Ethics Exam, Ethics I Exam - Amy's

conversation

"Patients are part of a network of relationships and responsibilities. Particular choices, say about what course of treatment to seek, are not made in isolation from other choices and responsibilities in peoples' lives but in ________________ with them." -Nicholas & Gillett

PATIENT'S GOALS OF CARE Is it in the patient's best interest? Risks Benefits Burdens (e.g. time in hospital=$) Probability (chance it'll help) Harm Richard Bets Butter Probably Hardens.

*Evaluating treatments to pursue, consider:* Give a mnemonic.

-A qualified healthcare professional (in most instances a physician, with some exceptions). -In the professional opinion of the HCP, the patient has necessary capacity to make a decision regarding his/her healthcare choices.

*Who determines MDM capacity?* What does this mean?

-increased sense of strength -humility -compassion -openness to learning -tolerance of uncertainty, -ambiguity, complexity -greater awareness of meaning in relationships

6 themes related to personal growth after error

Implies that the resolution of a moral problem is often less like the solution to a puzzle or answer to a question than *like the outcome of a negotiation*

According to Dr. Walker, what does the narrative picture of moral deliberation imply?

"is to address disparities in the provision and outcomes of clinical care within its system"

According to Eggleston and Finkelstein, what is the "first responsibility of any health organization"?

Notion of justice - "to treat all patients as individuals—with all the emotional, experiential, and cultural richness and depth that comprise an individual's identity—with fairness and compassion"

According to Kumagai and Lypson, what is "at the very heart of efforts to instill professionalism, humanism, and cultural openness/humility in medical students"?

distributive justice - the fair and equitable distribution of benefits and burdens

According to Pierce and Randels, "in the context of bioethics, the concept of justice refers to ______________ _______ (definition) - rather than other types of justice"

-everyone gets coverage no denial based on pre-existing conditions -triple aim -reduce acute inpatient care -reduce readmissions -shift nexus of care from hospital to community -expand medicaid to non-elderly adults <138% the federal poverty line + subsidies in the marketplace up to 400% the federal poverty line Triple aim= improves access reduce cost improves outcomes Accessible Costumes Outdoors

Affordable care act: define, general parts? Triple aim? Mnemonic

Yes - interfaith. They have their own preferences.

Are chaplains able to help all religious traditions?

NO - studies show this

Are physicians good at consent negotiations?

No - research suggests most physicians aren't as good at communication as they think Effective communication is not innate.

Are physicians good communicators?

informed consent

Assessing MDM capacity is part of the _________ _________ process.

WHAT IS THE PATIENT'S GOAL? Answer this first before: what else can we do/ what else can be offered to the patient -decisions should advance the best interest of the pt

At the end of life, what is the biggest thing to consider? Objectives in end-of-life care:

-fear of repercussion -fear of being viewed as incompetent -fear of legal discovery Morbidity and mortality conference: clinical colleagues gather to discuss in depth errors/ mistakes; work through so repeat is not made (vulnerable- discuss errors to learn)

Barriers to reporting M&M:

1. respect for persons: informed consent, additional protections 2. beneficence: maximize benefits, minimize risk 3. justice: fair distribution of risk, benefits

Belmont Report's 3 basic ethical principles that should govern human research:

capacity to meet the needs of racial and ethnic minorities and vulnerable populations"

Bentancourt, Corbett, and Bondaryk said "Accountable Care organizations (ACOs) will cover diverse populations in different communities and will be looking to reduce costs using predictive analytics that take into account race, socioeconomic status, education, and other risk factors for targeted interventions. Equipped with more meaningful data, targeted culturally competent QI interventions can be developed to improve quality and reduce the cost of care delivered to all patients, but with the..."

the right thing to do, but also the smart thing to do"

Bentancourt, Corbett, and Bondaryk said "Addressing disparities has long been viewed as both an ethical and social justice imperative. Healthcare transformation now reframes this lens, adding to the argument that addressing disparities is not only...."

one-size-fits-all approach"

Bentancourt, Corbett, and Bondaryk said "Most efforts to improve quality are broadly targeted to the general population, relying on a..."

For patient: improves adjustment to illness, lessens pain/symptoms, increases adherence to treatment plan, increases pt satisfaction For physician: increases job satisfaction, decreases stress/ burnout, decreases malpractice claims

Better pt-phys communication causes:

Bio-statistical: focuses on disease by pursuing history, exam, tests, imaging, differential diagnosis, clinical assessment Well-being: focuses on illness by understanding pt's experience, pt's beliefs, expectations, feelings, pt's need for care, attention, empathy *SHOULD BE INTEGRATED TOGETHER!! Can be done by clarifying goals of care of pt and harmonizing w/ concepts of health to form a treatment plan*

Bio-statistical concept of health vs Well-being concept of health

Bridge: gets you to something else, ie another treatment (transplantation) Destination is last therapy received

Bridge vs destination therapy

-Conflicts of interest are about money, power, greed, ego -interest of investigator and sponsor is before integrity of data, welfare of subjects and welfare/trust of public A situation in which a person has private/personal interest sufficient to influence objective exercise of his/her official/professional duties

COIs

NO!

Can a patient that lacks MDM capacity give informed consent for a medical intervention requiring such consent?

Yes - -to other healthcare people for purpose of providing care/healthcare operations -appropriate authorities when disclosure is legally required -to 3rd parties to mitigate threats -need consent for other disclosures

Can physicians disclose personal health info without specific consent of the patient/surrogate? If so, to whom?

In some states, yes. In other states, this is up to members of the state's department of public health

Can physicians notify sexual partners of HIV-positive persons?

Yes - intervention can reverse states of anxiety and depression affecting MDM capacity; titrating medication can reverse drug-induced confusion However, inability to understand simple explanations of facts/fixed delusions may be impossible to fix

Can you reverse patients with MDM incapacity?

voluntary opportunity to discuss/ address adverse outcomes w/ patient and work toward settlement for faster resolution than traditional methods open, honest, confidential discussion btw pt and physician (physician initiated) shortly after incident (must occur w/in *180 days of incident*) pt reminded in writing that all discussion is confidential; discussion is verbal and if offer of compensation occurs must be in writing Candor discussion doesn't prevent pt from seeking legal action, but none of discussion is admissible to court offer may include no further legal remedy

Candor Law

-state problem plainly -gather and organize data including medical facts, medical goals, patient goals/preferences, and context -Ask - is the problem ethical? -Ask - is more info or dialogue needed? -determine the best course of action and support it with reference to sources of ethical value - virtues, principles, etc

Clinical ethical reasoning model

clinical need: distribute care based on need justice: if there is more need than resources, distribute equally

Clinical need view vs distributive justice view

formalized rules and standards that describe principles and behavior expected of all members of a discipline Includes: Osteopathic pledge of commitment American medical association code of ethics Geneva declaration

Codes of ethics

-virtue-based -duty-based -consequence-based

Commitment to truthfulness may be:

Beneficence: duty to care for each person Utility: duty to maximize care for many people

Common ethical tension

REMEMBER... ITS NOT BAD NEWS JUST SERIOUS NEWS! -prepare -establish pt's prior understanding -ASK: how much does the pt want to know? -TELL: give information then stop- give time to process -*Respond to patient's feelings (empathy)* most important skill is ability to detect and respond to emotions- only then can the patient discuss next steps -ASK: ascertain the patient's understanding -organize a plan/ follow-up

Communicating serious news: steps

-privacy = singular feature of individual -confidentiality = relational context involving 2 or more people -overlap = privacy may have relationship context such as privacy of personal associations or private records

Compare privacy and confidentiality and their overlap

1 - do no harm 2 - maximize possible benefits/minimize possible harms

Complementary expressions of beneficent actions

Formal: med school Informal: rotations, residency Hidden: ethical dilemmas w/in informal curriculum... what do you do in face of dilemma?

Curricular realism: formal, informal and hidden curriculums

goal-oriented context

Decisions should be placed in a ____-______ __________ to give them meaning and direction

a child <18 years old who is unmarried, childless, and is not living separately from parents with independent financial support

Define a minor

Patient is empowered to make the decisions that support his/her values and choices.

Define autonomy

Duty of healthcare providers to be of benefit to the patient (healing, to make whole again)

Define beneficence

-Cognitive aspect of healing to fit the unique predicament of the patient -Suggests idea of co-suffering and of fellowship in the experience

Define compassion

Concerns the communication of private and personal info from one person to another with the expectation that the recipient of the info (healthcare provider) will not ordinarily disclose this info to third persons

Define confidentiality

The psychological or educational perspective that responds to the classic empirical approach that the mind passively receives information by arguing that instead *the process of knowing is far more active.* We are constantly constructing meaning and organizing knowledge.

