Transcript What are the goals of treatment?

Chapter Three
Indications for medical
intervention
The principles of Beneficence and Nonmaleficence
 What is the patient’s medical problem?
 Is the problem acute? chronic? critical?
emergent? reversible?
 What are the goals of treatment?
 What are the probabilities of success?
 What are the plans in case of therapeutic
failure?
 In sum, how can this patient be benefited
by medical and nursing care, and how can
harm be avoided?
Definition of medical indications
Medical indications are the facts,
opinions, and interpretations about
the patient’s physical and/or
psychological condition that provide
a reasonable justification for
diagnostic and therapeutic
interventions.
The goals and benefits of medicine
Cure sometimes, support
frequently, comfort always.
The essential point of clinical ethics is to
know when cure is possible, how long
support should be continued, and when
comfort should become the primary mode
of care.
To understand the ethical issues in a case,
it is necessary to consider the clinical
situation of the patient, that is, the nature
of the disease, the treatment proposed,
and the goals of intervention.
The disease
 A disease may be acute (rapid onset and short
course) or chronic (persistent and progressive).
It can be emergent (causing immediate
disability unless treated) or nonemergent
(slowly progressive). Finally, a disease can be
curable( the primary cause is known and
treatable by definitive therapy) or incurable.
 These clinical distinctions are relevant in the
ethical analysis of any case.
The treatment
Patients’ decisions about treatment will
vary based on their goals, desires, and
values.
A medical intervention may cause serious
adverse effects.
Both patients and physicians should
consider it when agreeing on a treatment
plan.
The goals of medicine
 Promotion of health and prevention of
disease
 Maintenance or improvement quality of
life through relief of symptom, pain, and
suffering
 Cure of disease
 Prevention of untimely death
The goals of medicine
 Improvement of functional status or
maintenance of compromised status
 Education and counseling of patients
regarding their condition and prognosis
 Avoidance of harm to the patient in the
course of care
 Assisting in a peaceful death
Clinical judgment and clinical uncertainty
“What are we accomplishing?”
 “Is the expected outcome worth the
effort?”
 “Do the benefit justify the risks?”
 “A science of uncertainty and an art
of probability.”
clinical judgment.
The process by which a clinician attempts
to make consistently good decisions in the
face of uncertainty is called clinical
judgment.
clinical uncertainty
Clinical medicine was described as “A
science of uncertainty and an art of
probability.”
Although evidence-based medicine and
practice guidelines aim to reduce the
“uncertainty” and the “probability” of which
Osler spoke, some degree of uncertainty
always remains.
The shared decision making that
constitutes an appropriate
professional relationship.
Shared decision making
 Paternalistic
The doctor made a diagnosis, prescribed
treatment, and gave “orders”, providing minimal
information to the patient.
 Patient autonomy
The patient was seen as the authoritative
decision maker.
Shared decision making
a collaboration in which the physician
shares with the patient medical knowledge
and opinion, and the patient shares with
the physician values and preferences.
The best medical decision for an individual
patient will depend on how the patient
evaluates different risks and benefits.
Even when the physician’s
recommendation is based on sound
evidence, the patient should be the final
decision maker, because only patients can
assess the risks, benefits, goals, and costs
of treatment in their own lives.
Medical error
A 1999 Institute of Medicine (IOM) report
on medical error estimated that between
44,000 and 98,000 Americans die each
year as a result of medical errors, as many
as those who die of vehicular accidents,
breast cancer, or AIDS.
Medical error
Medical error was defined as the failure
of a planned action to be completed as
intended, or as the use of a wrong plan to
achieve an aim.
Some errors resulted from incompetence
or mistake judgment by competent
physicians.
Other errors were caused by system
failure that often went unrecognized and
uncorrected.
When medical error occurs as a result of
incompetence or negligence, it constitutes
a serious breach of the physician’s
professional responsibility.
Indicated and Nonindicated
Interventions
Innumerable interventions are available to
modern medicine, from advice to drugs to
surgery.
Interventions are indicated, then, when the
patient’s physical or mental condition may
be benefited by them.
