Bioethics Newsletter Fall 2015

Editorial Notes from Joseph Breault, MD

Welcome to the fall issue of the Ochsner Bioethics Newsletter.

The November Annual Bioethics Grand Rounds is an opportunity for all of us in the Ochsner community to hear a nationally known speaker present an important medical ethics issue. The Grand Rounds is videoconferenced to all available sites and is an Ochsner Health System event. This year, we are very happy that Dr. Sulmasy will speak to us on “Substituted Interests and Best Judgments: Helping

Surrogates to Make Decisions for their Loved Ones at the End of Life.” The full text of his JAMA article on this topic is available through the Ochsner Medical Library if you are on the Ochsner intranet. The second page of this newsletter is a flyer you can use to help advertise the event. The videoconference sites and the names of those to contact at each location for more information are as follows:

OMC Baton Rouge - Café Conference Room - Dr. Ralph DauteriveWestbank - Cypress Room - Cathy GreenSlidell - Camellia Room - Dr. James NewcombKenner - Medical Office Building 7th FL. - Dr. Aderonke AkingbolaChabert - Classroom A - Melinda Baronne

As some of you are aware, the American Medical Association issued a medical ethics opinion in 1994 stating that using the term “futile care” is not a good way to explain why some treatments should be withdrawn or withheld. A recent article on this topic was discussed at the last OMC Bioethics Committee meeting. A review of the article’s highlights with some of the committee’s discussion is included in this newsletter.

Annual Bioethics Grand Rounds

November 24, 201512:00-1:00 pm • Monroe HallLunch is providedTeleconferenced to all available sites

Page 2Bioethics Grand Rounds

Pages 3-4Futile Care

Page 5Bioethics Resources for You

I N S I D E

AccreditationThe Ochsner Clinic Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

DesignationThe Ochsner Clinic Foundation designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DisclosureThe presenters, their spouses or partners, have no actual or potential conflict of interest in relation to this program or presentation.

CME Designation StatementOchsner Health System (OHS), Nursing Professional Development is an approved provider of continuing nursing education by South Central Accreditation Program, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This program has been approved for 1.0 CNE hour.

“Substituted Interests and Best Judgments: Helping Surrogates to Make Decisions for their Loved Ones at the End of Life”Daniel P. Sulmasy, MD, PhD

Dr. Sulmasy is the Kilbride-Clinton Professor of Medicine and Ethics in the Department of Medicine and Divinity School at the University of Chicago, where he serves as Associate Director of the MacLean Center for Clinical Medical Ethics and as Director of the Program on Medicine and Religion.

He received AB and MD degrees from Cornell University; completed his residency, chief residency, and postdoctoral fellowship in General Internal Medicine at the Johns Hopkins Hospital; and holds

a PhD in philosophy from Georgetown University. His research interests encompass theoretical and empirical investigations of the ethics of end-of-life decision-making, ethics education, and spirituality in medicine.

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Bioethics Newsletter Fall 2015

Futile Care by Joseph Breault, MD

(Continued on p.4)

Opinion 2.035 - Futile CarePhysicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them. Denial of treatment should be justified by reliance on openly stated ethical principles and acceptable standards of care, as defined in Opinion 2.03, “Allocation of Limited Medical Resources,” and Opinion 2.095, “The Provision of Adequate Health Care,” not on the concept of “futility,” which cannot be meaningfully defined. (I, IV)

American Medical Association

As the American Medical Association’s Code of Medical Ethics states (see text box), the concept of futility cannot be meaningfully defined. Other ethical principles and acceptable standards of care should be used to explain why certain types of treatments are not indicated.

At a recent meeting, the OMC Bioethics Committee discussed “Laying Futility to Rest,” an article by Michael Nair-Collins that was published in August 2015 in The Journal of Medicine and Philosophy. The following highlights of the article and our discussion can help us all think through how to discuss this difficult concept with patients.