Define constructivism

Generally, a normative stance that views what should be done as determined by fundamental principles that do not derive solely or even primarily from consequences. An act or rule is right insofar as it satisfies the demands of some over-riding (non-consequentialist) principle of moral duty. Deontologists sometimes stress that the value of actions lies more in motives than in consequences

Define deontology (non-consequentialist)

-Putting the needs of the patient first -Can be viewed in context of the individual patient and the community

Define effacement of self-interest

Language in which subject or representative is required to waive or appear to waive legal rights OR releases investigators from liability NO INFORMED CONSENT CAN INCLUDE THIS

Define exculpatory language and its role in informed consent

-physician impelled to develop relationship that includes being familiar with who the patient is and how the patient wants to meet the challenges of illness, disability, and death

Define fidelity to trust

-sustained moral courage -resisting temptation to diminish patient good through self-fear or through social/bureaucratic pressure -*being an advocate for patient*

Define fortitude

-arises primarily in the stomach -decreases with decreased blood flow to the GI tract

Define hunger

-Final determinant in quality of research = character and conscience of the professionals -Intellectual integrity - know what you know and admit what you don't know

Define integrity and intellectual integrity

-both a virtue and principle -one of the most complex virtues -strict habit of rendering what is due to others -emphasis is not on the individual patient (why this is challenging for clinicians) -focus on pattern of distribution of the good AKA distributive justice

Define justice

Obligation to be fair. Fairness with goods and services in short supply

Define justice

When two or more moral principles are at odds and support mutually inconsistent paths

Define moral dilemma

When one knows the right path but professional, institutional, or cultural constraints prevent them from taking it

Define moral distress

When one is unsure what the right path is

Define moral uncertainty

The approach to ethical decision making that places the personal stories of constituents at the core of deliberation

Define narrative bioethics

Requires caregivers to avoid causing a patient harm

Define nonmaleficence

Limiting access of others to one's body or mind, such as through physical contact or disclosure of thoughts/feelings Law/ethics - refers to rights as well as limited access. In law, it is linked to freedom from intrusion by the state or third persons. May designate a "domain of personal decision" about personal info, associations, abortion, or bodily integrity.

Define privacy in general as well as in law/ethics.

Cluster of occupational roles in which functions valued by society are performed and by these activities one can earn a living Learned specialized knowledge Self-limiting: limited entry, supervised training, assessment of competence and trustworthiness

Define profession

-practical wisdom -possessing moral insight -capacity to make the right decision at the right time for the right reasons

Define prudence-wisdom

an institutional and corporate reality defined by "structures, rituals, and doctrines"

Define religion

completed by specialized professionals who are skilled at informally applying assessment tools to both identify spiritual needs and establish a supportive relationship More thorough

Define spiritual assessment

completed by any staff to identify when consultation to spiritual care is urgent and to trigger a referral for spiritual assessment and care. In the initial interview with the patient.

Define spiritual screening. When is it done?

a personal reality that includes an "awareness of relationships with all creation, an appreciation of presence and purpose that includes a sense of meaning"

Define spirituality

A "systematic investigation" is an activity that involves a prospective plan that incorporates data collection, either quantitative or qualitative, and data analysis to answer a question. -Examples of systematic investigations include: -surveys and questionnaires -interviews and focus groups -analyses of existing data or biological specimens -epidemiological studies -evaluations of social or educational programs -cognitive and perceptual experiments -medical chart review studies

Define systematic investigation and give examples

-arises primarily in mouth -depends on sense of smell -negatively impacted by age, medication, disease

Define taste

-Greatest temptations in society are excesses of all sorts -Per Plato - *doing good in one's business or affairs* -Victory over desire

Define temperance

-arises primarily in the mouth (need to keep mucous membranes moist) -persists -implications to optimal care

Define thirst

One's philosophy of life, the metanarrative that makes sense of the world and one's place in it. Worldview is informed by family of origin, culture of origin, religious systems, educational systems, personal choices, the myriad of experience all humans integrate, adaptive behavior, etc.

Define worldview

-DNR: do not resuscitate; other modalities NOT excluded (like blood pressure meds, etc.); may be negatively perceived by family ("DO NOT") DNaR: do not attempt resuscitation; gives family realistic expectations (American heart association) saying that resuscitation attempts are unlikely to succeed. Less familiar than DNR. AND: allow natural death. More likely in hospice than hospitals; conveys more comfort and supportive care; withdraw no longer beneficial treatments. Can be confused with conjunction; still needs clarification in orders about what is not wanted and what is wanted; may not fit all situations. Recommended to use AND/DNR until AND is well used.

Define: DNR DNaR AND

Distort/compromise investigator's objectivity with respect to protocol and procedures of research. This raises harm to participants and future patients.

Describe how COIs can harm future patients.

-Diagnosis/ Prognosis first, then establish goals of care w/ pt before proceeding to treatment (treatment selection will be influenced by goals) -Consider cost to patient (but first, be patient advocate) -probability of outcomes and level of burden/ suffering when selecting treatment/testing -Then, after treatment assess/ adjust treatment based on goals of care, probability of outcomes and level of burden/ suffering

Dimensions of Decision-making for practical wisdom in medicine (Model)

Need to know

Disclose PHI only to those who _______ ___ _______.

-Decide why you need to discuss a DNR -elicit pt's perception of illness and values for care -discuss "big picture" of what's happening medically -make recommendation about DNR as part of care plan -respond to emotion -document conversation and write order

Discussing DNRs

Yes!

Do participants in research studies still need to be protected if the research isn't published?

NO unless natural parents have signed consent allowing it

Do step-parents have right to medical records of a minor?

No - Interactions between physicians and pharmaceutical representatives have involved the exchange of gifts, samples, free meals, funding for travel to attend educational symposia, exposure to pharmaceutical representative speakers, CME sponsorship, honoraria, research funding and employment.

Does a COI have to be related to financial gain?

No - the intent is to contribute to generalizable scholarly knowledge

Does research need to be published or presented to qualify as research?

NO - if they're competent and they refuse, you can't treat them

Does the emergency privilege given to ED physicians allow them to treat competent patients with emergency conditions who refuse treatment?

Duty, breach of duty, causation, damage/injury

Elements of a Malpractice Case

-withdrawing/ withholding life-supporting treatment -palliation of symptoms -palliative sedation -physician assisted suicide

End of life decisions may include:

Branch of philosophy, includes morals, moral principles and moral judgement Uses reason and logic to analyze problems and find solutions Practice that improves welfare of people in a moral way

Ethics define

-thoughtful integration of best available evidence w clinical expertise -healthcare practitioners address questions w evaluative and qualitative approach -allows HCP to assess current and past research, clinical guidelines and other information to identify relevant and quality literature -evidence-based medicine, -elucidates basic mechanics of health/disease, -legal obligation to test new products, -curiosity and academia

Evidence-based practice: define Why Research is done:

E.g. sundowner's syndrome - patient is clear/oriented early in day, but becomes increasingly confused later in the day

Explain an example of how MDM capacity changes during the day

study me

Features of medicine's contract with society

The ability to detect and respond to the patient's emotions

For physicians giving serious news, what is the most important skill to acquire?

1. Be cured 2. live longer 3. improve/ maintain function/ quality of life/ independence 4. Be comfortable 5. achieve life goals 6. support for family/ caregiver 7. clarify diagnosis/ prognosis Change over time! Over lifespan or course of progressive disease (early, middle and late stages of disease; early- cure disease, vs late- palliate symptoms)

General goals of care (7) How do they change?

Good (correct) information

Good ethics always begin with ______ __________ ___________.

Health Insurance Portability and Accountability Act covers health plan, health insurance clearinghouse and healthcare providers protects PHI (protected health info: specific identifiers that are created, used or disclosed in health services, held/transmitted by covered entity) Personally identifiable information: similar, may become PHI if linked to health information (ex vital signs)

HIPAA; PHI PII

-Hard: difficult situation, but w/ support but morally complicated -Bad: w/out support at end of life

Hard death vs bad death

We now have tools like mechanical ventilation to fix respiratory failure, which would have been a solution "yesterday." Today, however, we have the quandary of "when do we initiate and/or discontinue mechanical ventilation?"

How are today's problems in medicine now yesterday's solutions?

-encourage patient to play an active role in decisions (elicit patient's perspective about illness, build a partnership) -encourage that patients are informed (avoid bias, check for understanding) -protect patient's best interests (help a patient deliberate, make a recommendation) -don't try to persuade/dissuade patients

How can one promote shared decision making?

-plan what will be discussed -ensure all the medical facts/confirmations are available -choose an appropriate, comfortable setting -deliver the news in person, privately -allow time for discussion -minimize interruptions

How can you best prepare for a meeting where you have to give difficult news?

-what have other doctors told you about your condition? -how sick are you? -how is your illness impacting your life -what can't you do that you still wish you could?

How can you establish the patient's understanding?

-Use an executive summary (a short form format) -Use a neutral educator or a team member to talk one-on-one with participants to ensure their understanding -more time in consent process -ensure comprehension at time of enrollment and ongoing -exit interview: review how study results will be shared, review research components, discuss follow-up care

How can you simplify the consent form and improve the consent process?

As a more corrective justice - people's lives are different enough that you can't just idealize away. "A positive societal obligation to reduce or eliminate barriers that prevent fair equality of opportunity, an obligation that extends to programs to correct or compensate for various disadvantages. It views disease and disability as undeserved restrictions on persons' opportunities to realize basic goals. A health care system designed to meet these needs should attempt to prevent disease, illness, or injury from reducing the range of opportunity open to the individual. The allocation of healthcare resources, then, is constructed to ensure justice through fair equality of opportunity."

How did Beauchamp and Childress see justice in relation to healthcare?

Gradually Expected part of continuum of medical care Going from curative/life-prolonging therapy to relieving suffering (palliative care)

How do goals change near end of life?

Better in more equal countries

How does child well-being change in more equal countries?

