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It’s All Ethics in Health Care

Kentucky / Tennessee Chapter6th Annual Case Management

ConferenceSeptember 6, 2012

Objectives

At the end of this presentation participants should be able to:

Identify key principles in health care ethics.

Describe specific ethical concerns commonDescribe specific ethical concerns common to all patients.

Describe unique ethical issues at the end-of-life.

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What is Ethics?It can be about resolving dilemmas, but not only this.

It can be about individual actions, but not only this.

It is also about what kind of persons we are becoming – our character and how our choices shape us.

Ethics is ultimately about human flourishing, about living well, about achieving good through means that are consistent with real human values and needs.

Stake Holders

HCF’sOther HCPs

University

Family

ProfessionNurse

University

Patients

Pt. Families

Profession

Society

What is Organizational Rthics?

It can be about compliance, but not only this.

It can be about due diligence, but not only this.

It can be about resolving value conflicts, but not only this.

Organizational ethics is primarily about integrity, about making decisions that are consistent with the moral identity and values of the organization, so that the organization, its employees, and the communities it serves can truly flourish.

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ModelProfessional’s

ObligationNature of

RelationshipNature of

Health Care

Contractual

Business Commodity

Service

Buyer/Seller

Contracting

Commitment,Skill

Supply specific

Health Care Models

Preventive

Covenant Obligation

Life-style

Sacred trust

Unilateraloption

equals

Commitment tolife

N/A

Beneficent Negotiatedgood

Trust(fiduciary bond)

Act for good ofpatient

service

Moral CompassVision

Ethics

Mission

Values

Ethics

ANA Code of Ethics1. Compassion and respect for human dignity.2. Primacy of the patient.3. Advocacy for the patient.4. Accountability for nursing practice.5 D t t lf d th5. Duty to self and others.6. Improving care environments and

employment.7. Advancing the profession.8. Collaboration with other professionals

and the public.9. Obligations to the profession, social reform.

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Law and Ethics

Protect Ethics/Reduce Liability Identify and clarify the dilemma

Demonstrate good judgment

Communicate effectivelyy

Facilitate negotiation

Improve decision-making

Ethics is the ceiling, law is the floor

Ethical Dilemmas

Conflict between two ‘rights’

Principles, decision making frameworks, or tools help clarify what is important.

Ethics processEthics process

Goal/hope: a 3rd way forward Something besides two extremes

Ethics Lessons LearnedElemental work is to protect (the most vulnerable)from harm(s).

Functions may serve as a social safeguard for complex areas with potential harm(s).

Issues relate to difference.

Conflicts also present emotional, psychological, communication challenges.

Need awareness of values in play, conflicts of interest.

Ethical theories help clarify, strengthen understanding.

Ethics is a group activity, levels the playing field.

Highly individualized decisions worked out in the context of relationships vs. board rooms.

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Role of Ethics MechanismsImprove and enhance the quality of care Care of employees

Education Committee, staff, community

AdministrativeP li d l t d i Policy development and review

Oversight and comment on operations with ethical impact

Consultation and case review Conflict resolution

Inform other institutional efforts Regulatory compliance Reduction of costs (without increasing mortality)

The Ethics Iceberg

Case consultsDecisions and actionsCrisis oriented

What is really going on?Environment, culture Personal

Patterns and trends Systems and processes Polices, procedures

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Common Issues

Clinical: Patient andFamily Issues Patient rights Advance directives Surrogate decision

Organizational: Hospital /System’s health Resource allocation Conflict resolution Surrogate decision

making Goals of care Code status End of life Culture and Religion Access/coverage Mediation

Conflict resolution Conflicts of interest Confidentiality Research Public actions Access Quality & Safetu Mediation

Consider this Case…

Mrs. B is 72 with a long history of cardiac disease including a recent MI in the last 3 months.At in patient rehabilitation, doing well, when she suffered a massive left-sided stroke Paralyzed on the right Profound expressive aphasia to non-responsiveness Can’t swallow – nasogastric tube in place.

