Ethics Consultation Process

Maggie Procunier RN BSNBioethics & Patient RightsSouth Miami Hospital

Morals

An individual’s own code for acceptable behavior

They arise from an individual’s conscience

They act as a guide for individual behavior

They are Learned

Ethics

Ethics deals with the “rightness” or “wrongness” of human behavior

Concerned with the motivation behind the behavior

Bioethics is the application of these principles to life-and-death issues

Ethical Principles

AutonomyNonmaleficenceBeneficenceJusticeFidelityConfidentialityVeracityAccountability

AutonomyThe freedom to make decisions about oneselfThe right to self-determinationHealthcare providers need to respect patient’s

rights to make choices about healthcare, even if the healthcare providers do not agree with the patient’s decision.

Nonmaleficence

Requires that no harm be caused to an individual, either unintentionally or deliberately

This principle requires nurses to protect individuals who are unable to protect themselves

BeneficenceThis principle means

“doing good” for othersNurses need to assist

clients in meeting all their needs◦Biological◦Psychological◦Social

Justice

Every individual must be treated equally

This requires nurses to be nonjudgmental

Fidelity

LoyaltyThe promise to fulfill all

commitments The basis of accountabilityIncludes the professionals

faithfulness or loyalty to agreements & responsibilities accepted as part of the practice of the profession

ConfidentialityAnything stated to nurses or health-

care providers by patients must remain confidential

The only times this principle may be violated are:◦If patients may indicate harm to

themselves or others◦If the patient gives permission for the

information to be shared

VeracityThis principle implies

“truthfulness”Nurses need to be truthful

to their clientsVeracity is an important

component of building trusting relationships

Accountability

Individuals need to be responsible for their own actions

Nurses are accountable to themselves and to their colleagues

Ethical Dilemmas

Occur when a problem exists between ethical principles

Deciding in favor of one principle usually violates another

Both sides have “goodness” and “badness” associated with them

Why call an Ethics Consult?Ethics Consult can help:

◦Discover and understand the issues◦Serves as a forum for sharing of concerns and

questions◦Identifies possible treatment alternatives◦Provides guidance to the staff, patient, and

family members◦Resolves conflicts

Using the Nursing Process

AssessmentPlanningImplementati

onEvaluation

Approach to Ethical Dilemma

W h at V alu es are in con flict

C ollectth e facts

A m I in volved

A ssessm ent

L ist andR an k the op tions

Id en tifyD ecis ion -M ak ers

D eterm in e goa lsof treatm en t

P lan n ing

U se o fd iscu ssion and

n egotia tion

W ork tow ardsa m u tu ally

accep tab le d ecis ion

Im p lem en tation

R e-evalu ate as n ecessary

D eterm in ew h eth er d es ired

ou tcom es h ave b eenreach e d

E valu ation

A p p roach

Ethical Decision Making ProcessDescribe the problemGather the factsClarify valuesNote reactionsIdentify ethical PrinciplesClarify legal rulesExplore options and alternativesDecide on a recommendationDevelop an action planEvaluate the plan

Case #1Patient is an 89 year old male admitted with Hyperkalemia, ESRD, HTN, and Bladder Cancer. Patient’s past medical history includes recurrent bladder carcinoma, CVA, hernia repair and hemodyalisis. Patient was admitted due to weakness and 2 weeks of diarrhea for which he had refused to be dialyzed for 7 days. Patient lives at home with wife and daughter who are both his healthcare surrogates. Based on patient’s poor prognosis, oncologist had recommended on previous admissions that patient be made Hospice Care with comfort measures.

Case #1 Cont.

Daughter and wife have refused Hospice care and want patient to be dialyzed and continue aggressive treatment to include full resuscitation if cardiopulmonary arrest. Daughter and wife have requested all physicians to refrain from speaking to patient about his prognosis.

At this time all physicians have followed daughter and wife’s request not let patient know that his cancer has returned, except for the “new” attending physician.

• Autonomy?• Nonmaleficence?• Beneficence?• Justice?• Fidelity?• Confidentiality?• Veracity?• Accountability?

Is there an Ethical dilemma?

What would you do?

Tell “new” physician to get on board with the rest of the healthcare providers in following the wife and daughter’s request…

Tell the patient that his wife and daughter are keeping information from him…

Do nothing…Call for an ethics consult?

Ethical Decision Making Process

Describe the problemGather the factsClarify valuesNote reactionsIdentify ethical PrinciplesClarify legal rulesExplore options and alternativesDecide on a recommendationDevelop an action planEvaluate the plan

ResolutionEthics spoke with Attending physician and plan

was to speak first with daughter and wife regarding their role as health care surrogates.

