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

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. Bioethics Is Critical to ICU Care?. 20% of all Americans die in an ICU 10-20% of ICU patients will die

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

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  1. 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

  2. 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

  3. Ethical Challenges in the ICU • Denial unrealistic expectations • Prognostic uncertainty paralysis • Patient “autonomy” burden / conflict • “Silos” of disciplines / specialties fragmented care

  4. “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; 29:1893 -Pochard, JCC 2005; 20:90

  5. What is Bioethics? Medical Ethics and History - Course Trailer.wmv

  6. Bioethics Building Blocks Moral Theories - Principles of Bioethics.wmv

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Clinical Ethics ConsultationExplain the Synthesis • Communicate findings to key participants • Document suggestions • Follow up on the patient’s case • Critical self-review of the individual consult and the consultative process Support the Consultation Process

  15. 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

  16. 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

  17. 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

  18. 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

  19. Bioethics in a Modern World Star Trek_ Voyager Nothing Human.wmv

  20. Bioethics The Quest for Goal Alignment

  21. Practical Approach to Decision-Making in the ICU Curtis and White, Chest 134 (2008)

  22. Difficult Conversations • Begin by listening …instead of talking • Open-ended questions • Don’t interrupt 18 second rule • Establish trust • Explore perceptions before defining reality • Legitimize emotions • End by summarizing

  23. 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

  24. 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

  25. 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

  26. 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

  27. A SyMPLE Approach to Palliative Care Symptoms Medical Problems / Prognosis Psychosocial (Spiritual) Legal Ethical

  28. Why Bioethics?Death and Taxes NHDD Speak Up Video.wmv

  29. 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?

  30. 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

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