No improvement over 10 days with aggressive therapy, including surgical intervention and ventricular drain placement Neurological decline, MRI revealed that the stroke has expanded Aspiration pneumonia – on mechanical ventilation.

…case continued

Glasgow coma scale of 5-6Neurologist and neurosurgeon believe no chance for improvement.Primary care physician reports that this is exactly the kind of situation she wanted to avoid Completed medical directives with instructions about

such a condition, appointed a decision maker Many conversations about her wishes No artificial supports if she was not going to recover

to independence.

Decision maker (POA): her sister. Alternate: cousin.

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…case continued

Sister demands the patient have PT and OT services to help to heal her. She also refuses to carry out Mrs. B’s wishes, LW instruction can’t be right, obviously the patient was coerced The sister feels her appointment trumps the living will instruction

The documents appear valid

Cousin not surprised by the sister’s response. Willing to carry out the patient’s wishesFamily and friends report the instruction is exactly what the patient always said to do in a situation like this. All feel sister is crazy

ICU attending is spooked by the sister’s threats of lawsuit and asks for an ethics consult.

Process

Is there a moral or ethical issue?

Who are the stakeholders?

What are the relevant facts?

What values are at stake?What values are at stake?

What are the options?

What resources might be helpful?

Are there legal or ethical norms at stake?

Am I comfortable with the decision?

Make a decision and evaluate its results.

Principled Decision Making adapted from Robert Orr, MD

Respect for lifeTruth tellingNon-exploitationAdvocacyBenefit/burden

Free willObedience

StewardshipFaith

SovereigntyDominion

God’s purpose

FAITH BASED

SECULAR

DiagnosisPrognosis

ValuesGoals

Patient Preferences

Medical Indications

Non-Maleficence Autonomy

Sanctity of lifeCompassion

ServiceMeritorious suffering

Redemptive sufferingContentment

MercyGraceHopeScriptureEternityRitualSocial justice

PrognosisTreatment options

GoalsWishes

SocialCultural

LegalFinancial

PhysicalPsychologicalSocialSpiritual

Contextual Features

Quality of Life

Non-Maleficence

BeneficenceJustice

Autonomy

Fidelity

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Strategies and Obligations

Understand the patient

Understand the disease

Understand the system

Understand yourself

Understand the Patient

How do they make sense of life? Role in the family

Employment

Social factors Social factors

Cultural factors

Spiritual factors

Special Populations

Elderly

Children

Cognitively impaired

Substance use/abuse history

Cultural, spiritual, or religious considerations

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Decision Making Capacity

Incompetence is a legal determination General or specific incapacity

Decision making capacity Is the information understood? Can the person reason, appreciate the Can the person reason, appreciate the

consequences? Dialog with you? Can the person make a decision?

Reassess for each decisionCaution with neurological conditions, intubated patients, medications, psychological conditions

Determining the Surrogate

Is there paperwork? Power of attorney

Healthcare

General---may also have healthcare language

Durable Durable

Court appointed decision maker Guardianship, conservatorship

Determine validity of any documents Reasonable person determination

Reconcile conflicts

Examine the relationships

Who Speaks for the Patient?

Best Interests No clear idea

Reasonable person in similar circumstances

Implied consent

S b tit t d J d tSubstituted Judgment Specific statements

Goals, values, wishes

Step into the patients shoes

State Law Community standard

Healthcare surrogate rules

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Living Will

Can’t make decisionsTerminal/irreversible Desire natural death Artificial nutrition Organ donation Pain treatment even if death may be

hastened Need two witnesses or a notary End of life document

Proxy Directives

Durable Power of Attorney for Health Care (DPAHC)/Health Care Agent Any time a person can’t make decisions

Appoint a decision maker Appoint a decision maker

Need two witnesses or a notary

Applies in a broader range of circumstances including end of life.

DNR OrdersHospital DOES NOT mean

“do not treat”

NOT automatic with living will

Out of Hospital Applies between

facilities

Applies at home

Discharge planning Requires more

nursing hours

g p g

Universal DNR

POLST or POST Mandatory for out of

hospital DNR

Meant for end of lifeCPR

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Healthcare Surrogate Selection

1. An adult who has shown special care and concern, who is familiar with the patient’s values and who is reasonably available.

