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Healthcare Ethics: To Serve and Protect A Practical Approach to Understanding the Clinical Ethics of Advance Planning

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Title: Healthcare Ethics: To Serve and Protect A Practical Approach to Understanding the Clinical Ethics of Advance Planning


1
Healthcare Ethics To Serve and Protect A
Practical Approach to Understanding the Clinical
Ethics of Advance Planning
2014 Quality of Life Coalition Conference
Rick Bassett, MSN, RN, APRN, ACNS-BC,CCRN Adult
Critical Care CNS
June 2, 2014
2
Overview
  • Provide oversight of Clinical Ethics Model
  • Understand the model elements and how that
    applies to the advance planning process
  • Recognize fundamental ethical principles
  • Understand the role of decision-making capacity
    in addressing advance planning and healthcare
    wishes
  • Identify the key differences between the Idaho
    POST and other Advance Planning documents
  • Understand role as a member of the healthcare
    team in preparing, interpreting and executing
    advance planning documents

3
A format for systematic discovery of all
pertinent information
  • "The fragment gives insight into the whole, the
    total picture. The shadow brings insight to the
    light. -Monet
  • In examining a particular ethical issue, it is
    frequently the "fragment" that gives insight into
    the process of resolution and understanding
    because its significance has been overlooked. In
    examining a patient's narrative or history
    through chart review and conversation with all
    those involved and we can discover information
    that can lead to clarity and resolution. The
    Jonsen model provides a framework for this
    systematic review.

4
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5
Also known as the Four Box Method
Medical Indications Patient Preferences
Quality of Life Contextual Features
6
Medical Indications and the Goals of Medicine
  • What is the diagnosis? Is the problem acute,
    chronic, reversible, emergent?
  • What are the goals of treatment from the patient
    and physician perspectives?
  • How likely or unlikely is success for the various
    treatment options?
  • What are the risks and burdens of treatment or
    non-treatment, and what are the potential
    benefits?

7
Special Considerations Related to Patient
Preferences
  • Has the patient been fully informed of potential
    benefits and risks, processed this information,
    and given consent?
  • Is the patient mentally and emotionally
    capable of giving consent? (capacity)
  • Are the expressed patient preferences
    consistent with previously expressed
    wishes? Are Advance Directives in place?
  • If the patient is unwilling to cooperate with
    the recommended treatment, why?
  • If incapacitated, who is the appropriate
    surrogate decision maker?

8
Quality of Life
  • By the patients estimation, what was their
    previous quality of
  • life? What are the prospects for returning to
    that baseline?
  • If unlikely to return to that QOL, what level of
    QOL is
  • acceptable to the patient?
  • Are there any biases on the part of surrogate
    decision-makers
  • or providers that might prejudice their
    evaluation of the
  • patients QOL?

9
Contextual Features
  • Legal rules
  • Hospital policies
  • Family wishes
  • Conscientious objection by providers
  • Allocation of scarce resources
  • (triage and justice)
  • Issues of public health and safety
  • Patient/family financial constraints
  • Religious preferences
  • Conflicts of interest among providers, or within
    the institution.
  • Other parties who have an interest in the
    decisions made.

10
After the information is gathered, then what?
  • This is a fact gathering model, not a decision
    making tool.
  • Once the information is sorted, the relationship
    between that information and ethical principles
    must be assessed.
  • Sometimes, reflection upon the data will
    naturally lead to clarity on the problem and
    solutions. Other times, a conflict remains and
    communication between relevant parties is
    necessary to share information, understand
    divergent perspectives, and work toward a
    solution that most (if not all parties) find
    acceptable.

11
What is Ethics?
  • "Ethics has to do with what my feelings tell me
    is right or wrong." "Ethics has to do with my
    religious beliefs." "Being ethical is doing what
    the law requires." "Ethics consists of the
    standards of behavior our society accepts." "I
    don't know what the word means.