Law is rules or actions prescribed by a governmental entity that have binding legal force. Medical ethics is based on moral principles or practice customs of the medical profession

How does law differ from medical ethics?

Mental illness is more common in more unequal societies

How does prevalence of mental illness change in unequal societies?

It's one of the domains. Domain 5: Spiritual, Religious, and Existential Aspects of Care: Guideline 5.1 - Spiritual and existential dimensions are assessed and responded to based upon the best available evidence, which is skillfully and systematically applied."

How does spirituality relate to palliative care?

study this image!

How goals of care change over time

It used to involve many more people. Now it involves a lot of machines substituted for people.

How has care of the dying changed?

-w/ some chronic illnesses there are few cures -patients can live longer w/ a chronic illness (maintenance) -dying process prolonged

How has modern health care changed with regard to illness and dying?

-society is death adverse - productivity/ youth/independence is valued -people don't want to be a burden to their families (devalue age, family, and interdependent caring) -medicine: fight aggressively against illness and death -prolong life at all cost -improved sanitation, public health, antibiotics, other therapies all increase life expectancy -death is enemy; if pt doesn't survive it is failure -rather than asking "what does the patient want?" we ask "what can we do?"

How has there been a shift in society/ medicine (general) related to death? What has changed in healthcare to increase life expectancy?

Process of consent is documented in signed consent form entered in patient's record

How is informed consent documented?

Through practice

How is practical wisdom developed?

-until WWII - bedside MDM was almost exclusively made by the individual physician -1960s-70s: Harvard releases blistering account of research abuses/failures of research ethics -1960s-70s: Quinlan vs NJ supreme court decision = father petitioned court to allow his daughter's ventilator be removed. Start of when law and legislation came to bedside. -New commitment of public to protect autonomy -Commitment to collective decision making -written documentation over word of mouth orders (charts are now evidence rather than communication) -new strangers at bedside (govt, lawyers etc)- pt & physician relationship now more normative, governed by outsiders

How is there a larger circle of decision-makers in relation to death?

-pt increasingly brought into center of decision-making -pt now has right to refuse treatment INCLUDING life-sustaining treatment (LST) -pt/ family and health provider conflict over the decision making capacity of pt

How is there growing pt autonomy related to death?

Can I rely on this person to have good intentions towards me AND can I respect this person's capabilities?

How is trust defined in modern America?

-In ethics and law, they're viewed the same -In medicine, they may not feel the same

How is withdrawing and withholding considered in ethics, law, and medicine?

98,000 The problem is the faulty systems, not faulty people. Change conditions people work in so reporting errors to institutions is more favorable.

How many preventable deaths are there per year? What's the problem?

building trust/ relationship and good communication w/ patients!

How to avoid malpractice cases

-risks minimized (done by 1 - using sound research design and 2 - procedures already being performed when possible) -risks to subjects are reasonable in relation to anticipated benefits -equitable subject selection -informed consent is sought from each subject and documented -data monitored to ensure pt safety -privacy/ confidentiality is protected -additional safeguards for vulnerable pops

IRB approval criteria

Institutional Review Board: ethics committee of scientists and non-scientists, act as advocates for human subject research- review/ oversee subjects project must be BOTH research and involve human subjects: includes all interventions/interactions w human subjects (includes advertising, recruitment, screening)

IRB: What requires IRB approval?

Consult the Hopsital ethics committee— they are there to help you through these problems that arise

If there is an ethical dilemma regarding life saving support or a patients wishes, you should:

6 months A letter/form from a physician is required

In Iowa, how long must a driver be seizure-free before a driver's license restriction is lifted? What is required for this to happen?

-Life threatening emergencies or threat of severe disability creating inability to express preferences/give consent -immediate action is necessary to preserve life and/or function -no surrogate available (document attempt to ID or contact surrogate)

In what situation does a physician rely on implied consent?

-STD, contraception, and substance abuse -HIV testing Minors must arrange for self-pay or be notified that insurance explanation will be sent to policy-holder

In what situations can minors seek care, authorize release of medical records, and consent to treatment without guardian approval? What's important to note about this testing?

-child is seeking care for addiction, contraception, or STIs -divorce decree prohibits one parent from access -parental rights have been legally terminated

In what situations do both divorced parents of a minor NOT have a right to the minor's medical record?

-shift from death at home to death in hospital (more intensive care units and artificial respirators) -kidney dialysis -prenatal diagnosis -mood-altering drugs -genetic engineering -availability of medically safe abortion -methods to alter contraception technology is neutral; how its used gives it moral valance (goodness or badness). It's whether we have the skill and expertise to use technology properly.

In what ways are we seeing an era of technological progress in general and related to death perception? Is technology inherently moral or amoral?

-civil rights -rebirth of feminism -post-war individualism (affluence and mobility) -responsibility for trashing the environment

In what ways are we seeing cataclysmic cultural shifts?

-limited entry -supervised training -assessment of competence and trustworthiness

In what ways is medicine self-regulating as a profession?

Information =/= knowledge =/= wisdom! -Pts need physician to interpret information and add medical knowledge, clinical judgement and experience (wisdom) that is not available on a website

Internet... patients have all the information! What do they need a physician for??

"focus on distribution of material goods and resources inappropriately restricts the scope of justice because it fails to bring social structures and institutional contexts under evaluation" "rights are not fruitfully conceived as possessions. They are institutionally defined rules specifying what ppl can do in relation to one another" "Self-respect names not some possession or attribute a person has, but her or his attitude toward her or his entire situation and life prospects"

Iris Young's critique of distributive justice

No - it must be accompanied by a release from the patient

Is a subpoena a court order?

NO - you can say you're sorry without being liable. Iowa law also supports this (it's inadmissable as evidence). Admission of liability should wait until after responsibility for a preventable mistake is confirmed (AKA after investigation)

Is an apology after an error an admission of guilt?

Built on a continuum

Is determination of capacity built on a continuum (more or less) or a threshold (either/or)?

No - e.g. vital signs aren't protected without an identifier

Is healthcare info by itself (without an identifier) protected by HIPAA?

NO - avoid deciding MDM capacity based on global descriptions Instead, consider how these diagnoses affect ability to understand and choose in a particular situation

Is it a good idea to declare someone incapable of MDM capacity based on their mental diagnosis (e.g. schizophrenia, depression, dementia)?

No - there is no absolute guarantee

Is there an absolute guarantee of privacy?

NO. There is no absolute rule or absolute right to confidentiality

Is there an absolute rule/right to confidentiality?

Original position: stripped down frame of mind. Think of oneself as human only. What is good for people in general? Veil: what it would be like to be ignorant of all your own values. If you were ignorant of race or wealth, what would be best for us? The values/position in life that alter our opinions- what we leave behind w/ original position

John Rawls: Original Position Veil of ignorance

"understand ones own assumptions, biases, and values and a shifting of one's gaze from self to others and conditions of injustice in the world"

Kumagai and Lypson - "By critical self-reflection around justice, we do not mean a singular focus on the self, but a stepping back to"

mental capacities MDM capacity or incapacity

Legally competent patients can have their _________ __________ compromised by anxiety, pain, or hospitalization. This clinical situation is referred to as ________ ____________ or _____________

"being treated equally"

Levin and Schiller said "It is important to recognize that giving people the same choices about medical treatments does not necessarily mean that they are _________ ________ ______, because patients do not lead equal lives"

"autonomy that enjoins healthcare professionals to honor the choices of their patients"

Marco said "the goal of freedom of choice thus reflects the basic bioethical principle of respect for _________....."

"beneficence that directs healthcare professionals to act for the benefit of their patients"

Marco said "the goal of quality care is linked with the basic bioethics principle of _________....."

distributive justice

Marco said "the goals of affordability and universal access to care raise questions of resource allocation, namely, who should bear the burdens of financing the U.S. health care system. Answers to these allocation questions may appeal to a variety of ethical principles of ______ ________"

preventable adverse event, includes "near misses" (errors w/ no harm) errors are inevitable, complex and charged. Reactions can be profound, chronic. We need support after errors. We may be our own worst critics. Communicating about errors is very important because: -need to care for affected pt -need to improve pt safety -need to enhance professional learning

Medical errors define: in general are: communicating abt error is important bc:

Identifying, analyzing and resolving moral problems in patient care Based on moral principles or customs of medical practice Consideration of others Learned in the medical community May be expressed as a 'code' Differs from the law and may not always be legally binding

Medical ethics

Can we? Should we? Do we have to? Boundaries of care

Medical question Ethical question Legal question Ethically permissible vs impermissible

existential crisis

Mr. Johnson argues that anytime someone comes to the hospital, it's an ________ ______ for them.

