Medical Ethics Exam 1
Medically Indicated Definition
A *competent clinician* would judge a certain medical treatment as being both physiologically and medically appropriate in a particular case.
Negligence accounts for...
A small percentage of all medical errors. When adverse events are preventable, they are called medical errors. A small proportion of these are due to negligence on the part of the provider.
Quality of Life: Contributing Factors
A subjective measurement that takes into account the patient's values. Can be influenced by your caregiver's QOL as well.
Five Wishes Document
A type of a patient's living will that specifies: 1. Who they want to make decisions for them when they cannot 2. the kinds of medical treatment they want or don't want 3. How comfortable they want to be 4. How they want people to treat them 5. What they want their loved ones to know.
Disclosure: Acknowledge Emotions
"I can tell that you are upset." "I sense you are disappointed in me." "I understand your desire to change physicians and I can help you find another provider."
What is the therapeutic relationship? How does professionalism factor in?
Certified or certifying PA's shall respect appropriate professional boundaries in their interactions with patients. They must avoid behavior posing a threat to health, well-being, or safety of patients apart from reasonable risks taken in the patient's interest during treatment.
Two Features of Suffering
Consideration of the future -What will become of me in the future because of this problem? Constant anxiety about the future can cause suffering. The Meaning attributed to suffering -What is the meaning of this suffering? When people see a meaning in their suffering, they can tolerate it better. However, if they see it as a punishment, it can be more difficult to tolerate.
How can this patient be benefitted by medical and nursing care, and how can harm be avoided?
To answer this question, the provider must collect the factual info about the patient's condition and treatment and relate them to the principles of beneficence and nonmaleficence. They must consider the benefit/risk ratio in forming a recommendation about appropriate actions.
Rationale of Disclosing Medical Errors
Honesty, transparency, preservation of trust Justice is extended to the patient Extends the informed consent further generates opportunities to improve the system (forcing accountability), allows for forgiveness (assuage provider guilt), and because of regulatory requirements. You should disclose medical errors.
What is the aim of CPR, BLS, and ACLS? When are they not indicated?
To reverse the effects of cardiac or cardiopulmonary arrest. CPR is not indicated when clinical judgment indicates that it will not reverse the effects of the arrest, or the patient or their designated surrogate authorizes omission (DNR). Emergent or crisis situations with high unlikelihood of patient survival due to extreme traumatic injury or an extended period of time being "down in the field", CPR does not have to be administered based on futility of the intervention.
What does the Charter on Medical Professionalism have to say about the definition of professionalism?
"Professionalism demands placing the interests of the patient above those of the physician," maintaining standards of competence, and providing expert advice to society on matters of health.
Consumerism Model of the Therapeutic Relationship
"The Customer is always right". The patient is the driving force in what is decided. The problem with this is that the patient is not always right, and they often don't know what they need.
SPIKES: Strategy and Summary
"The next steps are..." Talk to them about possible game plans and how you can still move forward.
Leading Causes of Death: Medical Errors
#1 - Heart Disease #2 - Cancer #3 - Medical Errors
Medical Errors: Statistics
1/2 million deaths/year from preventable harm, costing 29 billion/year. 42% of public have experienced an error (24% were serious). Variable disclosure - Not all of these errors are reported (about 1/3 are reported)
Anatomy of a Decision: the three steps to making an ethical decision about death and dying
1. Identify the decision-maker: is the patient capable? If not, look for an advance directive and a surrogate. 2. Identify the criteria used to make the decision 3. Resolve conflict
7 Key Points for Improving End of Life Communication - From Dr. Wes Ely
1. It is a PRIVILEGE to serve this patient. 2. We are gathered to serve the patient and not the wishes of the loved ones. 3. Do not ask patient or family "Do you want everything done?" 4. Discuss "withdrawing support" rather than "withdrawing care". 5. "Burden of care" should be "honor and privilege of care" 6. Reassure the family/patient that no one will abandon them during the dying process 7. Instead of predicting time of death, flip it, saying "I would not be surprised if he/she died in [amount of time].
DNR orders without/contrary to consent: 3 situations where a DNR would be helpful
1. Patient is unable to give consent and no surrogate can be identified 2. Medical indications do not support the utility of CPR, but the surrogate insists on CPR being performed. 3. An emergent situation when survival is very unlikely.
When does clinical judgment show that CPR is not indicated?
