md consult - clinical pragmatism, ethics consultation, and ... · clinical pragmatism, ethics...

Use of this content is subject to the Terms and Conditions

COMMUNICATION BETWEEN OLDER PATIENTS AND THEIR PHYSICIANS

CLINICAL PRAGMATISM, ETHICS CONSULTATION, AND THE ELDERLY PATIENT

Joseph J. Fins 1 2 3 MD Franklin G. Miller 2 4 PhD 1 Departments of Medicine (JJF) 2 Psychiatry (JJF, FGM) 3 Weill Medical College of Cornell University, New York Presbyterian Hospital-Cornell Campus (JJF)New York, New York 4 Department of Medical Education, University of Virginia,Charlottesville, Virginia (FGM)

Work on this article was supported in part by a Project on Death in America of the Open Society Institute Faculty Scholar Award to Dr. Fins and a bequest to the Medical Ethics program at the Cornell Campus of New York Presbyterian Hospital from the estate of Elisabeth Dent Wilson.

CLINICAL PRAGMATISM, ETHICS CONSULTATION, AND THE ELDERLY PATIENT Clinics in Geriatric Medicine - Volume 16, Issue 1 (February 2000) - Copyright © 2000 W. B. Saunders Company

Address reprint requests to Joseph J. Fins, MD Weill Medical College of Cornell University New York Presbyterian Hospital 525 East 68th Street F-173 New York, NY 10021

Although most readers of this article are not clinical ethicists called on to consult in cases that present difficult dilemmas, the skills used in ethics case consultation can be valuable in geriatric practice. In this article, we describe a process of moral problem solving for medicine that we call clinical pragmatism. [2] [3] [5] [6] [11] Our goal is to provide a structured and disciplined method of addressing ethical problems in medical practice that clinicians will find useful in their daily routines. The American Board of Family Practice has highlighted this approach to clinical ethics. [8] We hope that geriatricians find clinical pragmatism equally helpful as they strive to better integrate the technical and humanistic dimensions of patient care. After outlining the method of clinical pragmatism, we illustrate its use in a case involving an older patient refusing medical treatment. We conclude with comments on the importance of process in ethics case consultation.

CLINICAL PRAGMATISM

Clinical pragmatism has its philosophical roots in the American pragmatic tradition and the work of John Dewey (1859-1952), arguably the nation's greatest philosopher during the first half of the 20th century. [9] [10] Dewey was a pragmatist, democratic theorist, and education reformer. [4] He emphasized the interdependence of theory and practice and had a strong interest in using the scientific method of reasoning to address normative questions. [1] Rather than applying absolute moral truths, duties, or obligations, Dewey sought to articulate a process of analysis that would draw on empirical understanding and intelligent interventions to resolve moral problems. Dewey's reliance on inductive reasoning employed in the scientific method, and his life-long desire to integrate theory and practice in a way that would have a bearing on real life situations, makes his work an ideal foundation for ethical problem solving in the clinical setting.

of 8MD Consult - CLINICAL PRAGMATISM, ETHICS CONSULTATION, AND THE ...

04/03/2010http://www.mdconsult.com/das/article/body/0/jorg=clinics&source=MI&sp=1127779...

Like Dewey's pragmatism, clinical pragmatism does not view ethical principles as fixed or absolute truths. Instead it views principles as hypotheses that must be validated by their consequences for practice in light of clinical and narrative details. When only a single ethical principle is clearly at stake it can guide conduct. In more complex cases, however, in which two or more principles are at odds--for example patient autonomy and nonmaleficence--we must turn to the details of the case to resolve the dispute and help reach a reasonable consensus.

Our method focuses on the promotion of what Dewey called inquiry. We engage in this process through a contextually situated analysis. Our objective is to consider the range of medical and narrative facts necessary to reach a judgment about a reasonable course of action. In this way, clinical pragmatism is analogous to the process of differential diagnosis used in medical practice [5] (Table 1) . We begin with data collection, interpret our findings, negotiate with patients and their intimates, intervene, and then engage in periodic review. This is comparable to the diagnostic process used by physicians who collect data through the history and physical examination and then interpret the information through the promotion of a differential diagnosis.

Whereas physicians create a differential diagnosis that centers on complaints, signs, symptoms, physical findings, and laboratory tests, the clinical ethicist uses clinical pragmatism to develop an ethics differential diagnosis drawing on both medical and narrative facts. The goal in both cases is to delineate the range of possible options suggested by the data collection phase, communicate these findings and suppositions to the patient, negotiate a plan of action, make an intervention, and then assess its efficacy.