Object vs subjective In practice vs not

Normative vs non-normative ethics Applied vs theoretical ethics

-Cohort study: prospective (future events) and retrospective (past events) (either have or don't have a risk factor and follow in time to determine if they develop disease/outcome) -Case-control study: control vs treatment overtime - compare those with disease to those without disease (start with outcome and look back for risk factors) -Cross-sectional study: random cross section of pop, prospective or retrospective at a specific point in time (examines exposure and outcome at same time) Most common is randomized controlled trial (a form of a clinical trial): tests safety (adverse effects of a drug) and efficacy/ effectiveness of healthcare services or technology

Observational studies: types Treatment study

Federal law passed in 1990s healthcare providers must give adults at time of admission/ enrollment information about their legal rights to advance directives; includes right to: -participate in and direct own healthcare decisions -accept or refuse medical/surgical treatment -prepare advance directive also prohibits discrimination against pt w/out advance directive and requires ongoing education on advance directives

Patient Self-Determination Act

-Phase 0: pre-clinical studies exploratory, first-in human trials, in accordance w/ FDA usually microdosing -Phase I: first stage of testing in humans; small grp (20-100) healthy volunteers, assess safety/tolerance -Phase II: initial safety confirmed, larger grp (20-300), assess how well the drug works and continue phase I on a larger group. *Phase II is where failure usually occurs for a new drug.* -Phase III: randomized controlled multicenter on lrg pt group (300-3,000+); definitive efficacy of drug vs current gold standard tx -Phase IV: post-marketing surveillance trial; safety surveillance and ongoing technical support after permission for sale -Phase V: comparative effectiveness research and community-based research- integration of treatment into widespread public health practice

Phases of clinical trials

requires drug-makers, device manufacturers and other medical supplies report annually any payment or transfer of value to individual physicians. If >$10, physician's name, value, and kind of payment is posted on public website part of social contract w/ society

Physician Payments Sunshine Act

-Physician assistance in dying: means both suicide and euthanasia -Physician assisted suicide - legal in some jurisdictions in the US; Physician only supplies means, pt acts; pt must have decision-making capacity and can take lethal medication w/out assistance -Physician assisted euthanasia: not legal anywhere in US; INTENT IS DEATH -voluntary: requested by pt; killed (Netherlands) -involuntary: expressed opposite by pt; killed (like if family wants it) -nonvoluntary: no request, no consent, unable to give or withhold consent; killed "Passive euthanasia"- erroneous term. IT'S NOT EUTHANASIA. Physician withholds non-beneficial treatment from patient. It is actually withdrawing ineffective/burdensome/unwanted treatment. Giving high dose of pain-killers needed for pain management but that may be life-threatening etc... It's not technically euthanasia because intent of death is lacking.

Physician assistance in dying - suicide vs euthanasia (types) "Passive euthanasia"

-TO PATIENT FIRST! (individual pt health and patient care) -Then obligations to self AKA professional (integrating personal values and professional ethics in conscientious practice - to education, research, colleagues, etc) -Then to society (social contract, public health)

Physician's obligations in medicine

health personal security reasoning respect attachment self-determination Healthy Personal Shoppers Really Respect Attractive Self-Dress

Powers & Faden's essential dimensions of well-being - layout of what it looks like when people are thriving. Give a mnemonic.

-Pursuit of worthwhile ends/goals directed from a concept of human flourishing -accurate perception of concrete circumstances detailing the specific practical situation at hand -commitment to moral principles and virtues that provide a general framework of norms -deliberation that integrates ends (goals), concrete circumstances, and moral principles and virutes -motivation to act in order to achieve the conclusions reached by such deliberation In summary *ends/means* *perception* *virtues/principles*

Practical wisdom parts

Prescriptive: must do/ cannot do Permissive: may choose to do, not required to

Prescriptive vs Permissive

Complementary

Principles and virtues are ____________

Powerless

Principles without virtues are ________

there is great potential for coercion (limited choice and subject to other authority) -To avoid exculpatory language: -use subject advocate -consider private setting for consent process -ensure ability to weigh risks and advantages isn't impaired

Prisoners and avoiding exculpatory language

-acknowledge event -express regret -minimize further harm -explain what happens next -commit to investigate event (remember apology =/= admitting liability, is inadmissible as evidence in court) -disclose results of investigation -apologize -make changes to prevent failure from reoccurring -continue emotional support to pt/ others involved (admission of liability should wait until after responsibility is confirmed/ after investigation)

Pt interaction immediately after error: Later follow-up:

subjects assessed for eligibility recruitment (w informed consent) then randomly allocated to receive one or other treatment under study may be: Double-blind: both investigator and patient don't know which treatment; produces objective results Single-blind: patient doesn't know test groups assigned Non-blind: neither are blind to treatment assignment

Randomized Controlled trials May be:

compensation, public acknowledgement and deterrence

Rationales for malpractice system

-goals should guide care -assess priorities to develop initial plan w/ changes in health status, advancing illness, setting change or new treatment preferences, REASSESS GOALS!

Regarding goals of care, remember:

Could be both - note the "us/we" is religion. The individual aspects emphasize spirituality.

Religion or spirituality?

Goal isn't the treatment!! The treatment is a road/ way to get to goal!

Remember about goals vs treatment...

-person should have legal capacity to give consent and be able to exercise free power of choice; -person should have sufficient knowledge and comprehension to make decision. -In order for a person to have sufficient knowledge, they need to be made known of the nature, duration and purpose of experiment, method and means it will be conducted and all inconveniences and hazards

Requirements for informed consent to research:

-Honesty: convey info truthfully, honor commitment -Accuracy: report findings precisely, avoid errors -Objectivity: let facts speak, avoid bias -Efficiency: use resources wisely, avoid waste Horny Aquaman Observed Eunuchs.

Research ethical guidelines to follow. Give a mnemonic.

required prior approval and strict adherence to protocol; monitored by specific committee, protect wellbeing of lab workers/public overseen by federal/ international law too

Research involving biohazards or recombinant DNA:

prior approval, licensure and strict monitoring; monitored by research and compliance office, protect wellbeing of lab workers/public overseen by federal/ international law

Research involving controlled substances

prior approval, strict adherence to protocol; monitored by IRB, protect wellbeing/ safety of patient and quality of data overseen by federal/ international law

Research involving humans or data/materials from humans

1 - magnitude of harm (severity, duration) 2 - probability of harm probability vs magnitude graph... less severe magnitude of problem but more common (higher probability) may be involved but is manageable vs more severe magnitude but possibly less likely

Risk involves two dimensions:

stigma and class

Schroeder says "Although more women die of lung cancer than of breast cancer, there is no social movement to combat smoking in women - no race for the cure or brown ribbon, for example. And there is no public spokesperson against smoking. In my view there are 2 reasons for this neglect: _________ and _________. The ______ occurs because there is often a sense that smokers caused lung cancer by making unwise decisions. And social ____ pertains because today smoking is essentially concentrated among marginalized populations that have little public or political clout"

-part of informed consent case law -beginning of right of self-determination -Ms. Schloendorff was admitted in 1908 for a stomach issue -A fibroid tumor was found -Advised that nature of lump could not be determined without ether exam -She consented to exam and informed the surgeon/anesthesiogist she DIDN'T want surgery -tumor was removed while she was unconscious -she developed LUE gangrene and needed fingers amputated -where's the fault? (this was a charity hospital)

Summarize Schloendorff vs society of NY hospital

How system defenses can be penetrated by the "trajectory" that runs from an error to a harm. If system has too many holes, an error can become a harm; change the system to close up holes so this doesn't happen

Swiss cheese model

-major - burns, surgical materials left, drug side effects, brain damage. Recovery delayed -minor - infections, misset fractures, fall in hospital. Recovery delayed. -insignificant/slight - lacerations, contusions, minor scars, and rash. No delay in recovery

Temporary injury in medical malpractice - 3 types

-patient lacks MDM capacity -patient wants more than medical standard (medical futility debates e.g. antifungal for a bacterial infection) -patient requests are not consistent with standards of treatment -physician conscientiously refuses (e.g. abortion)

The healthcare provider is obligated to act in accord with the patient's wishes EXCEPT WHEN

fiduciary (confidence, trust)

There is an expectation that physicians should be honest with patients as part of their _____ responsibility

-400 blood samples collected from 100 tribe members, study genetic risk factors for diabetes, couldn't find links; -then studied (WITHOUT CONSENT) for genes related to schizophrenia, alcoholism, and inbreeding. -Inbreeding/ migration testing: resulted in tracing ancestry, results contrasted tribal belief that they originated from the canyon; tribal members upset bc they didn't have permission to study this University banned from canyon, sued by tribe and was awarded settlement

Therese Markow (Arizona university) and tribal study (Havasupai)

Physical: touching, imaging, observation Informational: HIPPA, GINA Proprietary: ownership of human identity Decisional: choices Overall, pts must share intimate details, submit to intrusive exams and tests, have documentation of encounter (other health personnel access)

Types of privacy in healthcare

-physical -psychological -social: damage to relationships/ status in community -legal: study leads to illegal activities -economic - real or potential economic harm -Secondary subjects: subject siblings or family members (e.g. breast cancer) -Communities: ex Havasupai indians' leftover DNA -Society: possible transmission to the public of a disease (like from a pig)

Types of risk to patients: Risk to others

1. Death is natural part of life 2. Dying now "medicalized"- 70% of people die in hospitals or nursing homes; new "no one should die w/out CPR" approach 3. Palliative medicine/ hospice 4. Death on demand (physician-assisted dying)

US - 4 Paradigms of death

Gelsinger died after participating in gene therapy study PI's financial ties to study sponsor were questionable misrepresentation/ omissions to IRB failed to alert subjects to emerging adverse reactions failed to maintain accurate medical records toxicities to subjects that should have ended trial were ignored eligibility criteria not respected animal data w/ adverse events not reported Led to the May 2000 adoption by the American Society of Gene Therapy of a policy recommending that gene therapy researchers avoid owing equity, stock options, or other interests in the companies whose products they test in clinical trials.