2. Preference for a. Spouse

b. Adult child

c. Parent

d. Sibling

e. Any other relative

f. Adult who satisfies #1

Not mandatory, should rule out

persons higher onlist first, document

No People/No Paperwork

Attending/treating physician must get: Ethics recommendation OR Second

attending level physician Not directly involved in the patient’s care Not directly involved in the patient s care

Not in a capacity of decision making or influence over/under the attending MD

Concurs in the decision, documented in the record

Any treatment decision including research

…case continued

Ongoing conversations, negotiations

Eventually the sister agrees to hospice care Patient expires 4 days later.

Hospice people attend the funeral, paid special p p p , p pattention to helping the sister through the death

From stroke to death, it was about 21 days.

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Understand the Disease

Natural course of the disease Symptoms

ChronicSpiritual dis-ease Fear

Acute Fear

Isolation

Guilt

Grief

Trust

Expanded Notion of Pain and Suffering

Physical: “pain” in all its forms Delirium, dyspnea, agitation, constipation, etc.

Any physical symptom

Psychological/emotional Fear, anxiety, grief, guilt, confusion

Social Isolation, abandonment

Spiritual Questions of meaning, relationship to God,

challenges to personhood

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Understand the System

Cure orientation High tech Uncertainty Fragmentedg Organ based

Lack capacity Surrogates probably don't know

EconomicsIllness and death are bad, not normal

Chronic, Eventually Fatal Illness

CURE PALLIATIVE

DE

AT

H

Time

Melvin TA. The primary care physician and palliative care. Primary Care Clinics in Office Practice.2001;28:239-248.

FURTHER READING:

New Model of Care

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Integrated Palliative Care

Symptom management Pain in all its forms, in all realms Comfortable enough to be functional

Communication managementI f ti fl Information flow

Anticipatory planning

Environmental management Adaptive and therapeutic

Resource management and referral Social services, pastoral care, financial

counseling, meals on wheels

Issues in Care of the Dying

Tension between two extremes Use of (possibly)

burdensome t h l

Care even when cure is impossible

Effective management of pain

technology

Withdrawal of technology (possibly) intending death Killing vs. letting die

g pin all its forms Management of

suffering

Refusal

WithholdLetting Die

Assisted SuicideWithdraw

Euthanasia

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“Sorry I’m late, but they had me on a life support system for two months.”

Understand Yourself

Seek first to understand, then to be understood.

• Covey

Moral Distress…

“Painful feelings and/or the psychological disequilibrium that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible toconstraints make it nearly impossible to pursue the right course of action.” Jameton A. Nursing Practice: The Ethical

Issues. NJ:Prentiss-Hall. 1984

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…distress

“…the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility and makes a moral judgmentresponsibility, and makes a moral judgment about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing.” Alvita Nathaniel MSN, RNCS

In Nursing World, July 28, 2002

Other Distress

Compassion fatigue (CF) Gradual lessening, over time of ability to be

compassionate. The price one pays for caring. Emotional stress experienced from exposure to

th ff i f ththe suffering of others.Secondary Traumatic Stress (STS) Presence of Post-Traumatic Stress Disorder

(PTSD) in the caregiver.Both STS and CF are caused by exposure to persons who have been traumatized or are suffering, not to the traumatic event itself. Vicarious traumatization

Contributing FactorsTeam function

Role/Relevance questions

Closeness/Identification

Isolation

Lack of, staff, skill, time, resources

Acuity

Cure orientation/Death as failure

Belief “doing everything” a sign of faithfulness

Assertive/aggressive patients and families

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Causes…

Feelings of failure or guilt

Futility

Compromise of one’s standards of care

Inadequate staffing Inadequate staffing

Inability to meet perceived needs of patient

Lack of resources, services

Feelings of powerlessness or helplessness

Inability to talk about feelings

…causes

Limited role in decision-making

Decisions contradict patient’s “best interest”