To further describe this method, let us delineate this process of inquiry. Inquiry begins with the recognition of a problematic situation. A morally problematic situation is one that needs deeper consideration because ethical tensions are present but as yet unexplored. Although problematic situations in clinical practice often are obvious in retrospect, they are not always recognized in a timely fashion or fully considered.

Once a situation is appreciated to be problematic, we can begin to collect the medical, narrative, and contextual details necessary for inquiry. This process is a series of related steps that can occur in sequence or simultaneously. In general, our evaluation begins with an assessment of the medical facts. The goal is to clarify the patient's condition, diagnosis, and prognosis and determine the patient's and family's knowledge and understanding of the clinical picture .(see Box 1)

TABLE 1 -- CLINICAL PRAGMATISM: METHODOLOGY

Clinical Pragmatism Clinical Analog

Data collection History and physical exam

Interpretation Differential diagnosis

Negotiation Communication

Intervention Therapeutics

Periodic review Follow-up

Box 1. Clinical Pragmatism and Inquiry

I. Recognition of the problem

1. Recognition of a problematic situation prompts inquiry

II. Data collection: Medical, narrative, contextual

1. Medical facts:

Determine and clarify clinical diagnosis



We then seek to assess the patient's preferences, decision-making capacity, religious beliefs, values, desires, and needs. This information is put into the context of the family dynamic and the impact of the patient's situation on the family unit. As we consider family issues, it is also critical to determine who is the spokesperson for the family if the patient is unable to speak himself or herself.

From family considerations, we turn to the influence that institutional factors may have on the provision of care. We pay attention to the continuity or discontinuity of the doctor-patient relationship, staff interactions, and the influence of the institutional setting on care. For example, it is important to know whether treatment is being provided at home or in a hospital, nursing home or hospice. Finally, we need to appreciate that the patient's case does not occur in a cultural vacuum. For this reason, we are sensitive to the influence of broader societal currents on care. The recent debate over physician-assisted suicide or ongoing dialogue about Medicare benefits are two examples of societal issues that could potentially influence the dynamics of a case.

Once we have collected this comprehensive array of medical, narrative, and contextual information, we can begin to formulate an ethics differential diagnosis and consider the range of reasonable moral considerations that might bear upon the development of a workable consensus to resolve the moral

Medical condition and prognosis Patient and family knowledge and understanding of the medical facts

2. Patient preferences:

Decision-making capacity Religious beliefs Values Articulated preferences Desires and needs

3. Family dynamics:

Impact of care on family members and others Burden of illness Identify spokesperson or surrogate decision-maker

4. Institutional arrangements:

Structure of care Continuity/discontinuity of care Clinical service Floor/boarder Attending/house staff/nursing interactions

5. Broader social norms/context

Access to health care Change in attitudes to death and dying



problem. Once we have completed this interpretative process, we can suggest provisional goals of care, offer the patient or family a plausible plan of action and agree on the next steps. Finally, because we are not moral absolutists and appreciate that we may have erred in our deliberations, we undertake periodic review to modify our course of action as necessary. This assessment can be an evaluation of action in an individual case or a systematic empirical appraisal designed to modify institutional practices (see Box 2) .

To illustrate our approach, we consider a case brought to the attention of the ethics case consultation service.

Box 2. Clinical Pragmatism: Interpretation, Negotiation,Intervention, and Review

I. Interpretation

1. Consider range of moral considerations:

Ethics differential diagnosis

II. Negotiation

1. Suggest provisional goals of care. 2. Offer a plan of action:

Plausible treatment and care options

3. Negotiate an acceptable plan of action:

Consensus

III. Intervention

1. Implement the agreed-on plan

IV. Periodic review

1. Evaluate the results of the intervention 2. Undertake periodic review 3. Modify the course of action as the case evolves 4. Organize empirical observations to reconstruct clinical practice

Case Presentation

SM is a 94-year-old woman with a broken arm. * She had been brought to the hospital by ambulance after falling. Given the emergent nature of her fall, she was transported to the nearest hospital and not the facility where she generally received her care. She was admitted with a closed but complicated fracture of the humerus. Four days after admission, she wanted to leave the hospital and sign out against medical advice. After trying to elope, she was seen by psychiatry, and treated with haloperidol. She improved with medication.

The patient lives alone in her apartment with 'round-the-clock help who she frequently dismisses. She is able to manage her finances. Her only family is a cousin or nephew. Staff describe him as a "weird guy" who "obviously was waiting for her money." He reportedly has promised her that she will never have to go to a nursing home.

CASE ANALYSIS

The Problematic Situation

When responding to a narrative such as this it is important to make explicit many of the assumptions and unarticulated goals and conflicts that are embedded in the case presentation. Although this was all the



information initially shared with the ethics case consultation service, it contains multiple issues that need further exploration.