1. When there is conclusive evidence that the patient is dead. 2. No medical benefit is expected due to level of deterioration of the patient despite the maximal therapy. 3. Cardiopulmonary arrest occurs as the natural end of a terminal disease and all treatment options have failed.
6 questions to use when assessing ethical problems regarding patient preferences.
-Has the patient been informed of benefits and risks of the diagnostic and treatment recommendations, understood the information, and given consent? -Is the patient mentally capable and legally competent or is there evidence of incapacity? -If they are mentally capable, what preferences about treatment is the patient stating? -If incapacitated, has the patient expressed preferences previously? -Who is the appropriate surrogate to make decisions for the incapacitated patient? What standards should govern the surrogate's decisions? -Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
Decisional Capacity - Determination (How to decide if someone has decisional capacity)
-Talk with the patient, observe behavior, and speak with family, friends, familiar staff to note inconsistencies, confusion, or incoherence in the patient. -Schizophrenia, depression, or dementia do not rule out the patient's mental capacity to make decisions. Mental disease and decisional capacity are not mutually exclusive. -If mental disease is present, providers should consult with experts (psychiatrists, neuropsychologists, or clinical psychologists). Many local laws or hospitals require mental health assessment by a professional when deciding decisional capacity. -No single test is sufficient to capture the complex concept of decisional capacity in a clinical setting. -Refusal of treatment should not, in and of itself, be considered a sign of incapacity
Significance of Patient Preferences
1. Clinically significant, because they can drive decisions of care. 2. Legally Significant, because people have legal rights to self-determination and autonomy. 3. Psychologically Significant, as the patient's preferences give them a feeling of control in their lives.
Three types of approaches to clinical decision making in the therapeutic relationship.
1. Consumerism Model 2. Paternalism Model 3. Shared Model (AKA Patient-Centered Medicine)
Identifying the Decision Maker
1. Does the patient have capacity? If not... 2. Does the patient have an advance directive? 3. Is there a surrogate decision-maker? -This person must know the patient's values, must give evidence for knowing those values, and must not have a conflict of interest. 4. If none of the above can make the decision, the healthcare provider becomes the surrogate, and also the decision maker, but make sure the ethics committee is also on the case.
Near Miss
A Medical process that could have resulted in loss/injury but did not.
How are Medical Indications most effectively assessed within the realms of beneficence and non-maleficence?
A benefit/risk ratio that helps identify how much risk is justified by the intended benefit. There is some form of risk of harm associated with almost all treatments.
Uniform Definition of Death Act
A bill proposed in 1981 that a dead individual is one who has sustained either: 1: Irreversible cessation of circulatory and respiratory function 2: Irreversible cessation of all functions of the entire brain, including the brain stem ...is dead. A determination of death must be made in accordance with accepted medical standards.
What are the probabilities of success of various treatment options?: Clinical Judgment
A clinician must use sound clinical judgment to make good decisions in the face of uncertainty. This is done by utilizing clinical data and medical science (EBM and Clinical Guidelines). Uncertainty can still exist even after applying clinical guidelines, EBM, and basic ethical principles. The clinician's aim should still be toward effective therapeutic relationship and professionalism. Always consider medical futility during patient interactions.
Definition of Pain
A complex sensation integrating physiologic, mechanical and neurochemical responses with social, behavioral and psychological responses to noxious stimuli. An unpleasant sensory and emotional experience associated with actual and/or potential tissue damage.
Pain Contract
A contract that the patient signs saying that they will only seek pain medications from their provider, unless specifically approved by the provider for them to go elsewhere as well. Outlines specific situations in which the provider will NOT refill the medication to prevent abuse.
Medical Error
A deficient process of care. Can be a misdiagnosis, an improperly given medication. Could be a problem with how the system is run, or how the provider administered healthcare, but it is still a medical error.
Documentation of informed consent
A signed consent form entered in the patient's record. Usually, this is required before certain medical and most surgical or invasive diagnostic procedures are initiated. The document will name the procedure and state that the risks and benefits have been explained to the patients. The process and details of the consent interview should be documented by the provider in the medical record.
Incurable Patient Definition
A patient that cannot be cured that has a progressive, lethal disease.
Decisional Capacity: Definition
A patient's ability to consent or refuse care. Linked with their ability to understand relevant information, to appreciate the medical situation and its possible consequences, to communicate a choice and engage in rational deliberation about one's own values in relation to the physician's recommendations about treatment options. If a patient lacks these abilities, a surrogate decision maker is required.