University of Pennsylvania: Jesse Gelsinger. What policy did it lead to?

Blind

Virtues without principles are ________

beneficence, maleficence, and respect for autonomy

What 3 principles relate to the quality of life topic?

-dishonesty in residency -fraud in clinical practice -misconduct in medical research

What 3 things does cheating in medical school lead to?

-medical indications (physicians are good at this) -patient preferences -quality of life -contextual features (physicians are bad at these 3)

What 4 ethical dilemmas should physicians consider in regard to end of life care? What are they good and bad at?

Patient self-determination act

What act is this?

-realists = 37% - would tell a patient a prognosis they thought was accurate -optimists = 40% - would be partially accurate (and usually optimistic) about prognosis -avoiders = 23% - would decline to discuss prognosis even if asked directly about it.

What are 3 physician strategies about prognosis? What percentage of physicians are each?

-age 13 to 19 - identity vs role confusion (who am I? How do I relate?) -age 20 to 24 - intimacy vs isolation (can I love? Am I lovable?) -age 25 to 64 - generativity vs stagnation (what difference do I make?) -age 65 to death - ego integrity vs despair (how did I do?)

What are Erik Erikson's final 4 stages of development?

-Goals are based on: -values, -preference, -clinical circumstances

What are a patient's goals based on?

-patient's right to exercise autonomy and protect his/her privacy jointly support confidentiality

What are arguments for confidentiality in the context of patient autonomy/privacy rights?

-patient may be reluctant to disclose full/forthright info if he can't trust physician to not disclose that to 3rd parties -physician can't make an accurate diagnosis as a result

What are consequence based arguments for confidentiality?

-potential physical harm to others is serious and imminent -likelihood of harm to self is great -no alternative means exist to warn or to protect others at risk -physicians can take steps to prevent harm

What are general principles regarding exceptions to confidentiality?

-attitudinal barriers (culture of perfectionism) -fears and anxieties (legal liability, financial liability)

What are impediments to disclosure?

Don't address inequalities. They're more like cultural safaris.

What are issues with efforts in cultural competency?

HIPAA GINA

What are laws regarding informational privacy?

-responsibility to patient (being straightforward, explaining circumstances, respect for patients, being fair, facilitate further medical care) -responsibility to self (accountability, duty, courage, etc)

What are motivations for disclosure?

Public

What are privacy and confidentiality the polar opposites of?

-change over time -shift over time -disagreements may arise - talking about goals encourages dialogue that can clarify sources of disagreement

What are some challenges with goals?

-prognosis in life-limiting illnesses -manipulation of info to 3rd party payers -training environment -medical errors

What are some contexts in which honesty comes under pressure?

-voluntarily stopping eating in drinking -palliative sedation (terminal sedation) -physician assistance in dying -patient/surrogate demands for futile therapies

What are some controversial issues in decision making in the care of seriously/terminally ill patients?

-voluntary, informed refusal of treatment by patient with MDM capacity -withholding/withdrawing treatment on behalf of incapacitated patients on the basis of substituted judgment or best interests -hospice or palliative care

What are some established practices in decision making in the care of seriously/terminally ill patients?

-patient permission (signed release) -danger to public/specific people -mandatory reporting statutes -legal process (court order) -"treatment, payment, and healthcare operations," per HIPAA -independent medical evaluation

What are some exceptions to the duty of confidentiality?

Bad = feeding, starvation, futility, hunger Good = artificial nutrition, quality of life, entering final stage of dying process

What are some good and bad words to use regarding end of life?

-deciding when artificial nutrition/hydration, resuscitation, and antibiotics are no longer beneficial -medical futility -physician assistance in dying

What are some major medical issues at end of life that are also significant ethical considerations?

Grief & Loss Care Crisis Intervention Debriefing Communication with Caregivers Facilitation of staff communication Mediation/Advocacy Responding to spiritual distress Support Organizational Mission Develop community clergy Perform religious, sacramental, and faith-based activities Assist patients/families with decision-making Support hospital staff Support Organization in times of change

What are some of the things chaplains do?

-increased education level = increased desire for information -more advanced illness correlates with wanting less information These trends are general and are NOT useful when having a discussion with an individual patient.

What are some patient preference trends about info? What's important to note about these trends?

-conflict of interest -monetary gain -different beliefs/values that motivate their decisions -lack MDM capacity

What are some potential problems with surrogate capacity?

-patient or surrogate decision maker gives consent (autonomous authorization) -requirements that an organization/institution fulfill prior to proceeding with treatment (institutional/policy rules of consent - conformity to the social rules of consent)

What are the 2 meanings of informed consent?

-principles - obligation to tell the truth, come what will -consequences (principle of utility) - maximize the overall goodness of the outcome, whether through truthfulness or deception -virtues - be honest, that's what moral character requires

What are the 3 common moral frameworks?

-to patients - as part of respectful patient care -to institutions - to improve patient safety -to colleagues - to promote professional learning

What are the 3 directions of communication about medical errors?

moral uncertainty moral dilemma moral distress

What are the 3 most common situations when the ethics committee might be consulted?

1 - no thank you 2 - push arm away 3 - clench teeth

What are the 3 signals that indicate a desire to refuse food? This happens as the body shuts down because the desire for food diminishes and ultimately disappears. Aversion to food often ensures.

-Beneficence -Nonmaleficence -Autonomy -Justice

What are the 4 ethical principles?

-patient confides (with fidelity to trust) -privacy is given up because confidentiality is promised and expected -relationship between patient and HCP is private -info exchanged is confidential

What are the 4 expectations of confidentiality?

-Prudence-wisdom -Justice -Fortitude -Temperance Powerful Wizards Judged Fisherman Timidly

What are the cardinal virtues? Give a mnemonic

-decision (in favor of proposed plan) -authorization (of chosen plan - e.g. can't sterilize someone when doing an appendectomy)

What are the consent elements of informed consent?

-Different facts -Different values (culture, religion) -Different emotions (fear, anger, guilt, denial) -Different reasoning (consequences, liability) -Different loyalties (patient, institution, society) -Different perceptions (personal or professional experiences)

What are the different sources of ethical conflict?

-Evangelical Christian - high value on confessing faith around time of death. -Buddhist - importance of mindfulness and understanding suffering may discourage analgesics. -Roman Catholic - may resist termination for non-viable pregnancies. -Hindu - some adherents may attach powerful meaning to particular pieces of jewelry and removal without the patient's permission (ER, OR) may cause great distress. -Traditional Jewish - Duty to preserve life vs. DNR -Muslim - Some traditions expect the husband to be present for birth to whisper a proclamation of faith in the baby's ear.

What are the differing values of the major belief systems?

-involves reason, emotion and will (not just private sensibility) -does negative and positive work -involves integration of personal and professional lives (counters pressure to compartmentalizes our lives) -need to integrate the personal (values we bring to medicine) and the professional (values instilled by medicine/ society)

What are the features of conscience?

-medical indications -patient preferences -quality of life -contextual features Manly Inflammable Perverts Pinched Quaint Ladylike Casanovas Feebly.

What are the four topics in the principle-based approach to medical ethics? Give a mnemonic.

-promotion of health/disease prevention -maintenance and improvement of quality of life by relief of symptoms, pain, and suffering -cure of disease -prevention of untimely death -improvement of functional status or maintenance of compromised status -education/counseling of condition and prognosis -avoidance of harm to patient in course of care -providing relief and support near time of death

What are the goals of the profession of medicine?

-disclosure (discussion) of material information -recommendation (of a plan - e.g. surgery vs no surgery) -understanding (disclosure/discussion and recommendation - e.g. risks)

What are the information elements of informed consent?

-fidelity to trust -compassion -integrity -effacement of self-interest Feral Turtles Crushed Impenetrable Elderly Studs.

What are the non-cardinal virtues? Give a mnemonic

from base to top: -biological and physiological needs -safety needs -belongingness and love needs -esteem needs -self actualization PS I love you (For I - think of the eye on the back of the dollar bill. It's on the top of the pyramid. It's self-actualization).

What are the parts of Maslow's hierarchy of needs? Give a mnemonic.

-Influenced by information from all team members (physician, chaplain, social worker) -Optimized by intentional listening (listening is not about being silent, it's about being present)

What are the patient's goals influenced and optimized by?

1 - understand relevant info 2 - appreciate medical situation and potential consequences 3 - communicate choice 4 - engage in rational deliberation about values in relation to physician recommendations and treatment options Uptight Accountants Championed Everlasting Ravishing Dollars.

What are the requirements for a patient to be able to consent or refuse care? Give a mnemonic.

-Masters level theological training (usually M.Div.) -Endorsement by a recognized faith tradition -At least 4 successfully completed units of CPE (clinical pastoral education) - 1 year residency -Passage of board certification process after 2 years of supervised service -Maintenance with 55 hours of continuing education annually and board review every 5 years.

What are the requirements for board certification as a chaplain?

Has a statutory right to access medical records, even those dealing with mental health/substance abuse treatment

What are the rights of the board of medical examiners to medical records?

1 - present positive requirements of action 2 - need not always be followed impartially 3 - generally do not provide reasons for legal punishment if agents fail to abide by them

What are the rules of beneficence?

1 - negative prohibitions of action 2 - must be followed impartially 3 - provide moral reasons for legal prohibitions of certain forms of conduct

What are the rules of nonmaleficence?

