1. Ethics and Emergency Medicine Part II Rebecca Burton-MacLeod Preceptor: Dr. Lisa Campfens Dec. 4th, 2003

2. Ethics zRefer to Moritzs presentation on Ethics in June 5th, 2003 for topics relating to consent, capacity, end of life issues, confidentiality, physician-assisted suicide zso that leaves us to talk about...

3. Todays topics zPatient autonomy zjustice zhealth care rationing zmoral decisions in disaster medicine zethics in research zgender/cultural issues in EM care zteaching of trainees zbiomedical industry ethics

4. 4 principles of health care ethics zAutonomy zbeneficence--doing good for your pt znonmaleficence--avoidance of harm for your pt zjustice

5. Patient autonomy zGreek words autos and nomos meaning self rule zpt autonomy--adults right to accept/reject recommendations for medical care if capable of appropriate decision-making capacity (Rosens)

6. Patient autonomy zmajor concept in last half of 20th century zassociated with spreading democracy, improvement in education, increase in diversity of values--encourages people to protect personal values z1914, USA Court Justice Cardoza, any individual of sound mind has the right to determine what shall be done to his body…

7. Violations of autonomy zMedical research performed on concentration camp victims in Nazi Germany zUSA Tuskegee syphilis study

8. Case 1 za 52y.o. gentleman presents to the ED complaining that he had a fall yesterday and hit his head. He denies any LOC, nor any symptoms since the event. However, he is concerned he may have injured his brain. He demands to have a CT head. yIs the pt ethically able to ask for possibly superfluous tests? yDoes your answer to him depend on: time of day, number of people waiting in dept, radiologist on call, strength of demand ?

9. Justice zOne of 4 principles of western health care ethics zjustice--upholding of what is right and lawful, especially fair treatment or punishment in accordance with honour, standards, or law (Websters dictionary) zdistributive justice--fairness in allocation of resources and obligations (Rosens)

10. Why justice? zAristotle--justice and prudence are primary virtues in Niomachean Ethics zPlato--justice principle theme in Platos Republic zRelated to idea of human equality zprinciple evoked when interests of individuals or groups compete

11. Theories of justice zUtilitarian yshould follow action that creates greatest possible balance of good vs. harm ythe end justifies the means z Deontological ybelief that actions are either right or wrong, based on higher rule or rules ynot based on consequence of action

12. Justice and EM zACEP Ethics Manual, emergency care is a fundamental individual right and should be available to all who seek it…Denial of emergency care or delay in providing emergency services based on race, religion, gender, ethnic background, social status, type of illness/injury, or ability to pay is unethical.

13. Justice and EM zrationing zaccess ztriage zresearch z*may replace autonomy as ordering principle in 21st century*

14. Health care rationing zUnder distributive justice, require equitable (but not always equal) allocation of health care resources yno information barriers, financial barriers, supply anomalies which prevent decent basic minimum of health care (Daniels, 1985)

15. Health care rationing z3 levels of rationing: y1. societal interests xhealth care vs. education vs. defense vs. environment xeffects of poor nutrition, inadequate housing, inadequate education, pollution, violence on an individuals health

16. Health care rationing y2. health care resources xpublic health/preventative medicine vs. child/maternal health vs. new technologies vs. prehospital/emergency care vs. comfort/palliation xdistribution based on medical need, cost effectiveness, and sharing of benefits/burdens in society

17. Health care rationing y3. institutional/bedside level xtriage decisions in EM xignoring cost considerations on one patient ignores consequences on other patients xuse resources to benefit patient, without causing undue burden xhow do we decide if specific treatment produces benefit, marginal benefit, no benefit, harm ?

