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Bioethics Advisory Committee Curriculum for House Officers 23 June 2014 What an Ethics Committee does Consults: Consultants are physicians, ethicists, or administrators who have special interest and training or experience in medical ethics. Review of Policies for Hospital DNR policy Futility policy Ohio Living Will policy Policies on Establishing Brain Death and Care after Brain Death is Declared Education of Nursing and Medical Staff, Students on Policies and procedures Mentoring of committee members, to be able to speak effectively in the language of Medical ethics. Residents and students are welcome to attend. Goals of Palliative, comfort care DNR does not mean do not treat. “Comfort care only” means active treatment of the underlying disease will stop, and comfort measures will continue or be instituted. Antibiotics, dialysis, lab draws, etc will stop. Legal, financial and quality issues Legal: The Legal ramifications of having an Ethics committee are obvious, as the policies and procedures developed do help to protect the hospital and staff. More importantly, improvement of communication with the patients family has been shown to be the most effective deterrent to lawsuit. As an example, Hospice care has the worst outcomes but the best communication about the dying process, and almost never gets sued. Financial: The hospital does not get reimbursed for the activities of an ethics committee, but JCAHO requires each hospital to have such a committee, and accreditation by JCAHO is required for Medicare reimbursement. Indirectly, a functioning and active committee saves the hospital and medical staff money by preventing lawsuits and limiting futile care. Quality: In addition to JCAHO requirements, there are numerous quality indicators which reflect the performance of the ethics committee, including Pain Management, Organ donation, Reporting of requests for organ donation, patient and family satisfaction surveys. Hospital death rates are lower if terminal care is provided through Hospice: and Hospice care is more likely to be used when the family understands that this is an option, and physicians view Hospice care as an ally, not a last resort. A. Principles frequently used in medical ethical decision making. 1. Paternalism - Doctor knows best, and acts based on the Doctor’s assumptions of what is best for the patient. 2. Natural Law - a body of law based on reason, discoverable by human rational intelligence. Generally used by the Church/Clergy, this can be summarized by the right to Life, Liberty, and the pursuit of Happiness. Allows for the patient to accept or refuse therapy, as Natural law recognizes that the disease is what is threatening life, not our decisions. For example, high doses of pain medicine may be given to a terminally ill patient to control pain, even if we recognize that such doses may suppress respiration, blood pressure, and the gag reflex. The physician is free of blame if the patient dies as a result, as long as the intent was to relieve suffering. This is the oldest set of principles used in medical ethics, but still is a powerful and useful force. 3. Autonomy - Act according to the patients wishes, which may be stated in a Level of Care document, may be implied by other actions or decisions the patient has made, or may be provided by a spokesperson. (Guardian for an incompetent patient or minor, or the Durable Power of Attorney for Health Care DPOAHC). Others may act as spokespersons based on their relationship to the patient. (Surrogate) 4. Utilitarianism - Do what is best for society as a whole, which is becoming more important as the costs of medical care increase beyond society’s ability to pay. There are also pressures being exerted by 1 Managed Care, Organized Medicine, and Trial Lawyers. The State of Oregon has used this priciple to decide which types of treatments and which diseases will receive funding by the state. 5. Non malfeasance - “primum non nocere” First do no harm. Health care providers have a right and an obligation to withhold care which carries more risk than good. When you are in doubt, the patient is better off if you do nothing. 6. Futility - an extension of the principle of non malfeasance, which allows the withdrawal of some types of supportive care when there is no definitive treatment for a patient’s medical problem. 7. Outcomes Analysis - a perspective on current and planned care for a patient which tries to predict the likely outcome of the sum total of care provided. There are many cases where conflict arises between the care providers and the patient or spokespersons because each weighs the potential outcomes differently. Often this is a very powerful perspective to use to help family members/POA recognize the futility of care they are requesting. In futile cases, if we can show that the best outcome is a prolonged stay in a Nursing Home with a feeding tube, tracheotomy and dialysis, most patients will agree that they do not wish to end up this way. It is difficult to do, but it is usually best to provide percentages of the likelihood of possible outcomes. This requires knowledge of predictors of mortality such as APACHE scores, or recognition of high mortality diagnoses such as sepsis, Acute Renal Failure, or Multi System Organ Failure (MSOF). There is also a functional status score which can help determine the best level of rehabilitation after an illness or the ability to tolerate certain treatments such as chemotherapy. (Karnovsky score). B. Levels of Care Orders Each hospital has a procedure for designating the Level of Care if limitations on resuscitation are requested. The following should be documented in the chart: Progress note detailing what was discussed and with whom. Order stating DNR CC-ARREST, DNR CC, or