Chapter 39: Ethics and Law
What is the Deciding to Forego Life-Sustaining Treatment document?
1983 President's commission for the Study of Ethical Problems in Medicine and biomedical Research published the document. Remains useful today when dealing with ethical decisions related to withholding and withdrawing therapies.
What is the significance of the Schiavo case?
1990 26 year old Theresa Marie Schiavo sustained severe brain damage, subsequently diagnosed with PVS, hospital inserted a PEG tube. Husband Michael was appointed guardian. 1998 he petitioned to have the feeding tube removed. Parents argued the opposite position. Resulted in 2 removals and reinsertions of the feeding tube and 4 rejected appeals to the US Supreme Court and unprecedented interventions of the Florida legislature and governor, US Congress and the president. March 2005 the federal district court refused to order reinsertion for the PEG tube for a third time and Schiavo died. Case led to the refinement of living will legislation with regards to ANH. In many instances the forgoing of ANH in decisionally incapable patients requires clearly expressed wishes in an advance directive. Trend goes against decades of legal and ethical opinion regarding the authority of a surrogate, even without an advance directive, to make decisions about ANH.
What is the defition of agent/proxy/representative or surrogate?
A person appointed to make healthcare decisions for a decisionally incapable patient.
What does abandonment refer to legally?
Abandonment is an unintentional tort, refers to the termination of the professional relationship without reasonable notice in situations when continued attention is required. Refusal to treat, insufficient or delayed treatment, withdrawal without adequate notice and premature discharge are potential triggers for allegations of abandonment.
What is the definition of preventative ethics?
Activities performed by an individual or group on behalf of a healthcare organization to identify, prioritize, and address systemic ethics issues, rather than approaching ethics on a case-by-case basis. Proposes that ethical conflict is largely preventable if common triggers are identified and proactively managed by interventions aimed at the organization, unit and individual levels.
What is beneficence?
Implies that the healthcare professional's primary goal is to seek the good of the patient. A nutrition support professional demonstrates beneficence by following evidence based guidelines for ANH when a patient is undergoing medical treatment and would become malnourished without nutrition support.
What is the doctrine of informed consent?
Legal and ethical doctrine of informed consent expresses the high valence of autonomy and respect for persons in Western bioethics. Not the mere signing of a form, outcome of a shared decision making process between patient and/or surrogate and the healthcare professionals caring for the patient.
What is the definition of health literacy?
The degree to which an individual can obtain, process and understand health information needed to make informed health decisions. Communication that does not reflect a patient's level of health literacy may undermine the individual's autonomy.
What is the definition of beneficence?
The fundamental obligation of a healthcare professional to seek the good of the patient above all other priorities.
What is the definition of autonomy?
The individual's right to self-determination in the healthcare decision making. The predominant value in American bioethics and law.
What are the 4 core ethical principles relevant to nutrition support therapy?
1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Justice
What 5 steps should be taken prior to a family meeting in a pre-meeting with healthcare clinicians only?
1. Clarify conference goals in advance, agree on medical facts and a facilitator 2. determine who to invite 3. arrange for teleconferencing or other technology to increase participation 4. choose a private meeting space (comfortable room with circular seating) 5. plan a strategy for disclosing information
What are the 2 major branches of the law?
1. Criminal 2. Civil
What are the 5 key ethico-legal concepts?
1. Informed consent and refusal 2. Decisional capacity 3. Surrogates 4. Standards of surrogate decision making 5. Withholding and withdrawing treatment
What are the 3 components of authentic informed consent?
1. Patient or surrogate is provided adequate information regarding the purposed treatment or procedure in understandable language. At a minimum includes the diagnosis for which the treatment is clinically indicated, prognosis (short and long term) with or without the proposed interventions, benefits, burdens and risks of the procedure, alternative to the proposed intervention including no treatment 2. Patient or surrogate has intact decision-making capacity 3. Patient possesses voluntarism, the ability to make a choice free of excessive internal or external coercion.
What are 7 questions to ask before placing a long-term enteral access device?