Attending physician, healthcare team, and ethics would then meet with patient and inquire if he wanted information regarding his prognosis and/or medical care.

After speaking with daughter, wife, and patient individually and obtaining a clearer understanding of the patient’s wishes, and the clarification of the healthcare surrogates role, a family conference would be scheduled with health care team and family to summarize the findings…

ResolutionThings never go as you plan them…Daughter refused to have wife speak with

the teamDaughter wanted to be part of the

conversation when attending spoke to her father to inquire if he wanted information or not…

Attending agreed to let daughter be present during the conversation (mistake)

Case # 2

88 year old male with extensive medical history including end stage Parkinson's disease. He was admitted due to pneumonia and was intubated and now is in Intensive care unit. Patient’s wife was identified as proxy since patient had never completed an Advance Directive or had a Living Will.

2 weeks have passed and patient has been unable to be weaned from ventilator.

Wife continues to indicate she wants to take patient home on the ventilator…

Attending physician did not feel that wife’s request to take patient home were realistic nor did he feel patient would have “a good quality of life.”

His recommendations were Comfort Measure/Withdraw of life support.

Case # 2 Continued

Palliative Care is involved and many family conferences have been held. Wife refuses to make patient a Do Not Resuscitate, or sign any type of withdrawal papers. She wants “full care”

She continues to verbalize she wants to take patient home.

Wife had full time 24 hour care team at home taking care of patient and she wants to take him home.

Ethics consult is called by attending physician….

What would you do?

Try to convince wife that a DNR would be the best for the patient in his condition…

Speak to physician to find out what he plans to do next…

Call for an ethics consult

Ethical Decision Making Process

Describe the problemGather the factsClarify valuesNote reactionsIdentify ethical PrinciplesClarify legal rulesExplore options and alternativesDecide on a recommendationDevelop an action planEvaluate the plan

Resolution

Palliative Care and ethics consultant met with wife and she understood that if he went home, he would have to have a tracheotomy. Recommendations from team was to arrange Respiratory department to show caregivers and wife how to take care of patient once he was at home with tracheotomy.

Wife agrees to tracheotomy and a consult is requested.

Wife was also informed of him having to go to a skilled nursing facility first and then after he was stronger would be able to go home.

Patient was trached and discharge to skilled nursing facility for rehab.

Case #3

54 year old male - history of previous subdural hematoma, HTN, and atrial fibrillation. Patient aspirated and coded. He is in intensive care unit on ventilator and Dopamine for hemodynamic stability.

Attempts at weaning have been unsuccessful…wife (healthcare surrogate) signed consent for tracheotomy in order for patient to be weaned off ventilator as recommended by pulmonologist…

On the same day wife signed consent for tracheotomy, Primary Care Physicians during rounds feels that his prognosis is poor, and his recommendation for plan of care is to have patient made CMO and eventually withdrawal of life support should be initiated, he did not agree with pulmonologist recommendations…

Pulmonologist does not agree with current plan to make patient CMO and withdrawal and wants to continue therapy…”he can improve, give him time”.

Case #3 Cont.Pulmonologist contacts wife regarding the scheduling of the

tracheotomy, and is surprised to find out that she has signed papers for Comfort Measures Only & withdrawal of ventilator…

Family is now confused with conflicting goals of care…wife has agreed to CMO and withdrawal of vent after speaking with attending but is still not sure she is doing the right thing…she would like to give time but “how long?”

Staff is torn between wife’s decision and her verbalization of “confusion” and physician’s recommendations and conflicting opinions by pulmonologist and attending physician…

Pulmonologists calls for ethics consult…patient is not withdrawn awaiting ethics recommendations…

What would you do?

Tell wife attending is right and she should sign the CMO papers…

Tell wife she should get a pulmonologists second opinion…

Call Risk Management because of the conflict between the attending and pulmonary doctor…

Call attending and tell him wife is confused…Do NOTHING!** Ethics Consult was requested by

pulmonologist…

Ethical Decision Making Process

Describe the problemGather the factsClarify valuesNote reactionsIdentify ethical PrinciplesClarify legal rulesExplore options and alternativesDecide on a recommendationDevelop an action planEvaluate the plan

Resolution Social Work and ethics chair spoke individually to

attending and pulmonologist to clarify goals of care and prognosis.

Social Work and ethics consultant spoke with patient's wife and she verbalized her confusion but had agreed to sign CMO and Withdrawal of life support at the time because she didn’t really understand what that meant…

Wife wanted to give her husband a chance to be weaned off ventilator and she rescinded the CMO and Withdrawal of Life Support forms

Patient had the scheduled trache done the following day Patient was transferred to vent floor and was transferred

to long term care facility for rehab…