To say a treatment is futile means the efficacy of the treatment is too low to consider it reasonable. The problems with this judgment (see page 6 of the article) include the following:

• One never knows for certain what the efficacy of a given treatment will be in a specific individual, and knowledgeable doctors may disagree. Therefore, a confidence interval needs to surround the estimation of low efficacy. But this is quite difficult to accurately estimate in a specific situation, and rarely is there enough time to calculate a confidence interval for a specific individual.

• Different people with different values may disagree on how low the efficacy of a treatment should be to not perform it. There may be differences among the medical team, and there may be differences between the medical team and the patient/family in this regard.

These issues obfuscate the discussions about what treatment options are appropriate when the term “futile care” is used to explain why a treatment is not appropriate.

Clarifying the goals of healthcare in a specific situation is often a better approach. Sometimes the goal is a cure. For example, an elderly sick person with severe pneumonia requires ICU care, antibiotics, and a ventilator, with the treatment goal being a cure so the patient can recover from the temporary illness and return to his/her baseline health and a good life. However, when a person is dying, treatment may prolong the dying process

some days, weeks, or even months but will not provide a cure, and there is no realistic hope that the patient will return to his/her former baseline health. In such cases, it is critically important for an attending physician to have ongoing open and honest communication with the patient and family about the realistic goals of care.

Bioethics Newsletter Fall 2015

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(Continued from p. 3)

Instead of talking about “futile care,” reframing discussions about treatment options in terms of the basic ethics principles of autonomy, beneficence, non-malfeasance, and justice is often helpful. Nair-Collins provides a series of examples on page 20 of his article:

• An infant born with multiple congenital abnormalities that rendered survival impossible required high-dose vasopressors to maintain blood pressure. After several days, gangrene developed in the extremities, and the parents sequentially demanded amputations of several limbs in an attempt to “do everything.” o The concern here is excessive harm to the infant or that the

balance between likely benefits to burdens is obviously skewed (beneficence, non-malfeasance).

• The surrogate decision-maker for a comatose woman dying in an intensive care unit (ICU) was her estranged husband; they separated because of repeated spousal abuse. Despite many conferences with the husband recommending comfort measures and a do-not-resuscitate order, the husband demanded that the medical staff “do everything to my wife.” o The concern is whether the estranged husband bears appropriate

care and concern for the patient, especially with the history of spousal abuse and language of doing everything to his wife rather than for his wife. Is the surrogate really acting in the best interest of the patient (autonomy, beneficence, non-malfeasance)?

• A public hospital serving an indigent community of several hundred thousand had a full ICU, and 3 patients were being kept in the emergency department on ventilators. One of the patients in the ICU was a gentleman who had been ventilator dependent and unresponsive for 4½ months after a cardiac arrest; his daughter insisted on full support because she was hoping for a miracle.o The concern is the just allocation of limited ICU beds. Treating

this patient in the ICU might not be futile from the perspective of keeping him alive longer, but it may be unjust in the number of people who may not have the opportunity to have their lives saved by use of that ICU bed (justice).

As the author states in his summary of this section:

The concept of futility, if used to justify unilateral, overriding decisions to limit life-sustaining treatment, is irreparably flawed. It does not justify unilateral decisions, even when subject to review by an ethics committee. Furthermore, futility qua ineffectiveness is not what generated much of the moral concern in the first place. Rather, more ethically defensible concerns such as harm or wrong done to patients, inappropriate surrogates or their decisions, and the just allocation of resources seem to be underlying many of the kinds of cases labeled “futile.” In order to make principled and defensible clinical decisions and public policies, these more salient concerns need to be articulated explicitly and held up to critical case-by-case scrutiny; but the label “futility” should be dropped altogether.

The Bioethics Committee discussion stressed the importance of the ongoing honest communication between attending physician and the patient/family about their evolving goals of care. If the attending physician and medical team think a cure is unlikely and a patient is dying, this information needs to be part of compassionate communication, along with realistic expectations of what treatments are useful or why they are not. A palliative care consult is a good option to help clarify goals of care and make patients comfortable.

