Ethics at the Bedside

1. Ethics at the Bedside Conflicts and Communication Bernard Scoggins, M.D., F.A.C.P.

2. Ethical actions and decisions should reflect the values of your staff and institution

3. How we decide can be as important as what we decide

4. Ethics often has tension with the law, risk management, regulations, and institutional policies

5. Ethics properly applied should lead to patient centered medicine • Ethical decisions poorly communicated can lead to distress and staff burnout

6. Can good ethical practices improve patient care? • Improve patient quality or satisfaction? • Reduce risks and malpractice?

7. First Clinical Case • Questions - • What did she really tell the doctor? • Was she or is she competent? • If not competent, who can decide for her? • What about her advanced directives

8. CompetencyDecision-Making Capacity Informed Consent

9. Competency is a legal decision

10. Decision Making CapacityClinical Judgment

11. Decision Making Capacity is task specific. The complexity and ambiguity of the options affect it.

12. Four Standards for Decision-Making Capacity* • Communicate a choice • Understand the relevant information • Appreciate the situation and its consequences • Reason about treatment options - New England Journal of Medicine

13. Decision-making capacity may wax and wane • Dementia does not mean lack of decision-making capacity

14. Myths about decision-making capacity • Decision-making capacity and competency are the same • Lack of decision-making capacity can be presumed when patients go against medical advice • There is no need to assess decision-making capacity unless patients go against medical advice • Decision-making capacity is an ‘all or nothing’ phenomenon • Cognitive impairment equals lack of decision-making capacity JAMA

15. Myths about decision-making capacity • Lack of decision-making capacity is a permanent condition • Patients who have not been given relevant and consistent information about their treatment lack decision-making capacity • All patients with certain psychiatric disorders lack decision-making capacity • Patients who have been involuntarily committed lack decision-making capacity • Only mental health experts can assess decision-making capacity JAMA

16. Informed Consent is the legal recognition that each individual has the right to make decisions regarding his/her own healthcare

17. Information sharing is patient centered • Decision-making in context of the physician patient relationship is building trust

18. “Trust me I’m a doctor”

19. If decision-making capacity is lacking, turn to the surrogate

20. Patient’s known wishes • Substitute judgment • Patient’s best interest

21. Advanced Directives

22. In Georgia • 1980 - First Living Will Law • 1990 - First Law of Durable Power of Attorney for Healthcare • In 2007, New law combined both

23. When does it apply? • Patient is terminable or permanently unconscious • Requires two physicians to certify this

24. Part 1 – Healthcare AgentPart 2 – Treatment Options • This must be properly signed and witnessed

25. Case 2 (involving brain death)

26. Criteria date back to Harvard Criteria 1968 • First Georgia Law 1975 • Uniform Determination of Death Act

27. Georgia Law – Death can be declared if: • There is irreversible cessation of circulation and respiratory function or • Brain death involving the whole brain

28. Clinical Evaluation • Other tests not required • Two physicians not required but advised

29. American Academy of Neurology Standards • Do not confuse with PVS, MCS, or Coma

30. Fuzzy language • Don’t fight it out in the chart • Communicate with staff and family • Document, document, document • Do not use the term “withdrawal of life support”

31. 3rd Case

32. DNR • First Georgia law passed in 1991

33. Personal decision-making capacity can always decide if no DMC (see list)

34. Must be a candidate for non-resuscitation with one attending and another physician declaring this. • Ethics Committee Role

35. Law expanded to include hospice in 1994 and DNR out of facility in 1999 with portability

36. Documentation? • Communication with family, nursing, others

37. What is Futility? Strictest sense – treatment is futile if it offers no benefit to the patient

38. Judgment of futility involves both values and scientific evaluation. Patient autonomy and goals

39. We all recognize when resuscitation is futile but we cannot make unilateral decisions

40. We are not obligated as providers to provide inappropriate treatment that could be harmful or of no value or technically impossible

41. Question treatment for families that want everything done... This can lead to moral distress

42. What is DNR Portability? • To Home? • To Nursing Home? • Return to Hospital? • To Assisted Living?

43. Nutrition/Hydration This is a medical procedure and can be withdrawn just like any other procedure

44. This is a very sensitive topic with religious and moral beliefs involved Must be discussed, shared, and documented

45. Laws do not address every option

46. There also are Georgia Laws or Case Law involving physician-assisted suicide and withdrawing/withholding of life support

47. “What this patient needs is a doctor” (a quotation from Dr. Stead, Duke University Medical School)

48. We will always have conflicts, tensions, doubts and uncertainties

49. Don’t forget to ask: • Nurses, yes - nurses • Lawyers • Risk managers • Dieticians • Chaplains • Social Workers/Case Managers • Patient Representatives • Ethics Committee

50. Always listen to patients, nurses, and staff and coordinate their message