Mature Minors giving consent
A person below the age of 18, still dependent upon parents, but who appears to make reasoned judgments. They appear to be able to decide for themselves, but parents remain legally responsible for them. Physicians can legally respond to their requests if: -the patient is at the age of discretion (15+) and appears to understand procedure and give genuine informed consent -The medical measures are taken for the patient's own benefit (e.g. not as transplant donor) -The measures can be justified as medically necessary -There is some good reason why parental consent cannot be obtained (including minor refusing to request it). The physician should inform the patient that medical bills may still be sent to the parents and breach confidentiality of the patient.
What governs the clinician's decision of what is medically indicated for a patient?
Beneficence - Duty to attempt to improve the physical and psychological health of an individual with medicine. Nonmaleficence - Administering medicine in a way that prevents further injury.
Difference between Advance Care Planning and an Advance Directive
ACP is the process, AD is the document.
Types of Advance Directives: Directive to Physicians
AKA Natural Death Acts In state legislation, these affirm a person's right to make decisions concerning terminal care after they lose decisional capacity. In essence, they state to the physician and family what they would want to happen if they lose decisional capacity
Informed Consent: Comprehension
Adequacy of information is equally important as the patient's comprehension of it. The physician is ethically responsible to ensure comprehension. Explanations should be given clearly and simply; Questions should be asked to assess understanding. Pamphlets, videos, computer programs can be provided to guide patients who face complex decisions. The patient doesn't necessarily have to be taught by YOU, they just must be educated.
Respect for Autonomy
Allowing patients to make their own decisions in their own ways. Even when illness or accident has caused them to lose some measure of independence, they still deserve to be treated with respect and to remain in control of their lives.
SPIKES: Definition
An Evidence based approach to delivering bad news. Setting up Perception of patient/family Invitation Knowledge Emotions and Empathic Response Strategy and Summary
Principle of Double Effect
An action that has two effects, one good and one bad, is generally OK so long as 5 conditions are fulfilled. 1. The act itself is good or at least morally neutral (giving morphine to relieve pain) 2. Only the good effect is INTENDED (relief of pain) and not the bad effect (killing the patient) 3. Good effect is not achieved THROUGH the bad effect (pain relief is not dependent on the hastening of death) 4. There is no alternative way to attain the good effect 5. There is a proportionately grave reason for running the risk (relief of intolerable pain)
Disclosure: Active Listening
Appropriate Body Language Be silent
Questions to diagnose suffering
Are you suffering? What is causing your suffering? Are there things worse than just the pain? What is the worst thing about all of this? Are you frightened by this? What are you frightened of? What do you worry will happen to you? Do you think this means your disease is getting worse/you are dying?
SPIKES: Perception of the Patient or family
Ask open ended questions to gauge how they are feeling. What was the patient like? What did the doctor tell you? You will waste your breath if you don't let the family/patient speak first.
Adverse Event
Bad outcome from an interaction with healthcare. Can be preventable or unpreventable. This is not necessarily a medical error. Preventable adverse events are considered medical errors.
Four Bioethical Principles
Beneficence - Do good! Nonmaleficence - Don't do bad! Respect for autonomy Justice
Informed Consent: Scope of Disclosure
Candid disclosure is best, and should include: 1. Patient's current medical status, including prognosis if no treatment is provided. 2. Interventions that could improve prognosis (+their risks and benefits and the probabilities of both) and uncertainties 3. A professional opinion about alternatives 4. A recommendation of the physician
Refusals due to Religious Beliefs and Cultural Diversity
Certain patients belonging to specific religious groups may have special medical preferences that providers would consider dangerous. Adherence to an unusual belief is not evidence of incapacity. In the absence of clinical signs of incapacity, that person should be considered capable of choice. A treatment acceptable to the patient and provider alike should be negotiated by finding common goals.
DNR Documentation
Clearly documented, signed, and placed in the patient's chart along with documentation of the terms of the order. Orders should be available to all caregivers of the patient so that they are aware of the DNR order and its rationale. DNR orders are portable.
Survival to D/C after CPR: Percentages.
Commonly, about 10% (7-14%) of people survive and are discharged after having CPR performed on them. For people with primary cardiac disease, this is more like 33%. For frail older adults, it is less than 5%.
