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

2. Summary DefinitionsDefinitions ImportanceImportance BarriersBarriers Doing the workupDoing the workup

3. Definitions Morality: individual or social beliefs about what is right and wrongMorality: individual or social beliefs about what is right and wrong –Cultural –Religious –Family –Personal Ethics: critical, systematic study of moral beliefEthics: 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: define how 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, selfMetaethics: 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, characterNormative ethics  principles, rules and behavioral guides that morally justify certain actions—actions, consequences, character

6. Importance Medical technological advancementMedical technological advancement Expectations (the rise of autonomy)Expectations (the rise of autonomy) Regulation and accountabilityRegulation and accountability Professional vs. business interests (market)Professional vs. business interests (market) Medical – legal issuesMedical – legal issues Changing demographic (aging, cultural shifts)Changing demographic (aging, cultural shifts) Organizations and systemsOrganizations and systems Changing relationshipsChanging relationships AccessAccess Decentralization of the patientDecentralization of the patient

7. Barriers to Moral Agreement Different sets of beliefsDifferent sets of beliefs Lack of understanding (health literacy)Lack of understanding (health literacy) Fluxuating role of the physiciansFluxuating role of the physicians Loss of the relationshipLoss of the relationship Complexity of health care organizationsComplexity of health care organizations Economic influencesEconomic influences Racial and gender biasRacial and gender bias Defining futilityDefining futility Inflated expectationsInflated expectations Fear and loss of trustFear and loss of trust

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

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

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

11. Ethics Workup What is the right and good decision for this patient? What is the right and good decision for this patient? Why? 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 systemsDX: treatable, preventable, risks, how many systems Prognosis?Prognosis? –Short and long term for the underlying condition –Short and long term for each proposed intervention Patient preferences?Patient preferences? Age?Age? Financial concerns have no place at the bedside in considering individual patient welfare, unless those of the patient.Financial concerns have no place at the bedside in considering individual patient welfare, unless those of the patient. What choices are being considered?What choices are being considered? Psychosocial components?Psychosocial components?

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

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

18. Clinical option(s) in the best interest of this patient? Ethical reasons for and againstEthical reasons for and against Is conflict resolvable?Is conflict resolvable? Is compromise possible without loss of personal or professional integrity?Is compromise possible without loss of personal or professional integrity? If not…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.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).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:Prognosis: –end stage chronic disease –? reversibility of her acute process Patient expressed preferencesPatient expressed preferences –Verbal HCD –Clear and convincing? Decision-making capacityDecision-making capacity Degree of suffering now and futureDegree of suffering now and future She has a family…She has a family…

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

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

27. Stakeholders PatientPatient Husband, family, friendsHusband, family, friends ProvidersProviders –Professional integrity SystemSystem

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

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

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