12
What is Ethics?
  • What then is Ethics?
  • Well based standards of right and wrong that
    prescribe what humans ought to do, usually in
    terms of rights, obligations, benefits to
    society, fairness, or specific virtues
  • -Velasquez, Andre,
    Shanks, and Meyer (2001)
  • The study and development of one's ethical
    standards
  • Continuous effort of studying our own moral
    beliefs and our moral conduct in order to
    effectively render professional opinion and care
  • A set of principles and values that govern the
    delivery of patient care

13
Values
  • Are standards or qualities which you consider
    worthwhile or desirable.
  • Help you to establish a sense of purpose and
    direction.
  • Act as guideposts that assist you in decision
    making and measuring the quality of life.
  • Have a great deal of affect over your choices,
    decisions, and how you view the world and others
    around you.

14
Value clarification
  • A series of strategies to help you identify core
    and supporting values
  • Raise issues, confront inconsistencies, sort out
    our values.
  • It is a process to determine the content and
    power of your values (not one size fits all).
  • A self-audit, an inventory to freely choose your
    values.

15
Values..
  • The clearer you are about what you value
  • The better able you are to choose and initiate a
    response that is consistent with what you say you
    believe.
  • You become conscious of your values
  • This is very important when making value
    judgments on behalf of patients.

16
Which way do I go?
17
Principles of Bioethics
  • Suggest direction or proposed behaviors
  • Serve as guides to organizing and understanding
    ethically relevant information in a dilemma.
  • They propose how to resolve competing claims.
  • They are the reasons justifying moral action.
  • Ethical principles are universal in nature. They
    are not absolute.

18
Principles of Bioethics
  • Autonomy
  • The view that ones actions are independent from
    the will of others. Moral autonomy is the
    freedom to reach ones own values about what is
    right and wrong.

19
Principles of Bioethics
  • Beneficence
  • Performing an act which is good or which brings
    about good effects.
  • Requires three types of action
  • Preventing harm
  • Removing harm
  • Doing good, even at some cost and risk to oneself

20
Principles of Bioethics
  • Nonmaleficence
  • Not performing an action that would cause harm to
    a patient. Above all, first do no harm.

21
Principles of Bioethics
  • Justice
  • A group of norms for distributing benefits, risks
    and costs fairly. These norms are typically
    reflective of societal norms and values and while
    they may be fair they may not be equitable.
  • What is fair?
  • What is equitable?

22
Principles of bioethics
  • Futility of Treatment
  • When a patient is so seriously ill or injured
    that sound clinical judgement would suggest that
    the goals of restoration of health and function
    seem beyond attainment.
  • When treatment goals can no longer be met
    regardless of intervention.

23
Informed Consent
  • Informed consent
  • Strong legal and ethical concepts providing the
    foundation for this process
  • Central to the moral and legal rights of persons
  • Requires members of the healthcare team to
    understand their role with regard to their
    discipline and the informed consent process

24
What is Meant by Informed Consent?
  • Permission granted in the knowledge of the
    possible consequences, typically that which is
    given by a patient to a doctor for treatment with
    full knowledge of the possible risks and
    benefits.
  • Informed consent is a legal term that denotes
    that a person is or has been made fully aware of
    the facts of a certain situation (in this case, a
    medical procedure) before agreeing to it. In
    order to obtain informed consent, the physician
    is both ethically and legally responsible to
    discuss RISK, BENEFITS and ALTERNATIVES
  • For example
  • The diagnosis
  • Details about the procedure or treatment, and why
    it is being recommended
  • The risks and benefits involved
  • Any possible alternative treatments
  • The risks and benefits of any alternatives
  • The risks and benefits of NOT undergoing the
    treatment or procedure

25
Elements of Informed Consent
  • Disclosure or Information
  • While Disclosure requires the physician to
    provide the patient with the information
    necessary to make an autonomous decision, they
    must also ensure that patient has adequate
    comprehension of the information provided
  • Capacity or Comprehension
  • Capacity pertains to the ability of the patient
    to both understand the information provided and
    form a reasonable judgment based on the potential
    consequences of his/her decision.
  • Voluntariness or Freedom from Undue Coersion
  • Voluntariness refers to the subjects right to
    freely exercise his/her decision making without
    being subjected to external pressure such as
    coercion, manipulation, or undue influence.

