practical medical ethics

Patama Gomutbutra MD.Dip., Thai Board of Family MedicineGrad Cert in Palliative Care APHN,UCSF

Dip., Thai Board of Neurology_____________________________

[email protected]

Practical medical ethics inPalliative care

1. Definition and elements of Palliative care

2. Advance care plan

3. Medical ethics

Outline

Case demonstration

60 years old widow no child. she is known case end stage colon cancer PPS 40% (mostly bed bounded) she was admitted from sepsis and multiorgan failure she developed arrest. She talked with relatives want to die peacfully without CPR. However, she had no formal living will or any surrogate decision maker.

If you are her physician, what would you do.A. CPR

B. Respect her choice let her go

• การดแลแบบบรบาลบรรเทา (Palliative care)

• การดแลในระยะทาย (end of life care)

• การดแลแบบบานพกระยะทาย (Hospice)

1.Definition

WHO’s definition of palliative care

Palliative care NOT for Euthanasia/ Suicide

Palliative care Vs End of life care

EAPC recommendation: standard and norms for hospice and palliative care 2009 http://www.eapcnet.eu/Themes/Organisation/EAPCStandardsNorms.aspx

Simplified version

Elements of Palliative care

• Wish

•Living will

•Surrogate decision maker

2.Advance care plan

• Spiritual• Goal oriented • เชน อยากกลบไปเสยชวตท�บาน อยากมสตรตวเพ�อภาวนา อยากหลบไปแบบไมทรมาน อยากกลาวขอบคณ ขอโทษ ใหอภยกบใคร

Patient preference ( Wish )

• Medicolegal • Procedural oriented • เชน การขอรบหรอไมรบการใสทอชวยหายใจ การขอรบหรอไมรบการกดนวดหวใจฟ� นสญญานชพ การขอรบหรอไมรบอาหารทางสายใหอาหาร

Advance directive( Living will )

• Legal (optional)

• Decision maker when patient lack decision capacity

Proxy nominator(Durable Power of Attorney)

Tool Form Limitation

1. Living will Paper document

Procedure oriented

Medical knowledge

Not available at time need

2.Durable Power of

attorney : DPOA

Designated person Medical knowledge

60% Mismatch between patient

and surrogate will

3.Five wishes© Web based Medical knowledge

4.Physician Orders

for Life Sustaining (

POLST)

Physician order after

discussion with

patient and family

Some physician may feel

discomfort

Advance care plan tools

Living will

Original living will

DPOA

5 wishes ?

Thai living will

DPOADPOA

Wish 1: บคคลท�ขาพเจาไววางใจใหตดสนใจแทน "หากขาพเจาหมดสต หรอไมสามารถตดสนใจเองWish 2: ขาพเจาตองการรกษาลกษณะใดWish 3: ความสขสบายท�ขาพเจาหวงใหเปนWish 4: ขาพเจาอยากใหคนท�ดแลปฏบตกบขาพเจาเชนไรWish 5: ส�งใดท�ขาพเจาอยากใหคนท�รกรบร

Five Wishes

What really work for Thai ?

http://www.budnet.org/sunset/sites/default/files/Baojai-final-2559-9-26.pdf

• Medical dilemma:When ‘save life’ is not absolute answer

• Medical ethicsA systematic decision making in medical dilemma

* 3.Medical ethics

Common dilemma in palliative care

• If this treatment futile? ( worth or not?)

– Quatitative futile : survival, chance to recovery

– Qualitative futile : Quality of life

• Example

– Antibiotic in end of life penumonia

– Percutaneous gastromy feeding in dementia

– CPR in terminal case

– Anticoagulant in bed bounded stroke

Basic principle

• Autonomy

• Beneficence

• Confidentiality (Loyalty)

• Do No harm (Nonmaeficence)

• Equity (Justice)

Apply to everyday practice

1. Medical indication

2. Quality of life

3. Patient preference

4. Contextual feature

Jonsen’s 4 boxes model

Simplified version

1. Medical indication :

– Beneficence + Do no harm

– ‘Worth to treat’ Risk vs Benefit by evidence based

– Quantitative measureemnt ie survival, chance to recovery

vs risk of adverse effect

Double effect principle

• การรกษาท�เปน “ดาบสองคม” ท�ถกจรยธรรม ตองมครบท �ง 4 ขอ1. การกระทาน �น (ท�ยงไมเกดผล)ไมผดตอศลธรรม

The nature-of-the-act condition2. ผกระทามเจตนาใหเกดผลด

The right-intention condition3. โอกาสเกดผลด มากกวาเกดผลเสย

The proportionality condition4. ผลดตองเปนผลของการกระทา

ไมใชเกดผลรายกลายเปนดThe means-end condition

Double effect principleDouble effect principle

Double effect principle : Vaccine

การผลตยา และฉดยา

= Morally neutralผฉดมเจตนา ปองกนโรค

= Good intentionผลขางเคยงรายแรง (เชน ตบวาย) มได แตโอกาสเกดข�นนอย

= Good effect outweighs bad effectผลของการปองกนโรค เกดจากการฉดยา ไมไดเกดจากตบวาย

= Good ends not justify by evil means

Double effect principle : Terminal sedation

การใหยาโดยแพทย (ไมใชใหใครส�งยาใหกได)