Competence vs. Capacity
Competence - A legal term, competence is something that can only be determined in a court of law. The ability to make financial or other important decisions. Capacity - The ability, determined in a healthcare setting, that the person in question has to make healthcare related decisions.
Disclosure A-List
Content of Disclosure: -Accurate Statement of Error -Accountability -Apology -Answers and A plan Communication Strategies: -Active Listening -Acknowledge and address emotions
SPIKES: Knowledge
Deliver it in very basic terms meant for the patient. "The biopsy shows cancer". Help answer any questions they might have about what it means.
Failure to Cooperate in the Therapeutic Relationship: What is the Appropriate Recommendation?
Determine whether the patient is acting voluntarily (some involuntary noncompliance is due to emotional disturbance, psych disability or ambivalence.) If physician judges noncooperation is voluntary, reasonable efforts at rational persuasion should be undertaken. If these fail, adjust therapy goal/treatment plan. Also ethically permissible to advise and/or offer to assist the patient to obtain care elsewhere and withdraw. If the noncooperation is resulting from psychological or physical disorder, the physician is strongly obligated to remain with the patient and adjust treatment plans. Frustration on the part of the physician is not sufficient to justify leaving the patient.
Management of pain
Diagnose and treat underlying cause(s) Set and achieve goals Involve other disciplines (Cog. behav. therapy, PT and OT, Biofeedback, Acupuncture, etc) Treat the person with exercise (Improving function), non-opiate analgesics, neuropathic drugs, interventional pain management (injections). Try to minimize opiates, and if they are used, set up a pain contract.
Informed Consent - Completeness of disclosure
Disclosure should include the options that the clinician thinks is less desirable but are still reasonable, and reasoning why the clinician thinks they are so. It is ethically appropriate to make a strong argument in favor of the option the physician thinks is best, but the patient should still be left to choose, even if they choose the less effective option. Coercion and manipulation of the patient should be carefully avoided.
Advance Directives: Types of Proxy Directives
Durable power of attorney for healthcare. This person becomes your surrogate decision maker, or "healthcare agent"
What are the probabilities of success of various treatment options?: Medical Futility Definition
Efforts to provide medical benefit to a patient that reason and experience suggests is highly likely to fail and whose rare exceptions can not be systematically produced.
Ethical Decision Making: An overview
Ethical Issues exist in every clinical encounter. The clinician can effectively and ethically perform daily duties without being a bioethicist. Not about deciding right and wrong, but the better, more right solution, then producing an appropriate course of action.
Where is a Five Wishes document legally valid?
Every state except AL IN KS NH OH OR TX UT
Negligence
Failure to provide the standard of care. This is an incorrect decision that was made, and is what you can be sued for.
Why Patients sue
Families litigating for perinatal injury (mom or baby) - Seeking info, perceiving a cover-up or lack of MD honesty, or felt the MD would not talk with them 71% of malpractice was due to physician-patient relationship issues. Many feel deserted, that information was not properly delivered, or that their opinions, need for info, or discomfort were not addressed 91% of medical negligence claims were due in part to a desire for an explanation
When actual harm comes to a patient due to a medical error, what can be assumed about the rest of the pieces of the medical process?
For every situation of actual harm to a patient, there are layers of unsafe conditions, near misses, and no harm events that were existing in the background, contributing potential harm to all patients.
What is the most effective way to resolve a conflict between a provider's judgment and a patient's preferences?
Find common goals, and then decide on the treatments that will allow you to reach those common goals.
Resolving Conflict: 3 ways
Focus on Shared goals (patient's values, beneficence) Keep Communication open (listen to the patient more than you talk. Let them express emotion) Use time as an ally (come back day after day to develop trust and understand their situation more.)
Ethical medical care seeks to...
Fulfill beneficence, nonmaleficence, respect for autonomy, and justice. Additional principles include empathy, compassion, fidelity, integrity.
Disclosure: Apology Types
Full Apology: I am sorry WE DID THIS TO YOU. Partial/Statement of Sympathy: I am sorry this happened to you.
SPIKES: Emotions and Empathic Response
Give them a moment to think about it, and name their emotion. DO NOT SAY YOU UNDERSTAND HOW THEY ARE FEELING. Instead, say, "I can see that you are angry/sad/etc." Don't get emotional yourself, while still being empathic.