1. Presumed oral intake will provide insufficient nutrition and/or is unsafe due to possible aspiration for a period greater than 4 weeks on NGT feeding? 2. Was a video swallow study completed? 3. Is use of G-tube consistent with patient preferences, as supported by patient's QOL goals? 4. How have patient's preferences, goals and values been obtained? 5. Are patient's preferences, goals and values formally documented in medical record or surrogate committee? 6. Is patient's medical condition expected to remain stable to discharge? 7. Is patient expected to survive for at least 30 days post G-tube placement?
What are the 4 most common ethical theories used in contemporary bioethics?
1. Principlism 2. Deontology 3. Utilitarianism 4. Virtue etics
What 6 charges are included in intentional tort?
1. allegations of assault (attempt or threat to touch another without justification) 2. invasion of privacy 3. defamation 4. misinterpretation 5. fraud 6. false imprisonment
What are the 4 conclusions of the Deciding to Forego Life-Sustaining Treatment document?
1. competent patients' voluntary and informed choice should determine whether a life-sustaining therapy is initiated, withheld or withdrawn 2. patient's best interests are served by healthcare professionals who maintain a presumption in favor of sustaining life while also recognizing that patients with decision-making capacity are entitled to choose to forgo any treatments including those that sustain life. 3. whether individualized treatment is warranted depends on the balance of its usefulness or benefits for a particular patient and consideration of the burdens and risks that the treatment would impose 4. appropriate surrogate, often a family member, can make decisions for patients who have insufficient capacity to make their own decisions.
Assault and battery charges against healthcare professionals can be precipitated by the absence of appropriate informed consent when any of the following 3 occur?
1. consent is not for the specific procedure performed 2. consent is not obtained for the individual(s) who perform the procedure 3. consent is obtained from a patient with decisional incapacity
What are the 15 components to the main family meeting?
1. elicit surrogates' perceptions first 2. use active listening skills, deliver information in small chunks, free of medical jargon 3. respond to questions, check for understanding of key facts using the teach-back method 4. assess how much the patient or family wants to know 5. address emotion and respond empathetically 6. assess the patient's or family's ability to discuss bad news 7. detect whether the patient or family is angry from verbal and nonverbal cues 8. support religious/spiritual needs and concerns 9. discuss the clinical prognosis and its degree of certainty 10. evaluate surrogate preferences for decision-making responsibility 11. elicit the patient's treatment preferences and health-related values 12. communicate evidence-based information on benefits versus risks and burdens for nutrition support therapies 13. differentiate emotions about food from feelings about nutrition support as a medical therapy 14. affirm non-abandonment, support the patient's and family's decisions 15. reinforce and clarify information. Emphasize that while treatments may be modified or withdrawn compassionate care will always be provided.
What are the 3 components of the healthcare meeting after a family meeting?
1. evaluate the ongoing process from each clinicians perspective 2. determine whether changes are needed for future interactions with the patient and family 3. document in the chart who was present at the family meeting, decisions made and the follow-up plan
What are 4 steps to the family meeting introduction?
1. seat participants (intersperse healthcare providers among family members) 2. introduce all participants, discuss goals for the meeting and assign a recorder. 3. ask the family members to describe the patient prior to the illness/hospitalization as well as the patient's values 4. initiate discussion of the family's concerns, questions and understanding of current medical status
What is the hierarchy or priority for surrogacy?
1. spouse - significant others, including same-sex partners, who are in long-standing relationships are considered the legal surrogate in some states but not others. 2. adult children 3. siblings 4. other relatives 5. in some states friends
What are the 3 levels of credibility established by the 1985 Conroy case for the exercise of substituted judgement for incompetent patients?
1. subjective test - provides clear and unequivocal evidence of the patient's wishes as expressed in an advance directive or oral instructions to a healthcare professional, family or friend. It is the most trustworthy test. 2. limited-objective test - used when a subjective test is unavailable. Based on other evidence of the patient's best interests, such as trustworthy testimony that he or she would have refused treatment, had informally or casually expressed preferences in reaction to news reports or condition of another person 3. pure objective test - appropriate when there is no trustworthy evidence of the patient's wishes, but it is the least credible form of substituted judgment. When the patient's wishes are not ascertainable, then the surrogate optimally would make decisions in accordance with the best interest standard.