1 - engage patient in conversation 2 - observe patient's behavior 3 - talk with third parties (family, friends, staff)

What are the steps in determining MDM capacity?

-tensions - we acknowledge fallibility when we strive for perfection -dilemma - we need to use errors as vicarious commodities for shared professional learning. We fear discussing errors due to embarrassment, concerns about reputation, possible professional repercussions

What are the tensions and dilemmas associated with discussing errors with colleagues?

-have MDM capacity -voluntariness (not coerced in deciding)

What are the threshold elements (preconditions) of informed consent?

-Ethics of care (virtue ethics) -Principle based ethics

What are the two basic approaches to solving ethical problems?

1 - it assumes a specific question (e.g. will you consent to this procedure?) 2 - it's not global, but specific in time and tasks

What are the two big factors to consider about MDM capacity?

Include: -diagnostic (error, delay, neglected results), -treatment (dose, procedure, delay, unintended), -preventive (ex screening or monitoring), or -other (communication, equipment etc)

What are the types of medical errors?

Attorney-client Physician-patient Counselor-client Marital communications (spousal)

What are the types of privileged communications?

-Acquired traits of character that integrate thinking, feeling, motivation, and intention. A character trait which disposes habitually to excellence in intent and performance. -Achieved through experience, practice, and imitation. NOT achieved through instruction alone.

What are virtues? How are they achieved?

Declaration of Geneva

What code of ethics is this?

Hippocratic Oath

What code of ethics is this?

Oath of Maimonides

What code of ethics is this?

Osteopathic pledge of commitment

What code of ethics is this?

Revised Hippocratic Oath

What code of ethics is this?

Self-determination and informed consent

What concepts does autonomy relate to?

"the way in which protecting normal functioning contributes to protecting opportunity" Saying he wants everyone to have basic equal access to opportunities, healthcare, education, etc

What did Daniels say the "central moral importance, for purposes of justice, or preventing and treating disease and disability for effective healthcare services...derives from"?

"emblematic of the struggles, resilience, and despair of whole communities in the United States who are not able to enjoy the benefits of an advanced industrial society"

What did Wear say about the death of Freddie Gray, Trayvon Martin, etc?

Invalidation of a state law banning contraception. A right to privacy law

What did the Griswold case establish?

"the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions"

What do Berkman, Davis, and McCormack define health literacy as?

-Duties of obligation and rightness or wrongness of actions -Doing -Provide the means to articulate normative direction for moral action.

What do the principles emphasize when addressing ethical conflicts?

-Something you live -*Emphasize the agent who performs the action* -Persons and defining importance of the kind of person we are and want to be -Being (as contrasted to thinking/doing) -Identify character traits that motivate people to follow the direction that principles provide

What do the virtues emphasize when addressing ethical conflicts?

-recommendation -indications -risks -benefits -alternatives -patient's agreement to recommended care

What do you need to document in informed consent?

"populations with special needs for or barriers to care from a variety of conditions or circumstances and less able than others to safeguard their own needs and interests"

What does Brock define vulnerable populations as?

-assumptive world = your philosophy of life/worldview -our brains are not actually good at thinking quickly. Our brains are good at predicting quickly, often in an optimistic way. -we have a collection of assumptions (we've driven on the highway 50 times so even though it's dangerous, we do it) -we build all these assumptions to help us function. If we didn't, we'd be paralyzed by fear. -when trauma happens - our worldview is threatened and our assumptive world could be shattered. Then we become paralyzed.

What does Dr. Janoff-Bullman discuss in the shattered assumptive world?

Genetic Information Nondiscrimination Act

What does GINA stand for?

Health Information Portability and Accountability Act

What does HIPAA stand for?

It is the dominant model by far, but it isn't enough - it works best on a micro level and not as good on a macro level

What does Mr Johnson argue about the distributive justice model of healthcare?

Communication issues

What does Mr. Johnson say is at the heart of a lot of ethical issues he deals with?

Makes decisions when patient lacks MDM capacity

What does a durable POA do?

What do I believe is best for patient? Used when patient's preferences are unknown.

What does best interest ask? When is it used?

tries to consider all predictable outcomes of an action for everyone concerned, not just the direct and immediate consequences usually guided by a single principle like "the greatest good for the greatest number" or some other principle of utility or value or goodness

What does consequentialism consider?

"demands that the benefits, risks, and costs of actions be apportioned fairly and without discrimination on both societal and institutional levels...there should be ethically defensible reasons for why certain individuals or groups receive benefits or endure burdens that others do not" assumes limited resources w/in the system

What does distributive justice demand according to Post, Blustein, and Dubler?

Defense against battery Doesn't provide a defense against negligence charges (especially if the emergency treatment falls below acceptable standards of care)

What does implied consent provide a physician with a defense against? What does it not defend against?

What patients choose to refuse

What does most autonomy rest in?

Narrative competence enables us to get at the big stories (metanarrative) of patient - their subjective reality

What does narrative competence enable us to do?

A signed consent form in the absence of a consent discussion

What does not indicate that an informed consent process occurred?

The best and appropriate means to that end

What does practical wisdom identify?

-Physicians should restrict disclosure to minimum necessary info and should notify the person of the disclosure when feasible -Patients need to be able to trust that physicians will protect info shared in confidence

What does the AMA code of medical ethics say about confidentiality?

National standards to protect individuals' medical records and other PHI. Gives patients rights over their health info (request corrections, examine/obtain records). Requires appropriate safeguards to protect the privacy of PHI

What does the HIPAA privacy rule establish? What does it require?

It is a fundamental right to safeguard their personal dignity and respect their cultural/psychological/spiritual values

What does the joint commission on the accreditation of healthcare organizations note about spiritual care?

-Improve the complex, high-stress disorganized work environment -accept fallibility (errors) but not injury (harms) -errors are occasions to fix problems, not blame

What does the patient safety movement center around?

Reasonable person standard

What emerged as an alternative to professional standard of consent?

Hippocratic Oath

What ethical oath has roots in confidentiality?

Disagreement about goals and benefits - often from miscommunication and value differences

What factors lead to disagreement about medical futility?

clinical ethical reasoning

What framework is this?

fired in Canada after employer discovered her convictions/punishment for falsifying data in US

What happened to Kristin Roovers?

A parent or legal guardian must be notified

What happens if HIV testing is positive in a minor?

We avoid all the upper parts of the triangle and revert back to the base of the triangle - biological and physiological needs

What happens if we're not meeting our base needs in Maslow's hierarchy? This often happens in an accident or illness.

Recurrent disclosures of scientific fraud, conflict of interest, and other forms of misconduct

What has cast a shadow over the moral integrity of the physician?

Clinical outcomes Symptom management Patient satisfaction scores

What has quality spiritual care been shown to benefit, according to research?

-F - faith (beliefs) -I - importance/influence of faith system -C - community (relationships that matter to patient) -A - address (plan)

What is FICA in the spiritual assessment/history?

Coordinator of chaplain services at unity point x10 years. Director of program in Blank children's hospital x6 years. Also works on ethics committee, ethics consultation team, and IRB. Master of divinity

What is Mr. Johnson's job? What is his degree in?

a norm or rule that one has a moral duty to follow

What is a moral principle?

What judges do. Looks at prior decisions that have been made to inform current cases.

What is casuistry?

-Universal norms -Not relative to cultures, groups, or individuals

What is common morality?

-Law uses "competence" and "incompetence" to indicate whether persons have legal authority to make certain choices, such as managing finances -Only a judge can declare a person incompetent

What is competence referring to? Who is the only person that can declare a person incompetent?

-a PROCESS in which the: -investigator discloses all relevant info -potential subjects have opportunity to ask questions that get answered by the investigator -the above are repeated as often as needed

What is consent? What does it involve?

-patient will harm himself or herself -patient will inflict serious harm on another identifiable individual(s)

What is considered reasonable threat to disclose info to third parties?

Control over intimate aspects of personal identity - "choice"

What is decisional privacy?

Physicians presume patient would give consent if he was able to do so. Physician recommends what is medically necessary for preservation of life/function.

What is implied consent?

Excellence in end of life care

What is included in the goals of medicine regarding end of life care?

-application of virtues -physicians committed to this method hold themselves accountable for the well-being of patients -emphasis is on quality care as a distinct moral obligation -Work of the National academy/institute of medicine

What is involved in the ethics of care approach to solving ethical problems?

-rational, analytic, problem-solving focus -imposes no general conception of the good of individuals -focus is on action -"What am I obligated to do?" = central question -Tends to reduce ethics to quandaries or dilemmas (more "legalistic" framework)

What is involved in the principle-based approach to solving ethical problems?

Identification, analysis, and resolution of moral problems that arise in care of a particular patient

What is medical ethics?

The "big stories" that operate, order, and define societies, people, groups, and families - nationalism, religion, science, ethnic identity, family stories. -Sometimes defined as the story about the stories

What is metanarrative?

Consequentialism - judges whether or not something is right by what its consequences are. Limited by inability to accurately determine outcome

What is often at odds with the principles and virtues method of addressing ethical conflicts?

Effacement of self-interest Putting others and their needs first is a difficult task for many. There seems to be a rise in self-interest.

What is one of the least popular virtues in medicine that seems to be eroding? Why?

this is for intractable suffering, near death - the only way the team can figure out how to relieve them from their suffering is to give them enough sedation to render the person unconscious

What is palliative sedation?

