Download Slide 1 - Idaho Quality of Life Coalition

2016 Quality of Life Coalition
Conference
Rick Bassett, MSN, RN, APRN,
ACNS-BC,CCRN
Adult Critical Care CNS
Palliative Sedation:
Ethical and Legal
Considerations
June 13, 2016
Overview
• Provide oversight of Clinical Ethics
• Recognize fundamental ethical principles involved with
providing palliative and EOL care
• 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
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.
Responding to Ethical Issues in Palliative Care
• Changes in social/family systems have added to complexity of
end-of-life/palliative care and palliative sedation
• Landmark cases influence legal/ethical history
• Team needs to help patients/surrogates make fully informed
decisions
• How each team member and the team collectively approaches
these clinical situations depends on:
• Their knowledge
• Their experience
• Their ability apply these in creating a safe, ethical and
meaningful EOL experience
Standards of Professional Practice
• Scope of practice & standards of care
• Codes of ethical conduct
• Guidance for responsible end-of-life/palliative practice
• Position statements and guidelines
Also known as the
“Four Box Method”
Medical Indications
Quality of Life
Patient
Preferences
Contextual Features
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?
Medical
Indications
Patient
Preferences
Quality
of Life
Contextual
Features
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?
Medical
Indications
Patient
Preferences
Quality
of Life
Contextual
Features
Quality of Life
• By the patient’s 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
patient’s QOL?
Medical
Indications
Patient
Preferences
Quality
of Life
Contextual
Features
Contextual Features
• Legal rules
• Hospital policies
• Family wishes
• Conscientious objection by providers
• Allocation of scarce resources
(triage and justice)
Medical
Indications
Patient
Preferences
Quality
of Life
Contextual
Features
• 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.
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.
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.
Principles of Bioethics
• Autonomy
• The view that one’s actions are independent from the will of
others. Moral autonomy is the freedom to reach one’s own
values about what is right and wrong.
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
Principles of Bioethics
• Nonmaleficence
• Not performing an action that would cause harm to a patient.
“Above all, first do no harm.”
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?
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.
Double Effect

The principle of double effect recognizes that, occasionally, clinicians
are faced with a decision that cannot be avoided and, in these
circumstances, the decision may cause both a desirable and undesirable
effect. With Palliative Sedation we may be concerned about how our
actions will affect the timing and circumstances of a patient’s death. The
principle states:
 An ethically permissible effect can be allowed, even if the ethically
undesirable one will inevitably follow, when the following conditions are
met:
 The action itself is ethically good or at least indifferent, that is
neither good nor evil in itself (e.g., the action is the
administration of a drug, a morally indifferent act);
 The agent must intend the good effects, not the evil effects, even
though these are foreseen (in this case, the intention is to relieve
pain, not to compromise respiration); and
 The morally objectionable effect cannot be a means to the
morally permissible one (in this case, respiratory compromise is
not the means to relief of pain). If this intention becomes
primary, the action would be judged unethical.
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
• Requires a thorough consideration of the benefits and
burdens of proposed treatment or withholding/withdrawal of
treatment
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
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 subject’s right to freely exercise
his/her decision making without being subjected to external
pressure such as coercion, manipulation, or undue influence.
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
Clinical Standards for D-M-C
•
•
•
•
1. Patient can communicate
2. Patient understands consequences/risks/benefits 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
Why Advance Planning?
• Nearly half of all Americans die in a hospital
• Nearly 70% of Americans die in a hospital, nursing home or longterm care facility
• 7 out of 10 Americans say they would prefer to die at home
• However, only 25% of Americans die at home
• >80% 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 patient’s preferences
(reportedly 25%)
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
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.
Advance Planning Documents
POST
Other ADs
1. Document designed primarily
for those who are seriously ill
or have some life limiting
condition (i.e. chronic end
stage disease, cancer)
2. Is a physician order recognized
throughout the healthcare
continuum
3. Is active and in force as soon
as the document is signed
4. Protected and legally enforced
by statute – most states have
legislation recognizing post in
their state and others that meet
the same legal stipulations
5. Requires the input and
signature of a LIP
1. Designed for use by all persons over the age of 18
2. Usually has two components
a.
Durable Power of Attorney for Healthcare –
defines and authorizes legal surrogate
b.
Living will
i.
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
ii.
provides surrogate and healthcare
providers with information regarding
wishes
c.
Additional instructions – provides for details
regarding patient wishes (beyond the
information in the living will)
3. May be completed with or without a healthcare provider
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
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 lifesustaining/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
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
QUESTIONS