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Ethics and End of Life Decisions

Ethics and End of Life Decisions. Jeffrey J. Kaufhold, M.D. Grandview Hospital. Grandview Hospital and Medical Center. “Treat the patient, not just the symptoms” 452 bed facility Inpatient and outpatient 3 Behavioral Health floors Over 100 Residents, Interns, and Medical Students

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Ethics and End of Life Decisions

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  1. Ethics and End of Life Decisions Jeffrey J. Kaufhold, M.D. Grandview Hospital

  2. Grandview Hospital and Medical Center • “Treat the patient, not just the symptoms” • 452 bed facility • Inpatient and outpatient • 3 Behavioral Health floors • Over 100 Residents, Interns, and Medical Students • Affiliated with Ohio University College of Osteopathic Medicine • Faith-based organization – part of KMCN

  3. Southview Hospital and Family Health Center • Offers surgical, inpatient, and outpatient services • Growing Women's Health Center • Sycamore Women’s Center feeds patients into SVH maternity center.

  4. Bioethics Advisory Committee • Provides consultations • Reviews policies • Education • Mentoring

  5. Legal, Financial and Quality Issues • Legal – protection • Financial – regulatory agency requirements • Quality – quality indicators • Pain management • Organ donation and reporting • Patient and family satisfaction surveys

  6. Key Factors • Communication • Goals of palliative, comfort care • Evidence based approach • Competency of patient to decide • Pain • Depression • Drug or disease induced delirium

  7. Communication • Common problems • Communication triangle – patient, doctor, and family • What are the goals? • Understanding the illness • Outcome of treatment

  8. Relationship Building • Nursing staff • Medical staff support • Patient/family wishes

  9. Goals of Care • Palliative and comfort care • DNR does not mean do not treat • What does comfort care involve? • What treatments/medicines are stopped? • What treatments/medicines are started?

  10. Principles in Ethical Decision Making • Paternalism • Autonomy • Utilitarianism • Non Malfeasance • Futility • Outcomes Analysis • Levels of Care

  11. Definitions • Ethics • Advance Directives • Brain Death • Cardiac Arrest • Comfort Care • Decisional Capacity • DNR

  12. Definitions • DNR Comfort Care • DNR Comfort Care Arrest • Futile Care • Health Care Power of Attorney • Level of Care Orders • Living Will • Respiratory Arrest • Resuscitation

  13. Cultural Issues • Cultural perspectives on end of life issues • Ethnicity • Religious beliefs • Poverty and illiteracy

  14. Resuscitation of Residents with DNR orders in LTCFs • Measured the frequency of EMS calls to ECFs for patients with DNR orders • Calls 392 • DNR 139 (35%) • Resus. Attempted 29 (21%) • Becker Yeargen et al. Prehospiital Emergency Care 2003: 7: 303-6.

  15. The Ohio Law on DNR-CC • Creates a portable DNR • Form ID bracelet wallet card • Description of Components of CPR • Stipulates what will NOT be done if pt is DNR • Provides protection from liability

  16. Ohio Law on DNR-CC • Living will applies to persistent vegetative state. • New version (1999) has provision for establishing DNR arrest or DNR Comfort Care only.

  17. Definitions • DNR • Old terminology, means Do not Resuscitate. • DNR-CC-Arrest • New Terminology, means do not resuscitate: Provide comfort care when the end comes, continue all other treatment until then.

  18. Definitions • DNR – CC • Means Comfort Care measures only are to be given. Discuss with pt/family as to whether certain measures could be STOPPED, such as dialysis, Vent support, Lab draws, pressors, antibiotics, etc.

  19. Level of Care Orders • Procedure for placing limits on resuscitative efforts • Progress note • Orders • Copy of Ohio DNR – CC form • End of each daily PN should state • “Pt is DNR “

  20. Order of Principles • Who Decides? • Patient’s wishes • Patient’s spokesperson • Caregiver • Physicians on case may invoke futility • Ethics committee or consultant

  21. Who to Contact • Each hospital has an Ethics Committee • Nursing supervisor, risk manager • Program Chairperson • Write an order • Discuss with attending if appropriate • Attend a committee meeting to learn more!

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