-Define your personal character -Inform your actions outside of medicine -Fabric of who you are

What is personal morality?

A good end (goal)

What is practical wisdom directed toward?

A private statement that must be kept in confidence by the recipient for the benefit of the communicator. Law protects against disclosure of these communications in a legal setting.

What is privileged communication?

-Norms that bind members of special groups/communities -may be "codified" -ways of thinking (principles) that guide actions/behavior

What is professional ethics?

Ownership of human identity (photos, genome)

What is proprietary privacy?

-18 specific "identifiers" used to identify individual

What is protected health info in HIPAA?

-systematic investigation including research development, testing and evaluation, designed to develop or contribute to generalized knowledge is hypothesis driven, experimentally executed and leads to further iterations of hypothesis/hypothesis testing

What is research per DHHS regulations?

What would the patient want? Surrogate relies on known preferences of patient

What is substituted judgment?

1 - gather relevant data 2 - ID the type of ethical problem 3 - identify an ethics approach to analyze it (virtues vs principles) 4 - explore the practical alternatives 5 - complete the action 6 - evaluate the process and the outcomes

What is the 6 step process in confidentiality situations?

A set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act (for example, relieving a terminally ill patient's pain) may also cause an effect one would otherwise be obliged to avoid (sedation and a slightly shortened life) -"foreseen but not intended consequences" -invoking it requires that all 4 elements are present: 1. nature of act is good or morally neutral 2. intentions were good; bad effects were foreseen, tolerated, permitted but not intended 3. distinction b/w means and effects- means must be good 4. higher proportions of good effect than bad effect nature, intentions, means, proportions (NIMP)

What is the Principle of Double Effect? What does invoking it require?

Assume adults have MDM capacity

What is the basic assumption about adults and MDM capacity?

Assume children lack MDM capacity

What is the basic assumption about children and MDM capacity?

Interaction with patient

What is the best way to determine MDM capacity?

Living will -> Designated POA -> Spouse -> Parents/adult children -> substituted judgment -> best interest

What is the chain of MDM decision making in Iowa if the patient is incapable?

Information conveyed and subject's willingness to participate

What is the consent form a record of?

Link virtue theory with four principles in an integrated medical ethics

What is the current trend in addressing ethical conflicts?

A sense or consciousness of the moral goodness or blameworthiness of one's own conduct, intentions, or character together with a feeling of obligation to do right or be good

What is the definition of conscience?

-Earnestly attempt to establish trust -Joint decision making -Negotiation of disagreements that are likely to arise -Involve ethics committee of institution -If can't reach consensus, transfer to another physician or institution Talkative Janitors Neutralized Cute Tinkerbell (trust, joint, negotiation, committee, transfer)

What is the due process for medical futility?

Autonomy

What is the ethical principle of MDM capacity?

Can MDM capacity be restored? If not, you need to find a surrogate decision maker

What is the first question you should ask about patients who lack MDM capacity because they're unconscious, delusional, or disoriented? What's a follow-up to this?

Shared decision making between doctor and patient

What is the ideal model of decision making?

Mental status exam

What is the most common test for cognitive functioning to assess MDM capacity?

Providing relief and support near time of death (preparation for death with dignity and comfort)

What is the most important goal of medicine in regard to end of life care?

Emergence of an ethic of distrust

What is the most serious outcome of erosion of trust?

Perceived deficiency in compassion

What is the most wide-spread criticism of medicine and physicians by patients?

secure health, well-being or good dying of pt; do this in a way that respects integrity of all participants in decision making process

What is the object of all clinical decision making?

Virtue ethics

What is the oldest and most durable theory of ethics (4000 years) that arose in the Western world?

Shared decision making

What is the optimal result of informed consent?

Physician relies on a judgment about what colleagues in similar situations would disclose (discuss)

What is the professional standard for informed consent?

To force release of records

What is the purpose of a subpoena?

Collaborative decision making process to create an ongoing partnership between healthcare professional and patient. Prevents coercion and deception.

What is the purpose of informed consent?

treatment or test -> goals of care -> health -> flourishing

What is the purpose-oriented landscape of healthcare/the continuum of intentionality?

One is required to disclose what a reasonable person would want or need to know in order to make an informed choice for or against a proposed treatment

What is the reasonable person standard of consent?

ex: old pt w/ decreased desire to eat/ drink -food is symbol: love, nurturing, culture/religion/ritual -distortion: the words we say matter! Enteral nutrition/parenteral nutrition viewed as food when it's not. -"starvation" sounds like killing, letting die, or torture = BAD!!! Starvation may feel like the family is letting their loved one die/ torture -withholding artificial nutrition: when artificial feeding may cause more suffering

What is the symbolism and distortion of food related to end of life treatment?

Futility can and should be defined by clinicians (clinicians can withhold or withdraw treatment) vs middle shared decision-making vs can't be defined- shaped by values of patient/ surrogate

What is the troubled concept of futility?

18 PHI items

What is this?

The AMA physician charter

What is this?

There is nothing more I can do for you - THIS IS SO DISRESPECTFUL

What language should be avoided in end of life care?

Property rights to tissues/samples, rights to compensation for injuries, rights to sue

What legal rights are infringed by exculpatory language?

Its conformity with a moral norm or rule. Its rightness is independent of the outcomes that follow.

What makes a choice right in moral principles?

Board certified chaplains must maintain competence in Patient/Family care (assessment, delivery, documentation, collaboration, ethics, confidentiality, respect for diversity), Staff/Organizational function (staff care, mission, leadership), and Development (quality improvement, research, education).

What must board certified chaplains maintain competence in, according to the Association of Professional Chaplains?

inform the patient of all the facts necessary to ensure understanding of what's occurred Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient

What must physicians ethically inform the patient of when there has been a medical error? Should legal liability influence this?

Commitment to honesty with patients

What part of the physician charter on medical professionalism is most important in the context of medical errors?

$100,000 = 64% $250,000 = 22% $<25,000 = <7%

What percent of medical students come from families who make $>100,000? $>250,000? $<25,000?

~1%

What percent of patients come back from CPR?

90% of ppl w/ chronic illness know of the disease that will kill them for >2 yrs - have more time to prepare sometimes dying process is more scary than of being dead

What percent of people with chronic illness know for >2 years what disease will ultimately kill them?

70+% remember emotional data can be more important than cognitive data

What percentage of communication is non-verbal?

90%

What percentage of patients in the ICU don't have MDM capacity?

Beneficence

What principle is in effect in the implied consent process?

principle of justice (loyalty and fairness)

What principle relates to the contextual features topic?

autonomy

What principle relates to the patient preferences topic?

How will this test or treatment help achieve this patient's goals of care?

What question is key to wise clinical judgment?

Same as for the patient 1 - understand relevant info 2 - appreciate medical situation and potential consequences 3 - communicate choice 4 - engage in rational deliberation about values in relation to physician recommendations and treatment options

What should be considered when deciding whether the patient's surrogate is capable of doing MDM for them?

The patient has the right to make the wrong decision as you see it.

What should be respected in regard to patients with MDM capacity?

goals of care

What should we make sure we're clear on before dealing with tests and treatments?

Make a medical recommendation consistent with their goals of care. Patients come to physicians because they trust our expertise. DO NOT ask a patient a question like "what do you want us to do?" or "do you want us to do everything?"

What should you do after listening carefully to patient/surrogate decision maker's goals?

-review clinical situation -assess decision maker's understanding -*establish patient's goals of care* -present options to manage clinical issue -weigh risks/benefits with values/preferences -measure effects the decision has on family/loved ones -offer additional sources of decisional support -provide ongoing support and recognize need to revisit the decision

What should you do in your goals of care decision making conversation?

-avoid making assumptions -know that patients have the right to be told the truth AND decline to learn unwanted info -remember a patient may not want to know full details and a patient may wish to have a family member informed instead

What should you do to determine what and how much the patient wants to know?

-use phrasing that sends a "warning shot" to prepare the patient -don't say bad news, say serious news. Bad news can set off their fight or flight response

What should you do when delivering serious news?

Track the patient's emotional data because it can be more important than cognitive data

What should you do when giving serious news to a patient?

How MDM capacity was assessed Who assessed MDM capacity When MDM capacity was assessed

What should you document regarding MDM capacity?

Treatment is no longer beneficial

What should you say instead of withholding/withdrawing treatment?

-STIs -gunshot wounds -stab wounds -suspected child abuse -suspected dependent adult abuse

What situations require physicians be mandatory reporters?

Based on deontological theory. This approach depends on the concept that because there are some values that are common to most all people, rules can be extrapolated from those values. If those rules, then, are thought to apply equally to all people, then organizations of people are duty-bound to observe them.

What theory is principle ethics based on? What does this approach depend on?

The (shattered) assumptive world

What theory is this quote describing? "The assumption that I will grow old with my significant other, that my children will die after me, that people are decent and generally kind, that God is a protector, or that I will have a healthy future, give a clear prediction of the way things are, or at least, should be. In this way, our life experiences lead us to assume that the world is generally predictable."

beneficence and nonmaleficence

What two principles relate to the medical indications topic?

Autonomy Beneficence - patient's best interests

What two principles should be used as touch points when questions about MDM capacity arise during informed consent process?

Closed loop

What type of communication is needed to prevent patient harm?

1995 - 76 years female - 79 years male - 73 years

What were the average life expectancies in general and also for men and women in 1995?

