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Medical Ethics Medical Decision Making

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Medical Ethics Medical Decision Making Jeffrey J Kaufhold, MD FACP Chair, Bioethics Advisory Committee, ... Emergency Med Clinic North Am, 2000; 18: 233-241. – PowerPoint PPT presentation

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Title: Medical Ethics Medical Decision Making


1
Medical EthicsMedical Decision Making
  • Jeffrey J Kaufhold, MD FACP
  • Chair, Bioethics Advisory Committee, Grandview
    Hospital

2
Factors to Consider
  • Medical Indicators
  • Diagnosis
  • Prognosis
  • Treatment
  • Quality of Life
  • Patient Preference
  • Advance Directive
  • Prior Statements
  • Prior Choices pt has made.
  • Context
  • Social
  • Cultural
  • Legal
  • Financial

3
Medical Decision Making
  • Heirarchy for decision making
  • 1. Competent Patient is always first
  • 2. Substituted judgment
  • Family in rank order
  • Spouse
  • Parents
  • Children
  • Others
  • 3. Best Interest of the Patient
  • Paternalistic approach by caregivers
  • 4. Ethics Committee.

July 17, 2004 Robert Orr
4
Summary
  • History of Conflict in medicine
  • Justice in Medicine
  • Social responsibilities of Physicians
  • Medical Futility

5
Justice in Clinical Medicine
  • Edmund Pellegrino, MD
  • Professor Emeritus of Medicine and Medical
    Ethics, Georgetown University Medical Center
  • Lecture from conference
  • Conflict and Conscience in Healthcare
  • July 16, 2004

6
History of Conflict in Medicine
  • Pre-Hippocrates Self Interest of Physician
  • Hippocrates dared to see pt as primary focus
  • This was taken up by all of the monotheistic
    religions, and preserved by the Muslims during
    the middle ages
  • Adam Smith Enlightened self interest
  • Bad outcome is bad advertising
  • Karl Marx All serve society

7
History of Conflict in Medicine
  • Managed Care
  • Limited Resources (Marx influence)
  • Are they really limited?
  • Physician is steward of those resources
  • Inevitable ranking of the Worth of Patients
  • Healthy pt is good for society
  • Chronic illness is bad for society
  • Patient may not be the primary focus

8
Justice in Medicine
  • Assumptions
  • Physician has competence, acts professionally,
    and in the interest of the patient.
  • Implicit covenent with society
  • We are allowed to do Illegal acts, in order to
    learn the art.

9
Justice in Medicine
  • Commutative Justice
  • Contract with patient
  • Distributive Justice
  • Allocation of resources
  • Charitable Justice
  • What we ought to do even if pt is abusing
    themselves
  • General Justice
  • What do we owe the common good?
  • What does the patient owe the common good?

10
Justice in Medicine
  • General Justice
  • Patient has obligation to follow the
    recommendations of the physician
  • Physician must take responsibility to define what
    the patient needs
  • Not required to do what pt wants
  • What good can we do for the patient.
  • Epicaya
  • Preservation of equity
  • Look at the big picture/everyone makes mistakes

11
Social Responsibility of Physicians
  • Best Medicine possible
  • Stay up to date
  • Participate in public debate
  • We have the knowledge needed to inform the debate
  • Advocacy for those who need help
  • Legislators have the responsibility to make
    decisions about distribution of resources.

12
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13
Medical Futility
  • Daniel P Sulmasy, OFM, MD, PhD
  • Director, The Bioethics Institute
  • New York Medical Center
  • July 17, 2004

14
Case
  • 76 y.o. female with Multiple Myeloma admitted
    with Sepsis.
  • Heavily pretreated, no further chemo available
  • On vent, Pressors
  • Daughter wants everything done.

15
The Basis for Medical Futility
  • History of Futility
  • Religious Principles
  • Moral Principles
  • Probability
  • Dealing with the case.

