‘they’ve fallen and hit their head… now what…?’ · • the ethical issues following a...
TRANSCRIPT
‘They’ve Fallen and
Hit their Head… Now What…?’
Workshop
APM Ethics Committee Study Days
Telford, January 2016
Dr Craig Gannon
• Princess Alice Hospice, Esher, 1995-
– Medical Director, clinical ethics committee
• University of Surrey, Guildford, 2012-
– Visiting Reader, ex-university ethics committee
• Association of Palliative Medicine
– Ethics Committee, 2009 – on-going
• Publications / teaching
– Ethics in BMJ, JME, IJPN, CE, NE
• Royal College Physicians
– SCE Question Writer, Exam Board, Standard Setting Group
Jobbing Consultant
Not Philosopher, Lawyer...
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J7 to J14 of M25
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• Make your own mind up
– Workshop!
• The ethical issues following a head injury
– Three cases
• How make mind up not what is right action
– Enhances clarity of thought
• Better decisions
• Better communication
• Better engagement
Plan – Get You Thinking!
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Be Provocative…
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• Explore clinical, ethical, legal principles
– Generalisations... not case-by-case!
• Share my / our opinions
– No absolute right vs. wrong
– I’m not necessarily ethical!
• Healthcare isn’t always ethical!
– No perfect answers...!
– Realistic expectations…?
NO Answers… NOT Tell!
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Who Here is Already
an Expert in Ethics?
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• Our choices…
– Test of our behaviour / character
• Our opinion…
– View on others’ behaviour / character
Ethics is Everywhere:
… We’re Life-Long Learners!
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• Descriptive ethics –
– Observe; what do we see people decide?
• Normative ethics – Judge; what should people think is right?
• Applied ethics – Do; How to put moral knowledge into practice?
• Meta-ethics – Nature; what does 'right' even mean?
Gentle Reminder:
Classes of Ethics
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Normative Ethics Made Easy!
• Three key ways to test our care:
• Duty-based ethics (deontology)
– Do duty
• Consequentialism
– Get result
• Virtue ethics
– Match good character
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• Do right thing
– Whatever the outcome
• Only path matters
– Traditional
– Clear, follow rules
– Inflexible
• Risk jobs-worth doctor
– No DNACPR, so do CPR in T/C
– Not use CD drugs if not signed
– Never admit from out of area
Kant’s Duty-Based Ethics
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• Try for best results
– Whatever it takes
• Outcome only
– Modern / selfish
– Clear, results
– Presumptive
• Risk cavalier doctor
– ‘T/C’ just to get in hospice
– ‘Ca2+ normal’ when forgot
– Not admit out-of-area if no £
Consequentialism
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Lance Armstrong “wins” stage
Tour de France in 2004
• “Good” character
– Reflects “worthy”
• Balancing all needs
– Ideal vs. naïve…?
– How; subjective?
– Who; judges?
• Risk drippy doctor
– Too nice, not able to decide!
– No help when it’s difficult
– No help when it’s urgent
Virtue Ethics
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• Cannot ‘mix & match’ or unprincipled
– One principle you / everyone should follow…
– Choose one to use in workshop section…
• Duty-based ethics
– Follow rules… whatever outcome, even patient harm
• Consequentialism
– Get result… at any cost / break rules, even GMC / law
• Virtue ethics
– Do what a person of good character would do
Which Moral Philosophy
is Right for You at Work…?
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Different Ethical Approaches;
30 mph Speed Limit
• Duty-based ethics
– 30 mph maximum
– Law is law, full stop
• Consequentialism
– 33 mph usually
– Never “done” <34 mph
• Virtue ethics
– 30 mph normal max
– 35 mph if emergency
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Same Road… Same Principle
You Notice You're Speeding…?
• Duty-based ethics
– 30 mph maximum
– Law is law, full stop
• Consequentialism
– Hit brakes so 29 mph!
– No risk <30 mph
• Virtue ethics
– Carry on at 33 mph, take the fine; as not safe to hit brakes
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• Moral elasticity and moral multiplicity
– Bend / shift ethics to do what you want!
– Real world... increasingly “accepted”
– Play clever is the new ‘worthy’...?!
2016: Un-Virtuous Ethics:
…Morals, Only When Suits!!
