patients how much they want to know are you the type that likes ... – PowerPoint PPT presentation

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Title: Ethics, Decision Making and Dilemmas


1
Ethics, Decision Making and Dilemmas
2
Objectives
  • Learn the definitions of ethical principles
  • Recognize that ethical issues are raised by
    virtually every clinical decision
  • Understand the value of a team approach in
    ethical decision making with patient as primary
    focus
  • Recognize that every clinical situation is unique
    and presents unique choices between greater or
    lesser goods or evils
  • Develop an approach to decision making
  • Develop approach to ethical dilemma

3
Definitions
  • Morality refers to a set of deeply held widely
    shared and relatively stable values within a
    community.
  • Ethics philosophical enterprise involving the
    study of values and the justification for right
    and good actions.
  • Clinical ethics the identification, analysis
    and resolution of moral problems that arise in
    the care of a particular patient.

4
Why?
  • The principles of beneficence, non-maleficence,
    autonomy and justice are the foundations of
    ethical health care delivery which should be
    the way we consider all our actions and
    decisions.
  • The principles are usually balanced and weighed
    in any clinical decision making.

5
Definitions
  • Beneficence
  • To prevent or remove evil or harm and do or
    promote good.
  • Nonmaleficence
  • Do no harm implies attention to burden vs
    benefit before proceeding with treatment and
    avoidance of futile treatment

6
Definitions
  • Autonomy
  • Self determination or the moral right to choose
    and follow ones own plan of life and action.
    Requires informed consent and a capable competent
    person.
  • Justice
  • Concept of fairness or what is deserved by
    people.

7
Definitions
  • Informed consent Willing acceptance of a
    medical intervention by a patient after adequate
    disclosure of the nature of the intervention, its
    risks and benefits as well as alternatives with
    their risks and benefits.
  • Non abandonment Do not leave patient without
    care

8
Definitions
  • Competency/Capacity
  • The person can understand, reason, and evaluate
    the consequences of the decision and communicate
    it.
  • Matter of clinical judgment-no legal definition
  • May fluctuate with time and patient may be
    competent to make some decisions but not others.
  • If patient is impaired must obtain consent from
    proxy in accordance with local health and legal
    practices. Usually defers to family members whom
    make decision in keeping with known patient
    intentions.

9
Definitions
  • Incapacity
  • Respect for value and dignity of others means
    they must be protected from making decisions that
    would
  • result in harm
  • be different from decisions they would have made
    if capable

10
Definitions
  • Truthful Disclosure
  • We have an ethical obligation to tell the truth
    to patients about their diagnosis and its
    treatment in a way that
  • Uses measured and sensitive disclosure which
    respects autonomy
  • Is in accordance with the hearers emotional
    resilience and intellectual comprehension
  • Reinforces the patients ability to deliberate and
    choose but not to be overwhelmed

11
Definitions Truth Telling Contd
  • Discuss matters that may be important in decision
    making in keeping with patients wishes
  • May ethically withhold truth if
  • There is compelling evidence that disclosure will
    cause real and predictable harm
  • Patient state a preference not to be told the
    truth (often defer to family)
  • Your own safety???????

12
Definitions Truth Telling Contd
  • Common ethical dilemma
  • Practically, if patient unaware of diagnosis/
    prognosis they are unable to participate in
    decisions and advanced care planning ie., not
    based upon reality.
  • Can give rise to conspiracy of silence prevents
    patient and family from having any meaningful
    sharing about feelings, worries, hopes.
  • But must be culturally sensitive -gt family
    meeting.

13
Definitions
  • Paternalism
  • - Overriding or ignoring peoples preferences in
    order to benefit them or enhance their welfare.
  • - Violates autonomy and is not beneficent but is
    non-maleficent.
  • A competent and informed person has the right to
    refuse treatment.

14
Definitions
  • Futility
  • When treatment is incapable of attaining the
    desired goal, it is not indicated. An
    intervention is futile if it prolongs dying and
    brings discomfort but no improvement.
  • Health care team has no obligation to provide
    futile treatment.
  • Withdrawing and withholding treatment are
    ethically and legally justifiable.