26
Moral Values and Principles
  • Truth and Honesty
  • Full disclosure and support of a relationship of
    trust
  • Recognizes the value of self-determination and
    the ethical principle of Autonomy
  • Respect
  • We have an ethical duty to protect the human
    rights and human dignity
  • Belmont Report
  • Foundational document defining key ethical
    principles of human research
  • Upholds the concept that our actions are
    consistent with and supportive of

27
Clinical Standards for D-M-C
  • 1. Patient can communicate
  • 2. Patient understands consequences/risks/benefit
    s of choice
  • 3. This choice is consistent with values
  • 4. Decision is not result of delusions,
    medication side effects, psychosis, coercion
  • 5. Patient can process information logically

28
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29
Decision-Making Capacity Myths
  • DMC and legal competency are the same
  • Autonomy
  • Assent
  • Lack of DMC can be presumed when patients go
    against medical advice
  • Autonomy
  • Justice
  • Contextual features

30
Decision-Making Capacity Myths
  • DMC is an all or nothing phenomenon
  • Some patients may lack DMC to make any decisions
  • Some patients may have limited DMC and able to
    make less complex decisions
  • Some patients may have full DMC and able to make
    complex decisions weighing multiple risks and
    benefits
  • Ex. Demented patient and abx tx for a UTI vs.
    same patient and weighing the multiple and
    complex risks and benefits of a neurosurgical
    procedure with uncertain tradeoffs between
    quality and quantity of life
  • While cognitive ability and DMC are co-related,
    cognitive tests (i.e. MMSE) should not be used as
    a substitute for determining DMC
  • This also applies to those with certain
    psychiatric disorders. While they may have
    limitations they frequently have at least some DMC

31
Decision-Making Capacity Myths
  • The lack of DMC is a permanent condition
  • DMC can change over weeks/months for less
    temporary conditions or over minutes for acute
    issues affecting DMC
  • (i.e. TBI vs. acute delirium)
  • Who can assess DMC?
  • Only a trained psychiatrist
  • Only physicians
  • Only Social Workers and Physicians
  • All clinicians responsible for patient care

32
Jonsen Model
  • Medical indications
  • Diagnosis and treatment of the pathological
    condition
  • Demographics
  • age, gender, etc.
  • Medical Hx
  • Goals of treatment
  • Plan in case of therapeutic failure
  • Quality of Life
  • What are the prospects with or w/o treatment for
    return to normal life.
  • HCP bias that might prejudice evaluation of
    patients QOL
  • Are physical, mental /or social deficits likely
    to accompany successful treatment?
  • Is present or future QOL possibly viewed
    undesirable by patient w or w/o treatment?
  • Any plans for comfort or palliative care?
  • Patient Preferences
  • Patients preferences re treatment
  • RBA, informed consent
  • Competency, decision making capacity
  • Prior preferences-Advanced Directive
  • Who is surrogate?
  • Patient agreeable to treatment
  • Patients autonomy respected
  • Contextual Features
  • Family/HCP issues influencing treatment
  • Financial or economic factors
  • Religious or cultural factors
  • Problems with allocation of resources
  • Legal implications of treatment decisions
  • Provider or institutional conflict of interest
  • Clinical research or teaching involved

33
Case Overview
  • MEDICAL INDICATIONS
  • 53 yo male admitted with hematemesis, elevated
    WBCs and lactate and dehydration with a hx of
    chronic anemia, cirrhosis r/t chronic ETOH abuse,
    tobacco use.
  • EDG with esophogeal lacerations
  • 7th admission in 8 months
  • Developed new GI bleed in hospital
  • Renal and hepatic function worsening
  • Delirius
  • Mech. Ventilated and transitioned to CPAP

34
Case Overview
  • PATIENT PREFERENCES
  • In previous admissions has always insisted on
    aggressive treatment and full code status
  • Sister doesnt think that he would want to live
    in a diminished state
  • QUALITY OF LIFE
  • Declining in recent years
  • Very unlikely that we will be able to restore him
    to any similar quality of life
  • CONTEXTUAL FEATURES
  • Estranged from family
  • ETOH rehab multiple times w/o success

35
Discussion
  • What are the key pieces of information under
  • Medical Indications
  • Patient Preferences
  • Quality of Life
  • Contextual Features
  • As an ethics committee how would you approach
    this consult?
  • What is/are the primary ethical issue(s)?
  • Are there any cases that provide precedence in
    how this is handled?

