Title: Medical Ethics Medical Decision Making
1Medical EthicsMedical Decision Making
- Jeffrey J Kaufhold, MD FACP
- Chair, Bioethics Advisory Committee, Grandview
Hospital
2Factors to Consider
- Medical Indicators
- Diagnosis
- Prognosis
- Treatment
- Quality of Life
- Patient Preference
- Advance Directive
- Prior Statements
- Prior Choices pt has made.
- Context
- Social
- Cultural
- Legal
- Financial
3Medical Decision Making
- Heirarchy for decision making
- 1. Competent Patient is always first
- 2. Substituted judgment
- Family in rank order
- Spouse
- Parents
- Children
- Others
- 3. Best Interest of the Patient
- Paternalistic approach by caregivers
- 4. Ethics Committee.
July 17, 2004 Robert Orr
4Summary
- History of Conflict in medicine
- Justice in Medicine
- Social responsibilities of Physicians
- Medical Futility
5Justice in Clinical Medicine
- Edmund Pellegrino, MD
- Professor Emeritus of Medicine and Medical
Ethics, Georgetown University Medical Center - Lecture from conference
- Conflict and Conscience in Healthcare
- July 16, 2004
6History of Conflict in Medicine
- Pre-Hippocrates Self Interest of Physician
- Hippocrates dared to see pt as primary focus
- This was taken up by all of the monotheistic
religions, and preserved by the Muslims during
the middle ages - Adam Smith Enlightened self interest
- Bad outcome is bad advertising
- Karl Marx All serve society
7History of Conflict in Medicine
- Managed Care
- Limited Resources (Marx influence)
- Are they really limited?
- Physician is steward of those resources
- Inevitable ranking of the Worth of Patients
- Healthy pt is good for society
- Chronic illness is bad for society
- Patient may not be the primary focus
8Justice in Medicine
- Assumptions
- Physician has competence, acts professionally,
and in the interest of the patient. - Implicit covenent with society
- We are allowed to do Illegal acts, in order to
learn the art.
9Justice in Medicine
- Commutative Justice
- Contract with patient
- Distributive Justice
- Allocation of resources
- Charitable Justice
- What we ought to do even if pt is abusing
themselves - General Justice
- What do we owe the common good?
- What does the patient owe the common good?
10Justice in Medicine
- General Justice
- Patient has obligation to follow the
recommendations of the physician - Physician must take responsibility to define what
the patient needs - Not required to do what pt wants
- What good can we do for the patient.
- Epicaya
- Preservation of equity
- Look at the big picture/everyone makes mistakes
11Social Responsibility of Physicians
- Best Medicine possible
- Stay up to date
- Participate in public debate
- We have the knowledge needed to inform the debate
- Advocacy for those who need help
- Legislators have the responsibility to make
decisions about distribution of resources.
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13Medical Futility
- Daniel P Sulmasy, OFM, MD, PhD
- Director, The Bioethics Institute
- New York Medical Center
- July 17, 2004
14Case
- 76 y.o. female with Multiple Myeloma admitted
with Sepsis. - Heavily pretreated, no further chemo available
- On vent, Pressors
- Daughter wants everything done.
15The Basis for Medical Futility
- History of Futility
- Religious Principles
- Moral Principles
- Probability
- Dealing with the case.
16Futility, a History
- Smith Papyrus, 1700 B.C.
- Entreaty to not intervene if spinal cord is
transected - This Egyptian papyrus, found in 1900s,
references a much older text.
17Futility, a History
- Smith Papyrus, 1700 B.C.
- Entreaty to not intervene if spinal cord is
transected - Hippocrates, 460 377 B.C.
- On The Art the physician should refuse to
treat in cases where medicine is powerless
18Social norms regarding cancer
- 1950s call it something else.
- 1960s Inform pt of diagnosis
- 1970s Informed consent
- 1990s - Informed Demand
19Religious Principles
- Intrinsic Dignity
- Made in the image of God
- Alien Dignity
- Relationships define our being.
- Also a fact that we are Finite
20Religious Principles
- Life is a gift, and we are its stewards
- Limits to stewardship
- Illness is a burden
- Costs and burden to family/caregivers
- Futile care need not be given.
21Moral Principles
- No moral obligation to provide futile Tx.
- What is Futile Treatment?
- Non-beneficial
- Inappropriate treatment at the end of life
- What is the real goal?
- Free of pain and suffering
22Moral Principles
- What is Futile Treatment?