Fright, but no physical damage

What's an example of emotional injury in malpractice?

25. Have your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences respected. 26. Exercise cultural and spiritual beliefs that do not interfere with the well-being of others. Certain cultural and spiritual beliefs may nevertheless interfere with the planned course of your medical therapy. You may exercise your cultural and spiritual beliefs and take actions in accordance therein as are legally recognized and permissible in the State of Iowa.

What's outlined in Unity Point's patient bill of rights regarding spirituality?

A - asking your friends and members of the community about their experiences with him/her

What's the answer?

A - cold sores in a child age 5

What's the answer?

A - durable power of attorney

What's the answer?

A - higher rates of infant and child mortality

What's the answer?

A - it summarizes principles and behavior expected by all members of the discipline

What's the answer?

A - yes. Retrospective record searches and quality improvement projects qualify as research.

What's the answer?

B - Spirituality involves a more highly individualized search for connectedness with the transcendent than religion

What's the answer?

B - Whether the young woman is able to make this decision for herself

What's the answer?

B - accurate perception of concrete circumstances detailing the specific practical situation at hand

What's the answer?

B - mechanization

What's the answer?

B - under laws of confidentiality, I cannot tell you anything about his diagnosis

What's the answer?

B - what are your goals in the face of the poor prognosis of your condition?

What's the answer?

B - you receive stock in the biotechnology firm sponsoring the research for each patient recruited.

What's the answer?

C - level of income inequality within a state

What's the answer?

C - tell the patient that you are sorry that they suffered harm and you will investigate the circumstances surrounding the adverse outcome

What's the answer?

C - the architect of moral space who mediates communication

What's the answer?

C - treatment for an infection acquired while obtaining a tattoo

What's the answer?

C - weekly morbidity and mortality conferences discussing surgical complications and deaths

What's the answer?

D - a palliative care consult to delineate her wishes at the end of life

What's the answer?

D - consequentialism tries to consider all predictable consequences of an action for everyone concerned, not just the direct and immediate consequences

What's the answer?

D - do I know what are the patient's goals of care?

What's the answer?

D - during the initial medical and psychosocial history

What's the answer?

D - fair and equitable sharing of benefits and burdens

What's the answer?

D - one's philosophy of life informed by family of origin, culture, religion, education, and personal experiences

What's the answer?

D - phase III

What's the answer?

D - strict habit of rendering what is due to others

What's the answer?

D - the discussion must occur in the first 180 days following the incident

What's the answer?

E - inclusiveness

What's the answer?

E - objective advice from the medical professional regarding treatment options

What's the answer?

E - prior smoking

What's the answer?

E - providing relief and support near the time of death

What's the answer?

E - there is no absolute guarantee

What's the answer?

talking one-on-one with participants appears to be the most effective way of improving understanding!!

What's the best way to ensure understanding of the consent process?

-nonmaleficence = non-harming or inflicting the least harm possible to reach a beneficial outcome. Harm and its effects are considerations and part of the ethical decision-making process. -nonmalfeasance = the performance of a public official of an act that is legally unjustified, harmful, or contrary to law. Wrongdoing (used especially regarding an act that violates public trust)

What's the difference between nonmaleficence and nonmalfeasance?

Agent administering drug -PAS - patient -PAE - physician

What's the distinction between physician assisted suicide and euthanasia?

Ask-Tell-Ask

What's the model you should use for communicating serious news?

In an emergent situation where you can't get consent, you do what's in the patient's best interests. Also, not everyone's a dude.

What's wrong with this statement?

When they express consistent preferences with clarity In general, a delirious patient's capacity should be considered impaired and lacking MDM capacity

When MDM capacity waxes and wanes, when should you take them seriously as capable? When shouldn't you?

-disclosure of privileged info is at risk -no exception or waiver compelling release of records applies

When can a court reject/void a subpoena?

-consent from patient - 18th century England -consent from others beside the patient - Indian traditional systems of medicine

When did consent begin historically?

<50 years ago

When did the notion that patient's consent must be *informed* in order to be legally effective begin?

~1970

When did the standard for consent begin to change from the professional standard?

Minimum necessary

When disclosing PHI, only the _______ _______ to fulfill the request should be disclosed to anyone

If a patient refuses a low-risk, high-benefit treatment without which they face serious injury or death

When do you need to evaluate MDM capacity further?

Bad about talking about harm, probability, and burden Good at talking about risks and benefits

When evaluating modalities of treatment, what are physicians good and bad at talking about?

In occupational/military medicine - physician's duty is to employee and employer. So may have to notify patient of that dual obligation.

When is confidentiality not necessarily a given?

Use of analgesics that may hasten death

When is the principle of double effect invoked when it doesn't really apply? (AKA it's overused as an argument)

Situations of larger stakes - like open heart surgery instead of a simple I&D

When might MDM capacity be subject to closer scrutiny?

When determination is problematic

When should you seek consultation regarding MDM capacity?

1990 Effective December 1991

When was the patient self-determination act passed and effective?

1957 by a California appeals court - "subjects himself to liability if he withholds any facts with are necessary to form the basis of an intelligent consent by the patient to the proposed treatment"

When was the term informed consent first used?

Relative or friend If no POA - states have established hierarchy

Who can be a durable POA? What happens if no durable POA has been designated?

patient's primary care provider

Who is in the best position to determine presence or absence of MDM capacity?

obtaining and ensuring quality of consent rests upon each individual who initiates, directs or engages in the experiment ITS EVERYONE'S RESPONSIBILITY!!

Who is responsible for getting consent?

-Physical paperwork is owned by the clinician -Info contained in the medical record is owned by the patient. Patient has right to access chart/copy records at their expense

Who owns the medical record?

Investigators IRB will also use its scientific expertise or hire outside consultants

Who should be the primary source of info about risks? Who else is involved in identifying risk?

-use technical language (can't communicate with patient) -difficulty interpreting to patient the uncertainty intrinsic to medical info -concern about information overload or alarming patient -time pressure -see consent process as bureaucratic and unnecessary

Why are healthcare professionals bad at getting informed consent?

-limited understanding -inattentive/distracted -overcome by fear and anxiety -selective hearing due to denial/worry (don't comprehend) -believe decisions are physicians' choices

Why are patients bad at informed consent?

-era of extraordinary technological progress -cataclysmic cultural shifts -growing emphasis on patient autonomy -circle of decision makers has widened

Why are there so many ethical challenges at end of life now?

probably d - consult the hospital ethics committee

You should.... -a- honor his wishes and extubate him in the ED -b- admit him to the ICU for further care -c- honor his wife's request that "everything possible" be done to help him survive and recover -d- consult the hospital ethics committee

1. Exploitation - when a non-dominant population is used to meet the needs of a dominant population 2. Marginalization - when a nondominant population is positioned in a society in a way that will prevent them from acquiring power (e.g. Mr. Jones and his colorectal cancer) 3. Powerlessness - self-perpetuating 4. Cultural Imperialism - expression that the people who have power make the rules and expect that everyone else will live the same way (e.g. family not grieving the right way) 5. Violence Power is the dominant motivator for structuring our society. Exploding Margaritas Provoke College-Innocents Viciously

Young's Five Faces of Oppression. Give a mnemonic.

Fear and loneliness Hospitals peel away people's sense of self (take their clothes, take them away from home, etc)

________ and ________ experienced during serious illness generate spiritual crises that require spiritual care

Learning and vulnerability

_________ and ______ go hand in hand

bad outcomes aren't always errors; may be due to complications, side effects, acceptable variations in clinical judgement or progression of disease remember informed consent w/ patients: talk abt complications, side effects, disease progression... pt needs to know COMMON issues and SERIOUS issues

bad outcomes vs errors

ongoing partnership btw physician and pt prevents coercion/ deception assess pt understanding, reviews risks/benefits hopefully leads to shared decision making

collaborative decision-making process allows:

study this image!!!

do it!

unacceptable likelihood of achieving a therapeutic benefit for the patient 1 - physiological - physician understands 2 - quantitative - how many times/ what degree do we fail before call it futile? 3 - qualitative: can pt appreciate benefit of what we're doing (only patients with MDM capacity)? This is often done by surrogate decision maker even though only the pt can say if it's beneficial

medical futility: define. What are the different types of futility?

justified, obligatory, principle

moral principles are believed to be _____ and are therefore seen as _________ unless outweighed by another such ________

whenever pt is injured as consequence of medical care, pt should be informed promptly bc failure to do so seriously compromises pt/ societal trust regardless of concern about legal liability, disclosure should be made by physician- be truthful with the patient! Adverse outcome is understood by the patient

physician's commitment to honesty after medical error physician must be sure that:

Physical environment (10%) Socio-economic factors ie education, employment, income, social support (40%) Health care access (20%) Health behaviors (30%)

social determinants of health (%)

study this image

study it

integrity - moral wholeness, unity, harmony. Moral identity. Moral responsibility.

virtue includes ______ (similar to conscience)

-States: licensure granted/ revoked -Hospitals: restricting/ limiting practice -Professional orgs -malpractice legislation

ways medical practice is held accountable (legal regulation of medical practice)

clinical reasoning

what framework is this?

commitment to truth functions as an irreplaceable foundation for interpersonal relations in society that are based on trust, which is essential to the pt-physician relationships

why is truthfulness important?