1 / 45

Clinical Ethics

This document by Peter Saul from John Hunter Hospital discusses critical aspects of clinical ethics in Intensive Care Units (ICUs). It covers the historical context of the Clinical Ethics Committee, ethical dilemmas faced at the bedside, and the importance of patient autonomy in decision-making. Real-life cases illustrate the complexities of providing care to vulnerable patients without clear consent. The text emphasizes the need for policy changes and better communication in end-of-life (EOL) decision-making, highlighting how to respect patients' wishes and improve the quality of care in critical situations.

noelani-blake
Télécharger la présentation

Clinical Ethics

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinical Ethics Prepared by Peter Saul ICU John Hunter Hospital 13th October 2006

  2. Medicine is a contact sport…

  3. Medicine is a contact sport… People get hurt

  4. A little history.. • JHH Clinical Ethics Committee • Founded 1993 • Survey 1995 (J Qual Clin Prac 1998) • CUEHL 1996 • Became Area (HACEC) 2000 • ACHS commendation 2001 • Consultation service published 2004 (MJA 2004;181:204-206)

  5. Macro and micro • Macro • Policy • Institutional change • Cultural change • Micro • The pointy end • Support for value-laden decisions at the bedside

  6. Time to have a go • The Wandering Man • Elderly man found wandering around a park • Investigations showed brain tumour (inoperable, incurable) • Immigrant, no family or friends in Australia • CEC contacted six weeks after admission • Still wandering, vomiting blood

  7. Questions • What can we do without consent? • Hide drugs in his food? • Do an endoscopy? • Restrain him? • Write a no-CPR order?

  8. Time to have a go 2 • Young woman with severe Crohn’s disease • Unable to give up smoking • New (expensive) drug available – evidence suggests drug much less effective if patients smoke. • Should the drug be withheld?

  9. Ethics consultation • Formal and informal • Knowledge deficit or dilemma (values) • Expertise and accountability

  10. “Can you tell me, Socrates - is virtue something that can be taught? Or does it come by practice? Or is it neither teaching nor practice that gives it to a man, but natural aptitude, or something else?” Plato Protagoras and Meno

  11. Macro stuff • “Patient autonomy” • A short and undistinguished career • An issue of culture • Can patients become meaningfully involved in decisions about their care? • A worthy subject for experimentation

  12. A few facts (AIHW 2002) • Life is still getting longer • But slower • At high cost • All the gain is at the end • Last 5-9yrs with disability • Extremes of age now common • > 90% of Australians now get to be old • Chronic illness now common

  13. 80 deaths a month 90% have no attempt at resuscitation 80% have no involvement in their own EOL decisions

  14. 80% die after a decision to withdraw or withhold treatment Almost all these decisions are made by surrogates

  15. Place of death • US data - 20% in ICU (60% in Miami) • Crit Care Med 2004;32:638-643 • UK data - institutions 80% (hospitals 66.5%) • BMJ 2003;326:30-34 • Bankstown data - > 60% have multiple hospital admissions during last year of life, av bed days 25 • Age & Ageing 2004

  16. Death in hospital is an actively managed event…

  17. That doesn’t involve the patient

  18. Principles of a good death • To know when death is coming, and to understand what can be expected • To be able to retain control of what happens • To be afforded dignity and privacy • To have control over pain relief and other symptoms • To have choice and control over where death occurs (at home or elsewhere) • To have access to information and expertise of whatever kind is necessary • To have access to any spiritual or emotional support required • To have access to hospice care in any location • To have control over who is present and who shares the end • To be able to issue advance directives which ensure wishes are respected • To have time to say goodbye, and control over other aspects of timing • To be able to leave when it is time to go, and not to have life prolonged pointlessly • Age Concern, London 1999

  19. Advance care planning in residential care • Questionnaire study of 4625 residents of nursing homes and hostels in NSW • <0.2% had a written advance directive • 1% had a no-CPR order • decision making largely informal Aust NZ J Med 2000;30:339-343

  20. “There is always an easy solution to every human problem - neat, plausible, and wrong” H L Mencken 1917

  21. Advance directives • Level 1 evidence that you can get people to write them • J Crit Care 2004;19:1-8 • Level 1 evidence they don’t work • Arch Int Med 2004;164:1501-1506

  22. End of life decision making in NSW • No legislation (unlike our neighbours) • A complex (and disputed) intersection of guidelines and perceptions about what the common law might say

  23. An outline of the RPC Program • Born in LaCrosse Wisconsin in the 90’s • Adopted and adapted by Austin Health in Victoria in 2002 - trialed 02-03 • Extended to acute care pilot hospitals in all states 2004-2006 • Extended to residential aged care 2005 • Rural pilot and GP’s 2006

  24. The essence of RPC • Starts at the top • Changes hospital systems • Trains facilitators • Focuses on families/carers, not just patients • Aims to provoke documented discussions (not just AD’s) • Educates absolutely everybody

  25. ACP pre RCP Program • Only 1% of in-patient notes included any reference to a plan or patient preferences (4 states) • Legislation not influential • 0.2% of notes in nursing homes in Hunter Region of NSW contained a plan

  26. Surrogates pre RCP Program • No recognition of guardianship provisions in acute care (on admission or subsequently). • < 5% of residents in nursing homes in Hunter had a recorded guardian

  27. Evaluation • “Program logic map” • Outsourced to a group at LaTrobe • Looked at several tiers, quantitative and qualitative • Tries to establish links between changes made and outcomes

  28. Outcomes at JHH • Changes to hospital administration • Changes to processes of care in the pilot wards • 120 trained staff • High level of confidence in trained staff • Incorporated into routines of care • Extended into clinics

  29. Early results at JHH • 2 plans and no identified proxies (PR) in 200 patients pre-implementation • 50/200 identified preferred proxy and 30/200 recorded preferences in evaluation period • A smorgasbord of documents produced • Impact evaluated Jan-Apr 2006

  30. Outcomes at JHH • (1 in 50 told us to go away) • 15 in-patients/week introduced to RPC (4 wards) and lots of outpatients • 8 ask for follow-up • 3 identify or appoint a proxy • 2 request a no-CPR order • 1 writes a plan (may include an advance care directive). Takes about 2hrs. • All plans followed so far

  31. Guidelines for end of life care and decision making • A “shared decision” • Based on “consensus” • Ethical principle • In the absence of a competent adult patient, nobody has the trump card

  32. Patient wishes doctors family

  33. Patient wishes doctors family No trump card

  34. Advance care planning in NSW • Identify who will make decisions for you • If not OK, appoint somebody else • Talk to them • Make sure everybody knows what you’ve said • Write something down and keep it with you

More Related