Medical Ethics Medical Decision Making

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Medical EthicsMedical Decision Making

• Jeffrey J Kaufhold, MD FACP
• Chair, Bioethics Advisory Committee, Grandview
  Hospital

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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

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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
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Summary

• History of Conflict in medicine
• Justice in Medicine
• Social responsibilities of Physicians
• Medical Futility

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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

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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

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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

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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.

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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?

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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

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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.

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Medical Futility

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

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Case

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

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The Basis for Medical Futility

• History of Futility
• Religious Principles
• Moral Principles
• Probability
• Dealing with the case.

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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.

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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

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Social norms regarding cancer

• 1950s call it something else.
• 1960s Inform pt of diagnosis
• 1970s Informed consent
• 1990s - Informed Demand

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Religious Principles

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

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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.

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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

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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

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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.

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Probability

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

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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.

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Probability

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

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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

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Ultimately, Ethics is about What to Do

• Aristotle, 384 322 B.C.

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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?

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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?

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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.

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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?

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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.

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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.

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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

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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
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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
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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
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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.

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Competency Assessing Decision Making Capacity

• Jeffrey J Kaufhold, MD FACP
• Chair, Bioethics Advisory Committee,
• Grandview Hospital

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• 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.

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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.

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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?

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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?

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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?

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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!

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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.

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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

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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?

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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.

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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.

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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.

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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.

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Algorithm

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

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Algorithm

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.