ConflictConflict

Inter-disciplinary or intra-disciplinary

Patient or family

Sustained proximity contributes to sense of responsibility

Others walk away

…causesLack of/or confusion about plan

Too many partners or consultants

Communication failures

Within team

With patient/family

Grief and loss

Repeated

No time to process

Lack of closure

Isolation

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Crescendo Effect

Solid lines indicate moral distressDotted lines indicate moral residue

Moral Distress

Moral distressd

TimeMoral residue crescendo

Moral residue

crescendo

Symptoms…

Fatigue Emotional, physical

Somatic concerns Diet, sleep, physical illness

AbsenteeismAbsenteeismPoor or inappropriate care Recipients of care Self

Feelings of inadequacy Personal, professional Feeling victimized Feeling traumatized

…symptoms

Irritability, anger, insults, resentment, conflicts

Anxiety

F t tiFrustration

Depression

Blaming others

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…symptoms

See self as having lost Integrity

Authenticity

Di t i lfDistancing oneself Isolation

Friends, family

Colleagues

Loss of meaning Crisis of faith

Other Costs

Operational

Legal

Marketing and public relations

Competition Wages

Price

Efficiency

Cost of capital

Customer service, patient rights,

Organizational awareness,performance improvement, information management

Cost control, safety, infection control,

facility, others

Self esteem/self confidence

Accountability, self-control, and resilience

Professionalism/self-development/respect and rational decision making

p gcommunication, and teamwork

Decker, Hospital Topics, 1999

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Additional Slides

Principled Decision Making adapted from Robert Orr, MD

Respect for lifeTruth tellingNon-exploitationAdvocacyBenefit/burden

Free willObedience

StewardshipFaith

SovereigntyDominion

God’s purpose

FAITH BASED

SECULAR

DiagnosisPrognosis

ValuesGoals

Patient Preferences

Medical Indications

Non-Maleficence Autonomy

Sanctity of lifeCompassion

ServiceMeritorious suffering

Redemptive sufferingContentment

MercyGraceHopeScriptureEternityRitualSocial justice

PrognosisTreatment options

GoalsWishes

SocialCultural

LegalFinancial

PhysicalPsychologicalSocialSpiritual

Contextual Features

Quality of Life

Non-Maleficence

BeneficenceJustice

Autonomy

Fidelity

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The 4 Topics Method of Case Analysis (Clinical Ethics, 5th Ed., Jonsen, Siegler, Winslade)

Medical Indications

Patient Preferences

Quality of Life

Contextual Features

Systematic method for identifying pertinent features of a case.

Not exactly a system for resolution.

Medical Indications

What is the story about the disease? How does the patient/family understand it?

What is the patient’s medical problem? History? Diagnosis? Prognosis?History? Diagnosis? Prognosis?

Is the problem acute? Chronic? Critical? Emergent? Reversible?

What are the goals of medical treatment?

Patient Preferences

What is the patient’s story? Who are they to this family?Is the patient decisional?What has the patient stated regarding his/her t t t f ?treatment preferences? Has the patient been informed of the benefits & risks, understood this information, and given consent?If incapacitated, has the patient expressed prior wishes? Is there paperwork?Who is the appropriate surrogate?

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Quality of Life

How does the patient define QOL?What physical, mental, and social deficits is the patient likely to experience if treatment succeeds?What are the prospects, with or without treatment, for a return to normal life?Is the patient’s present or future condition such that his or her continued life might be judged undesirable?

Contextual Features

Who is the patient to this family?

Family or social issues that might influence treatment decisions?

Provider issues? How do we feel about this story?

Financial considerations? What is really possible in this story?

Religious/cultural factors?

Legal considerations?

Allocation of resources?

Death Trajectories

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Death

MI, Accident~10-15%

Sudden Death

Time

Fields, M., Cassell, C. (Eds) Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press 1997.

FURTHER READING:

Death

Non Small Cell Lung Cancer,

Pancreatic Cancer

Progressive Disease with a Terminal Phase

Time

Death

Cancer~10-15%

Chronic, Eventually Fatal Illness, “Sudden” Death

CHF, COPDDM, AIDS

Neuro

Time

Death

Neuro~70-80%