Download Slide 1 - Idaho Quality of Life Coalition

2014 Quality of Life Coalition
Conference
Rick Bassett, MSN, RN, APRN,
ACNS-BC,CCRN
Adult Critical Care CNS
Healthcare Ethics:
To Serve and
Protect
A Practical
Approach to
Understanding the
Clinical Ethics of
Advance Planning
June 2, 2014
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
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.
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.
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.”
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
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.
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.
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.
Which way do I go?
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.
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
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
Decision-Making Capacity Myths
1. DMC and legal competency are the same
a. Autonomy
b. Assent
2. Lack of DMC can be presumed when patients go against medical
advice
a. Autonomy
b. Justice
c. Contextual features
Decision-Making Capacity Myths
3. DMC is an all or nothing phenomenon
a. Some patients may lack DMC to make any decisions
b. Some patients may have limited DMC and able to make less
complex decisions
c. 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
Decision-Making Capacity Myths
4. The lack of DMC is a permanent condition
a. DMC can change over weeks/months for less temporary
conditions or over minutes for acute issues affecting DMC
(i.e. TBI vs. acute delirium)
5. Who can assess DMC?
a. Only a trained psychiatrist
b. Only physicians
c. Only Social Workers and Physicians
d. All clinicians responsible for patient care
Jonsen Model
Medical indications
Quality of Life
• Diagnosis and treatment of the
pathological condition
• Demographics
• age, gender, etc.
• Medical Hx
• Goals of treatment
• Plan in case of therapeutic failure
• What are the prospects with or w/o
treatment for return to “normal life.”
• HCP bias that might prejudice evaluation of
patient’s 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
Contextual Features
•Patient’s preferences re: treatment
•RBA, informed consent
•Competency, decision making capacity
•Prior preferences-Advanced Directive
•Who is surrogate?
•Patient agreeable to treatment
•Patient’s autonomy respected
•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
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
Case Overview
PATIENT PREFERENCES
• In previous admissions has always insisted
on aggressive treatment and full code
status
• Sister doesn’t 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
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?
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
Advance Planning Documents
Advance Planning Documents
Advance Planning Documents
Advance Planning Documents
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
Ethics of Palliative Care
• Autonomy
• What are the patient’s defined goals?
• Have all their options been provided to them?
• Beneficence
• Do their goals reflect what will provide the most “good?”
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
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
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