specific limits (No shock, no CPR etc). Copy of Ohio form, living will, etc. if available. Then, each daily progress note should end with a line restating that the patient is DNR or has a limited resuscitation. (doesn’t need to list every detail) This last step is most important for the house officer, as you will usually turn to the progress notes to find out what has been going on with a patient you are called about. In an emergency, that last line of the note will be the first thing you see, and can help avoid inappropriate interventions. You will be surprised how often a DNR designation gets lost if it is not renewed daily in the progress note. C. Order of utility of these principles: First do no harm. When there is a decision to be made, the patient’s own expressed wishes are best, provided they are informed and free of duress. This means that a discussion has taken place with the physician so the patient has all the information they need and the physician is comfortable that the patient understands the implications of their decision. The patient should also be free of pain and not making a decision based on financial concerns, or feel under pressure by family members or the health care team. Next best is the word of the patient’s spokesperson or DPOAHC. Again the decision should be informed and free of duress, and should reflect the spokespersons understanding of the patient’s wish, not their own. (documentation note: do not write “the patients surrogate requested …” better to say “ the patient’s surrogate reported that the patient would have wanted …). If the patient is unable to speak for themselves and there is no surrogate, the caregivers must make a decision based on what they believe is in the best interest of the patient. Getting the Input of the physicians who have a long term relationship with the patient can be very helpful. Documentation note: “ based on Doctor X’s interaction with the patient over the course of ..time period.. We believe the patient would have wanted (or not wanted) ……. Also be sure to document efforts at finding a spokesperson/family member, to fulfill the requirement of “Due Diligence”. List the phone numbers called, who you spoke to, what they said. At any point in the process, the healthcare team may request an Ethics Committee consultation, to help clarify the issues, or to help identify or educate the patient/surrogate or if needed to identify another provider if the primary provider is uncomfortable with the decision the patient is making. Most doctors 2 will request an ethics consultation when they wish to invoke the futility principle in the absence of a surrogate. D. Cultural Issues pertaining to Level of Care decisions. There are many cultural perspectives on End of Life issues, and these need to be taken into account too. When there is conflict based on culture, it helps the healthcare team accept the decisions made even if they would not make the same decision themselves. A. African American culture holds a deep suspicion of American Medicine, due to historical mistreatment documented in the Tuskegee experiment, segregation, and certain urban myths related, for example, to immunizations. This explains the low rate of organ donation in this population and it is common to see resistance to making family members DNR. B. Religious beliefs will play a role in medical decision making. Some patients/families will need to speak to a hospital chaplain or their own religious advisor to help with end of life matters. Most religions DO allow DNR status and the withdrawal of life support, as well as organ donation. C. Poverty and illiteracy may result in insecurity and misunderstanding. E. Definitions of Terms Advance Directive A document which instructs physicians on the care the patient wishes to receive if the patient is incapable of making those decisions when the healthcare decisions are being considered. It can also appoint someone to make those decisions for the patient. Brain Death The point at which all electrical impulses in the brain ends; the brain no longer functions and no brain function can be restored. The patient is dead by accepted medical and legal standards. Cardiac Arrest The patient’s heart stops beating. Comfort Care Interventions that are not aggressive and are designed to keep the patients free of pain. Decisional Capacity The ability of the patient to understand information that is presented to him/her or to make decisions based on information that is given to him/her. DNR The physician’s order, based on the condition of the patient and conversations with the patient and/or surrogate, not to resuscitate the patient in the event of cardiac or respiratory arrest. DNR comfort care The identification given to a patient who, in consultation with the physician, decides that he/she does not want to be resuscitated in case of cardiac or respiratory arrest; the patient has decided that they want no medical interventions other than comfort care. Usually also the patient does not want further testing or treatment of the underlying condition either. DNR comfort care - arrest The identification given to a patient who wants all medical interventions up to the point of cardiac or respiratory arrest; when the arrest occurs, they want to be kept comfortable but do not want CPR, Electric shocks, or other resuscitative measures. Usually also the patient will consent to further testing or treatment of the underlying condition. Futile care Medical interventions that cannot achieve the goals of medical expectations or the personal expectations of the patient. Health care Power of Attorney/ DPOA-HC A document which appoints a person whom the patient trusts to make healthcare decisions for the patient when the patient is unable to make those decisions themselves. This person is sometimes called the