15
CPR at end of life in metastatic cancer
  • Pts dying with metastatic cancer or multisystem
    organ failure have near a 5-10 chance of
    surviving CPR and almost no chance of leaving
    hospital. Quality of life is not improved.
  • Burdens of CPR
  • -vegetative state 10
  • -neurological and functional impairment 25
  • -chest wall or intrathoracic trauma 25-50
  • -Indignity, suffering, cost

16
CPR in this case Is this futile?
  • Yes or No
  • What ethical principles are being respected or
    compromised
  • Non-malificence vs beneficence
  • Non-malificence vs patient autonomy

17
Definitions
  • Euthanasia
  • Goal of patient is death, patient has recruited
    someone other than their physician to assist with
    death.
  • Physician assisted suicide
  • Deliberate actions taken by a physician to
    terminate the life of a patient by the patients
    request.
  • Palliative sedation
  • Legally and morally acceptable alternative to
    above
  • If patient has refractory suffering, intentional
    sedation is performed to relieve suffering.
  • Many studies show this does not hasten death

18
How do you Feel
  • What do you think about Euthanasia and physician
    assisted suicide?
  • What ethical values are being respected or
    compromised?
  • Patient autonomy vs non-malificence
  • Professional autonomy vs beneficence
  • Beneficence vs non-malificence

19
Oregon Die with Dignity Act
  • 1997, law to enact physician assisted suicide
    (PAS)
  • Goal to respect autonomy, ? beneficence
  • Specific criteria including meetings with 2
    physicians over at least 2 weeks.
  • Family input not needed but patient must be
    competent
  • Patient decides when lethal injection given.
  • 0.3 of registrants underwent PAS control

20
Oregon Die with Dignity Act
  • Reasons for following through with PAS
  • Losing autonomy 87
  • Less able to enjoy 83
  • Loss of dignity 80
  • Loss of control of body function 59
  • Burden on family 36
  • Inadequate pain control 22
  • Financial costs of treatment 3

21
Ethics in Palliative Care
  • Foundations of ethical practice are
  • Effective Communication
  • Interdisciplinary team
  • Patient and goals/preferences/values as center
  • Have an approach to decision making/dilemmas

22
Decision Making
  • Moral duty to help with decision-making
  • Patients want to know how treatments will improve
    their quality or quantity of life and whether
    they will achieve goals
  • Explore what they want, fear, hope for and value
    Define goals of care.
  • Place risks and benefits into context and
    likelihood of treatment achieving desired
    outcomes

23
Decision Making
  • Decision-making is a process not a one time event
  • May need several meetings, this takes time.
  • Multidisciplinary team involvement in these
    meetings helps to convey information, discuss
    alternatives, provide emotional and psychological
    support and provide expertise.
  • Team involvement also avoids giving mixed
    messages.

24
Decision Making Approach
  • Example Decision Making Matrix

25
Decision Making MatrixJonsen, Siegler,
WinsladeClinical Ethics, Third Edition, 1992
26
Decision Making MatrixJonsen, Siegler,
WinsladeClinical Ethics, Third Edition, 1992
27
Medical Indications
  • Medical Condition (Diagnosis, Prognosis)
  • Treatment
  • Past and present
  • Risks and benefits
  • Pain and symptoms
  • Past experience with the health care system
  • Functional level
  • Suffering
  • Reversible component of illness

28
Patient Preferences
  • Understanding of diagnosis and treatment
  • Goals of treatment curative, palliative -
    spectrum
  • Goals for life
  • Physical
  • Psychological
  • Spiritual
  • Emotional
  • Social
  • Understanding of end of life/palliative care
  • How do you make decisions?
  • Health care proxy, living will

29
Quality of Life
  • What does quality of life mean to you?
  • What gives you meaning in life?
  • Consider physical, social, psychological, and
    spiritual issues.
  • Are there circumstances under which you would
    consider stopping all medication/treatment?
  • What sustains you at present?
  • What is achievable with regard to the patients
    preferences?
  • This will change with time.

30
Contextual Features
  • Terminal illness
  • Dying role vs sick role
  • Disposition home, hospice, hospital
  • Available resources
  • Emotional
  • Physical
  • Fiscal/economic
  • Fairness and equality in distribution
  • Who does what?
  • Is everyone comfortable with this plan?

31
Ethical Decision Making
  • Gather information using Decision Making Matrix
  • Have a family meeting with interdisciplinary team.

32

9-Step Approach to Effective Formal Communication
  • Start the meeting
  • Agree on purpose
  • What does patient/family know/understand?
  • What information is necessary for
    decision-making?
  • Share the information/respond to emotions

33

9-Step Approach to Effective Formal Communication
  • Discover goals/hopes/expectations/fears Values
    History
  • Address their needs/empathy
  • Develop a plan
  • Follow up

34
Case 1
  • Mr K 55 male with known Hepatitis C, presents
    with severe back pain, leg weakness and is
    diagnosed with acute spinal cord compression.
    Neurosurgery consult and biopsy reveal
    hepatocellular carcinoma. No functional recovery
    in spite of steroids and radiation -gt paraplegia.
    ECOG 4, jaundiced in liver failure. 2 daughters
    live abroad his partner is by his side.