Interventions may be nonindicated for a
variety of reasons.
Case
Mrs. Care, a 48-year-old married woman ;
was diagnosed with MS 15 years ago ;
is confined to a wheelchair ;
is blind in one eye ;
she has become profoundly depressed, is
uncommunicative even with close family,
and refuses to leave her bed.
The moribund patient
“Moribund” means “about to die”, that is,
the patient’s death is inevitable and will
soon take place.
The patient’s organ systems are
disintegrating rapidly and irreversibly.
Death can be expected within hours.
The terminal patient
The prognosis of any patient with a lethal
disease.
“Terminal” is defined as having 6months or
less to live.
The benefits of accurate prognostication
include informing patients and families
about the situation, allowing them to plan
their remaining time and arrange
appropriate forms of care.
Medical futility
The Oxford English Dictionary defines it as
“incapable of producing any result, failing
utterly of the desired and through intrinsic
defect.”
Many commentators prefer to use
“medically ineffective or non-beneficial
treatment” rather than “futility”.
 What level of statistical or experiential
evidence is required to support a
judgment of futility?
Who decides whether an intervention is
futile, physicians or patients?
 What process should be used to resolve
disagreements between patients (or their
surrogates) and the medical team about
whether a particular treatment is futile?
Is probabilistic futility a substantive or
procedural norm for clinical judgment?
Orders not to resuscitate (DNR)
3.3 Legal implications of forgoing
treatment
Determination of death
cardiorespiratory criterion ----irreversible
cessation of circulation and respiration
Brain Death
Brain Death
In 1968, this concept was clarified in the
Harvard Report on Brain Death.
Unreceptivity and unresponsivity to
external stimuli,
no movements or breathing,
no relaxes,
and no discernible electrical activity in the
cerebral cortex as shown by EEG.
The physician has the authority to declare
the patient dead .
Certain philosophical problems about the
adequacy of the definition of death by
brain criteria remain open to debate.
Working in groups of 3 or 4, describe
values you feel are important in directing
professional behavior
Good Behaviors
Honesty
Altruism
Excellence
Empathy
Compassion
Responsibility
Accountability
Integrity
Respect
Self-Regulation
Confidentiality
Apply Principles
Excellence
Be the best physician possible
Commitment to continued learning
throughout your career
Give all patients best care possible
Altruism
Act for the good of others
Act for the good of your community
Do NOT act for your own personal gain
Respect
Recognize the feelings and rights of
Patients
Families
Other physicians
All members of the health care team
Self-regulation
Know the limits of your knowledge and
skill
Seek help from colleagues when needed
Refer patients to a capable colleague
Confidentiality
Keep patient and other information
confidential
Be careful when, where, and with whom
you talk about patients
Get permission before sharing
confidential information with others
Integrity
Defend what is the best practice
Expect your self to meet the highest
standards
Act fairly with others
Acknowledge the work of others
Relationships With Patients
Respect beliefs and cultural differences
Include patients and families in making
decisions
Identify alternatives for treatment
Help patients understand, make choices
Relationships With Colleagues
Respect and courtesy
Learn how to work well with other
members of the health care team
Acting for the Good of society
Adopt these good behaviors in all aspects
of your life
Recognize physician’s responsibilities in
society
Dealing With Dying Patients
Continue to care for a patient even when
cure is not possible
Provide care to reduce pain and suffering
of the dying patient
Do NOT abandon or “give up” on a patient
Empathy
Ability understand the experience or
viewpoints of others
What are the concerns of an adult who parent is
dying?
What are the feelings of a patient who is
dealing with a diagnosis of cancer?
Compassion
Act with concern for others’ feelings
Act to improve others’ well being
Act to end suffering
Responsibility
Do what you are expected to do
Get to clinic on time
Complete tasks assigned
Keep promises to individual patients and
their care
Keep promises to colleagues and other
health care professionals
Accountability
Take responsibility for your own actions
Admit to errors or bad decisions you have made
Accept the consequences of your behavior
Do not make unnecessary excuses