Transcript Document 7131198

ETHICS
Part I
June 5, 2003
Moritz Haager PGY-2
Dr. Carol Holmen
Ethics vs.. Law
“..ethics and law are not equivalent.
Adherence to the law does not result in
ethical behaviour, and ethical behaviour
may not be covered by the law or may in
fact be contrary to law or policy….ethical
duties typically exceed legal duties, and in
some cases, the law mandates unethical
conduct”
• Derse. Emerg Med Clin North Am. 1999; 17(2): 30725
Ethics vs. Law
 Law


A formal expression of a social ethical
consensus that sets a minimal standard of
conduct
Does not cover large areas of conduct
 Ethics


Branch of philosophy dealing with human
conduct which acts as a moral repository of
societal norms
Less formal but more pervasive than law
What is unique about ED ethics?







Most literature and discussion focused on nonacute setting
Pts present w/ rapid change in health
Little continuity of care / familiarity w/ pt
Lack of reliable information
Need to make rapid potential life or death
decisions w/ limited information
Pts often not in ED of their own volition
Pts often impaired, noncompliant, or hostile
What is an Ethical Dilemma?
 Deciding
which of 2 or more choices
provides the greater overall good




Autonomy vs. justice
Confidentiality vs. public duty
Beneficience vs. non-maleficience
etc
Ethical Models
Ethics
Deontologic Theory
Consequentialist Theory
Relies on ‘fundamental’ rules
e.g. first, do no harm
Based on predicted outcomes
e.g. do more good than bad
Fundamental Ethical Principles
 1.


 2.
Preservation of Life
Beneficience
Non-maleficience
Respect Autonomy
 3. Justice
 4. Truthfulness
Preservation of Life
 Beneficience


Acting in the pts benefit (= doing “good”)
Alleviation of suffering
 Nonmaleficience

Primum non nocere (first do no harm)
Autonomy
 From
Greek for ‘self-rule’ = Patient right to
self-determination
 Respecting vs.. creating autonomy


Respecting = following pts wishes
Creating = allowing pt to make a choice e.g.
informed consent
 Autonomy
vs. paternalism
 Benign paternalism

Making therapeutic decisions for incompetent
pts in good faith
Justice
 Complex
concept E.g. resource allocation
 3 major types:

Egalitarian
• equal access for all

Libertarian
• social or economic ability should be allowed to
determine access

Utilitarian
• combines features of above to maximize public
utility (Canadian System)
Case 1
 A 83
you Punjabi male is brought to the
ED for ‘constipation’. He looks cachexic
and dehydrated but is oriented and able to
communicate.
 Physical exam reveals an enormous hard
irregular mass in the abdomen which is
almost certainly cancerous.
Case 1

You call the radiologist to arrange an abdominal CT.
You don’t realize the son is standing behind you as
you relate your suspicion about the “cancer”.
 After you hang up the son approaches you and
asks you not to tell his father the Dx because he is
very afraid of death and would not want to know. In
India the word Cancer is like a death sentence he
tells you. He feels that telling him would destroy his
fathers quality of life.
Truthfulness


Trust b/w pt and physician
Is truth always best? Straightforward?




Therapeutic privilege



Cultural differences
Impact of disease
Gradual vs.. immediate disclosure
Concept that a physician may withhold information if
doing so would result in harm to the pt (nonmaleficience)
Becoming a historical concept
Withholding information, at least temporarily, may
be justified, BUT only if there are compelling &
defensible reasons
McMaster Decision Model
List the alternative courses of action
Assess each alternative in 3 spheres:
1.
2.