As we approach this case, we must determine what prompted the clinical team to ask for an ethics consult. How did the clinical staff see the problem and what led them to feel that they needed additional assistance to address this patient's treatment refusal? Is their call for assistance a reflection of the power dynamics that often occur when patients refuse the recommendations of their physicians? Or does it reflect conflicting goals of care on behalf of the clinical team and the patient? By asking these questions, we can begin to untangle this problematic situation. At this juncture, it appears that the clinical team has curative goals of care for this elderly patient. They want her to stay in the hospital so that her arm can be repaired. The patient, however, wants to leave.

To compound this tension between patient and clinical staff, the narrative suggests that there may be an implicit bias against the aged. Is the interpretation of her treatment refusal by staff a reflection of their presumptions about the cognitive ability of such an elderly patient to make decisions about care, continued hospitalization, or other treatment? Is there enough information about the patient's functional status to suggest that she is cognitively impaired?

From the patient's point of view, the narrative leads us to ask whether the patient is fearful of institutionalization. After all, what we know of the relative's conversations with her is that he promised that she will not have to go to a nursing home. The references to the relative also point to another potentially important feature of the problematic situation. His exact status as nephew or cousin must be resolved, pointing to the inadequacy of the family history. His description as a "weird guy" motivated by inheritance may be a biased appraisal but suggests a need for vigilance regarding his motives. Furthermore, it alerts us to a potential conflict that already exists between the relative and the clinical staff who requested a consult. Finally, the case points to eventual problems with informed consent for any proposed treatment. If the patient is found not to have decision-making capacity, who should provide consent for treatment? This question points to the potential need to identify a surrogate decision-maker.

Inquiry

Medical Status

With these issues in mind, we begin to focus our process of inquiry. Our objective is to elucidate the medical, narrative, and contextual details of the case. Clinically, we must determine and clarify the clinical diagnosis and assess the patient's medical condition and prognosis. Specifically, we need to know what precipitated the fall. Was it mechanical, for example, a stumble on a slippery carpet? Or was it prompted by a neurologic or cardiac event? Discussions with the medical team reveal that the fall was precipitated by an arrhythmia.

In addition to knowing why she fell, we also must determine if any other medical consequences resulted from her fall. For example, did she have a subdural hematoma or concussion that could have led to acute cognitive impairment? Did she have injuries other than her broken arm or untreated pain that could affect her mood and interactions with staff? Finally, did she lose her glasses or hearing aid during transport to the hospital? The loss of such assistive devices could transform a functional nonagenarian into one easily viewed as demented or otherwise impaired.

We turn next to the treatment recommendations that were made by the patient's physicians. Her orthopedists recommended conservative treatment and immobilization over surgical repair of her closed fracture. Their risk-benefit assessment was related to their concern about the cardiac precipitant that led to the patient's fall. The cardiology consult service, however, after their management of her arrhythmia and noninvasive assessment, which included telemetry, resting nuclear scan, and an echocardiogram, felt that it was safe to take the patient to the operating room.

From a psychiatric standpoint, we must determine whether the patient has decision-making capacity--the ability to make rational and informed decisions about her own care. Additional historical information was provided by her relative. He described the patient as "being demented for a number of years." In addition he reported that she was quite particular about her housekeepers. He also commented that the patient's geriatrician had said that the patient was demented.

To help clarify the patient's ability to participate in decisions about her care, psychiatry was asked to consult. The psychiatrist noted that the patient did not want to have an operation. She was fearful of the



surgery and was medically sophisticated, having worked many years ago in a hospital. Her experience as a hospital worker had made her wary of institutions. She was intelligent with mild dementia but not delirious, was not depressed, and did not want to die. She was aware of her general situation but fearful that she might die from surgery. The psychiatrist felt that this was a reasonable fear, although the patient was hesitant to enter into a dialogue about the consequences of not having surgery. He found her distrustful, but not formally "paranoid" and concluded that the patient had decision-making capacity but that it was a "close call." The patient's consulting cardiologist and a medical resident, however, disagreed with the psychiatric assessment. They felt that the patient was demented, "vague and only clear to a point."

To put all this medical information to use, we also must determine the consequences of surgical versus nonsurgical management on the patient's baseline functional status. Finally, we must determine if there is need to operate within any particular time frame to optimize a surgical result.

Patient Preferences and Family Dynamics

Given that the consultant psychiatrist found her able to participate in medical decisions, we now turn to the patient's perspective on care. In discussions with a member of the ethics consultation service who was not otherwise involved in providing medical care to her, the patient emphasized her desire to live independently and the importance she placed on her autonomy. She also expressed a desire to be treated by her own doctor.