What are the 5 components of the summation of a family meeting?
1. summarize consensus, disagreements, decisions and resulting plan 2. explain what is going to happen next 3. identify a family member and a spokesperson for the transdisciplinary team who will partner for ongoing communication; exchange contact information 4. schedule follow-up meetings as needed 5. whenever possible, have the family representative sign the written plan
What was the importance of the Quinlan case?
1976 Karen Ann Quinlan 21 year old with brain injury in a PVS rendering her ventilator dependent. New Jersey Supreme Court ruled that the ventilator, a life-sustaining measure, could be removed if a prognosis existed of "no reasonable possibility of a patient returning to a cognitive, sapient state" and a hospital ethics committee could confirm such a conclusion. Quinlan case served as a stimulus for the establishment of hospital ethics committees and enactment of states' living will legislation.
What is the importance of the Cruzan case?
1983 25 year old Nancy Cruzan had an anoxic brain injury and a feeding tube was placed. Spent several years in a PVS, her parents requested permission from the courts to remove her feeding tube. Missouri Supreme Court determined that the tube could lawfully be removed only if there was "clear and convincing evidence" that such removal was in accordance with Cruzan's wishes. Without the documentation in an advance directive, the court concluded that the relatively stringent evidential standard it had set was not met by the family's testimony that Cruzan would prefer to not receive ANH. Court required such evidence to override the state's compelling interest in preserving the life of a patient who lacked decisional capacity to make her own choices. Cruzan family appealed the decision to the US Supreme Court, who upheld the right of states to set their own evidential standards for withdrawal of feeding tubes. Within a year additional testimony from friends of Cruzan was presented in Missouri court, ruled that this evidence met the Missouri criteria for clear and convincing evidence and the feeding tube was legally removed in 1990, with Cruzan dying shortly after. Notable outcomes of the US Supreme Court decision include affirmation of the authority of individual states to establish their own standards of evidence for withdrawal of ANH, establishment of ANH as life-sustaining medical treatment comparable to ventilators and hemodialysis, greater use of healthcare proxies or durable powers of attorney for healthcare decisions and the enactment of the PDSA mandating advance directives.
What is the definition of ethical decision making?
A decision-making approach in which every stakeholder in the decision participates and focuses on the best interests of the patient.
What is the definition of living will?
A document in which the patient states his or her wishes about life-sustaining medical treatment.
What is the definition of durable power of attorney for healthcare?
A document that appoints someone else to make all medical treatment decisions for the patient if he or she cannot make them. Instructions for decision making can also be included.
What is the definition of transdisciplinary care?
A holistic, collaborative approach that minimizes traditional boundaries between healthcare disciplines as clinicians across disciplines continually collaborate to provide patient-centered care. The team collectively determines what functions are to be performed and who is the most appropriate individual available to do them at a particular time and in a given environment. When providing transdisciplinary care, each individual acts within limits of his/her state or federal certificate or license.
What is the definition of shared decision making?
A patient centered approach to healthcare decision making in which clinicians relinquish their traditional authoritative role and train to become more effective coaches or partners to patients, who are educated about the essential role they play in decision making and given effective tools to help them understand their options and the consequences of their decisions. Patients also receive the emotional support they need to express their values and preferences and ask questions without censure from their clinicians.
What is the definition of ANH? A. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth B. Provision of specialized nutrients orally, enterally or parenterally with therapeutic intent C. Nutrition provided through the GIT via a tube, catheter or stoma that delivers nutrients distal to the oral cavity D. Administration of nutrients and fluid intravenously to maintain the patient's nutrition status during acute illness
A. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth ANH involves technology-assisted administration of nutrients when a patient is unable to swallow or unable to absorb nutrients through the GIT. Considered a medical intervention.
Which of the following core ethical principles is the predominant value in American bioethics? A. Respect for autonomy: The patient has a right to self-determination in healthcare decision making B. Beneficence: The healthcare professional is fundamentally obligated to seek the good of the patient above all other priorities C. Nonmaleficence: The prime directive of medicine is to prevent, minimize and relieve needless suffering and pain D. Justice: When treating patients, healthcare providers should consider only clinically relevant factors and provide equitable care to clinically similar patients.