3.
4.
5.
Medical
Patient
Legal
Apply relevant ethical principles to each
Justify each choice as a moral statement
Formulate a conclusion
Iserson Model
Have you already dealt w/ a similar
problem? Do you have a rule for it?
Is there a safe time-buying option?
If immediate decisions needed:
1.
2.
3.
1.
2.
3.
Impartiality test – would you want this done
to you?
Universality test – would you want this
done in all similar situations?
Interpersonal Justifiability test – can you
strongly justify your actions to others?
Case 2
 You
are taking care of a 25 yo female
suffering from acute traumatic C1 on 2
dislocation with complete cord transection.
She is ventilator-dependant and a
complete quadriplegic with no chance of
recovery. She is alert enough to answer
questions through eye opening and
closing.
Case 2
 Her
husband indicates to you that they
wish for the ventilator to be turned off.
They had discussed this hypothetical
situation in the past as the family knows
Christopher Reeves who used to ride
horses at their ranch She confirms this
when you ask her if this is true.
Consent
 The
pts right to agree to, OR refuse a
medical treatment (autonomy)
 Requires physicians to inform pts about
the potential consequences of both
accepting and refusing a treatment
Implied vs.. Explicit Consent
 Implied


Pts actions in keeping w/ agreeing to Tx
E.g. Pt rolls onto side and pulls down pants
when told of need to perform a DRE
 Explicit



Consent
Consent
Verbal or written, and documented on chart
More involved discussion of risks, benefits, and
alternatives
Should be obtained by person doing procedure
Components of Consent
1.
2.
3.
Possession of decision-making capacity
Provision of pertinent information about
the proposed therapy on which to base a
decision
Consent is voluntary, and obtained w/o
coercion or manipulation.
Guidelines for informed consent





Discuss procedure including anticipated
impact, significant risks, and alternatives
Encourage questions
Explain likely outcome if treatment is not
provided without resorting to coercion
Specifically address individual concerns
Adhere to above for all patients even if
they seem prepared to accept any
treatment
Assault vs.. Battery
 Assault

Threatening to touch someone
 Battery


Touching someone without that persons
agreement
Any intervention in the ED provided w/o the
pts consent in situations other than those
where consent is not required
Exceptions to Need for Consent
 Based

on concept of beneficience
Emergencies: If immediate threat to life or
limb, and unable to give consent
• Unconscious trauma victim

Person lacking capacity and at acute risk
• Intoxicated drug OD pt wanting to leave
• May require invocation of Mental Health Act

Treatment of minors
• 12 yo Jehovah's witness w/ acute blood loss

Public Health Regulations
• Mandatory reporting laws
Age of Consent


No age of consent in Canadian tort law
Provincial legislation for age of consent:

PEI
• 18 yo or married (for surgery)

NB
• 16 yo or younger if ‘competent’

PQ
• 14 yo

SK
• 18 yo or married (for surgery)

BC
• 16 yo if unable to obtain parental consent; need 2nd physician
to provide written opinion of necessity of Tx
Case 3

14 yo female is brought in by her mother. A
friend of the girl has just phoned the mother to
say that she had gotten drunk, done drugs, and
then had sex with a nineteen year old. The pt
denies all this. Mom demands a drug screen
AND pelvic examination. She firmly states that
as the pt is a minor, and she the parent, you
must abide by her wishes. Do you? What if the
girl refuses the blood and urine tests, and pelvic
exam? Are you obliged to refer her to the sexual
assault team? Are you obliged to notify the
police?
Case 4
 A 12
yo girl is brought to the ED by her
mother c/o fever & dysuria. The pt does
not want her mom present during the
interview or exam. She is pre-menarchal,
and denies being sexually active, or
sexual or physical contact against her will.
Her temp is 38.0. Superficial genital exam
reveals multiple labial ulcerations and
malodorous vaginal discharge.
Case 5
 A 16
yo female is brought to the ED by her
mother for abd pain, vomiting, and PV
bleeding. You examine her in private. She
admits to consensual sexual activity. A
urine pregnancy test is +ve, and she has a
tender R adnexal mass. U/S confirms a
ectopic pregnancy. She understands the
need for intervention and is willing to see
O & G but insists you not tell her mom.
Case 6

A 70 yo man with gangrene of R foot + leg from
a diabetic ulcer is in your ED. He is requesting a
Rx for abx & painkillers. You tell him that you
think he should come into hospital and see a
surgeon. He refuses this saying he does not
want his leg amputated. “better to die than lose
your independence” he tells you.
 His daughter is present and argues with him
vehemently. At one point she tells him “you can’t
go on like this, all cooped up by yourself in that
house not taking care of yourself”. She tells you
he has been depressed since his wife’s death 2
yrs ago.
Capacity

= Ability to comprehend & process:



Capacity can fluctuate with situation & time



Information about the treatment or test
Potential consequences of acceptance or refusal
Assess on sliding-scale: the more serious the decision,
the more competent the pt should be
Age does not necessarily preclude capacity
Assessment of capacity poorly studied & subject
to bias
 Few statutory laws other than those regarding
formal admissions for psychiatric pts to guide you
Impaired Capacity
 Examples





of impaired capacity
Intoxication
Organic brain disease (e.g. Alzheimer’s)
Minors
Suicidal pts
Other psychiatric illnesses
Aid to Capacity Evaluation (ACE)
 Tool
for systematic evaluation of capacity
developed at U of T by experts in law,
ethics, and medicine
 Scores 7 areas as ‘yes, no, or unsure’
 Requires identifying & addressing any
communication barriers
 Done in conjunction w/ discussing risks,
benefits, & alternatives of proposed Tx
 ACE questionnaire available at
http://www.utoronto.ca/jcb/_ace/ace(fm).htm
ACE Questions
 Ability






 Is


to understand:
Current medical problem
Proposed Tx
Alternative therapies (if any)
Option of refusing any Tx
Reasonably foreseeable consequences of
accepting proposed Tx
Reasonably foreseeable consequences of
refusing proposed Tx
the person’s decision influenced by:
Depression
Delusions or psychosis
ACE Conclusions
 Final
assessment subjective, but based on
score in prior areas

Pt should demonstrate ability to understand
relevant info AND possible consequences
 Clinician




designates pt as one of:
Definitely capable
Probably capable
Probably incapable
Definitely incapable
Validity of ACE
 Cross-sectional
study of 100 inpatients w/
questionable capacity facing serious
medical decisions
 Assessed by residents & research nurse
using ACE + MMSE, general impression of
attending physician, and formal
assessments 2 separate experts
 Compared results of each
Validity of ACE

Results





ACE took ~15 min to administer
Agreement b/w ACE and expert opinion was sig
higher (k = 0.90-95) than the general impression of
attending physician (k = 0.86)
MMSE scores of 0-16 correlated sig w/ incapacity (k =
0.93)
A MMSE score of 0-16 combined w/ an ACE score of
probably or definitely incapable resulted in post-test
prob of 96% for incapacity
A MMSE score of >24 combined w/ an ACE score of
probably or definitely capable resulted in post-test
prob of incapacity of 3%
Validity of ACE
 Conclusions



ACE & MMSE both agree well w/ expert
opinion
Indeterminate results (probably capable or
incapable; MMSE score 17 – 23) correlate
more poorly and should prompt alternative
evaluation
Combining ACE and MMSE preferable
• Etchells et al. J Gen Intern Med. 1999; 14: 27-34
Case 7
 An
ill-appearing 2-year-old with a fever
and stiff neck appears to have meningitis.
His parents refuse a lumbar puncture on
the grounds that they have heard spinal
taps are extremely dangerous and painful.
They refuse treatment and investigation,
saying, " We'd prefer to take him home
and have our minister pray over him."
Case 8
 A 5-year-old
child has just had his second
generalized tonic-clonic seizure in a 4
month period. You have recommended
starting an anticonvulsant. The parents
have concerns about the recommended
medication and would prefer to wait and
see if their son has more seizures. How
should you respond to the parents
request?
Treatment Refusal
 A person
of proper mental capacity has
the right to refuse even life-saving Tx
 A parent or guardian may NOT make this
same decision for a minor in their charge
 Written documentation corroborated by
family members have been deemed
sufficient grounds to withhold emergent
therapy in an unconscious patient
Treatment Refusal

The key question in the ED regarding refusal of
treatment is whether the patient is competent to
make this decision
 Difficult area, but generally based on:







Set of values and goals
Consistency in decision-making
Ability to understand & communicate info
Linguistic & conceptual skills
Sufficient life experience
Ability to reason
Refusal of life-saving measures usually mandates
assistance in determination of competency
Case 9
 A 50
yo male receiving palliative care for
metastatic stomach CA is brought in by his
family b/c of poor pain control and inability
to tolerate PO feeds
 His vitals are 37.4 / 110 / 96/70
 He looks cachectic, jaundiced, dry, is
drowsy & unable to answer Q’s or
cooperate with exam
 He has multiple metabolic abnormalities
including renal failure on his lab work
Case 9
 His
wife states that he did not wish for lifeprolonging measures or resuscitation, only
for “comfort and dignity”
 His wife does not want you to start an IV,
however his son & daughter argue that he
is dehydrated and should not starve to
death
 How do you approach this?
Case 10
 A 79
yo male is brought to the ED from a
nursing home in acute resp distress.
 Recent admission records indicate COPD,
end-stage RF, and dementia. He is nonambulatory.
 On exam he is in sig resp distress. His
vitals are 38.0 / 130 / 140/90 / 30 / 79% on
40% O2
 He is frail and unable to answer Q’s.
Case 10
 There
is no documented code status
anywhere
 The only family member you can reach is
a son who lives in Miami. He last saw his
father 8 mo ago. The son informs you that
his father would not want any aggressive
treatment.
Substitute Decision Makers
 Person
chosen to make medical decisions
on behalf of an incompetent pt
 Role is to use “Substituted Judgment” to
try and mirror what the pts wishes most
likely would be
Substitute Decision Maker
 Murky

 If

 If
area in Canadian law:
family members probably not legally
empowered to act as substitute decision
makers unless specifically court appointed,
although this is common practice
no appointed SDM, use in rank order:
Court-appointed guardian  spouse / partner
 child  parent  sibling  other relative
no one available need public guardian
Minors
 “Mature

Minor”
Minor capable of understanding the risks &
benefits of a Tx are entitled to make
autonomous decisions
 “Emancipated


Minors”
Sub-group of mature minors
Those who support themselves independently
and live separately from their parents, are
married, and / or serve in the armed forces.
Case
 A 45
yo male is brought in by EMS for
polydrug OD. He is intubated and placed
on a ventilator for resp failure.
 A suicide note is found on scene in which
the pt claims he has the right to choose to
die on his own terms given his Dx of ALS,
that he is rational and not depressed, and
that he will sue anyone resuscitating him.
Case
 His
common-law wife arrives with his
‘living will’. It was formulated 6 mo prior,
witnessed and notarized. In it the pt clearly
states that if he is “..in a condition that is
terminal with no reasonable hope of
recovery I do not want heroic measures to
prolong my dying..”
 His wife states he would not want these
interventions and demands you turn the
ventilator off
Case 11

An elderly man with end-stage emphysema
presents to the emergency room awake and alert
and complaining of shortness of breath. An
evaluation reveals that he has pneumonia. His
condition deteriorates in the emergency room and
he has impending respiratory failure, though he
remains awake and alert. A copy of a signed and
witnessed living will is in his chart stipulates that
he wants no "invasive" medical procedures that
would "serve only to prolong my death." No
surrogate decision maker is available. Should
mechanical ventilation be instituted? What if he
presents confused and somnolent?
Advance Directive
 Legal
document outlining a pts wishes
regarding their medical Tx in the event of
becoming incapable of directing their care
 May assign a person to be SDM in which
case it is a “proxy directive” or “durable
power of attorney”
 Can be revoked by the pt at any time
Case 12
 A 16
yo female presents w/ PV bleeding
and abd pain. She came alone.
 By Hx & exam she is 10 wks pregnant and
is having an incomplete abortion with sig
bleeding
 You discuss the situation with the pt and
after discussing the options she states she
wants a D & C
Case 12
 As
you hang up the phone after talking to
O & G the mother identifies herself to you
and asks what is going on with her
daughter. You ask her to speak with the pt.
She returns stating her daughter has no
idea what is going on and as the parent
she demands to know what is wrong.
Case 13
 A 24
yo male presents w/ penile d/c. He
admits to using the services of a prostitute
on a recent business trip to Thailand. You
feel he likely has gonorrhoea and Tx him
accordingly. His wife is in the waiting
room. He demands you keep his Dx
confidential stating that it was a “one time
thing” and if she knew it would ruin their
marriage. You buy yourself some time by
going to grab a prescription padOutside
you are approached by his wife who asks
what is the matter with her husband.
Case 14
 A 60-year-old
man has a heart attack and
is admitted to the medical floor with a very
poor prognosis. He asks that you not
share any of his medical information with
his wife as he does not think she will be
able to take it. His wife catches you in the
hall and asks about her husband's
prognosis. Would you tell his wife?
Confidentiality
 Pts
has the right to hold the physician to
secrecy regarding personal info
EXCEPT where:



Doing so contravenes legal obligations
Doing so may result in harm to others
Doing so may result in harm to the pt AND the
pt is incompetent
 All
reasonable steps must be taken to
inform pt of intended breach of
confidentiality
Case 15
 A 55
yo female is brought to the ED for
decreased colostomy output and abdominal
pain. She has a Hx of TAH & BSO for
ovarian CA 5 yrs ago. She looks mildly
unwell and has generalized abdominal
tenderness, but is otherwise stable. An U/S
shows peritoneal carcinomatosis. Your staff
surgeon who has not seen the pt, shrugs
and tells you to send her back to the
peripheral hospital from where she came.
When you ask him about what you should
tell her he says “Nothing. Let the GP handle
it”
Case 16
 You
are about to go see your next pt who
is here after a minor MVA when you are
intercepted by her daughter in the hall
 She tells you that her mother has cancer,
but she has not told her of this and asks
you to keep this secret.
 On exam there is an obvious mass lesion
on the left breast. As you are auscultating
the pt asks you about the mass.
Case 17
 A 89
yo male is brought to the ED for
cough & resp distress.
 You find he has b/l pneumonia, chronic
pulmonary edema, as well as a UTI
 He was discharged 3 wks ago for CHF
exacerbation with multiple complications
 He was a full code status at that time
Case 17
 Despite
treating him with Abx, diuretics,
and O2 his breathing continues to
deteriorate. He starts to look more septic
so you start him on biPAP and dopamine.
 You discuss the situation w/ his wife.
When you bring up code status she
becomes upset and insists everything be
done
 Just then you are called into the resus
room – your pt is in PEA
Case 18

A 45 yo female of is brought to the ED w/ fever +
cough. She is in a persistent vegetative state x 2
yrs following an MVA, lives in a nursing home
and depends on a G-tube for nutrition. She is
tachypneic and her O2 sats are 86% on RA. You
Dx her w/ pneumonia and start her on abx and
O2. As she looks unwell you broach the topic of
code status. The family, who are Orthodox Jews,
insist that she receive all measures including
intubation & ICU care if necessary. Is this
appropriate?
Medical Futility
 Futility

action that is ineffective or w/o useful purpose
 Medical


futility
Variety of definitions but none widely
accepted
based on largely subjective opinions as we
often don’t really know the true efficacy of a
treatment, nor can predict its success in a
particular patient
Medical Futility
 AHA ACLS
guidelines for terminating
resuscitation:



BLS & ALS have been attempted appropriately
w/o ROSC or breathing
Deteriorating pt condition despite maximal
therapy precludes likelihood of recovery (e.g.
septic shock in ICU)
Disease states from which no successful
resuscitation has been reported in welldesigned studies (e.g. metastatic CA)
Medical Futility
 Schneidermann


et al 1990
A treatment is futile if “…merely preserves
permanent unconsciousness or …fails to end
total dependence of intensive medical care”
Efforts can be terminated, or care withdrawn
w/o pt approval “..when physicians conclude
(either through personal experience,
experiences shared with colleagues, or
consideration of empiric data) that in the last
100 cases, a medical treatment has been
useless”
Medical Futility
 Brody

and Halevy 1995
Physiologic futility
• failure to produce a physiologic response

Imminent demise futility
• failure to prevent death in the very near future

Lethal condition futility
• intervention not expected to impact fatal outcome
in near future due to underlying condition

Qualitative futility
• intervention not expected to result in an acceptable
quality of life
Pro-futility arguments

Professional Integrity


Professional Expertise


Physicians should not be forced into providing
treatments they believe offer no benefit or are
potentially harmful
Pts seek the advice of a physician regarding diagnosis
and treatment options and would not normally expect to
be offered Tx w/ little or no benefit
Resource Stewardship

Selective use of limited resources to maximize societal
benefit
Anti-futility Arguments

