The Clinician’s Ethics Workup

1. TheClinician’s Ethics Workup David A. Fleming, M.D. MU Center for Health Ethics 573-882-2783 flemingd@health.missouri.edu

2. Summary • Definitions • Importance • Barriers • Doing the workup

3. Definitions • Morality: individual or social beliefs about what is right and wrong • Cultural • Religious • Family • Personal • Ethics: critical, systematic study of moral belief • Arguments for a universal understanding of what ought to be done • Language of obligations, duties, rights • Character, virtue, values

4. Moral Statement : “Abortion is immoral because I believe it’s wrong to kill another human being.”Ethical Argument: “Abortion is immoral because every human being deserves the same level of respect and no person should be unjustly sacrificed for the welfare of another.”

5. Ethics: definehow we should act in consideration of others, not how we feel or what we believe[“Theory of action.”] • Metaethics: ultimate source of moral belief based on theory, logic, meanings (“language games”)—reason, rationality, faith, self • Normative ethics principles, rules and behavioral guides that morally justify certain actions—actions, consequences, character

6. Importance • Medical technological advancement • Expectations (the rise of autonomy) • Regulation and accountability • Professional vs. business interests (market) • Medical – legal issues • Changing demographic (aging, cultural shifts) • Organizations and systems • Changing relationships • Access • Decentralization of the patient

7. Barriers to Moral Agreement • Different sets of beliefs • Lack of understanding (health literacy) • Fluxuating role of the physicians • Loss of the relationship • Complexity of health care organizations • Economic influences • Racial and gender bias • Defining futility • Inflated expectations • Fear and loss of trust

8. Before it was the “doctor-patient relationship” Patient Office Hospital Doctor

9. Now it’s a complex “matrix of accountability” Government Patient Marketing Visiting Nurse Nursing Home SW, Chaplain Office Pharmacist Hospital Case Manager Lawyers TelehealthStaff—UR, QI, RM Phone email eHealth Provider AdministrationInsurersRegulators

10. Today’s healthcare environment is not conducive to trust… • Technologically driven • Decisions to withhold or withdraw Tx • Patients and families often demand: “do everything possible” • Access to information • Transparency and error reporting • Economic and time constraints • “Doc for the day” • Expect restitution if things “go wrong”

11. Ethics Workup What is the right and good decision for this patient? Why? Who (or what) decides? Resolving conflict

12. The Ethics Workup (EOL) • Clinically relevant facts? • What options exist? • What should be done, and why? • What is the ethical dilemma (conflict)? • Who are the stakeholders? • How will they be impacted? • Who ultimately decides? • What action(s) should be taken? • Can it be implemented? • If not—why, what other options exist?

13. What are the clinical facts? • DX: treatable, preventable, risks, how many systems • Prognosis? • Short and long term for the underlying condition • Short and long term for each proposed intervention • Patient preferences? • Age? • Financial concerns have no place at the bedside in considering individual patient welfare, unless those of the patient. • What choices are being considered? • Psychosocial components?

14. What options exist • WH/WD vs. aggressive treatment (DNR) • Palliative care and hospice • Limiting freedom and privileges • Risky or minimally beneficial Tx • Treating without expressed permission • Changing providers or institutions

15. What are the ethical concerns as perceived by the key stakeholders? • Futility? • DNR/DNI, WH/WD • Informed decision-making? • Capacity? • Surrogate or HCD? • Undue risk or suffering (burden > benefit) • By whose definition of “quality of life”? • Double effect? • Fair and dignified treatment?

16. Conflict? Who are the stakeholders and how are they impacted? Why is there conflict? What is the nature of the conflict? What are the objections to the choices being considered? Can it be resolved?

17. Who decides? • Patient • Surrogate (family) • HCD (written or verbal) • Providers (team) • Courts • other

18. Clinical option(s) in the best interest of this patient? • Ethical reasons for and against • Is conflict resolvable? • Is compromise possible without loss of personal or professional integrity? • If not… • Physician may be discharged • Physician may withdraw as soon as another is employed

19. Can the decision be implemented? If not, why? • Physically impossible • Irresolvable conflict among decision-makers • Moral boundaries

20. Ultimately… • If no other physician is available or none agrees to take the case, the physician of record is not ethically obligated to compromise his/her professional or moral integrity. • The physician is not obligated to help the patient or family find another physician or facility to do what he/she feels is immoral (moral complicity).

21. Case 37 yo WF with metastatic breast cancer (CNS, liver) has decided to refuse further chemotherapy after her second recurrence. You feel she has full decision making capacity. On evening rounds she informs you and the nursing staff that she does not want to be treated aggressively, intubated or to undergo cardiopulmonary resuscitation should she deteriorate. You concur based on her prognosis, recording this conversation in the medical record. Several hours later she lapses into coma and is responsive only to deep tactile stimuli.

22. The next day, the patient begins to show signs of impending respiratory failure. Her husband arrives and notices her declining condition and asks what you plan to do. To your surprise, when you explain and relate the content of your conversation with his wife he states that he believes that she is too ill and disabled to be capable of deciding about her treatment and would “not want to leave her two daughters without a fight”. He demands that she be treated aggressively, and that she undergo CPR efforts and be intubated and sent to the intensive care unit, should she arrest.

23. The appropriate course of action would be to…

24. Clinical Facts • Prognosis: • end stage chronic disease • ? reversibility of her acute process • Patient expressed preferences • Verbal HCD • Clear and convincing? • Decision-making capacity • Degree of suffering now and future • She has a family…

25. Options • Treat and resuscitate • “LIVE TO FIGHT ANOTHER DAY” • Palliative care and comfort pathway • “Partial” treatment • treat sepsis but DNR/DNI • Transfer care

26. What is the ethical dilemma? • Respecting patient autonomy vs. the surrogate’s right to decide • ? Impaired surrogate decision-making • Obligations to the patient vs. the family • Are there obligations to treat treatable conditions? (benefit > burden) • Are there obligations to “make sure” the patient would to want not to be treated? • Legal concerns and the system’s integrity

27. Stakeholders • Patient • Husband, family, friends • Providers • Professional integrity • System

28. Who decides? • Patient (?competency) • Husband (?valid surrogate) • You… • (courts)

29. What should be done? -ethical arguments whyCan it be implemented?If not…why?

30. Summary • Conflict is often unavoidable • Seek compromise without breaking moral boundaries • It’s a longitudinal process, not an event • Effective communication is the key • If compromise is not possible transfer of care may be necessary • ? Risk management