36
Why Advance Planning?
  • Nearly half of all Americans die in a hospital
  • Nearly 70 of Americans die in a hospital,
    nursing home or long-term care facility
  • 7 out of 10 Americans say they would prefer to
    die at home
  • However, only 25 of Americans die at home
  • gt80 of patients with chronic diseases say they
    want to avoid hospitalization and intensive care
    when they are dying
  • Only 20-30 of Americans report having an advance
    directive
  • Even when they do have an AD, physicians are
    often unaware of the patients preferences
    (reportedly 25)

37
Advance Planning Documents
  • Physician Orders for Scope of Treatment (POST)
  • Replaced the Comfort one in July 2007
  • Legally recognized
  • Inpatient
  • Outpatient
  • Clinics
  • MD offices, etc.
  • Intended to direct care consistent with patient
    wishes
  • Not just a DNR form

38
Advance Planning Documents
39
Advance Planning Documents
40
Advance Planning Documents
41
Advance Planning Documents
42
Surrogate Decision-making
  • Who decides?
  • 1. The legal guardian of the patient
  • 2. The person named in the Durable Power of
    Attorney for Healthcare
  • 3. If married, the spouse of the patient
  • 4. The adult son or daughter
  • 5. A parent of the patient
  • 6. Any relative representing himself or herself
    to be an appropriate responsible person to act
    under the circumstances
  • 7. Any other competent individual representing
    himself or herself to be responsible for the
    health care of the patient
  • 8. The attending physician, if none of the
    foregoing exists or is available.

43
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44
Advance Planning Documents
  • POST
  • Document designed primarily for those who are
    seriously ill or have some life limiting
    condition (i.e. chronic end stage disease,
    cancer)
  • Is a physician order recognized throughout the
    healthcare continuum
  • Is active and in force as soon as the document is
    signed
  • Protected and legally enforced by statute most
    states have legislation recognizing post in their
    state and others that meet the same legal
    stipulations
  • Requires the input and signature of a LIP
  • Other ADs
  • Designed for use by all persons over the age of
    18
  • Usually has two components
  • Durable Power of Attorney for Healthcare
    defines and authorizes legal surrogate
  • Living will
  • only in force when the criteria have been met
    (If person is unable to communicate instructions
    AND has an incurable or irreversible injury,
    illness or condition AND a medical doctor has
    certified that the condition is terminal AND life
    support would only serve to artificially prolong
    life AND death is immenent
  • provides surrogate and healthcare providers with
    information regarding wishes
  • Additional instructions provides for details
    regarding patient wishes (beyond the information
    in the living will)
  • May be completed with or without a healthcare
    provider

45
Ethics of Palliative Care
  • Autonomy
  • What are the patients defined goals?
  • Have all their options been provided to them?
  • Beneficence
  • Do their goals reflect what will provide the most
    good?

46
Prolongation of Life and Quality of Life
  • Life sustaining treatments
  • Palliative vs. prolonging suffering
  • Provides time for family
  • Is not incompatible with DNR
  • What is life-sustaining?
  • Nutrition, hydration, dialysis

47
Withholding/Withdrawing Treatment
  • Withholding - the act of not instituting measures
    that would serve to either prolong life or delay
    death.
  • Withdrawing - the removal or discontinuation of
    life-sustaining/life-prolonging therapies of a
    treatment considered medically futile in
    promoting an eventual cure or control of disease
    or symptoms
  • Lesage Latimer, 1998 Sulmasy, 1998

48
Developmentally Disabled
  • Currently two standards in place for decision
    making
  • Competent persons
  • Gives provision for surrogate decision makers to
    act in behalf on one who is unable to make their
    own decisions
  • If decision is felt to be in the best interest of
    the patient the ability to withhold or withdraw
    treatment is not limited
  • Developmentally delayed persons with a court
    appointed guardian
  • Gives limited provision to the appointed guardian
    to act as the surrogate in behalf of the patient
  • Ability to withhold or withdraw treatment is
    conditional
  • No physician or caregiver shall withhold or
    withdraw such treatment for a person whose
    condition is not terminal or whose death is not
    imminent

49
Conclusion
  • Ethical discernment, discourse, decision-making
  • Application of principles of ethics to create
    best solutions to complex ethical dilemmas at the
    end of life
  • Address values and understanding of needs
  • Advocate for patient/family rights
  • Work closely with other disciplines

50
QUESTIONS
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