16
Futility, a History
  • Smith Papyrus, 1700 B.C.
  • Entreaty to not intervene if spinal cord is
    transected
  • This Egyptian papyrus, found in 1900s,
    references a much older text.

17
Futility, a History
  • Smith Papyrus, 1700 B.C.
  • Entreaty to not intervene if spinal cord is
    transected
  • Hippocrates, 460 377 B.C.
  • On The Art the physician should refuse to
    treat in cases where medicine is powerless

18
Social norms regarding cancer
  • 1950s call it something else.
  • 1960s Inform pt of diagnosis
  • 1970s Informed consent
  • 1990s - Informed Demand

19
Religious Principles
  • Intrinsic Dignity
  • Made in the image of God
  • Alien Dignity
  • Relationships define our being.
  • Also a fact that we are Finite

20
Religious Principles
  • Life is a gift, and we are its stewards
  • Limits to stewardship
  • Illness is a burden
  • Costs and burden to family/caregivers
  • Futile care need not be given.

21
Moral Principles
  • No moral obligation to provide futile Tx.
  • What is Futile Treatment?
  • Non-beneficial
  • Inappropriate treatment at the end of life
  • What is the real goal?
  • Free of pain and suffering

22
Moral Principles
  • What is Futile Treatment?
  • Subjective Futility
  • Patient wont be able to appreciate benefit
  • This is not sufficient moral argument to withhold
    therapy
  • Objective Futility (biomedical use)
  • No objective benefit to any observer

23
Moral Principles
  • Medical Realism
  • There are facts
  • Trained people can make judgements
  • But we are fallible
  • We have to relate the data to the patient
  • This is the tricky part of the art.
  • Requires use of probability.

24
Probability
  • Is this patient going to die?
  • Probably.
  • Even with treatment?
  • Probably.
  • Can you be more specific?
  • Probably.

25
Probability
  • Prognosis is the probability that a patient will
    respond to tx, plus the probability that the
    disease will kill them.
  • Probability that we use in individual cases comes
    from objective data about the particulars of the
    case, plus experience, plus common sense.
  • This process is fallible, but we do the best we
    can.

26
Probability
  • Three factors
  • Frequency
  • Prediction
  • Strength of belief
  • Lets apply to the case

27
Probability Myeloma with sepsis
  • Frequency (80 of myeloma pts do not wean from
    vent)
  • Based on studies
  • Prediction (1 likelihood of survival for this
    pt)
  • Based on Karnovsky score in Onc literature
  • Based on APACHE score in ICU literature
  • Strength of belief
  • P value
  • Reasonable degree of medical certitude

28
Ultimately, Ethics is about What to Do
  • Aristotle, 384 322 B.C.

29
Morality of Futility
  • Judgment enters Morality when decision is made
    about taking action.
  • Actions
  • Wean from vent?
  • Wean from pressors?
  • Stop Antibiotics?
  • Stop tube feedings/ IV fluids?

30
Morality of Futility
  • Judgment enters Morality when decision is made
    about taking action.
  • Approaches
  • Pragmatic does this help the patient?
  • Remember, removing pt from life support may kill
    them, but might it also stop their suffering?
  • Moral (prudential) is this the right thing to
    do?

31
Back to the CaseMyeloma with sepsis
  • Frequency
  • (80 of myeloma pts do not wean from vent)
  • Prediction
  • (1 likelihood of survival for this pt)
  • Strength of belief
  • Reasonable degree of medical certitude
  • Pragmatic approach
  • CPR will not help pt get better
  • Prudential approach
  • Morally wrong to provide inappropriate treatment.

32
Back to the CaseMyeloma with sepsis
  • Pragmatic approach
  • CPR will not help pt get better
  • Prudential approach
  • Morally wrong to provide inappropriate treatment.
  • Recommendation
  • Make the pt DNR CC arrest
  • Consider withdrawal of life support
  • How do we proceed with the family?

