Transcript Medical Ethics Medical Decision Making

Medical Ethics
Medical Decision Making
Jeffrey J Kaufhold, MD FACP
Chair, Bioethics Advisory
Committee, Grandview Hospital
Factors to Consider
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Medical Indicators
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Diagnosis
Prognosis
Treatment
Quality of Life
Patient Preference
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Advance Directive
Prior Statements
Prior Choices pt has
made.
Context
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Social
Cultural
Legal
Financial
Medical Decision Making
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Heirarchy for decision making
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1. Competent Patient is always first
2. Substituted judgment
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Family in rank order:
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3. Best Interest of the Patient
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Spouse
Parents
Children
Others
Paternalistic approach by caregivers
4. Ethics Committee.
July 17, 2004 Robert Orr
Summary
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History of Conflict in medicine
Justice in Medicine
Social responsibilities of Physicians
Medical Futility
Justice in Clinical Medicine
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Edmund Pellegrino, MD
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Professor Emeritus of Medicine and Medical
Ethics, Georgetown University Medical Center
Lecture from conference:
Conflict and Conscience in Healthcare
 July 16, 2004
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History of Conflict in Medicine
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Pre-Hippocrates: Self Interest of Physician
Hippocrates dared to see pt as primary
focus
This was taken up by all of the
monotheistic religions, and preserved by
the Muslims during the middle ages
Adam Smith: Enlightened self interest
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Bad outcome is bad advertising
Karl Marx: All serve society
History of Conflict in Medicine
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Managed Care
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Limited Resources (Marx influence)
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Are they really limited?
Physician is steward of those resources
Inevitable ranking of the Worth of Patients
Healthy pt is good for society
 Chronic illness is bad for society
 Patient may not be the primary focus
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Justice in Medicine
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Assumptions:
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Physician has competence, acts professionally,
and in the interest of the patient.
Implicit covenent with society
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We are allowed to do Illegal acts, in order to learn
the art.
Justice in Medicine
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Commutative Justice
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Distributive Justice
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Allocation of resources
Charitable Justice
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Contract with patient
What we ought to do even if pt is abusing themselves
General Justice
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What do we owe the common good?
What does the patient owe the common good?
Justice in Medicine
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General Justice
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Patient has obligation to follow the
recommendations of the physician
Physician must take responsibility to define
what the patient needs
Not required to do what pt wants
 What good can we do for the patient.
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Epicaya
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Preservation of equity
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Look at the big picture/everyone makes mistakes
Social Responsibility of Physicians
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Best Medicine possible
Stay up to date
Participate in public debate
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We have the knowledge needed to inform the
debate
Advocacy for those who need help
Legislators have the responsibility to make
decisions about distribution of resources.
Medical Futility
Daniel P Sulmasy, OFM, MD, PhD
Director, The Bioethics Institute
New York Medical Center
July 17, 2004
Case
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76 y.o. female with Multiple Myeloma
admitted with Sepsis.
Heavily pretreated, no further chemo
available
On vent, Pressors
Daughter wants everything done.
The Basis for Medical Futility
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History of Futility
Religious Principles
Moral Principles
Probability
Dealing with the case.
Futility, a History
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Smith Papyrus, 1700 B.C.
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Entreaty to not intervene if spinal cord is
transected
This Egyptian papyrus, found in 1900’s,
references a much older text.
Futility, a History
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Smith Papyrus, 1700 B.C.
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Entreaty to not intervene if spinal cord is
transected
Hippocrates, 460 – 377 B.C.
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“On The Art” – the physician should refuse to
treat in cases where medicine is powerless
Social norms regarding cancer
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1950’s
1960’s
1970’s
1990’s
–
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–
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call it something else.
Inform pt of diagnosis
Informed consent
Informed Demand
Religious Principles
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Intrinsic Dignity
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Alien Dignity
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Made in the image of God
Relationships define our being.
Also a fact that we are Finite
Religious Principles
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Life is a gift, and we are its stewards
Limits to stewardship
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Illness is a burden
Costs and burden to family/caregivers
Futile care need not be given.
Moral Principles
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No moral obligation to provide futile Tx.
What is Futile Treatment?
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Non-beneficial
Inappropriate treatment at the end of life
What is the real goal?
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Free of pain and suffering
Moral Principles
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What is Futile Treatment?
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Subjective Futility
Patient won’t be able to appreciate benefit
 This is not sufficient moral argument to withhold
therapy
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Objective Futility (biomedical use)
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No objective benefit to any observer
Moral Principles
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Medical Realism
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There are facts
Trained people can make judgements
But we are fallible
We have to relate the data to the patient
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This is the tricky part of the art.
