Medical Ethics Medical Decision Making

1. Medical EthicsMedical Decision Making Jeffrey J Kaufhold, MD FACP Chair, Bioethics Advisory Committee, Grandview Hospital

2. Medical Indicators Diagnosis Prognosis Treatment Quality of Life Patient Preference Advance Directive Prior Statements Prior Choices pt has made. Context Social Cultural Legal Financial Factors to Consider

3. Medical 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

4. Summary • History of Conflict in medicine • Justice in Medicine • Social responsibilities of Physicians • Medical Futility

5. Justice 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

6. History 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

7. History 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

8. Justice 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.

9. Justice 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?

10. Justice 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

11. Social 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.

13. Medical Futility Daniel P Sulmasy, OFM, MD, PhD Director, The Bioethics Institute New York Medical Center July 17, 2004

14. Case • 76 y.o. female with Multiple Myeloma admitted with Sepsis. • Heavily pretreated, no further chemo available • On vent, Pressors • Daughter wants everything done.

15. The Basis for Medical Futility • History of Futility • Religious Principles • Moral Principles • Probability • Dealing with the case.

16. Futility, a History • Smith Papyrus, 1700 B.C. • Entreaty to not intervene if spinal cord is transected • This Egyptian papyrus, found in 1900’s, references a much older text.

17. Futility, 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

18. Social norms regarding cancer • 1950’s – call it something else. • 1960’s – Inform pt of diagnosis • 1970’s – Informed consent • 1990’s - Informed Demand

19. Religious Principles • Intrinsic Dignity • Made in the image of God • Alien Dignity • Relationships define our being. • Also a fact that we are Finite

20. Religious 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.

21. Moral 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

22. Moral Principles • What is Futile Treatment? • Subjective Futility • Patient won’t be able to appreciate benefit • This is not sufficient moral argument to withhold therapy • Objective Futility (biomedical use) • No objective benefit to any observer

23. Moral 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.

24. Probability • Is this patient going to die? • Probably. • Even with treatment? • Probably. • Can you be more specific? • Probably.

25. Probability • 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.

26. Probability • Three factors: • Frequency: • Prediction: • Strength of belief • Lets apply to the case:

27. Probability 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”

28. “Ultimately, Ethics is about What to Do” Aristotle, 384 – 322 B.C.

29. Morality 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?

30. Morality 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?

31. Back 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.

32. Back 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?

33. Back 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, 50;105-115. • Its Stressful to be the surrogate • Guilt, Ambivalence, Depression, Anger.

34. How 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.

35. Praying 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 doesn’t come

37. Hippocratic 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

38. Hippocratic 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

39. Hippocratic 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

40. Aesculpius • Staff with single serpent • “Life is short, Art is long, experience difficult.” • Greek: Obi OE BpAXYE, HTEXNH MA KPH, O KAI POE OE YE.

42. Competency 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.

44. Summary • 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.

45. Case 1 • Pt admitted for sepsis • Poor access for pressors and labs • Pt is confused • No family is available • Can pt consent to line placement?

46. Case 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?

47. Case 3 • Pt admitted with acute pneumonia • Also diagnosed with severe depression • Many answers are “I don’t know/I don’t care” • Pt refuses treatment, stating “ I don’t care if I live or die” • Does pt have decision making capacity? • If not how do you procede?

48. Consent • 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!

49. Competency • 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. • President’s commission for the study of Ethical Problems in Medicine 1982. • Avoid Routine recourse to legal system.

50. Clinical 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”