You must obey rules… I just want fair play
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I don’t obey rules, they’re just for fools
Decision-Making After
Head Injury in ‘Hospice’
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• On-call doctor for a hospice
– Live 25 minutes drive away
• Telephoned, “patient has fallen”
– Good details from on-site staff
– Possibly “serious” head injury; details on handout
– Patient “too woozy” to give view
• Need decision now as you are ‘lead clinician’
– Stay put for comfort and T/C or 999 / send to A&E?
– What influences your advice?
Decision-Making After
Head Injury in ‘Hospice’
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• In 3 groups, “quick” 15 minutes – 1 of 3 different scenarios on hand-outs
• Abbreviations – S/C, symptom control; ‘expected’ to get home
– T/C, terminal care; ‘imminently’ dying
– QoL, quality of life
– HCP, healthcare professional
– LPA, lasting power of attorney
– DNACPR, do not attempt resuscitation
– PPC, Preferred Priorities of Care
– ADRT, Advance Decision to Refuse Treatment
Decision-Making After
Head Injury in ‘Hospice’
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Why Do Some Decisions
Feel So Difficult...?
• Misplaced HCP fears create problem
– Not unique, any treatment = a treatment
– Explicit, but same issues at end of life
– Not more difficult patients / families
• Mustn’t abandon normal approach
– Our best advice (uncertainties)
– Individualised care (different views)
– Imperfect, but sufficient, as always…
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Paradox:
Everyone is on Same Side…
• No conflict…
– Need reassure / remind everyone (ourselves!)
• Be realistic…
– Decision as right as possible
– Satisfies all stakeholders:
• Patients / families / friends
• Professionals, organisations
• Media
• Courts
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When at Odds…
…Always Avoidable?
• HCP suboptimal practice
– Clinical, legal, ethics gaps
• Poor clinical decisions
– Don’t do it right
• Poor explanations
– Don’t explain it right
• Unhappy when told not for any food or fluids by unsure F1
• No ethical dilemmas:
• To offer / give treatment it must be:
– Required
– Acquired
– Desired
Our Duty for Any Treatment
…is Simple!
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1. Could treatment work?
– Predictable net gain
2. Is treatment available?
– Ambulance / in hospital
3. Is treatment wanted?
– Consent / no refusal
Our Duty… is Simple…!
“Required, Acquired and Desired”
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‘Yes’ X3 = Transfer!
Your Decision
After Head Injury…
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• Reassure
– Never wrong…
• Scare
– Never right!!!
Ethical Deliberation:
None or Many Answers…!
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• As in clinical practice, we won’t all agree
– Could it work?
– Is it available?
– Is it wanted?
Your Decision
Case 1, After Head Injury…
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• Could it work? No
– Clinical ‘triage’; no treatment indicated – no net gain
• Is it available? No
– Rationed; neurosurgery not on offer / paramedic “no”
• Is it wanted? No
– No is “sufficiently” in-line with patient…?
• Notes – clinical / patient first
– Over-rules “family”
– Your CEO may have a view if ignore lawyer…?!
– If consequentialist vs. virtue vs. duty-based
Case 1 Potential Answer…
T/C in Hospice
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• As in clinical practice, we won’t all agree…
– Could it work?
– Is it available?
– Is it wanted?
Your Decision
Case 2, After Head Injury…
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• Could it work? No
– Clinical triage; not fit to move / no indication; no net gain
• Is it available? No
– Ration; dying; no neurosurgery even if paramedic ‘yes’
• Is it wanted? N/A!
– Over-rule patient and family: clinically best in hospice
• Notes – clinical / patient first
– Scary… less certain! Even LPA (…in theory?)
– Defensive; fell from a hoist, your benefit vs. your guilt…?
– If consequentialist vs. virtue vs. duty-based
Case 2 Potential Answer…
T/C in Hospice!
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• As in clinical practice, we won’t all agree…
– Could it work?
– Is it available?
– Is it wanted?
Your Decision
Case 3, After Head Injury…
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• Could it work? Yes
– Potentially reversible pathology
• Is it available? Yes
– Active management would be offered in hospital, but…
• Is it wanted? No
– Clear Best Interests +/- valid and applicable ADRT
• Notes – clinical / patient first
– In theory… but send in practice (for her family)???
– Flaw in ADRT; was this foreseen, could mind changed?