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Requires use of probability.
Probability
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Is this patient going to die?
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Even with treatment?
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Probably.
Probably.
Can you be more specific?
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Probably.
Probability
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Prognosis is the probability that a patient
will respond to tx, plus the probability that
the disease will kill them.
Probability that we use in individual cases
comes from objective data about the
particulars of the case, plus experience,
plus common sense.
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This process is fallible, but we do the best we
can.
Probability
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Three factors:
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Frequency:
Prediction:
Strength of belief
Lets apply to the case:
Probability
Myeloma with sepsis
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Frequency: (80% of myeloma pts do not
wean from vent)
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Based on studies
Prediction: (1% likelihood of survival for
this pt)
Based on Karnovsky score in Onc literature
 Based on APACHE score in ICU literature
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Strength of belief
P value
 “Reasonable degree of medical certitude”
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“Ultimately, Ethics is
about What to Do”
Aristotle, 384 – 322 B.C.
Morality of Futility
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Judgment enters Morality when decision is
made about taking action.
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Actions:
Wean from vent?
 Wean from pressors?
 Stop Antibiotics?
 Stop tube feedings/ IV fluids?
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Morality of Futility
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Judgment enters Morality when decision is
made about taking action.
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Approaches:
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Pragmatic – does this help the patient?
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Remember, removing pt from life support may kill them,
but might it also stop their suffering?
Moral (prudential) – is this the right thing to do?
Back to the Case
Myeloma with sepsis
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Frequency:
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Prediction:
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“Reasonable degree of medical certitude”
Pragmatic approach
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(1% likelihood of survival for this pt)
Strength of belief
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(80% of myeloma pts do not wean from vent)
CPR will not help pt get better
Prudential approach
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Morally wrong to provide inappropriate treatment.
Back to the Case
Myeloma with sepsis
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Pragmatic approach
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Prudential approach
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Morally wrong to provide inappropriate treatment.
Recommendation:
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CPR will not help pt get better
Make the pt DNR – CC arrest
Consider withdrawal of life support
How do we proceed with the family?
Back to the Case
Myeloma with sepsis
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The family in town wants to keep Mom
comfortable, and see she is suffering on
life support.
However, the out of town daughter is “in
charge” and insists everything be done.
Cultural barriers arise.
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Tilden. Nurs Res: 2001, 50;105-115.
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Its Stressful to be the surrogate
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Guilt, Ambivalence, Depression, Anger.
How to proceed Clinically
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Establish relationship with family
Review case (how did she get here)
Describe level of illness
Lay out options
Establish goals
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keep her alive until son gets here
Maintain comfort no matter what.
Establish Limits
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will not resuscitate her if heart stops.
Praying for a Miracle
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Affirm that this is OK
Bear witness in faith, resurrection
God is present and answering all our
prayers, even if a miracle doesn’t come
Hippocratic Oath
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Now being admitted to the profession of
medicine, I solemnly pledge to consecrate
my life to the service of humanity.
I will give respect and gratitude to my
deserving teachers.
I will practice medicine with conscience
and dignity.
The health and life of my patients will be
my first consideration.
Part 1
Hippocratic Oath
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I will hold in confidence all that my patient
confides in me.
I will maintain the honor and noble traditions of
the medical profession.
My colleagues will be as my brothers and sisters.
I will not permit consideration of race, religion,
nationality politics or social standing to intervene
between my duty and my patient.
Part 2
Hippocratic Oath
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I will maintain the utmost respect for
human life.
Even under threat I will not use my
knowledge contrary to the laws of
humanity.
These promises I make freely and upon
my honor.
Part 3
Aesculpius
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Staff with single serpent
“Life is short, Art is long, experience
difficult.”
Greek: Obi OE BpAXYE, HTEXNH MA KPH,
O KAI POE OE YE.
Competency
Assessing Decision Making
Capacity
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Jeffrey J Kaufhold, MD FACP
Chair, Bioethics Advisory Committee,
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Grandview Hospital
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A Guide to assessing Decision Making
Capacity.
Roger C. Jones, MD, Timothy Holden, MD
Cleveland Clinic Journal of Medicine
Vol 71, December 2004, p 971-5.
Summary
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Physicians need an efficient way to
determine a pts decision making capacity
This capacity must be assessed for each
decision and not inferred on the basis of
pts diagnosis.
Documentation of the process used and
decisions reached is necessary.
Case 1
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Pt admitted for sepsis
Poor access for pressors and labs
Pt is confused
No family is available
Can pt consent to line placement?