A. Respect for autonomy: The patient has a right to self-determination in healthcare decision making US ethico-legal framework the primary goal is to provide medical therapies based on the individual's QOL goals, as determined by the patient with decision-making capacity or an authorized surrogate. Completion of advance directives for individuals is encouraged. Beneficence is the fundamental obligation of a healthcare professional to seek the good of the patient above all other priorities, nonmaleficence addresses the aspect of "do no harm". Justice principle deals with fairness and requires that nutrition support clinicians equitably treat similar patients similarly, consider only clinically relevant information.
What are Palmisano's ABCD with regards to a credible malpractice claim?
ABCD Accept - healthcare practitioner must accept the patient, establishing a legal relationship between the 2 parties Breach - indicates a breach of duty that leads to a cause Cause Damage - breach results in a specific alleged damage
What is the purpose of the advanced directive?
Advance directives are documents that allow individuals to document their treatment preferences and identify a surrogate or proxy decision maker to act in the patients' stead when he or she loses the ability to make decisions. Use or nonuse of ANH is a component of some advance directives. Advance directive is effectuated only if and when the patient loses the capacity to make his or her own decisions.
What does the 2014 International Clinical Ethics Section of the ASPEN special report on gastrostomy tube placement in patients with advanced dementia near end of life state?
Advocates for weighing the potential benefits derived from a mode of nutrition support therapy against inherent burdens and risks within a patient-centered framework that recognizes the individual's culture, religion, ethical principles and personal values.
What is the definition of palliative care?
An approach to care for patients with serious, life-threatening, or terminal illness that aims to ease pain and discomfort, alleviate or control symptoms, improve or sustain quality of life and meet the psychosocial and spiritual needs of the patient and family. Not a curative treatment.
What is the definition of teach-back method?
Approach to patient education in which patients are asked to explain or demonstrate what they have been taught to ensure that they understand. If patients do not understand, they are retaught using a different method and then asked again to explain or demonstrate what they have been taught.
What is autonomy?
Autonomy refers to individual self-determination. US healthcare a decisionally capable patient is authorized to make decisions about his or her treatment and care. Nutrition support is a medical treatment. Autonomy means that a patient with intact decisional capacity can determine whether he or she will receive ANH, regardless of the clinician's recommendation for or against the medical therapy. If the patient is unable to make decisions about treatment, an informed surrogate represents the patient for healthcare decision. Respect for autonomy of the patient in decision making is as paramount in the legal sphere as autonomy is in the ethical arena.
Which of the following would be a reason to not place a long-term feeding tube in a patient with advanced dementia? A. A swallow evaluation was not recently completed B. During the hospitalization, the healthcare team did not have a meeting where the family could ask questions about the rationale for the tube placement C. The patient's expected survival post feeding tube placement is less than 30 days D. The patient does not have an advance directive indicating a designated decision maker and specific healthcare wishes
C. The patient's expected survival post feeding tube placement is less than 30 days A patient's expected survival time affects the evaluation of the benefits versus burden and risks of the procedure. swallow evaluation, family meeting and the presence of an advance directive are not limiting factors for placement of a long-term feeding tube.
What is the definition of patient-centered care?
Care that is respectful of and responsive to individual patient preferences, needs and values. Ensures that the patient's values guide all clinical decisions and patients or their surrogates are actively engaged when healthcare decisions must be made. Recognizes the health literacy level of the patient and provides healthcare information that is understandable at that level.
What section of the law dominates the legal concerns for the healthcare professional?
Civil law applies to most cases involving healthcare professionals. Contract and tort (harm) are the most notable components of civil law. Contract law may be occasionally implicated in cases of alleged abandonment, tort law dominates the legal concerns for the healthcare professional. Tort law includes intentional and unintentional harm as well as strict liability. Latter is often associated with product liability, does not usually involve healthcare professionals.