The patient's family situation was clarified. She lived alone and was socially isolated, having survived her generational cohort. She was financially secure. Her only relative was the individual described uncharitably in the initial call to the ethics consultation service. It was determined that he was the patient's nephew. Contrary to his earlier characterization, he was found to be an advocate for his aunt. He wanted her to receive the best available care; he did, however, admit frustration with her frequent dismissal of home health aides who were essential to her living alone.

Institutional Context

We next turn to the influence of the hospital setting on the development of this case. In this analysis we must pay special attention to the structure of care provided to the patient and how this might influence her perceptions and decision-making. Her medical record revealed that multiple teams of residents, attendings, and consulting physicians were involved in the patient's care from the medical, psychiatric, and orthopedic services. To further complicate matters, she had experienced a rotation of house staff during her brief hospitalization.

Moreover, the physicians from differing services were not communicating well with each other. They were involved in a power struggle over treatment plans for the patient. As already noted, the orthopedic surgeons were hesitant to bring the patient to the operating room. They appeared to overstate the risks of surgery in order to avoid operative morbidity or mortality. The cardiologists, however, felt that she was an acceptable operative candidate. This disagreement over treatment recommendations was communicated to the patient by each service when they saw the patient during their respective rounds. Conversations with the patient and her nephew were not coordinated by the clinical services involved in her care.

Interpretation

The Ethics Differential Diagnosis

With this wealth of clinical and narrative information, we are ready to make some speculations about the genesis of the patient's treatment refusal. In this case, the ethics differential diagnosis is broad, ranging from the medical to the psychological to the social context of her care in the hospital.

To be inclusive with our differential we must consider impaired decision-making from an acute or chronic cognitive impairment. The lingering question of the patient's decision-making capacity was resolved by contacting the patient's geriatrician and by obtaining an additional psychiatry consult. Contrary to earlier reports, the patient's geriatrician affirmed that the patient has always had decision-making capacity. Furthermore, he denied ever telling the nephew that the patient was demented. The additional psychiatry consultation also confirmed that the patient had capacity.

The more likely cause of her treatment refusal and distrust of her doctors was contextual and related to her hospitalization. She had suffered from discontinuity of care and had received mixed messages from



her cardiologists and orthopedists. Having been labeled as demented by some of her physicians, she had been given incomplete information about her medical condition and been excluded from the decision-making process. Beyond this, her nephew, who was her lone advocate, had been erroneously characterized by staff who failed to form an alliance with him. This marginalization of the patient and her nephew could have heightened her suspicion and distrust. All of this was likely compounded by her historic aversion to institutionalization and the anxiety of being hospitalized where her own doctor did not have privileges.

Negotiation and Intervention

Reaching a Consensus on the Goals of Care

At this juncture it is appropriate to share these diagnostic impressions with the patient and negotiate shared goals of care. The ethics consultant sought to foster trust by ensuring that the patient was included in decision-making and that she understood her medical condition and available treatment options. Every effort was made to coordinate recommendations made by her clinical teams to minimize conflicting messages and confusion and to involve the patient's own geriatrician in these deliberations. This resulted in a recommendation for the patient to have surgery. In addition, psychiatry was asked to provide additional support to help the patient explore her fear of institutionalization.

By addressing the reasons for the patient's discomfort with her hospitalization, respecting her ability to participate in decisions about her care, providing her with necessary medical information, and involving her own physician in these discussions, the patient was able to articulate her goals of care. She stated that she wanted to retain her functional status and wanted neither to be institutionalized nor die from surgery.

Given the patient's articulation of her goals of care, the ethics consultant was in a position to offer a plan of action including potential care options. With the assistance of the patient's own doctor by phone, this resulted in a recommendation for surgical repair of her broken arm. This seemed to be the only way to meet all of the patient's goals of care. Operative mortality risk was low. Furthermore, surgery could preserve her functional status and preclude institutionalization or prolonged rehabilitation.

Outcome and Retrospective Review

Although these interventions promoted patient trust and facilitated dialogue, they did not change the patient's mind about surgery. She continued to refuse surgery at our institution. Conversations with her geriatrician, however, prompted the patient to request that he assume responsibility for providing care. He agreed to see the patient in follow up and the patient agreed to a release of the medical record to him. Home care arrangements were made and the patient then signed out of the hospital, asserting her right to a treatment refusal.