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• Request a consult online - http://academics.ochsner.org/blankform.aspx?ekfrm=54674

• Call an Ochsner Chaplain 504-842-3286• Call Risk Management 504-842-4003• Contact your OMC local bioethics coordinator

Any ClinicOMC-Eastbank OMC-WestbankOMC-KennerOMC-BaptistOMC-BROMC-St. AnneOMC-ElmwoodOMC-SlidellChabert MC

Aderonke Akingbola, MDFrank Wharton, MDRalph Dauterive, MDAllyson Vedros, CNO

James Newcomb, MDJana Semere, CNO

Bioethics Education Program• Bioethics Grand Rounds - Tuesday, November 24, 2015

• Bioethics Website (consults) - http://academics.ochsner.org/bioethics.aspx

• Bioethics Website (resources) - http://www.ochsner.org/health-resources/medical-ethics-at-ochsner/medical-ethics-at-ochsner-resources/

• Quarterly Bioethics Newsletter - http://www.ochsner.org/health-resources/medical-ethics-at-ochsner/medical-ethics-at-ochsner-resources/

• The Ochsner Journal Bioethics column - http://www.ochsnerjournal.org

• Schwartz Rounds

What is a bioethics consult?• Medical Ethics Website http://academics.ochsner.org/bioethics.aspx• Bioethics Consultations and Resources http://www.ochsnerjournal.org/doi/pdf/10.1043/1524-5012-11.4.357

What is sometimes helpful prior to a bioethics consult?• Asking the chaplain to come visit • Holding a family conference

http://www.atsjournals.org/doi/pdf/10.1164/rccm.2501004• Requesting a palliative care consult

http://ochweb/page.cfm?id=2429• Having a discussion with Risk Management

http://ochweb/page.cfm?id=3325

Bioethic Education Fund When a bioethics consult is called, the expectation is that those providing services are well trained, not just people of good will. This training is the responsibility of the Bioethics Committee. Please support the committee’s educational work by donating to the Bioethics Education Fund - Endowed, managed by the Philanthropy Department as fund #3804126. In Lawson, employees can select the Bioethics Education Fund in the dropdown box during the annual giving campaign, and anyone can click the Donate Now button at www.ochsner.org/lp/bioethics_fund/. Every donation, however small, does great good and is used to build an endowment fund to permanently support bioethics educational programs at Ochsner.

“...most hospitals in the USA provide clinical ethics consultation that is mainly due to the requirement of The Joint Commission for Accreditation of Healthcare Organizations—in 2007 renamed the Joint Commission—that accredited hospitals must have a method for addressing ethical issues that arise.” From http://www.iep.utm.edu/bioethic/

End-of-Life Resources• 5 Wishes http://ochweb/documents/Best%20Practices/RobertWoodsJohnsonFiveWishesnoWM1.pdf• Advance Directives, Living Wills, & Healthcare Power of Attorney http://ochweb/page.cfm?id=965 scroll down to Advance Directives• Palliative Care http://ochweb/page.cfm?id=2429• State Living Will Declarations • UpToDate: Ethical Issues in Palliative Care http://www.uptodate.com/contents/ethical-issues-in-palliative-care• Katy Butler: Slow Medicine http://katybutler.com/site/slow-medicine/• Dr. Atul Gawande: Letting Go http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all• LaPOST: Handbook for Health Care Professionals http://lhcqf.org/images/stories/LaPOST/LaPOST-Handbook-for-Health-Care-Professionals-2013.pdf• LaPOST: State Website https://lhcqf.org/lapost-home• LaPOST video: Using the LaPOST Document to Improve Advance Care Planning (intranet only) http://mediasite.ochsner.org/mediasite50/Viewer/?peid=b54700807b474e1e8fe96113ca985e4b• Respecting Choices Training

How to Request a Bioethics Consult at Any Ochsner Facility

Bioethics Resources for You

Bioethics Newsletter Fall 2015

Bioethics Q&A