Bioethics Consultation at the Bedside

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• Bioethics Consultation at the Bedside
• Adding Value in a High Tech World

David E. Taylor, M.D. ICU Medical Director
Chairman, Pulmonary/Critical Care Palliative Care
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Bioethics Is Critical to ICU Care?

• 20 of all Americans die in an ICU
• 10-20 of ICU patients will die
• 70 - 90 of ICU deaths occur in the context of
  withholding or withdrawing life support
• Most ICU patients are at risk of dying
• Many ICU patients
• Live with significantly reduced quality of life
  after the ICU
• Return to the ICU

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Ethical Challenges in the ICU

• Denial unrealistic expectations
• Prognostic uncertainty paralysis
• Patient autonomy burden / conflict
• Silos of disciplines / specialties
  fragmented care

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Autonomous Decision-Making

• Fewer than 10 of ICU patients can participate in
  treatment decisions.
• Easy to drown in a sea of surrogates, whose
  levels of anxiety and depression impair their own
  capacity for decision-making.
• -Pochard, CCM 2001 291893
• -Pochard, JCC 2005 2090

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What is Bioethics?

• Medical Ethics and History - Course Trailer.wmv

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Bioethics Building Blocks

• Moral Theories - Principles of Bioethics.wmv

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Fundamentals in Bioethics

• Respect for Persons
• Autonomy
• Confidentiality
• Truth Telling
• Act in the Best Interests of Patients
• Beneficence
• Non-maleficence
• Lack of Decision-making Capacity
• Conflicts of Interest
• Allocate Resources Justly

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What is Bioethics Consultation?

• Service provided by an individual consultant,
  team or committee
• To address ethical issues in a specific clinical
  case
• To improve the process and outcome of patient
  care
• To identify, analyze, and resolve ethical problems

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Why Request a Clinical Ethics Consultation?

• Efforts to resolve an ethical issue have reached
  an impasse
• Life-sustaining treatment for a patient who lacks
  decision-making capacity with no appropriate
  surrogate decision-maker
• Surrogate decision-maker is unable/unwilling to
  provide substituted judgment

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Why Request a Clinical Ethics Consultation?(cont)

• Heathcare team wants to discuss ethically
  supportable strategies that could help prevent an
  ethics crisis
• Case that is ethically challenging, unusual,
  unprecedented, or complex

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Clinical Ethics Consultation

• CASES Approach
• Clarify the consultation request
• Assemble the relevant information
• Synthesize the information
• Explain the synthesis
• Support the consultation process
• Bioethics Mediation

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Clinical Ethics ConsultationClarify the
Consultation Request

• Process of requesting a consult
• https//academics.ochsner.org/bioethicsform.aspx
• Uncertainty or conflict over which
  decisions/actions are ethically justifiable
• Does the request pertain to an active patient
  case?
• Formulate the ethics question as precisely as
  possible

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Clinical Ethics ConsultationSynthesize the
Information

• Review relevant information
• Apply ethics knowledge
• Formal meeting vs. other communication strategy
• Identify and assist ethically appropriate
  decision-maker in reaching decisions

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Clinical Ethics ConsultationExplain the Synthesis

• Communicate findings to key participants
• Document suggestions
• Follow up on the patients case
• Critical self-review of the individual consult
  and the consultative process

Support the Consultation Process
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Clinical Ethics ConsultationCommon Reasons to
Request a Consult

• Advance Directives
• Autonomy in Tension with Best Interest
• Confidentiality
• Decisional Capacity
• Disclosure and Truth Telling
• End-of-life Care

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Clinical Ethics ConsultationCommon Reasons to
Request a Consult

• Forgoing Life-sustaining Treatment
• Goals of Care
• Informed Consent and Refusal
• Medical Futility
• Parental Decision Making
• Surrogate Decision Making

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Ethics Consultation at Mayo Clinic

• Most common diagnoses
• Malignancy 18
• Neurologic disease 18
• Cardiovascular disease 17
• Multi-organ failure 11
• Pneumonia 9
• Requested by
• Physicians 68
• Nurses 19
• Patient or Family 9
• Social Workers 5
• Site of care
• Non-ICU acute care 55
• ICU 40
• Outpatient 6

Swetz et al. Mayo Clin Proc. 2007
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Clinical Ethics ConsultationPrimary Indications
at Mayo Clinic

• Competency or decisional capacity 82
• Staff or professional conflict 76
• Quality of life / end of life care 60
• Appropriateness of treatment / futility 54
• Withdrawing or withholding treatment 52
• Patient autonomy 38
• Advance directives 24
• Family conflict 22

Swetz et al. Mayo Clin Proc. 2007
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Bioethics in a Modern World

• Star Trek_ Voyager Nothing Human.wmv

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Bioethics The Quest for Goal Alignment
Patient Family Provider
Knowledge Think Prognosis
Emotion Feel Suffering
Action Do Plan of care
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Practical Approach to Decision-Making in the ICU
Curtis and White, Chest 134 (2008)
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Difficult Conversations

• Begin by listening instead of talking
• Open-ended questions
• Dont interrupt 18 second rule
• Establish trust
• Explore perceptions before defining reality
• Legitimize emotions
• End by summarizing

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Patient / Family Conference

• Change in patient status or goals of care
• Provider / family miscommunication or conflict
• Long length of stay without clear discharge plan
• Blanket family directions Do everything
• Differing messages from various family members
• Need for further cultural and spiritual insight
• Family conflict or mistrust of medical caregivers
• Uninvolved family members Relative from
  Alaska
• Alternative sites of care to be considered

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Provider Care Conference

• No clear physician leader MD coordinator of
  care
• Disagreement among healthcare team members
• Inconsistent assignments of nurse to patient
• Nurses request different patient assignments
• Patient / family reported as difficult or
  challenging
• Co-morbid acute or chronic mental health
  condition
• Debriefing after a death

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• Steps to Improve Family Communication
• V .. Value family statements
• A .. Acknowlege family emotions
• L .. Listen to the family
• U . Understand the patient as a person
• E . Elicit family questions

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Domains of Palliative Care Patient and
Family-Centered Decision Making

• Assess patient competence
• Identify family spokesperson
• Pre-existing advance directives
• Living Will
• Healthcare Power of Attorney
• Establish parameters of care (DNR status)
• Share plan of care with patient / spokesperson
  daily
• Formal family conference within 48 hours of admit
• Provider care conference to determine care plan

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A SyMPLE Approach to Palliative Care

• Symptoms
• Medical Problems / Prognosis
• Psychosocial (Spiritual)
• Legal
• Ethical

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(No Transcript)
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Why Bioethics?Death and Taxes

• NHDD Speak Up Video.wmv

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Ethical Approach to Dilemmas in Clinical Medicine

• Clarify the facts of the case
• What is the clinical situation?
• Who is the primary decision maker?
• What are the concerns, values, and preferences of
  stakeholders?
• Analyze the ethical issues
• What are the pertinent ethical issues?
• How should ethical guidelines be applied to these
  issues?

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Ethical Approach to Dilemmas in Clinical Medicine

• Address psychosocial issues
• What pragmatic issues complicate the case?
• Hold a team meeting
• Meet with the patient and/or family
• Negotiate to reach agreement
• Seek assistance as needed