= Morally neutralมเจตนาบรรเทาอาการเจบปวดทรนทราย

= Good intentionขนาดท�ให ปรบตามความอาการ โอกาสกดการหายใจมไดแตนอย

= Good effect outweighs bad effectผลของการบรรเทา เกดจากการหลบ ไมไดเกดจากกดการหายใจ

= Good ends not justify by evil means

* จงไมควรเขยนวา drip morphine for good death

2. Quality of life :

– Beneficence + autonomy

– ‘Worth to treat’ concern well being

– “Well being” in patient’s view

– Function ie ADL = predictive factorPerception = true indicator

3. Patient preference

– Autonomy

– Individual value vs Decision making capacity

– Patient’s advance care plan

1. General cognition : Awake + AttentionDepression and uncontroled symptom

2. Understand information : Tell me your understand about ‘Endotracheal tube’

3. Know consequence : Why you choose no Endotracheal tube

Decision making capacity test

4. Contextual feature

- Justice and Confidentiality

4.1 Family

– Family dynamics

– Care giver burden

4.2 Health care provider

– Cost

– Resource allocation

4.2 Society and religious value

- Reputation

Case demonstration

60 years old widow no child. she is known case end stage colon cancer PPS 40% (mostly bed bounded) she was admitted from sepsis and multiorgan failure she developed arrest. She talked with relatives want to die peacfully without CPR .However, she had no formal living will or any surrogate decision maker.

If you are her physician, what would you do.A. CPR


From 100 metastatic cancer who received CPRhow many survival to discharge?

A. 0

B. 5

C. 15

D. 30

Apply to everyday practice

1. Medical indication : -

2. Quality of life : -

3. Patient preference : +/- (no living will)

4. Contextual feature : - (ICU?)

Sum : - not encourage CPR

Exercise cases :A

60 years old widow no child.she is known case end stage colon cancer PPS 40% (mostly bed bounded) suffered from depression took overdose morphine : she was brought to ER with coma and reparatory depression (RR=6/min), she write in notepad that ‘No need helping, please let me go’. However, she had no formal living will or any surrogate decision maker.

If you are ER physician, what would you do.A. Intubation


Analysis

1. Medical indication : + Since cause is toxicity-> high chance of reversibility

2. Quality of life : -After reverse she may worsen PPS worsen spiritual suffering

3. Patient preference : + /-Her decision cannot count due to under depressionNo living will (the decision during intact capacity)

4. Contextual feature : +

Social and religious values negative to suicide

Sum : + encourage intubation

Exercise cases :B

60 years old widow no child. she is known case end stage colon cancer PPS 40% (mostly bed bounded) she was brought by 1669 after her relative found arrest (cause?),She had formal living will indicated that do not need intubation, CPR.

If you are her physician, what would you do.A. CPR and intubation


Analysis1. Medical indication : + /-

Since we don’t know it potential reversible (+) ie electrolyte imbalance or non-reversible (-) ie massive pulmonary embolii.

2. Quality of life : -cerebral anoxia ->she likely to worsen PPS Patient

3. preference : -living will

4. Contextual feature : +/-

It may took heavily investigation, ventilator need

Sum : - not encourage CPR

Exercise cases :C

60 years old married. she is known case end stage colon cancer PPS 40% (mostly bed bounded) she developed severe dyspnea and fever suspected aspiration pneumonia. She had formal living will indicated that do not need intubation. However her daughter want to save her life because fear of others might blame her if she refuse the treatment.

If you are her physician, what would you do.A. Intubation and antibiotics


Analysis

1. Medical indication : +/-End of life pneumonia is uncertained prognosis

2. Quality of life : +/-Since dyspnea may be contributed by infectionbut long intubation may increase suffering

3. Patient preference : -She had clear living will

4. Contextual feature : +

Her family issue

Sum : +/- Need discussion with her relatives

Exercise cases :D

80 years old married with advance alzheimer disease she develop difficult swallowing and poor intake. Her PPS is 30% (Complete bed bounded, totally care need). Her family worry if she should receive parenteral nutrition. Her daughter, only care giver, is economic strain single mom.

If you are her physician, what would you do.A. Advise PEG

B. Advise oral per mounth as tolerate

Analysis

1. Medical indication : +/-Evidence based showed PEG did not increase survival in advance dementia. However no RCTs

2. Quality of life : +/-Low intake not cause hungry It is part of catabolic stage

3. Patient preference : +/-She had no living will

4. Contextual feature : -

Increase burden to care giver

Sum : - Oral per mouth as tolerate

1. Palliative elements “3S”System, Symptom, Spiritual

2. Advance care plan Wish = GoalLiving will = Procedure +/- DPOA

3. Medical ethics in everyday life 4 boxes : Indication, QOL, Preference, Context

Take home massage

practical medical ethics

Health & Medicine