- Subjective Futility
- Patient wont be able to appreciate benefit
- This is not sufficient moral argument to withhold
therapy - Objective Futility (biomedical use)
- No objective benefit to any observer
23Moral Principles
- Medical Realism
- There are facts
- Trained people can make judgements
- But we are fallible
- We have to relate the data to the patient
- This is the tricky part of the art.
- Requires use of probability.
24Probability
- Is this patient going to die?
- Probably.
- Even with treatment?
- Probably.
- Can you be more specific?
- Probably.
25Probability
- Prognosis is the probability that a patient will
respond to tx, plus the probability that the
disease will kill them. - Probability that we use in individual cases comes
from objective data about the particulars of the
case, plus experience, plus common sense. - This process is fallible, but we do the best we
can.
26Probability
- Three factors
- Frequency
- Prediction
- Strength of belief
- Lets apply to the case
27Probability Myeloma with sepsis
- Frequency (80 of myeloma pts do not wean from
vent) - Based on studies
- Prediction (1 likelihood of survival for this
pt) - Based on Karnovsky score in Onc literature
- Based on APACHE score in ICU literature
- Strength of belief
- P value
- Reasonable degree of medical certitude
28Ultimately, Ethics is about What to Do
29Morality of Futility
- Judgment enters Morality when decision is made
about taking action. - Actions
- Wean from vent?
- Wean from pressors?
- Stop Antibiotics?
- Stop tube feedings/ IV fluids?
30Morality of Futility
- Judgment enters Morality when decision is made
about taking action. - Approaches
- Pragmatic does this help the patient?
- Remember, removing pt from life support may kill
them, but might it also stop their suffering? - Moral (prudential) is this the right thing to
do?
31Back to the CaseMyeloma with sepsis
- Frequency
- (80 of myeloma pts do not wean from vent)
- Prediction
- (1 likelihood of survival for this pt)
- Strength of belief
- Reasonable degree of medical certitude
- Pragmatic approach
- CPR will not help pt get better
- Prudential approach
- Morally wrong to provide inappropriate treatment.
32Back to the CaseMyeloma with sepsis
- Pragmatic approach
- CPR will not help pt get better
- Prudential approach
- Morally wrong to provide inappropriate treatment.
- Recommendation
- Make the pt DNR CC arrest
- Consider withdrawal of life support
- How do we proceed with the family?
33Back to the CaseMyeloma with sepsis
- The family in town wants to keep Mom comfortable,
and see she is suffering on life support. - However, the out of town daughter is in charge
and insists everything be done. - Cultural barriers arise.
- Tilden. Nurs Res 2001, 50105-115.
- Its Stressful to be the surrogate
- Guilt, Ambivalence, Depression, Anger.
34How to proceed Clinically
- Establish relationship with family
- Review case (how did she get here)
- Describe level of illness
- Lay out options
- Establish goals
- keep her alive until son gets here
- Maintain comfort no matter what.
- Establish Limits
- will not resuscitate her if heart stops.
35Praying for a Miracle
- Affirm that this is OK
- Bear witness in faith, resurrection
- God is present and answering all our prayers,
even if a miracle doesnt come
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37Hippocratic Oath
- Now being admitted to the profession of medicine,
I solemnly pledge to consecrate my life to the
service of humanity. - I will give respect and gratitude to my deserving
teachers. - I will practice medicine with conscience and
dignity. - The health and life of my patients will be my
first consideration.
Part 1
38Hippocratic Oath
- I will hold in confidence all that my patient
confides in me. - I will maintain the honor and noble traditions of
the medical profession. - My colleagues will be as my brothers and sisters.
- I will not permit consideration of race,
religion, nationality politics or social standing
to intervene between my duty and my patient.
Part 2
39Hippocratic Oath
- I will maintain the utmost respect for human
life. - Even under threat I will not use my knowledge
contrary to the laws of humanity. - These promises I make freely and upon my honor.
Part 3
40Aesculpius
- Staff with single serpent
- Life is short, Art is long, experience
difficult. - Greek Obi OE BpAXYE, HTEXNH MA KPH, O KAI POE
OE YE.
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42Competency Assessing Decision Making Capacity
- Jeffrey J Kaufhold, MD FACP
- Chair, Bioethics Advisory Committee,
- Grandview Hospital
43- A Guide to assessing Decision Making Capacity.
- Roger C. Jones, MD, Timothy Holden, MD
- Cleveland Clinic Journal of Medicine
- Vol 71, December 2004, p 971-5.
44Summary
- Physicians need an efficient way to determine a
pts decision making capacity - This capacity must be assessed for each decision
and not inferred on the basis of pts diagnosis. - Documentation of the process used and decisions
reached is necessary.