18. Health care rationing zMacroallocation (at level of society) ybased on distributive justice zmicroallocation (level of individual) ybased on beneficence, relies on distributive justice

19. Health care rationing zEx: Oregon Health Plan yin 1987, 7y.o. Coby Howard died from leukemia after not receiving bone marrow transplant yOregon tried to pass legislation restoring Medicaid funding for bone marrow transplants yJohn Kitzhaber (emerg doc and later Oregon governor) argued that better use of resources to expand insurance to cover everyone, instead of paying for costly services for few

20. Oregon Health Plan zExpanded Medicaid to cover all residents below poverty line, but in return would ration health care services zrank list compiled of condition/treatment pairs--based on community priorities, physicians opinions, data on effectiveness of treatment outcomes zdelisting occurred if financial shortfall

21. Oregon health plan zProblems with the plan: ylittle rationing actually took place (physician noncompliance, political concessions to move medical services on the list) yno substantial savings zpositive outcomes: yuninsured rate significantly reduced ycovers more people

22. Oregon health plan zSimilar delisting experiences in Britain, New Zealand, Netherlands, Ontario zwhen rationing decisions made public, less likely to be able to ration services

23. Case 2 zA plane crashes, resulting in injury to many patients. Victims range in age from 1y.o. to 93y.o. One victim is Prime Ministers son. One victim has 90% body burns. Some patients have blunt head, abdominal, or chest trauma. Eight patients are in cardiopulmonary arrest. A woman is in labour. Five patients are in shock. You are the sole physician. yhow would you proceed to care for these patients?

24. Disaster medicine zImbalance between needs and supplies zEx: ynatural disasters ywar ygenocide (Rwanda, Yugoslavia, Cambodia) yterrorist events ylarge-scale accidents

25. Disaster medicine z1st principles of mass casualty care: triage ztriage based on utilitarian principles to provide greatest benefit to largest number

26. Triage models z3 possible models: yfirst-come, first-served ypatients best prognosis ypatients social worth

27. Triage models y1. First-come, first-served xpotential for less bias, but not equitable resource distribution during catastrophes xfavours population that has access to media, transportation, health care xdiscriminates against those with physical/mental disabilities or financial difficulties

28. Triage models y2. Patients best prognosis xtriage decisions based on patient survivability xrequires using clinical skills to provide maximum benefit to most people from fewest resources xmost favourable model in catastrophes xmay be hard for the general public to accept consequences of triage in their environment

29. Triage models y3. Patients social worth xage, occupation, status xage should not be a triage factor in itself--cannot predict individual life expectancies xselecting based on occupation/status uses the limited resources to save a few xgeneral consensus--social worth is unfair criteria for triage

30. Triage zWhat about health care workers priority for treatment and prophylaxis? yQuestion of individual social worth zAbility to help others--multiplier effect zas physicians, should look after own safety first, then teams, then patients

31. Triage zFactors to consider ylikelihood of benefit yeffect on improving quality of life yduration of benefit yurgency of pt condition ydirect multiplier effect yamount of resources required for successful treatment z Factors NOT to consider yage, ethnicity, sex ytalents, abilities, disabilities, deformities ysocioeconomic status, social worth, political position ycoexistent conditions that do not affect short-term prognosis ydrug/alcohol abuse yantisocial/aggressive behaviour

32. Triage algorithm

33. Case 3 zYou are at the scene of an accident, and only have 2 chest tubes with you. There are 3 accident victims…all of whom require chest tubes. 2 of the patients each only need one tube, while the 3rd patient requires bilateral chest tubes. To whom do you give your 2 chest tubes?

34. Case 4 za 39y.o. man took 30mg of lorazepam. He was somnolent but arousable and his vitals were stable. He and his family were informed he would be transported to the medical center across town since they have a medicine to treat this overdose (the center was conducting trials with a benzodiazepine antagonist). yis it appropriate for this pt to be transported in order to enroll them in a research protocol?