SPIKES: Setting Up
Have a designated space for consultation of the patient. Know your facts before you go in. Don't get distracted, know the information about it. Sit down.
5 Questions of Medical Indications: What are they used for?
Help clinicians define the scope of medical indications and connect beneficence and nonmaleficence to the clinical situation/circumstances.
Placebo treatment
Involves the patient being ignorant to their treatment (deception). This is ethical in research because patients are informed that they MIGHT get a placebo or inert substance. With a clinical experience, it is unethical because you are intentionally deceiving them without their knowledge.
Persistent Pain May Result in...
Impaired functional status Depression Anxiety Social Isolation Poor Sleep
Disclosure: Answers and A Plan
Implications of error -How will it impact health? -What future treatment, procedures, or monitoring is required? -Extra cost? Never tell them you will cover it.
Consent of minors
Important in the case of: 1. emergencies 2. Special legal allowances for treatment of some conditions like drug abuse, venereal disease (some states may permit or specifically exclude contraception, abortion, mental illness) 3. Emancipated minors, married minors, those in the armed forces, those living away at college 4. Mature Minors
Statutory Authority to treat against patient's will
In all jurisdictions, statutes exist that authorize psychiatrists (and ONLY psychiatrists) to restrain mentally ill persons who are dangerous to themselves or to others for psychiatric treatment against their will. These statutes pertain to persons suffering from mental disease, and treatment authorized is treatment only for mental disease. In some situations, both mental disease AND medical problems may be present. These situations of dual diagnosis deserve special consideration.
Implied Consent: Which medical principle is the ethical justification for the emergency treatment?
In life-threatening emergencies, patients may be unable to express their preferences or give consent due to shock or being unconscious. If no surrogate is available, it is customary for physicians to assume the patient would give consent if they were able because the alternative would be death or severe disability. The principle of beneficence is the ethical justification for emergency treatment of an incapacitated person.
Durable Power of Attorney for Health Care
Individuals can appoint another person to act for them to make all decisions concerning their health care after they are incapacitated. Most laws require that the appointment be made in writing, although some allow oral designation to be documented in a patient chart. this designated decision maker is given legal priority over all other parties.
SPIKES: Invitation
Invite them in to the results. "Do you want to know the biopsy results? Can I tell you about this?"
Approach to Suffering
Involve multiple disciplines (chaplain, nurse, psychologists, PT/OT) Palliative care (when appropriate) Use time as an ally Listen, good communication Practice good self-care (on the end of the provider)
Types of Advance Directives: Personal Notes or Letters
Informal, and quite vague. May generate some confusion for those who interpret them, but they have legal power in some areas to represent the patient's wishes.
Incapacitated Patients: Advance Planning/Advance Directives
Information given to physicians about who should be a surrogate for a patient if they should be incapacitated. Medicare regulations require hospitals to provide patients with information about their rights to accept or refuse recommended care and to formulate advance directives.
Informed Consent - Standards of Disclosure: The Subjective Standard
Information provided is specifically tailored to the particular patient's need for information and understanding. It is the highest standard of disclosure. It is patient specific, and conforms to the highest ethical goals of clinical care.
Assessment of Pain: Physical Exam
Inspection, auscultation, palpation Physiological parameters (what is happening with HR, BP, etc?) General Observations (are they faking?): -Facial expressions -Vocalizations -Body Activity/position -limb withdrawal -writhing
What process is used to resolve disagreements between patients (or surrogates) and the medical team about whether a particular treatment is futile?
Institutions should design policies for conflict resolution regarding nonbeneficial treatment.
4 Topics for organizing ethical reasoning
Medical Indications Patient Preferences Quality of Life Contextual features (helps to collect, sort, and order the facts of an ethical problem)
What is the Patient's Medical Problem?
Is it acute or chronic, critical (at a turning point of deciding life and death), reversible, emergent, terminal? Defining the medical problem can allow you and the patient to discuss which options are most ethical. Patients should have clarity in regards to the nature of the disease as part of their responsibilities in the therapeutic relationship
Assessment of Pain: Psychosocial History
Is there a comorbid depression or anxiety? What is the impact of the pain on function/everyday life?
What is Quality of Life? What measures might it involve?