45Case 1
- Pt admitted for sepsis
- Poor access for pressors and labs
- Pt is confused
- No family is available
- Can pt consent to line placement?
46Case 2
- Elderly pt with Alzheimers and a MMSE score of
23 of 30 refuses elective Chole. - Daughter/DPAHC requests surgery.
- Can the pt refuse?
- How can his competency be evaluated?
47Case 3
- Pt admitted with acute pneumonia
- Also diagnosed with severe depression
- Many answers are I dont know/I dont care
- Pt refuses treatment, stating I dont care if I
live or die - Does pt have decision making capacity?
- If not how do you procede?
48Consent
- Requirements
- Autonomy
- Capacity to understand and communicate
- Ability to reason
- Recognized set of values or goals
- Agreement with the physician does not imply that
pts capacity to give consent is intact!
49Competency
- Legal designations determined by the courts.
- Decision making capacity is clinically determined
by physician at the bedside. - Adults are presumed competent unless legally
judged to be incompetent. - Presidents commission for the study of Ethical
Problems in Medicine 1982. - Avoid Routine recourse to legal system.
50Clinical Approach
- Urgency of the clinical situation determines how
to procede. - Urgent situation
- Pt not able to communicate / no spokesperson
- Assume that a reasonable person would not want to
be denied life saving treatment. - Implied Consent
51Clinical approach
- Nonemergent situation
- What are the risks and benefits?
- Low risk may not require much decision making
capacity. - Im here to draw your blood for a hct.
- High risk may require significant deliberation.
- Should a pt with lung cancer and severe CAD
undergo pneumonectomy for possible cure?
52Algorithm for assessment
- Miller and Marin, Emergency Med Clinic North Am,
2000 18 233-241. - Series of simple questions
- Doesnt take into account the level of risk or
benefit of a treatment.
53Algorithm
- 1. Do the history and physical confirm that the
pt can communicate a choice? - Is their memory good?
- Is judgement appropriate?
- Can they maintain a conversation/follow your line
of questioning? - Are their answers consistent?
- If yes procede to question 2
- If No pt needs help with decision making.
54Algorithm
- 2. Can the pt understand the essential elements
of informed consent? - What is your present condition?
- What treatment is being recommended?
- What might happen to you if you agree to the
treatment? - What might happen to you if you refuse the
treatment? - What are the alternatives available?
- Test of pts understanding of the discussion.
55Algorithm
- 3. Can the pt assign personal values to the
risks and benefits of intervention? - Jehovahs witness refusal to accept transfusion
reflects different set of values.
56Algorithm
- 4. Can the pt manipulate the information
rationally and logically? - Can you follow how the patient got to their
decision?
57Algorithm
- 5. Is the patients decision making capacity
stable over time? - Repeat the question several minutes later/ after
more discussion.
58Algorithm
- Benefits of this approach
- Avoids the tendency to devalue capacity of
chronically ill pts - Reduces reliance on surrogate decision makers
when not necessary - Avoids judgement based on whether pt agrees with
Doctor.
59Algorithm
- Limitations
- Language barriers
- Cultural barriers
- African Americans tendency to not look at
speaker, distrust of system leading to
misinterpretation of options provided - Some of the assessment questions are subjective.
60When surrogate must be consulted
- If the pt is incompetent as determined by the
court - If the pts decision making capacity is in doubt
- If the pt is unable to understand options or is
unable to decide.
61Case 1
- Pt admitted for sepsis
- Poor access for pressors and labs
- Pt is confused
- No family is available
- Does pt have to consent to line placement?
- No, use implied consent.
62Case 2
- Elderly pt with Alzheimers and a MMSE score of
23 of 30 refuses elective Chole. - Daughter/DPAHC requests surgery.
- Can the pt refuse?
- MMSE can miss cognitive deficits
- How can his competency be evaluated?
- Psychiatry consult, ethics consult if needed.
- In this case, daughter served as decision maker.
63Case 3
- Pt admitted with acute pneumonia
- Also diagnosed with severe depression
- Many answers are I dont know/I dont care
- Pt refuses treatment, stating I dont care if I
live or die - Does pt have decision making capacity?
- Physician determined that pt does not, due to
depression. - Treat depression and pneumonia.
- Capacity may return once depression treated.
64Summary
- Physicians must determine decision making
capacity every day. - Diagnosis does not imply impaired capacity, nor
does good MMSE imply that pt has capacity. - Agreement or disagreement with physicians
recommendation does not imply capacity is intact
or impaired.
65Summary
- Differing pt values may result in conflict and
raise questions about pts capacity. - Algorithm provides a simple method to determine
D.M. capacity - Competency is legal determination
- DMC is clinical determination.