Which of the following statements is true about the decision to withhold or withdraw ANH? A. There is no ethical distinction between withholding and withdrawing treatment B. Decision to withhold ANH tend to be more psychologically and emotionally charged for families than decisions to withdraw ANH C. There is a legal distinction between withholding and withdrawing any treatment D. The term forgoing refers to both withholding and withdrawing ANH
D. The term forgoing refers to both withholding and withdrawing ANH Forgoing refers to both withholding and withdrawing ANH. There is no ethical or legal distinction between withholding and withdrawing treatment. Decisions to withdraw ANH may be more psychologically and emotionally charged for clinicians, patients and families than decisions to withhold intervention.
Can patients in vegetative state or coma regain consciousness?
Early stages of vegetative state or coma, patients have the potential for regaining some or all consciousness and awareness. Clinicians are cautioned against the premature forgoing of ANH in these patients based solely on their neurologic status. Importance of accurate diagnosis and reassessment of the patient's neurologic status throughout this period of potential recovery cannot be overemphasized. Decisions to forgo PEG tubes in the early phase of the vegetative state may be premature, particularly if the diagnosis of PVS is not confirmed. A time-limited trial of EN may be warranted, along with frank discussions with the surrogate decision maker, other family members and significant others regarding specific goals and expectations.
What is the central ethical question to ask about the use of ANH at the end of life?
Ethical issue is whether omission of nutrition and hydration causes suffering
What is deontology?
Ethics of duty, assumes the existence of absolute duties or judgments that are nearly unconditional in their application to particular circumstances. Immanuel Kant is one of the most significant figures. For a decision to be ethical under the rubric of deontology, the decision would be universal, as expressed in Kant's famous categorical imperative as a philosophical formulation of the golden rule. Rightness or wrongness of decisions from the deontological perspective depends on the intentions of the agent, not on the consequences of the act. Deontological reasoning is the basis of the sanctity-of-life claims that ANH must be provided to all human beings including those who are potentially in PVS.
Do patients in PVS suffer?
Evidence of the absence of suffering in patients in a PVS has been provided through sophisticated functional neuroimaging techniques such as position emission tomography scans. Scans have established the disconnect between the thalamic and cortical areas necessary to experience pain in patients in a PVS compared to conscious patients. Neuroimaging has also demonstrated a return to normal functional imagery when the clinical picture demonstrates return of consciousness.
What is the definition of justice?
Fairness. In healthcare justice involves the equitable treatment of clinically similar patients with a sole focus on clinically relevant factors.
What is the definition of advance directive?
General term for any document that gives instructions about a patient's healthcare and/or appoints someone to make medical treatment decisions for the patient if he or she cannot make them. Living wills and durable powers of attorney for healthcare are types of healthcare advance directives.
Are PEG tubes beneficial in end-stage dementia?
Given the evidence that PEG tubes may cause more harm than good in patients with end-stage dementia. PEG tube use in advanced dementia does not reduce aspiration or prevent the pneumonia to which patients with dementia so often succumb; aspiration from oral and gastric secretions continues unabated. PEG tube placement requires concomitant use of physical or chemical restraints exacerbating discomfort, increasing the risk of pressure sores and further compromising patient comfort and human dignity. Short-term survival may be reduced after placement of the feeding tube, especially in hospitalized patients who often have acute delirium superimposed on chronic dementia.
What is the National Healthcare Decisions Day (NHDD)?
Initiative to encourage advance care planning, completion of advance directives.
What is justice?
Justice deals with fairness. Nutrition support clinicians to treat all patients with similar clinical status equitably without regard to nonclinical factors, such as the patient's ability to pay for treatment. Medical ethics has traditionally focused on treatment decisions and advocacy for the individual patient. Economic pressures related to the cost of healthcare, the advent of managed care systems and the number of uninsured patients have underscored issues of social and distributive justice in public health and population health debates. Nutrition support professionals are obligated to responsibly and wisely utilize scarce resources, financial cost of treatment may be a consideration in a patient's care plan. Most ethicists would caution providers against employing bedside rationing when deciding on the appropriateness of ANH. Treatment decisions ideally would be based on the clinical standard of care, evidence-based medicine, patient and family preferences and institutional policy.
What is malpractice legally?
Malpractice (negligence) unintentional tort.
What is MCS?
Minimally conscious state. A subgroup of patients with severe alterations in consciousness who do not meet diagnostic criteria for coma or the vegetative state.