35. Research zEthical principles for biomedical research: yrespect for people as autonomous agents ytruth telling ybeneficence in maximizing the benefits and minimizing the burdens for research subjects yjustice in equitably distributing the benefits/burdens of research (participating as subject in research is altruistic act) zACEP Code of Ethics, accurate, compassionate, competent, impartial, honest conduct of scientific research

36. Research zEthical issues in research: yscientific misconduct (plagiarism, inappropriate stat tests, neglecting negative results, omitting missing data points, data dredging, fabrication of data) yunethical treatment of human/non-human subjects yconflict of interest yresponsibilities to colleagues/students/trainees

37. Research in EM zInformed consent for resuscitation and other research when pt does not have capacity to decide ydeferred consent (illogical concept) ywaived consent

38. Waived consent zRequirements: ynecessity for research yprospect for direct benefit to subjects yinformed consent from pt representatives will be pursued yf/u consent will be pursued ycommunity disclosures must be performed yobtaining informed consent must not be feasible

39. Waived consent zCommunity notification: ydoes not protect personal preferences of individual yenhances community trust, signals integrity on behalf of researcher

40. Waived consent zFamily notification: zwho is defined as family member? yRelated by blood or affinity whose close relationship is equivalent of family zHow do you respect pts need for confidentiality? yCareful balance of confidentiality and disclosure is responsibility of researcher zBest way to find out what pt may want zsafeguard

41. Waived consent zIndependent physician and data monitoring committee: yevaluates necessity/value of the research ycomposed of individuals with no investment or connection to research yincreases integrity and fairness of study

42. Vulnerable populations zParticular circumstances that bring them as potential research subjects: ymedical condition ylimitation of intellectual function ysocial setting ypsychosocial stressors

43. Cultural/gender issues in research zTuskegee syphilis studies: y1930s-1972, US Public Health Service yblack males with tertiary syphilis (mostly poor and illiterate); no informed consent ystudy natural course of disease; not provide treatment yeven when penicillin available, decided not to treat subjects

44. Cultural/gender issues in research zconcerned about racial bias in research / treatments ySeattle committee for kidney dialysis pts--pt with productive jobs or family to support (middle class, white males) ztrauma centers concentrated in inner cities where minority gps tend to live, more violent crime zblack pts under care of white physicians, homosexuals involved in AIDS research (socially franchised studied the socially disenfranchised)

45. Cultural/gender issues in EM z2 studies shown that Hispanics and African-Americans receive fewer analgesics for extremity #, than white pts in ED; no difference in pain sensation zfailure in communication, or racial profiling/discrimination?

46. Case 5 zA 19y.o. North African female presents to the ED with her husband. She speaks no English, and her husband is acting as interpreter. She is 8wks pregnant and is hemorrhaging vaginally. She is hemodynamically unstable. You think she needs an emergent D+C. After conversing with his wife, the husband refuses the procedure. ywhat do you do?

47. Cultural/gender issues in EM zInterpreters: yinadequate interpretation is form of discrimination yoften only available if pt brings family/friend (confidentiality issues) yuntrained medical translators give translation errors (omissions, additions, substitutions)

48. Cultural/gender issues in EM zIdeal of culturally competent health care: ydemonstration of sensitivity yvaluing cultural differences yself-awareness of cultural background and biases

49. Case 6 zA hospitalized, elderly pt is being coded (full CPR). The code has gone on for 20min without evidence of success. You believe the pt will not survive the attempt. There is adequate IV access. Someone asks if you, as junior resident, would like to attempt a femoral venous line for practice, since the pt is going to die anyways. yIs this ethical?

50. Teaching issues zEthical issues of who provides care: yobligation of academic physicians to ensure that residents have adequate skills to provide good medical care yresident must acquire knowledge, technical abilities before assuming full responsibility for pt care ypts right to be treated by fully qualified physician

51. Teaching issues zOptions for teaching: yanimals--is it ethical to inflict suffering on animals, when alternatives are available? yMannequins--an imperfect model ycadavers--do not realistically mimic tissue of real pt ynewly dead--respect for autonomy? Does it apply? yLiving--pt autonomy and nonmaleficence?