It is whatever a patient says it means to them, and is a subjective measurement. Can involve Physical function, lack of pain/suffering, cognitive function, life satisfaction, happiness, hedonism (positive feelings), eudaimonism (being well and doing well)
The legal progression of surrogates for those without durable power of attorney
Legal Spouse (must have been married legally) Parent Child
Types of Advance Directives: Living Wills
Less formal than Directives, and spell out specific conditions and treatments that the patient may not desire to have or not have. An example is a "Five Wishes" document. Another Example: Various religious groups (Roman Catholics, Christian Science, Conservative Jews) recommend use of particular forms of living wills that reflect their own doctrines to their adherents.
Life Prolonging Therapies on a Continuum
Life Prolonging therapies are arranged on a continuum of how much burden or risk is associated with the treatment vs. how much invasiveness/intensity is associated with the treatment. On the low end is aspirin, and on the high end is CPR.
Advance Directives: Instructional directives types
Living wills - Ex: 5 wishes, DIY, State-specific forms Orders to limit treatment - DNR, DNI, DNH, POST, POLST, MOST
Most common sites of persistent pain
Low back (28.1%) Knee Pain (19.5%) Headache or Migraine (16.1%) Neck Pain (15.1%) Shoulder Pain (9.0%) Finger Pain (7..6%) Hip Pain (7.1%)
What are the predictors of a very poor prognosis upon admittance to the hospital?
Malignancy (esp. Metastatic) Chronic Renal Failure Sepsis or pneumonia as an admitting diagnosis Decreased Functional Status (Cannot perform some basic activities of daily living) Patient was homebound before being admitted to the hospital
Risk Factors for Persistent Pain
Obesity Low Fitness level Overuse of joints/muscles Chronic illness Lack of social support Low SES Vivid memory of childhood trauma Abuse
Moral and Legal Obligations of Disclosure for Informed Consent
Obligations and requirements become more stringent as the treatment situation moves from emergency to elective to experimental. In emergencies, very little info need be provided. Any attempt to inform may cost time, so ethically and legally, information can be curtailed in emergencies.
How to address refractory pain
Palliative Sedation (not really a common option) Address possible suffering Focus on QOL
Death and Dying: Statistics
Most Americans die in hospitals (shifted away from dying at home) About 1/4 older Americans dies in the ICU Of those who die in the ICU, 38% die from withholding life-prolonging therapy, and 36% die from withdrawing life-prolonging therapy. 20% die from unsuccessful CPR, 8% of brain death, 2% from active shortening of the dying process.
How does CPR differ from most other treatments regarding a doctor's orders?
Most other treatments require a doctor's note to perform, but CPR requires a doctor's note NOT to be performed. For example, you need a written order (DNR/No Code) to authorize NOT administering CPR for a patient
Disclosure: Accurate Statement of Error
Most patients want to be informed of all errors, even if no harm is done. They should be told what happened, as soon as the provider discovers the error.
What type of medical goals are attainable for someone who is dead by either the cardiorespiratory or brain criteria?
NONE! "No medical goals are attainable for a person who is dead by either the cardiorespiratory or brain criteria"
Litigation and negligence
Negligence is absent in most malpractice lawsuits, and only 3-5% of patients injured by negligence will sue.
In what circumstances are medical treatments not indicated?
No scientifically demonstrated effect. Known to be efficacious in general but may not have the usual effect on some patients because of their presentation of the disease or their constitution. It was appropriate at one point in the patient's course, but ceases to be appropriate in later points. If the patient is a dying patient, a terminally ill patient, or an incurable patient, it will change what is medically indicated for that individual.
Types of pain
Nociceptive - Visceral (constipation, renal colic) or Somatic (arthritis, post-operative) Neuropathic - Nerve pain (burning, tingling, etc) Mixture of both Undetermined sources
Suffering Definition
Not the same thing as pain. It is its own kind of distress, and happens to persons, not bodies. It occurs when individuals feel their intactness or integrity as persons is threatened. This suffering continues until the threat is gone or integrity is restored.
Which demographics have more DNR orders?
Older Patients, white patients, and women are more likely to have a DNR order. Disparities exist in the utilization of DNR orders in the US relative to age, race, gender and geography. Thus, providers have an ethical responsibility to initiate the discussion about DNR orders when appropriate and the patient/surrogate have not requested a discussion.
PAs and Medical Errors
PAs WILL experience a medical error in their careers. Because of the connection between PAs and physicians, the role of PAs in a medical error's occurrence and disclosure is unknown. A PA should disclose to their collaborating physician information about errors made. The PA and the physician should disclose the error to the patient then, if the information is significant to the patient's interest and wellbeing. Errors do not always constitute negligence or unethical behavior, but failure to disclose them may.