POA (power of attorney). Level of Care Orders The preprinted sheet of orders that a physician completes designating the type of care the patient is to receive. The focus of level of care orders is cardiac resuscitation and comfort care. Living Will A document that expresses the healthcare wishes of a patient when the patient is 3 terminally ill and has permanently lost the capacity to make those decisions. Some living wills contain a section which deals with resuscitation/DNR, some do not. Usually the living will specifies what is to be done when the patient is in a persistent vegetative state or has a terminal condition, and allows withdrawal of life support. MOLST Medical Order on Life Sustaining Treatment. A new form of advance Directive which is broader and takes into account other end of life decisions a patient or family may need to make. Incorporates the existing DNR law and designation forms, but adds things like ventilator, Trach, Organ and tissue donation. Persistent Vegetative State A condition of the patient in which they are unresponsive, due to a specific insult, for a specified period of time, despite treatment. Respiratory Arrest The patient is no longer able to breathe without mechanical assistance. Resuscitation The attempt to revive a patient when the heart stops beating or beats ineffectively, or when the patient stops breathing. Surrogate A person elected to speak for the patient when the patient is unable to speak for themselves. Could be formally designated in a Living Will or DPOA-HC, or chosen by the patient’s family, or the closest living relative or friend. The surrogate may need to be reminded that the frame of reference to use in decision making should be that of the patient. It also can be helpful to ease the fear of the surrogate, when making end of life decisions, by invoking the Natural Law principle that the disease is killing the patient, not the decision to withhold or withdraw treatment. Website for detailed exploration of some of the basic issues that arise in medical practice http://academic.udayton.edu/LawrenceUlrich/EIMP THE OHIO LAW ON DNR COMFORT CARE By Lawrence Ulrich, Ph.D. The Ohio law on DNR Comfort Care passed in 1998 with its rules published in 1999. The following website has more information on these issues: http://academic.udayton.edu/LawrenceUlrich/dnrohio.htm. The Ohio law creates a portable DNR, through its DNR Comfort Care Identification. When properly identified, the patient is designated as DNR Comfort Care, and this designation follows the patient from institution to institution to home to EMS transport. This identification is made during a conference with the patient or authorized surrogate and the attending physician. The DNR Identification is made visible by a bracelet, a wallet card, or a form carry the patient’s name, the physician’s name, and the state DNR Comfort Care logo. One major advantage of the Ohio DNR Comfort Care law is the clear description of what constitutes CPR – an issue that has been hotly debated for 25 years. The components of CPR are: Administration of chest compressions Insertion of an artificial airway Administration of resuscitative drugs Defibrillation or cardioversion Provision of respiratory assistance Initiation of a resuscitative intravenous line Initiation of cardiac monitoring The law distinguishes between DNR Comfort Care, in which no component of CPR is to be utilized and DNR Comfort Care Arrest, in which current interventions may be continued, such as medications for arrhythmia, ventilator support for respiratory distress, etc., until the patient experiences cardiac arrest. The protocol for DNR Comfort Care stipulates that when implementing a DNR Comfort Care order, caregivers WILL NOT: 4 Administer chest compression Insert artificial airway Administer resuscitative drugs Defibrillate or cardiovert Provide respiratory assistance (other than that listed above) Caregivers must honor the DNR Identification unless there are extremely rare circumstances where DNR is inappropriate for the patient, or the DNR Identification has been given fraudulently. Caregivers who honor the DNR Comfort Care Identification are protected from both civil and criminal liability. If it should happen that any of the care that is prohibited in the DNR Comfort Care protocol has been initiated and the Identification is subsequently discovered, the intervention(s) must cease immediately. While this law does create some confusion in some of it particulars, it does provide patients with the opportunity to discuss their care with their physicians with the result that they will receive the care that is appropriate for their condition. References: Policies of Grandview Hospital as listed above Ohio Revised Code 1337.17 approved in 1998 and endorsed by : Ohio Hospice OSMA OHA OOA OSBA AMA program on End of life care Physician’s Guide to End of life Care. Snyder, Quill eds. available through the American College of Physicians. (ACP-ASIM: acponline.org, 800-523-1546) Caring for the Dying: Identification and Promotion of Physician Competency, available from the American Board of Internal Medicine (ABIM: www.ABIM.org, phone 215-243-1562) The SUPPORT Studies: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Annals of Int Med Vol 130, No 2, 116-126, 143-152, 19 Jan 1999. Includes a report from the SUPPORT investigators, the Tavistock Group, and The Trouble with Families: Toward an Ethic of Accommodation. Faber-Langendoen and Lanken. Dying Patients in the Intensive Care Unit: Forgoing Treatment, Maintaining Care. Ann Int Med. 2000:133: 886-893. Steinhauser, Clipp et al. In Search of a Good Death: Observations of Patients, Families, and Providers. Ann Int Med. 2000; 132: 825-832. Bergevin, Bergevin. Discussing DNR Issues. AM J of Hospice and Palliative Care. May/June 1995: 1011. 5