52. Post-mortem teaching zPros: yconstrued consent yunable to obtain consent in ED setting ysocial ethics z Cons: yindividual autonomy yfamily possess rights of ownership over deceaseds body

53. Teaching issues--back to case zSurvey of 234 house officers (47% 1st yr postgrad training) z34% thought sometimes appropriate to insert FVC for practice during CPR z26% had observed someone insert FVC for practice during CPR z16% had attempted this zsignificant association b/w the experience of inserting FVC during CPR for practice and subsequent belief it may be appropriate to perform this

54. Case 7 zA drug company rep in the ED asks to speak with Sr. resident. They discuss value of his companys new antibiotic for ED use, vs. others on the market. He distributes promotional material to the Sr. resident and other residents in the area. Then passes out company pens, note pads, penlights, and gives a textbook on infectious diseases for the residents library. Leaves his card and says he can bring food to future conferences, pay for guest speaker to come and present on infectious diseases. yany ethical issues involved with this visit?

55. Biomedical industry zEthical concerns: ybiomedical industry is a business and is allowed to advertise yphysicians must base practice on scientific literature ybiomedical industry presentations are fundamentally biased yphysicians may not be aware of the influence of promotional materials/gifts, on their clinical decisions

56. Biomedical industry zACEP guidelines for research: yavoid conflicts of interest ymust disclose financial relationships in research ymust not allow investments from sponsors to jeopardize rights of subjects, compromise integrity of results yfinancial compensation must be at fair market value ymust establish agreements in writing before initiating research

57. Biomedical industry zACEP guidelines for gifts/subsidies: yshould be of minimal value and either benefit pts, or serve educational purpose yEP must be willing to disclose all gifts received yconference attendees should not accept direct subsidies to pay for costs of personal expenses yacademic training programs may accept subsidies to enable physicians to attend appropriately accredited programs yconference faculty should disclose all financial, material, or research support from industry

58. References zMarx. Rosens Textbook of Emergency Medicine. zWww.saem.org/download/ethics.doc zlarkin, G et al. Essential ethics for EMS: cardinal virtues and core principles. Emerg Med Clin North Am. 2002. 20(4). zOberlander, J et al. Rationing medical care: rhetoric and reality in the Oregon Health Plan. CMAJ. 2001. 164(11). zIserson, K et al. Are emergency departments really a safety net for the medically indigent? AJEM. 1996. 14:1-5. zMarco, C et al. Determination of futility in emergency medicine. Ann Emerg Med. 2000. 35(6):604-612. zDomres, B. Ethics and triage. Prehospital Disaster Med. 2001. 16(1):53-8. zPesik, N et al. Terrorism and the ethics of emergency medical care. Ann Emerg Med. 2001. 37;642-646. zBurkle, F. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. 2002. 20(2). zMilzman, D. Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score. J Trauma. 1992. 32(2):236-43. zMarco, C. Research ethics: ethical issues of data reporting and the quest for authenticity. Acad Emerg med. 2000. 7(6):691-4

59. References zAdams, J et al. Acting without asking: an ethical analysis of the Food and Drug Administration waiver of informed consent for emergency research. Ann Emerg Med. 1999. 33(2)218-223. zQuest, T. Ethics seminars: vulnerable populations in emergency medicine research. Acad Emerg Med. 2003. 10(11);1294-8. zSchmidt, T. The legacy of the Tuskegee syphilis experiments for emergency exception from informed consent. Ann Emerg Med. 2003. 41(1). zMulticulturalism and cultural competency. Www.mdconsult.com ziserson, K. Postmortem procedures in the emergency department: using the recently dead to practise and teach. J Med Ethics. 1993. 19(2):92-8. zIserson, K. Law versus life: the ethical imperative to practice and teach using the newly dead emergency department patient. Ann Emerg Med. 1995. 25;91-94. zMoore, G. Ethics seminars: the practice of medical procedures on newly dead patients--is consent warranted? Acad Emerg Med. 2001. 8(4):389-92. zKaldjian, L et al. Insertion of femoral vein catheters for practice by medical house officers during cardiopulmonary resuscitation. NEJM. 1999. 341:2088-2091. zACEP. Financial conflicts of interest in biomedical research. Ann Emerg Med. 2002. 40:546-7.

60. Questions ?