Refractory Pain
Pain that persists despite administration of appropriate therapies for its relief.
Common Symptoms at the end of life
Pain, constipation, N/V, Bowel obstruction, anorexia, delirium, depression, dyspnea, cough, loud respiration
Sources of suffering at the end of life
Pain/symptoms Loss of control Fear of prolonged dying Fear of burdening others Personal relationships
Decisions for Unrepresented Patients
Patients who lack surrogates (Often the homeless, alcoholics, addicts) and lack decisional capacity and lack and AD should be represented by a non-provider board or group (ethics committee). They should review the case before making a decision.
Persistent Pain: Incidence and Cost
Persists 3-6 months past normal tissue healing time, affecting >100mil US adults (4x prevalence of diabetes) Costs >500bil ann. in direct medical treatment cost and lost productivity. 50-75% of patients die in moderate to severe pain.
Informed Consent: Refusal of Information
Persons have a right to information about themselves, and they also have the right to refuse information about themselves. You should respect their refusal, and should offer more information at other appropriate times. You should make a full notation of the patient's refusal of offered info in the patient's charts. A provider may consider seeking patient permission to discuss the details of a treatment with someone else
What level of statistical/experimental evidence is required to support a judgment of futility? The difference between physiologic and probabilistic futility.
Physiologic futility - an utter impossibility that the desired physiologic response can be affected by any intervention. Probabilistic futility - Intervention is highly unlikely to produce the desired result based upon general clinical experience and clinical studies demonstrating low rates of success for particular interventions in a particular case. A lack of agreement exists about how low a level of probability should be to classify a treatment as futile.
Advance Care Planning
Process to help people formulate preferences for future medical care in the event of decisional capacity. This is meant to preserve autonomy. An advance directive is a document of the patient's wishes.
Informed Consent - Standards of Disclosure: 3 Categories
Prudent Provider Standard Reasonable/Prudent Patient Standard Subjective Standard
Patient Refusal of Treatment and Decisional Capacity
Refusal of treatment should not, in and of itself, be considered a sign of incapacity. Rather, the provider should ask why the patient is refusing the treatment before proceeding.
Patient Self-Determination Act
Requires all hospitals/healthcare facilities receiving federal funds (like Medicare and Medicaid payments) to ask patients at the time of admission whether they have advance directives. If they do not have an AD, the hospital is required to provide assistance preparing one.
Justice
Requires that we treat all patients equally.
Nonmaleficence
Requires us to do no deliberate harm to others. To achieve this goal, the healthcare provider is responsible to be competent, discerning, and give service to their patient.
Beneficence
Requires us to promote the well being of others
Which bioethical principle is most weighty?
Respect for Autonomy
Accepted medical standards for the clinical diagnosis of death by the brain criteria
Rule out confounding conditions like severe hypothermia or drug intoxication. The patient demonstrates no voluntary or involuntary movements, except spinal reflexes and not brain stem reflexes. They demonstrate apnea by elevated arterial CO2 levels when mechanical ventilation is temporarily halted.
Ethical Issues of Pain Control: Do the Benefits of treatment outweigh the risks?
Side effects of Opiates: Constipation, confusion, sedation, edema, endocrine dysfunction (sexual dysfunction, weight gain, decreased energy, moodiness, hyperalgesia) Dependence (physiological - results in a withdrawal response) Addiction (psychological, no withdrawal response) Overuse Diversion At end of life, results in respiratory depression.
Informed Consent - Standards of Disclosure: Prudent Provider Standard
The base amount of information that an average or prudent provider would provide to a patient. A more paternal standard. The least desirable of the three standards of disclosure.
Patients and Providers: What are the treatment goals?
The clinician must have a clear understanding of what the patient's treatment goal is in order to analyze and propose a resolution to the ethical issue. The provider and patient should clarify the goals of treatment together in determining a treatment plan. Treatment goals may conflict, and they may change throughout the course of a disease.
Shared Model of the Therapeutic Relationship
The combination of paternalism and consumerism. The patient is at the center of the goals and of the care. The patient tends to express greater satisfaction, and is less likely to sue a provider under these conditions.