35
Case Mr K Contd
  • Post op day 7 develops decreased Level of
    consciousness and dyspnea
  • O/E GCS 10/13, HR 150 regular, RR 35, RML
    bronchial breath sounds and wheeze.
  • Assessment sepsis from aspiration pneumonia.
  • Plan?

36
Approach
  • Gather information - Decision Making Matrix
  • What are his goals of care/preferences?
  • Medical information prognosis, options, likely
    outcome.
  • Quality of life Is he suffering?
  • Contextual features He is not competent. Has he
    expressed future wishes? Who guides decision
    making?
  • Family Meeting

37
Assessment
  • What are his goals of care/ preferences? His
    partner of 10 years provides
  • - Does not want life prolonging therapy
    (previously stated)
  • Does not want to suffer
  • But had wished to see daughters before death
  • Medical information
  • - Advanced hepatocellular carcinoma, not
    candidate for further disease modifying therapy.
  • - SCC-gt Paraplegia irreversible
  • - Septic reversible?

38
Contd
  • Quality of Life
  • Very upset at paralyzed status
  • Currently dyspneic, febrile, diaphoretic,
    restless.
  • Will treatment of sepsis restore his quality of
    life? Is this reversible?
  • Contextual features
  • It becomes evident that for him to see daughters
    is extremely important.
  • They also feel they need to see their dad before
    he dies some complicated family issues.
  • The team has mixed feelings about what to do

39
Action
  • Family Meeting
  • The nurse makes a phone call to daughters, phone
    placed to ear of father so they could tell him
    they love him -gt he looks as though he will die
    within hours. They decide to leave that night for
    Canada.
  • Decision with family and team to make sure we
  • keep him comfortable and
  • aggressively treat sepsis with IV fluids,
    antibiotics in hopes to prolong life so his
    daughters may make it to the bedside.

40
Outcome Contd
  • Progress
  • Over next hours GCS decreases to 7/13
  • Patient comfortable on regular opioid dosed every
    4 hours with breakthrough for dyspnea. Also
    receiving haloperidol for agitation/delirium.

41
Outcome Contd
  • Next morning patient is alert, GCS 13/13 with
    good urine output, normalized vital signs.
  • Daughters arrive that night.
  • Have good visit, closure. Family very grateful.
  • Patient stable alert for 10 days. Gradually
    condition declines, agreement with patient,
    daughters and partner to keep comfortable and to
    provide end of life care.
  • Dies peacefully 1 week later.

42
Ethical Dilemma
  • This can be very challenging
  • Is a situation that requires a choice between
    ethical options that are or seem equally
    unfavorable or mutually exclusive
  • This needs a formal process to determine how to
    make the best decision

43
Ethical Dilemma
  • Here there are pros and cons to each ethical
    principle
  • Our challenge is to recognize which clinical
    options are ethically acceptable and then
    ranking them to make a decision
  • The team may have very different ideas
  • This is not about the right answer or decision
    but the best decision given the information
    available

44
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social/Quality of life
  • Preferences
  • Contextual factors
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

45
Case 1
  • Mr K, 56 yr male with inoperable metastatic
    gastric carcinoma and pulmonary metastases
    presents with severe dyspnea. ECOG 4. Family
    states they do not want him to know prognosis.
  • What is the approach?

46
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Biological
  • Social/Quality of life
  • Preferences
  • Contextual factors
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

47
Approach
  • Articulate/Identify ethical question/dilemma
  • Autonomy vs beneficence
  • Autonomy vs non malificence
  • Beneficence vs non malificence
  • Non malificence vs beneficence
  • Family rights vs patients rights vs team rights

48
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social/Quality of Life
  • Preferences
  • Contextual
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

49
Gather Necessary Information
  • Medical
  • Diagnosis and course of illness
  • Prognosis
  • Treatments available with risks/benefits
  • Status of the patient
  • Clinical judgment
  • Our case No further disease modifying therapies,
    approaching end of life, prognosis 1 week
    patient is more comfortable than on admission,
    has had some good daysis competent.