– If consequentialist vs. virtue vs. duty-based
Case 3, Potential Answer…
T/C in Hospice?
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Key Issues
Across the Three Cases
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Legal
Policy Duty
Conscience
Patient / NoK Colleagues
• Could it work?
• If yes; it available?
• If both yes; is it wanted?
• If unclear, default is offer and give unless refusal:
– Competent refusal
– Valid and applicable ADRT / LPA refusal
• All other factors less influence, even if emotive
– Discretionary… ‘ethically’ no less important…?
– Consensus ideal, but not needed… the difficult bit…!
First do Clinical Questions… to
See if there’s a ‘Choice’
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• Get decision ‘just right’
– Not “we always send to be safe”!
– Not “we don’t send to hospital”!
– Not “we follow ACP”!
– Not “we do want family want”!
• All decisions, always ‘maybe’
– Acknowledge difficult
– May over-treat / may under-treat
– Not impossible… easy!!!!
No Blanket Approach:
Not Too Fast or Slow to Send!
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Goldilocks
• First step: will surgery help…?
– From evidence base: any predictable net gain?
– Only reasons for increased observations / investigations…
• Only if yes, then, is it available?
– Is HDU really on offer…?
– In this place / this context?
• Only then, is it wanted?
– Patient choice…
– If start here – it falls apart…!
Clinical Decision Making
Starts with Can Hospital Help...?
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Virtue Ethics: Not Lofty Ideal,
Just ‘Sits’ Between Two Vices
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Vice: Excess
Unethical practice
e.g. cavalier
Virtue
Best Practice e.g. courageous
Vice: Deficiency
Unethical practice
e.g. cowardly
Common-sense middle ground
Does Virtue Ethics
Apply to All Decisions…?
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Clinical Decisions Fail if Lacking
Professional Courage
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Vice: unethical If just follow rules / path least resistance; only do as
in notes
Vice: unethical If don’t consider rules / do it my way; a blanket
yes / no Aristotle (384 BC – 322 BC)
Need the Virtue of Courage:
…to Break Rules / Take Risks
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‘Virtues’ Aristotle
(384 BC – 322 BC)
Professionalism: Discerning: weigh pros / cons:
treat when appropriate
A considered
expert view
Conclusion: Ethics Means
No Blanket Decisions
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Chris Froome / Team Sky
Tour de France, 2015
Thank You
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Four Quadrant Approach Jonsen, Siegler & Winslade, 1992
1. Clinical issues 2. Patient preferences
Diagnosis / medical history
Goals of treatment?
What treatment options?
Probability of success / prognosis for each option
Best case / worst case / likely case
Does patient have capacity? Assess
Yes = consent, what do they want?
No = will it return / best interests;
Decide Best Interests – inform decision-making; prior expressed preferences or an
ADRT?
Consult stakeholders, is there a surrogate decision maker?
3. Quality of life 4. Contextual factors
What distress is the patient experiencing?
Multi dimensional: function / symptom /
existential
Difficult to define – person centred
Will treatment improve QoL / be acceptable
to the patient?
Religious, cultural, legal factors that need
to be taken into account?
Social / family influences... are there
conflicts of interest?
Resource limitations, or influence clinical
research / teaching?
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A Patient’s Right to Refuse
Medical Interventions...
Phew! I’m off… That was easy...
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• Even if they will die...?
• Even if it demands an action by HCPs...?
• Is ethical and legal guidance the same…?
• Are there ‘special’ cases?
Is the Right to Refuse
Treatment Absolute...?
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• Cannot force patients into treatment
– Since 1990’s case law clear
• High profile UK cases
• With / without capacity
– Since 2007, reinforced in statute
• Without capacity
• Mental Capacity Act, 2005
100% Legal Right to Refuse
Life-Prolonging Therapy
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• Any or no reason… even if irrational
– Agree to disagree, but cannot force care
– No harm required (unlike negligence)
– Risk battery, even if help
• Without prejudice
– All remaining best care must be offered
– Patient can change their mind
• Re B (2002) wanted discontinue ventilation
– Competent adult right to refuse medical treatment
– Deemed “unlawful trespass”
Legally Patients’ Right to Refuse
Absolute and Binding
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• Airedale NHS Trust v Bland [1993] HL, PVS
– Artificial hydration & nutrition are treatments
– Best practice into case law
• MCA 2005, since 2007
– Advance decision binding…if “valid & applicable”
– Statute – paradox, now harder to stop…???
