Transcript Ethical Issues

Ethical Issues: How to Begin the
Discussion with Patients and
Families
James Hallenbeck, MD
Medical Director,
Palliative Care Services
VA Palo Alto HCS
Premises
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Most people interpret and construct their lives
based on stories
Ethical crises often occur when personal storylines
have been disrupted
 Evolving patient/family stories conflict with
medical stories
Positive resolutions of ethical crises are enhanced
by the mutual construction of a new storyline
 Which requires patient/family and provider to
be “in-synch”
CASE PRESENTATION
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80 Man with respiratory failure admitted to
ICU and found to have metastatic cancer…
Ethical Dilemmas: Often More a
Problem of Communication than
Conflicting Principles
Bioethics based largely on “stories” or
model cases
 Bioethical “stories” very foreign to many
 Good communication involves sharing of
stories and gives rise to new, mutually
constructed stories, resolving the dilemma
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The Bioethical Story…
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Medical Facts – Patient “un-weanable” – likely to
die in a matter of days – weeks
ICU care perceived as “futile” relative to
significant life-prolongation
 Clinicians not required to provide futile care
Patient has capacity, no surrogate
Patients with capacity have a right to decide goals
of care, including code status
Dilemma – when is resuscitation deemed futile?
The Patient’s Story …
In the process of writing a book – wants a
year to finish
 Was unaware that he was this ill – acute
illness took him by surprise
 Trying to come to grips with prognosis – all
happening too fast
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Question:“What can we do for
you?”
Answer: “Give me TIME
Communication – specific skills
required
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General
 Active Listening
 Verbal and Non-Verbal
 Addressing emotional as well as
cognitive components of communication
 Recognition of barriers
 Language, Hearing, Speaking
Above presumes a connection between participants that may
not in fact be present
Entrainment as a Communication
Skill
Like gears must touch, but not crowd
 Spacing
 Gears must be synchronized
 Aligned temporally
 Work toward a common purpose
 Shared narrative construction
Space as an Aspect of
Communication
Culturally defined, out of general
consciousness
 Varies with roles and relationships
 Formal Space
 Friendly Space
 Intimate Space
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Time as an Aspect of
Communication
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With age time experienced more slowly
 Perception of time correlates with the
inverse of the square root of
chronological age
 Elders perceive the young to move too
quickly
 The young perceive elders to move too
slowly
Young and Old out of Synch:
Working toward a Common
Purpose
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Demonstration of respect for the person
Inquire regarding current understanding of illness
 Explanatory Model
Explaining one’s own explanatory model (and
story)
Inquire regarding goals (where is story headed)
Look for opportunities to come into synch with
these goals
The Good Acronym
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Goals
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Options
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Opinion
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Document
Goals
Identify stakeholders and their goals
 Future goals based on current understanding
 “What is your understanding of”
 “What did your doctor tell you”
 Identify ‘big picture’ goals first
 “Let’s look at the big picture, what is
most important to you?”
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Options
Identify relevant options and priorities
 Address benefits and burdens of options
 Do your homework
 Address probability of success
 Link options to identified goals
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Pearl: Too often clinicians get bogged down in
discussions over specific options without
understanding how options relate to overall goals.
Opinion
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In offering your opinion…
 Present data using neutral language:
 Crush the chest
 Massage the heart
 Press on the chest
Be clear what is data and what opinion
Incorporate goals, benefits/burdens and values into
your opinion
Listen to other’s opinions
Document
Who said what
 “Patient said he didn’t want tube feeding”
 What you did/will do with this information
 “Will cancel PEG tube insertion”
 Your assessment
 “This reasonable given …”
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SUMMARY
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Ethics work best when manifest in real
relationships between real people
Establishing such relationships requires:
 Entrainment
 Trust
 Sharing of stories
 Negotiation
 Mutual construction of a new story