Is there an ethical difference between withholding and withdrawing ANH?
No ethical distinction between withholding and withdrawing life-sustaining therapies including ANH. Decisions to actively withdraw ANH can be more psychologically and emotionally charged for practitioners, patients and families than decision to passively withhold intervention. Potential benefits of a limited trial of ANH ought not be eschewed in an effort to avoid the difficult emotional interactions of withdrawing nutrition support if those benefits are not realized.
What is the definition of morality?
Often used interchangeably with ethics to refer to standards of right and wrong behavior. Usually refers to conduct that conforms to widely accepted customs, values or beliefs of a group of people. Sources of moral guidance include parenteral and family values, cultural traditions and religious beliefs. A person's moral values create a disposition to make the right choices; however, a clinician cannot rely on personal morals as the only guidance in clinical ethics.
What is principlism?
One of the most widely employed modes of ethical analysis in contemporary bioethics. Based ethical decisions on general rules and principles that express broad moral considerations applied to particular situations. Dilemmas are resolved through the weighing , balancing and specification of the basic principles of autonomy, beneficence, nonmaleficence and justice.
How is competence determined?
Only a court can determine competence, such determinations are often materially based on healthcare providers' judgments regarding the patient's decisional capacity - that is, the ability of the individual to comprehend and communicate health information, reason regarding aspects of treatment, appreciate the consequences of medical decisions for his or her life and values, and freely choose a course of action.
What is ethics?
Originates from the Greek ethos, refers to establishing acceptable behavior. Ethics provide the basic structure for putting morals or rules of conduct into practice. In professional context, ethics involve the rules and standards that govern the actions of members of the profession.
What is the definition of Physician Orders for Life Sustaining Treatment POLST?
POLST forms translate an individuals treatment preferences into medical orders, including for cardiopulmonary resuscitation, scope of treatment, artificial nutrition by tube and in some states antibiotic use. An approach to end-of-life planning based on conversations between patients, loved ones and medical providers. Designed to ensure that seriously ill patients can choose the treatments they want and that their wishes ware honored by medical providers.
what is the predominant value in the ethical and legal framework for US healthcare?
Patient autonomy. Clinician may sometimes find it challenging to uphold this value if the patient or surrogate seeks treatment that the clinical regards as harmful. Clinicians should seek guidance from an ethics committee and/or legal counsel.
What is PVS?
Persistent vegetative state. PVS is characterized as a condition of wakefulness without awareness, eyes are open but there is no awareness of self, others or the surrounding environment. In contrast coma is "eyes-closed" unconsciousness. Patients whose brain injury was not caused by trauma are deemed to be in a PVS if they continue to exhibit the same conditions of unconsciousness and unawareness beyond 3 months. Brain injury was caused by trauma, PVS is defined as at least 1 year of eyes open unconsciousness.
What is the analgesic theory?
Proposes that starvation boosts the production of ketones, thereby having an anesthetic effect. Dehydration may increase the production of endogenous opioids.
What is nonmaleficence?
Refers to the clinician's goal to do no harm. ANH may potentially cause complications that harm the patient. In some cases ANH may not achieve the intended benefits of comfort or prolonged survival. Withholding or withdrawing ANH is ethically appropriate based on the ethical principles of beneficence and nonmaleficence when the burdens and risks of ANH outweigh its benefits, provided there is appropriate consent from a patient with decisional capacity.
What is abandonment?
Refers to the unilateral severance of the professional relationship without reasonable notice, under the circumstances when continued attention is required. If the clinician does not provide orderly transfer of care they can be accused of abandonment.
What is the role of a surrogate?
Surrogate is obligated to render decisions that are in accordance with legal criteria. When a patient's values and wishes are known, decisions are to be made in accordance with the standard called substituted judgment.
What is the definition of ethical dilemma?
Tension or conflict between and among ethical principles or obligations. In an ethical dilemma an act can be seen as both morally justified and unjustified.
what is the definition of nonmaleficence?
The "do no harm" (primum non nocere) principle. In medicine, the prime directive to prevent, minimize and relieve needless suffering and pain.
What is Barrocas "troubling trichotomy"?