50
Obtain Necessary Information
  • Social
  • Ethical
  • Professional/Institutional
  • Legal
  • Cultural
  • Financial
  • Our case Team feels ethical principles of
    autonomy and beneficence are being compromised.
    Eldest son spokesperson family feel that patient
    will lose all hope if told. Need to discuss with
    eldest brother whom has not yet arrived.

51
Obtain Necessary Information
  • Preferences and contextual factors
  • Patient wishes past, current
  • Patient competence
  • Advanced directive proxy decision maker
  • Family preferences
  • Health care team preferences
  • Our case Competent. Will knowledge of dying
    influence location of care our patient oxygen
    dependant No.
  • No known patient preferences although patient
    repeatedly asked what he would like to know and
    if he had questions.

52
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social/Quality of Life
  • Preferences
  • Contextual factors
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

53
Analyze the Information and Generate Options
  • Analyze the information and generate options
  • In this case, could
  • 1. Tell
  • 2. Not tell
  • 3. Wait and tell later
  • 4. Tell if asked
  • 5. Provide bits of truth

54
Analyze the Information and Generate Options
  • For each option generated, consider the
    corresponding immediate, short and long term
    consequences of deciding which ethical value must
    be recommended.
  • Be aware of ones own bias and preferences

55
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social
  • Preferences
  • Contextual factors
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

56
Weigh risks/benefits and make recommendation
  • Weigh and balance the options to make an ethical
    judgment on which one is best What to do
  • Why to do it?
  • reasoned arguments invoking the balancing of
    competing values, principles, and consequences
  • Qualifiers - unique aspect of this particular
    case which limits the ability to generalize
  • If have option consider ethics consult if
    necessary

57
Weigh risks/benefits and make recommendation
  • Our case
  • What are the risks and benefits of telling to
    patient. Not having closure, autonomy.
  • What are the risks and benefits of telling to the
    family. Trust, their autonomy as a
    culture/family.
  • What are the risks and benefits of telling to the
    team. Professional values, causing harm.

58
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social/Quality of Life
  • Preferences
  • Contextual
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

59
Implement Recommendation
  • Communicate effectively, Family meeting may be
    necessary with other team members
  • Our case
  • Multiple meetings with sons and eldest son on
    arrival. Explanations given.
  • Meetings with interdisciplinary team what
    cultural factors are relevant.

60
Implement Recommendation
  • The team recommended to eldest son to slowly tell
    his father as per his wishes. This respects his
    role and also achieves principle of autonomy for
    patient with least harm and likely most benefit.
  • The challenge is that the decision in a dilemma
    is not known to be the correct one until the
    outcome has occurred. Must learn from this.

61
Approach to Ethical Dilemma
  • Identify ethical question/dilemma
  • Gather necessary information
  • Medical
  • Social
  • Preferences
  • Contextual factors
  • Analyze information and generate options
  • Weigh risks/benefits and prioritize arguments and
    make recommendation
  • Implement recommendation
  • Provide follow up and evaluate the outcome

62
Provide follow up and evaluate the outcome
  • Learn from the process
  • Our case Patient was gradually told of disease
    progression and prognosis. His wife and close
    family were able to come see him as he slowly
    deteriorated.
  • The day of his death he had seen the close family
    and said he was tired. He had more dyspnea and
    expressed that he had nothing left to do and
    wanted the control of his dyspnea to be priority
    even if it required him being sedated.
  • He died that evening peacefully his eldest son
    closed his eyelids.

63
End of Life Care
  • British Journal of Cancer (2002), 86(10),
    1540-1545
  • Cancer patient's unrelieved symptoms during the
    last 3 months of life increase the risk of
    long-term psychological morbidity of the
    surviving partner
  • Conclusion Diagnosing and treating symptoms of
    terminally ill cancer patients may not only
    improve the patients quality of life but
    possibly also prevent long-term psychological
    morbidity of their surviving partners.

64
Oncology Nursing
  • Learn to be comfortable with uncertainty
  • Work with open heart
  • Take care of yourselves too!
  • Thank you for being nurses, what you offer is the
    highest a unique set of skills to facilitate the
    best holistic care of the patient in a
    compassionate manner. Never underestimate this.

65
References
  • Medical Care of the Dying 4th Edition. Downing,
    M.M. (Ed.) Victoria Hospice Society. 2006
  • Palliative Medicine, A case based manual 2nd
    Edition. MacDonald, N., Oneschuk, D., Hagen, N.,
    and Doyle, D. (Ed.). Oxford University Press,
    2005.
  • Dr. Manuel Borod, Approach to Ethical Dilemma
    Director, Division of Palliative Care, McGill
    University Health Center.
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