Case 2
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Elderly pt with Alzheimers and a MMSE
score of 23 of 30 refuses elective Chole.
Daughter/DPAHC requests surgery.
Can the pt refuse?
How can his competency be evaluated?
Case 3
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Pt admitted with acute pneumonia
Also diagnosed with severe depression
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Many answers are “I don’t know/I don’t care”
Pt refuses treatment, stating “ I don’t care
if I live or die”
Does pt have decision making capacity?
If not how do you procede?
Consent
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Requirements:
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Autonomy
Capacity to understand and communicate
Ability to reason
Recognized set of values or goals
Agreement with the physician does not
imply that pts capacity to give consent is
intact!
Competency
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Legal designations determined by the
courts.
Decision making capacity is clinically
determined by physician at the bedside.
Adults are presumed competent unless
legally judged to be incompetent.
President’s commission for the study of
Ethical Problems in Medicine 1982.
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Avoid Routine recourse to legal system.
Clinical Approach
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Urgency of the clinical situation
determines how to procede.
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Urgent situation
Pt not able to communicate / no
spokesperson
Assume that a reasonable person would not
want to be denied life saving treatment.
“Implied Consent”
Clinical approach
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Nonemergent situation
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What are the risks and benefits?
Low risk may not require much decision
making capacity.
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I’m here to draw your blood for a hct.
High risk may require significant deliberation.
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Should a pt with lung cancer and severe CAD
undergo pneumonectomy for possible cure?
Algorithm for assessment
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Miller and Marin, Emergency Med Clinic
North Am, 2000; 18: 233-241.
Series of simple questions
Doesn’t take into account the level of risk
or benefit of a treatment.
Algorithm
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1. Do the history and physical confirm
that the pt can communicate a choice?
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Is their memory good?
Is judgement appropriate?
Can they maintain a conversation/follow your
line of questioning?
Are their answers consistent?
If yes: procede to question 2
If No: pt needs help with decision making.
Algorithm
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2. Can the pt understand the essential
elements of informed consent?
What is your present condition?
 What treatment is being recommended?
 What might happen to you if you agree to the
treatment?
 What might happen to you if you refuse the
treatment?
 What are the alternatives available?
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Test of pts understanding of the discussion.
Algorithm
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3. Can the pt assign personal values to
the risks and benefits of intervention?
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Jehovahs witness refusal to accept transfusion
reflects different set of values.
Algorithm
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4. Can the pt manipulate the information
rationally and logically?
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Can you follow how the patient got to their
decision?
Algorithm
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5. Is the patients decision making
capacity stable over time?
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Repeat the question several minutes later/
after more discussion.
Algorithm
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Benefits of this approach:
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Avoids the tendency to devalue capacity of
chronically ill pts
Reduces reliance on surrogate decision
makers when not necessary
Avoids judgement based on whether pt
agrees with Doctor.
Algorithm
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Limitations:
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Language barriers
Cultural barriers
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African Americans tendency to not look at speaker,
distrust of system leading to misinterpretation of
options provided
Some of the assessment questions are
subjective.
When surrogate must be consulted
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If the pt is incompetent as determined by
the court
If the pts decision making capacity is in
doubt
If the pt is unable to understand options
or is unable to decide.
Case 1
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Pt admitted for sepsis
Poor access for pressors and labs
Pt is confused
No family is available
Does pt have to consent to line
placement?
No, use implied consent.
Case 2
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Elderly pt with Alzheimers and a MMSE
score of 23 of 30 refuses elective Chole.
Daughter/DPAHC requests surgery.
Can the pt refuse?
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MMSE can miss cognitive deficits
How can his competency be evaluated?
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Psychiatry consult, ethics consult if needed.
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In this case, daughter served as decision maker.
Case 3
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Pt admitted with acute pneumonia
Also diagnosed with severe depression
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Many answers are “I don’t know/I don’t care”
Pt refuses treatment, stating “ I don’t care if I
live or die”
Does pt have decision making capacity?
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Physician determined that pt does not, due to
depression.
Treat depression and pneumonia.
Capacity may return once depression treated.
Summary
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Physicians must determine decision
making capacity every day.
Diagnosis does not imply impaired
capacity, nor does good MMSE imply that
pt has capacity.
Agreement or disagreement with
physicians recommendation does not
imply capacity is intact or impaired.
Summary
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Differing pt values may result in conflict
and raise questions about pts capacity.
Algorithm provides a simple method to
determine D.M. capacity
Competency is legal determination
DMC is clinical determination.