The milieu of technology (what "can" be done), ethics (what "should" be done) and law (what "must" be done). In the context of nutrition care the troubling tichotomy often involves ANH.
What is the definition of Bioethics or medical ethics?
The set of moral values that governs the professional behavior of healthcare providers.
What is the definition of clinical ethics?
The type of ethics that guides daily clinical practice by healthcare providers in their care for patients. Clinical ethics are firmly grounded in medical science, law and policy and demonstrate respect for the autonomy of each patient.
What is the definition of team approach?
The view that ethics is a group effort involving all stakeholders and not hte action of a single agent.
What is the conscience clause?
There may be times in which a nutrition support professional or other practitioner feels he or she cannot participate in the care of a patient due to moral or religious objections. Federal, state and institutional policies have conscience clause provisions to define the clinician's options in such situations.
What is the Patient Self-Determination Act (PSDA)?
US Congress 1990, effective 1991 requires hospitals, SNF, home health agencies, hospice programs and health maintenance organizations to do the following: 1. Inform patients of their rights under state law to make decisions concerning their medical care 2. Periodically inquire as to whether a patient executed an advance directive and document the patient's wishes regarding his or her medical care 3. Not discriminate against persons who have executed an advance directive 4. Ensure that legally valid advance directives and documented medical care wishes are implemented to the extent permitted by state law 5. Provide educational programs for staff, patients, and the community on ethical issues concerning patient self-determination and advance directives.
Wha tis the definition of Patient Self-Determination Act?
US law that ensures that a patient's right to self-determination in healthcare decisions is communicated and protected.
What is terminal dehydration?
Used to indicate a process in which the dying patient's condition naturally results in decrease in fluid intake. Providing hydration in this situation has the potential to increase fluid accumulation and may lead to uncomfortable symptoms (edema, ascites, nausea, vomiting and pulmonary congestion). Patients experiencing terminal dehydration may have dysphagia, nausea and fatigue and gradually withdraw from ADLs. May report thirst, data show no correlation between thirst and hydration, and the use of artificial hydration to relieve thirst may be futile. Sensation of dry mouth can be easily treated, Sips of water or beverages, ice chips, hard candy and spraying normal saline into the mouth as well as meticulous mouth care are all reported to be of benefit.
What ethical principle is violated if a clinician imposes personal values on the patient or family?
Violates the fundamental ethical principle of respect for persons
Are ethics committees required?
Yes, Joint Commission requires that every US hospital must have an ethics committee. Referral to the committee is open to anyone in the institution, including patients and families.
How is autonomy expressed in the case of decisionally incapable patients?
case of decisionally incapable individual, the patient's wishes as expressed in an advance directive and/or by a surrogate decision maker ideally would be respected in a similar fasion. Many state statues provide immunity from legal recourse to providers who follow the stipulations of the advance directive.
What is utilitarianism?
ethical theory that begins from the opposite premise of deontology. Utilitarians posit that it is the consequences, not the intentions of decisions that determine their ethical valence. Most often associated with John Stuart Mill. Frequently informs debates over healthcare economics, resource allocation and policy. Many utilitarians content that actions and obligations that maximize the good or benefit for the largest number of people are the most ethical.
What is ethical theory?
general philosophical source of many ethical standards, guide for how those standards are applied through ethical reasoning in specific situations. Ethical theories are schools of thinking that form our moral decisions.
What is medical ethics or bioethics?
refers to a set of moral values that govern the behavior of healthcare professionals. Some bioethical principles have evolved with changes in medical technology, many remain immutable and offer basic guidelines for patient care.
What is decisional capacity?
task-specific, not global in nature. A person may be able to make medical decisions but not mange finances or the reverse. Decisional capacity can fluctuate, particularly when an impairment is secondary to physical or mental illness. A patient may thus be more or less capable of making specific decisions at different times and under varying conditions.
What is virtue ethics?
theory that finds the locus of right and wrong in the character of the individual. Deriving from Aristotle, among the oldest theories of professional ethics, one that many practitioners find the most natural. Suggests that a clinician whose conduct displays habits of compassion, honesty, integrity, fidelity and courage will develop a virtuous character from which will spring good clinical decisions.