At first glance, this outcome seems to be a failure. After all, the patient did not receive needed surgery and she left the hospital. But closer examination suggests that this was an ethically acceptable outcome, even though it was not the one initially preferred by either clinical staff or the ethics consultant. It could even be argued that this was the only reasonable outcome, if we consider that the only way to have her treated at our institution would have been to obtain a treatment order from the court for surgery. Since her fractured arm was not a life-threatening condition and she was found to have decision-making capacity, it seems highly improbable that a court would deem her incompetent and order treatment over her objections.

Clinically, allowing the patient to leave the hospital and follow up with her physician avoided the likely prospect of noncompliance at our institution and allowed her to obtain the emotional support of a long established doctor-patient relationship. Indeed, subsequent follow up confirmed the patient is doing well and living at home. She is receiving medical care from her own doctor and referral has been made to a local orthopedist. Thus, this outcome suggests that her refusal of treatment at our institution was not a rejection of treatment. It was simply a modification of where treatment would be provided.

Most critically, from a normative point of view, this outcome illustrates that the systematic and deliberate development of this patient's narrative led to the avoidance of a moral harm: the forcing of an unconsented to bodily invasion or treatment on a patient who had the capacity to refuse it. This moral harm was avoided by focusing on the interpersonal dimensions of care and addressing the distorted exchanges between the staff and the patient and the disjointed communication among members of the



medical team.

Although this intervention did not alter the patient's objection to treatment or result in medically optimal care, this effort did bring the parties together and lead to a reasonable plan of action given the constraints imposed by the patient's preferences. Although this result was an acceptable outcome in this case, retrospective review of the clinical scenario suggests the need to prevent such conflicts by developing organizational reforms that promote improved communication and enhance continuity of care.

CONCLUSION

This case illustrates the value of the pragmatic method of moral problem solving when addressing ethical dilemmas in geriatric practice. By focusing on a comprehensive process of inquiry, the use of clinical pragmatism led to an ethically appropriate result even though it may not have been the one that was anticipated at the outset. Although this process may be unsettling to some, it should be reassuring to those who appreciate that a thorough process of inquiry and deliberation is best positioned to yield a satisfactory result. [7] In medical ethics and in clinical practice, it is improper to engineer outcomes that will not withstand the test of consensus or peer review.

References

1. Dewey J: The logic of judgments of practice. In Hickman LA, Alexander TM (eds): The Essential Dewey: Ethics, Logic, Psychology, vol. 2.

Bloomington, Indiana University Press, 1998, pp 236-271 2. Fins JJ: Approximation and negotiation: Clinical pragmatism and difference. Camb Q Healthc Ethics 7(1):68-76, 1998 Citation 3. Fins JJ: From indifference to goodness. Journal of Religion and Health 35(3):245-254, 1996 4. Fins JJ: Klinischer pragmatismus und ethik-konsultation (Clinical Pragmatism and Ethics Case Consultation). Das Parlament 49, Jahrgang/Nr.

23, 4 Juni 1999, p 18 5. Fins JJ, Bacchetta MD: Framing the physician-assisted suicide and voluntary active euthanasia debate: The role of deontology,

consequentialism, and clinical pragmatism. J Am Geriatr Soc 43(5):563-568, 1995 Full Text 6. Fins JJ, Bacchetta MD, Miller FG: Clinical pragmatism: A method of moral problem solving. Kennedy Institute of Ethics Journal 7(2):129-145,

1997 7. Fins JJ, Miller FG, Bacchetta MD: Clinical pragmatism: Bridging theory and practice. Kennedy Institute of Ethics Journal 8(1):39-44, 1998 8. Fleetwood J, Lipsky M: Medical Ethics: American Academy of Family Physicians Home Study Self-Assessment, Series IV, Monograph 231.

American Academy of Family Physicians, 1998 9. Hook S: John Dewey: An Intellectual Portrait. Amherst, NY, Prometheus Book, 1995 10. Miller FG, Fins JJ, Bacchetta MD: Clinical pragmatism: John Dewey and clinical ethics. J Contemp Health Law Policy 13(27):27-51, 1996 Citation 11. Miller FG, Fletcher JC, Fins JJ: Clinical pragmatism: A case method of moral problem solving. In Fletcher JC, Lombardo PA, Marshall MF, et

al (eds): Introduction to Clinical Ethics, ed 2. Frederick, MD, University Publishing Group, 1997

*Some element of the case have been changed to protect the confidentiality of the patient Essential facts have not been altered.

Copyright © 2010 Elsevier Inc. All rights reserved. - www.mdconsult.com

Bookmark URL: /das/clinics/view/0/N/11277796?ja=216045&PAGE=1.html&issn=0749-0690&source=MI



md consult - clinical pragmatism, ethics consultation, and ... · clinical pragmatism, ethics...

Documents