Respect for Pt Autonomy


Prognostic Uncertainty


Where the goals of Tx, or odds of success worth
pursuing are perceived differently by the physician
and the pt or substitute decision makers, the latter’s
wishes should be respected
Literature of critically ill pts suggests physicians are
not good at accurately predicting outcomes making it
difficult to justify withholding care based on this
Lack of Societal Consensus on Futility

Unless universally agreed upon, no futility judgments
should be imposed on unwilling subjects
Approach to Futility
 Patient
Preferences
 Likelihood of medical benefit

Based on literature
 Likelihood

of non-medical benefits
Includes family needs, grieving process etc
 Family
Wishes
 Potential Risks of Intervention

Risks to pt and healthcare workers
Demands for Inappropriate Care
 Three

groups:
Demands for ineffective Tx
• E.g. antibiotics for common cold

Demands for effective Tx that supports a
controversial goal
• E.g. liver transplant for 104 yo pt w/ end-stage
liver dz

Cases at the fringe of standard medical
care
• E.g. chelation therapy
Demands for Inappropriate Care
 You
are under no obligation to provide Tx
that falls outside the standard of care, or
those for which there is very poor
evidence but which may be used by a
small number of physicians
 If an acute situation is complex, possibly
inappropriate requests for life-saving
measures should be respected
Demands for Inappropriate Care
 Demands
for effective Tx that supports a
controversial goal



Most difficult situation
Values of physician vs.. family / pt
Autonomy vs.. distributive justice
 Often



requires extensive discussions & help
Hospital ethics committee
Social workers
Clergy
Case 19

A 75 yo male is brought in by EMS. He was
found comatose in his bed next to an empty
bottle of barbiturates by a home care nurse. His
son arrives and tells you his father has
advanced lung CA with extensive bony mets
which cause him intractable pain despite
massive narcotic use. He is expected to die
within the next 6 mo and has repeatedly stated
the he is “ready to face the maker”. Your pt at
that point goes into resp arrest. The son pleads
with you not to intervene. “Please, just let him
go. He wants to die…..has he not suffered
enough?”
The BIG Question
 Are
some suicides reasonable decisions
rooted in the concept of autonomy?



90% of suicides felt to be associated w/ some
form of mental illness on post-mortem review
Beneficience in the form of intervention
overrules pt autonomy in these cases based
on the idea that the mentally impaired pt the
lacks capacity
Situations where an otherwise competent pt
chooses suicide are less straightforward
Are there “good” reasons for a pt to commit
suicide? Should these be respected?
 Pro



A pt who has capacity has the right to selfdetermination & should not suffer the
imposition of others moral beliefs
If all other medical options (beneficience)
have been exhausted then our next duty
should be to avoid further harm (maleficience)
We must clearly differentiate between our own
moral belief system and the choices we would
make for ourselves, and those of our pts
Are there “good” reasons for a pt to commit
suicide? Should these be respected?
 Con





Suicide is counter to the principle of
preserving life
Controversial whether suicide can truly
represent a rational choice
Not legally recognized as a right
Rejected by most major religions
In the ED in particular knowledge of the pt
and their circumstances limited
Physician Assisted Suicide
 Legal
in Netherlands & Oregon
 Not legal in Canada…yet
 Impact on ED





Failed suicide attempts – who do we
resuscitate?
Family members demanding resuscitation
Staff unable to comply with pts wish to die
Conflict b/w members of health care team
Conflict w/ institutional policy
Intervening in Suicide
 Catch


22: the need to avoid 2 mistakes
Intervening when it is not warranted
Not intervening when it is warranted
 Bottom

line:
~90% will have mental illness, combined with
the lack of prior intimate knowledge of the pt
alone should prompt intervention given the
irreversibility of suicide
And finally…the biggest question
Is this ethical, for
healthcare workers
to smoke?
THE END
Case 20
 51
yo male presents w/ 2 hr CP
 2 mm STE in ant leads
 Tx w/ ASA, nitro – r/o contraindications to
thrombolysis
 During risks & benefits discussion his pain
resolves & ECG normalizes – CCU consult
 2 hrs later nurse tells you pt is attempting
to leave b/c his pain has resolved and he
is tired of waiting around