Legally Refusal Still Binding After
Capacity is Lost
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• Can you think of any ‘special’ cases?!
– When might you say ‘no’...?
A Patient’s Right to Refuse
Ethically NOT Absolute…?
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• Turning off ventilator instant
• Removing an oesophageal stent invasive
• Turning off an ICD or pacemaker emotive
• Lack capacity just from ADRT nervous
Refusing a Patient’s Right to
Refuse the Special Cases?
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• Public health risk
– Enforce isolation, treatment e.g. Ebola
• Reasonable boundaries
– Personal hygiene... infested house?
• Ambivalent and “panicking” patient
– Re MB (1997); footling breech, agreed LSCS but refused
anaesthetic as needle phobic
– Ruled lack of capacity; panic from fear of needle!
Must Override Patient Refusal if
Greater Clinical Need...?
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• 34-year-old woman
• Jehovah witness
– ADRT; No Transfusion, even if life at risk
• RTA
– 999 to A&E; bleeding
• Retains capacity
– Refusing life-saving blood transfusion
• Can you give transfusion?
– What basis?
Case 1
Can You Refuse the Refusal?
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Why Can Decision-Making
Feel so Difficult…?
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Should I, or shouldn’t I...?
• 34-year-old woman
– 30/40 pregnant
• Jehovah witness
– Valid ADRT... even if life at risk
• RTA
– 999 to A&E; bleeding
• Retains capacity
– Refusing life-saving blood transfusion
• Can you give transfusion?
– What basis?
Case 2
Can You Refuse the Refusal?
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Key Issues for Both Cases
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Legal
Policy Duty
Conscience
Patient / NoK Colleagues
• Personal conscience
– Will vary
– Can you live with your decision?
• Professional duty
– Default is give, but “cannot” follow
– GMC / NMC may support either way…
• Unit policy
– Requirements will vary Trust to Trust...?
– May be disciplined
Key Issues for Both Cases
1 of 2
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• Legal requirements
– Don’t give (battery / trespass)
– Possibly give (best interests)
– Judge & jury will decide if innocent or guilty...?
– Statute / case law or may set new precedent
• Subsequent views of patient / next of kin
– May sue if do or don’t transfuse…
• Subsequent views of colleagues
– Whistle blow, refuse work with you, make life nightmare
Key Issues for Both Cases
2 of 2
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• Making DNACPR (omission)
• Turning off an ICD (act)
Acts vs. Omissions
Which is Easier for HCPs...?
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Act of omitting to remove
the scissors!
• Discontinuing a treatment
– Act / withdraw...
• Not starting a treatment
– Omission / withhold...
• Historically seen as different
– Common and comforting
– Convenient
– Arguably incorrect
Any Difference Between
Acts and Omissions?
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Act
Omission
• No professional bearing
– ‘Indistinguishable’ morally & legally » In Bland Law Lords decision, 1999
– “…act or omission…” » GMC, 2015
– Convicted arson, not for starting but as did nothing » Miller, R v [1983] HL
• Withholding is act of omission
– Same accountability / same responsibility
• Disease / therapy / time dictates if act / omission
– Already has NGT or doesn’t yet have NGT
No Clinical Distinction
Between Acts and Omissions
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• 72-year-old man
• Ca oesophagus and liver secondaries
• Slow decline; bed bound prognosis ~ 1-2 weeks
• PEG feeds on 24-hour regimen
– No net gain… possibly more harm than good?
– PEG working well, assumed life-prolonging
• Lacks capacity; no advocate, no ADRT / LPA
• Can we stop the feeds now?
An Act: Case 1
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• 72-year-old man
• Ca oesophagus and liver secondaries
• Slow decline; bed bound prognosis ~ 1-2 weeks
• PEG feeds on 12-hour regimen
– No net gain… possibly more harm than good?
– PEG blocked at end last feed, assumed life-prolonging
• Lacks capacity; no advocate, no ADRT / LPA
• Can we decide not replace PEG or restart feeds?
An Omission: Case 2
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• Carries weight in society
– May influence patient choice
– May influence a jury!
• Emotive differences need to be addressed
– Patients, families
– Colleagues – even if professionally irrelevant
Distinction Acts v. Omissions Still
Carries Impact
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