Transcript The Clinician’s Ethics Workup

The Clinician’s Ethics
Workup
David A. Fleming, M.D.
MU Center for Health Ethics
573-882-2783
[email protected]
Summary
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Definitions
Importance
Barriers
Doing the workup
Definitions
• Morality: individual or social beliefs about
what is right and wrong
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Cultural
Religious
Family
Personal
• Ethics: critical, systematic study of moral
belief
– Arguments for a universal understanding of what ought to
be done
– Language of obligations, duties, rights
– Character, virtue, values
Moral Statement : “Abortion is immoral
because I believe it’s wrong to kill another
human being.”
Ethical Argument: “Abortion is immoral
because every human being deserves the
same level of respect and no person should be
unjustly sacrificed for the welfare of another.”
Ethics: define how we should act in
consideration of others, not how we
feel or what we believe
[“Theory of action.”]
• Metaethics: ultimate source of moral belief
based on theory, logic, meanings (“language
games”)—reason, rationality, faith, self
• Normative ethics  principles, rules and
behavioral guides that morally justify certain
actions—actions, consequences, character
Importance
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Medical technological advancement
Expectations (the rise of autonomy)
Regulation and accountability
Professional vs. business interests (market)
Medical – legal issues
Changing demographic (aging, cultural
shifts)
Organizations and systems
Changing relationships
Access
Decentralization of the patient
Barriers to Moral Agreement
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Different sets of beliefs
Lack of understanding (health literacy)
Fluxuating role of the physicians
Loss of the relationship
Complexity of health care organizations
Economic influences
Racial and gender bias
Defining futility
Inflated expectations
Fear and loss of trust
Before it was the
“doctor-patient relationship”
Patient
Office
Hospital
Doctor
Now it’s a complex
“matrix of accountability”
Government
Patient
Marketing
Visiting Nurse
Nursing Home
SW, Chaplain
Office
Phone
Telehealth
email
eHealth
Pharmacist
Case Manager
Lawyers
Hospital
Staff—UR, QI, RM
Provider
Administration Insurers Regulators
Today’s healthcare environment is
not conducive to trust…
• Technologically driven
• Decisions to withhold or withdraw Tx
• Patients and families often demand: “do
everything possible”
• Access to information
• Transparency and error reporting
• Economic and time constraints
• “Doc for the day”
• Expect restitution if things “go wrong”
Ethics Workup
What is the right and good decision for this
patient?
Why?
Who (or what) decides?
Resolving conflict
The Ethics Workup (EOL)
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Clinically relevant facts?
What options exist?
What should be done, and why?
What is the ethical dilemma (conflict)?
Who are the stakeholders?
How will they be impacted?
Who ultimately decides?
What action(s) should be taken?
Can it be implemented?
If not—why, what other options exist?
What are the clinical facts?
• DX: treatable, preventable, risks, how many systems
• Prognosis?
– Short and long term for the underlying condition
– Short and long term for each proposed
intervention
• Patient preferences?
• Age?
• Financial concerns have no place at the bedside in
considering individual patient welfare, unless those
of the patient.
• What choices are being considered?
• Psychosocial components?
What options exist
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WH/WD vs. aggressive treatment (DNR)
Palliative care and hospice
Limiting freedom and privileges
Risky or minimally beneficial Tx
Treating without expressed permission
Changing providers or institutions
What are the ethical concerns as
perceived by the key stakeholders?
• Futility?
– DNR/DNI, WH/WD
• Informed decision-making?
– Capacity?
– Surrogate or HCD?
• Undue risk or suffering (burden > benefit)
– By whose definition of “quality of life”?
– Double effect?
• Fair and dignified treatment?
Conflict?
Who are the stakeholders and how are
they impacted?
Why is there conflict?
What is the nature of the conflict?
What are the objections to the choices
being considered?
Can it be resolved?
Who decides?
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Patient
Surrogate (family)
HCD (written or verbal)
Providers (team)
Courts
other
Clinical option(s) in the best
interest of this patient?
• Ethical reasons for and against
• Is conflict resolvable?
• Is compromise possible without loss of
personal or professional integrity?
• If not…
– Physician may be discharged
– Physician may withdraw as soon as
another is employed
Can the decision be
implemented?
If not, why?
– Physically impossible
– Irresolvable conflict among decisionmakers
– Moral boundaries
Ultimately…
• If no other physician is available or none
agrees to take the case, the physician of
record is not ethically obligated to
compromise his/her professional or moral
integrity.
• The physician is not obligated to help the
patient or family find another physician or
facility to do what he/she feels is immoral
(moral complicity).
Case
37 yo WF with metastatic breast cancer (CNS,
liver) has decided to refuse further
chemotherapy after her second recurrence.
You feel she has full decision making
capacity. On evening rounds she informs
you and the nursing staff that she does not
want to be treated aggressively, intubated or
to undergo cardiopulmonary resuscitation
should she deteriorate. You concur based on
her prognosis, recording this conversation in
the medical record. Several hours later she
lapses into coma and is responsive only to
deep tactile stimuli.
The next day, the patient begins to show signs
of impending respiratory failure. Her husband
arrives and notices her declining condition and
asks what you plan to do. To your surprise,
when you explain and relate the content of
your conversation with his wife he states that
he believes that she is too ill and disabled to
be capable of deciding about her treatment and
would “not want to leave her two daughters
without a fight”. He demands that she be
treated aggressively, and that she undergo
CPR efforts and be intubated and sent to the
intensive care unit, should she arrest.
The appropriate course of
action would be to…
Clinical Facts
• Prognosis:
– end stage chronic disease
– ? reversibility of her acute process
• Patient expressed preferences
– Verbal HCD
– Clear and convincing?
• Decision-making capacity
• Degree of suffering now and future
• She has a family…
Options
• Treat and resuscitate
– “LIVE TO FIGHT ANOTHER DAY”
• Palliative care and comfort pathway
• “Partial” treatment
– treat sepsis but DNR/DNI
• Transfer care
What is the ethical dilemma?
• Respecting patient autonomy vs. the
surrogate’s right to decide
– ? Impaired surrogate decision-making
• Obligations to the patient vs. the family
• Are there obligations to treat treatable
conditions? (benefit > burden)
• Are there obligations to “make sure” the
patient would to want not to be treated?
• Legal concerns and the system’s integrity
Stakeholders
• Patient
• Husband, family, friends
• Providers
– Professional integrity
• System
Who decides?
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Patient (?competency)
Husband (?valid surrogate)
You…
(courts)
What should be done?
-ethical arguments why
Can it be implemented?
If not…why?
Summary
• Conflict is often unavoidable
• Seek compromise without breaking
moral boundaries
• It’s a longitudinal process, not an event
• Effective communication is the key
• If compromise is not possible transfer
of care may be necessary
• ? Risk management