33
Back to the CaseMyeloma with sepsis
  • The family in town wants to keep Mom comfortable,
    and see she is suffering on life support.
  • However, the out of town daughter is in charge
    and insists everything be done.
  • Cultural barriers arise.
  • Tilden. Nurs Res 2001, 50105-115.
  • Its Stressful to be the surrogate
  • Guilt, Ambivalence, Depression, Anger.

34
How to proceed Clinically
  • Establish relationship with family
  • Review case (how did she get here)
  • Describe level of illness
  • Lay out options
  • Establish goals
  • keep her alive until son gets here
  • Maintain comfort no matter what.
  • Establish Limits
  • will not resuscitate her if heart stops.

35
Praying for a Miracle
  • Affirm that this is OK
  • Bear witness in faith, resurrection
  • God is present and answering all our prayers,
    even if a miracle doesnt come

36
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37
Hippocratic Oath
  • Now being admitted to the profession of medicine,
    I solemnly pledge to consecrate my life to the
    service of humanity.
  • I will give respect and gratitude to my deserving
    teachers.
  • I will practice medicine with conscience and
    dignity.
  • The health and life of my patients will be my
    first consideration.

Part 1
38
Hippocratic Oath
  • I will hold in confidence all that my patient
    confides in me.
  • I will maintain the honor and noble traditions of
    the medical profession.
  • My colleagues will be as my brothers and sisters.
  • I will not permit consideration of race,
    religion, nationality politics or social standing
    to intervene between my duty and my patient.

Part 2
39
Hippocratic Oath
  • I will maintain the utmost respect for human
    life.
  • Even under threat I will not use my knowledge
    contrary to the laws of humanity.
  • These promises I make freely and upon my honor.

Part 3
40
Aesculpius
  • Staff with single serpent
  • Life is short, Art is long, experience
    difficult.
  • Greek Obi OE BpAXYE, HTEXNH MA KPH, O KAI POE
    OE YE.

41
(No Transcript)
42
Competency Assessing Decision Making Capacity
  • Jeffrey J Kaufhold, MD FACP
  • Chair, Bioethics Advisory Committee,
  • Grandview Hospital

43
  • A Guide to assessing Decision Making Capacity.
  • Roger C. Jones, MD, Timothy Holden, MD
  • Cleveland Clinic Journal of Medicine
  • Vol 71, December 2004, p 971-5.

44
Summary
  • Physicians need an efficient way to determine a
    pts decision making capacity
  • This capacity must be assessed for each decision
    and not inferred on the basis of pts diagnosis.
  • Documentation of the process used and decisions
    reached is necessary.

45
Case 1
  • Pt admitted for sepsis
  • Poor access for pressors and labs
  • Pt is confused
  • No family is available
  • Can pt consent to line placement?

46
Case 2
  • Elderly pt with Alzheimers and a MMSE score of
    23 of 30 refuses elective Chole.
  • Daughter/DPAHC requests surgery.
  • Can the pt refuse?
  • How can his competency be evaluated?

47
Case 3
  • Pt admitted with acute pneumonia
  • Also diagnosed with severe depression
  • Many answers are I dont know/I dont care
  • Pt refuses treatment, stating I dont care if I
    live or die
  • Does pt have decision making capacity?
  • If not how do you procede?

48
Consent
  • Requirements
  • Autonomy
  • Capacity to understand and communicate
  • Ability to reason
  • Recognized set of values or goals
  • Agreement with the physician does not imply that
    pts capacity to give consent is intact!

49
Competency
  • Legal designations determined by the courts.
  • Decision making capacity is clinically determined
    by physician at the bedside.
  • Adults are presumed competent unless legally
    judged to be incompetent.
  • Presidents commission for the study of Ethical
    Problems in Medicine 1982.
  • Avoid Routine recourse to legal system.