Determination of Death: the Cardiorespiratory Criterion
The commonly accepted definition of death both legally and medically in the past. It is based on the "irreversible cessation of circulation and respiration". Later replaced by the brain criteria for death due to the implementation of mechanical ventilation.
Medical Indications - Definition
The facts about a patient's physiological and psychological condition and their interpretation of those that provide a reasonable basis for the clinician to make a judgment about diagnosis, therapy and education that are appropriate for that encounter.
Informed Consent: Truthful Communication
The medical provider should state the facts, and acknowledge their uncertainty if the facts are unclear. Facts should be stated in a manner acceptable to the patient's comprehension and emotional state. Difficult diagnoses can be stated caringly, and sensitively, and they should be disclosed, as demanded by patient autonomy, reinforcing the patient's ability to choose. You can also ask how much information the patient wants and if they want someone else told.
Providers have an ethical responsibility to initiate the DNR discussion when...
The patient is terminally ill or has an incurable disease with estimated 50% survival of less than 3 years. The patient has an acute, life-threatening condition The patient requests a discussion.
Paternalism Model of the Therapeutic Relationship
The physician acts as a parent in the model, and the patient is simply along for the ride. Does not allow for patient collaboration
What is "negotiated performance autonomy"?
The role of PAs delivering healthcare in partnership with physicians.
Terminal Patient Definition
Those with a lethal, irreversible disease that an experienced clinician expects will die in a relatively short time period (days-months) despite appropriate treatments.
Dying Patient Definition
Those with clinical conditions which definitively indicate the patient's organ systems are irreversibly disintegrating rapidly, and death is expected WITHIN HOURS.
Assessment of Pain: 5 questions to help categorize pain
Topography/location Intensity (1-10 Scale) Character (burning, dull, sharp, etc) Variability/timing of pain (worse at certain times of day?) Exacerbating/relieving (Is there anything that makes it better or worse?
The Standard of Surrogate decisions
Two types of surrogate decision making standards: -Substituted judgment standard -Best Interest Standard
Who decides whether an intervention is futile?
Ultimately, the physician has a huge amount of say on a treatment's futility, although the patient does have power to affect this decision.
Rationale of NOT Disclosing Medical Errors
Uncertainty whether an error actually occurred, a feared loss of reputation or potential litigation. Disclosure might increase a patient's suffering (load of worry) or decrease the patient's confidence in the MD/system. Errors also might not be disclosed because they are not trained on how to do so. You should disclose medical errors.
Informed Consent: Definition - What principle is it demonstrating?
Willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, and also its alternatives with their risks and benefits. It is the practical application of respect for the patient's autonomy in the practice of medicine.
Identifying criteria used to make a decision
What are the patient's values/goals? What is the prognosis? The likelihood of a complete recovery? What quality of life does the patient want? What are the risks of treatment?
The Quality of Life Dynamic: The Gap
What are you expecting vs. What are you experiencing. If your expectations are low but your experiences are high, you will generally experience and high quality of life. The distance of the gap between expectations and experiences is what Quality of Life is typically based on. Thus, if your expectations change, so can your QOL.
Informed Consent - Standards of Disclosure: The Reasonable/Prudent Patient Standard
What do reasonable patients need to know to make reasonable decisions? A patient centered way to disclose information, and meets the legal requirements. Still not as good as the subjective patient standard, as it is not tailored to the specific patient.
5 Questions of Medical Indications: What are they?
What is the patient's medical problem? What are the goals of treatment? In what circumstances are medical treatments NOT indicated? What are the probabilities of success of the various treatment options? In sum, how can the patient be benefited by medical intervention, and how can harm be avoided?
3 Questions of Medical futility
What level of evidence is required to support a judgment of futility? Who decides whether an intervention is futile (debatable... the physician)? What process should be used to resolve disagreements between patients (or surrogates) and the medical team about a treatment's futility?
Substituted Judgment Standard
When the patient's preferences are known, the surrogate must use knowledge of these preferences in making medical decisions
The Best Interest Standard
When the patient's preferences are not known, the surrogate's judgment must promote the best interests of the patient.
Disclosure: Accountability
Why did the error occur? -Involve patient safety and a root cause analysis How are you going to fix it for them? How are you going to prevent future errors? -Report to the healthcare system -Change care delivery process (Swiss cheese model)
Patients were asked..."Could anything have averted legal action?"
YES (41%). Answers and an Apology