50
Clinical Approach
  • Urgency of the clinical situation determines how
    to procede.
  • Urgent situation
  • Pt not able to communicate / no spokesperson
  • Assume that a reasonable person would not want to
    be denied life saving treatment.
  • Implied Consent

51
Clinical approach
  • Nonemergent situation
  • What are the risks and benefits?
  • Low risk may not require much decision making
    capacity.
  • Im here to draw your blood for a hct.
  • High risk may require significant deliberation.
  • Should a pt with lung cancer and severe CAD
    undergo pneumonectomy for possible cure?

52
Algorithm for assessment
  • Miller and Marin, Emergency Med Clinic North Am,
    2000 18 233-241.
  • Series of simple questions
  • Doesnt take into account the level of risk or
    benefit of a treatment.

53
Algorithm
  • 1. Do the history and physical confirm that the
    pt can communicate a choice?
  • Is their memory good?
  • Is judgement appropriate?
  • Can they maintain a conversation/follow your line
    of questioning?
  • Are their answers consistent?
  • If yes procede to question 2
  • If No pt needs help with decision making.

54
Algorithm
  • 2. Can the pt understand the essential elements
    of informed consent?
  • What is your present condition?
  • What treatment is being recommended?
  • What might happen to you if you agree to the
    treatment?
  • What might happen to you if you refuse the
    treatment?
  • What are the alternatives available?
  • Test of pts understanding of the discussion.

55
Algorithm
  • 3. Can the pt assign personal values to the
    risks and benefits of intervention?
  • Jehovahs witness refusal to accept transfusion
    reflects different set of values.

56
Algorithm
  • 4. Can the pt manipulate the information
    rationally and logically?
  • Can you follow how the patient got to their
    decision?

57
Algorithm
  • 5. Is the patients decision making capacity
    stable over time?
  • Repeat the question several minutes later/ after
    more discussion.

58
Algorithm
  • Benefits of this approach
  • Avoids the tendency to devalue capacity of
    chronically ill pts
  • Reduces reliance on surrogate decision makers
    when not necessary
  • Avoids judgement based on whether pt agrees with
    Doctor.

59
Algorithm
  • Limitations
  • Language barriers
  • Cultural barriers
  • African Americans tendency to not look at
    speaker, distrust of system leading to
    misinterpretation of options provided
  • Some of the assessment questions are subjective.

60
When surrogate must be consulted
  • If the pt is incompetent as determined by the
    court
  • If the pts decision making capacity is in doubt
  • If the pt is unable to understand options or is
    unable to decide.

61
Case 1
  • Pt admitted for sepsis
  • Poor access for pressors and labs
  • Pt is confused
  • No family is available
  • Does pt have to consent to line placement?
  • No, use implied consent.

62
Case 2
  • Elderly pt with Alzheimers and a MMSE score of
    23 of 30 refuses elective Chole.
  • Daughter/DPAHC requests surgery.
  • Can the pt refuse?
  • MMSE can miss cognitive deficits
  • How can his competency be evaluated?
  • Psychiatry consult, ethics consult if needed.
  • In this case, daughter served as decision maker.

63
Case 3
  • Pt admitted with acute pneumonia
  • Also diagnosed with severe depression
  • Many answers are I dont know/I dont care
  • Pt refuses treatment, stating I dont care if I
    live or die
  • Does pt have decision making capacity?
  • Physician determined that pt does not, due to
    depression.
  • Treat depression and pneumonia.
  • Capacity may return once depression treated.

64
Summary
  • Physicians must determine decision making
    capacity every day.
  • Diagnosis does not imply impaired capacity, nor
    does good MMSE imply that pt has capacity.
  • Agreement or disagreement with physicians
    recommendation does not imply capacity is intact
    or impaired.

65
Summary
  • Differing pt values may result in conflict and
    raise questions about pts capacity.
  • Algorithm provides a simple method to determine
    D.M. capacity
  • Competency is legal determination
  • DMC is clinical determination.
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