medical ethics and physician patient...

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© 2015 NORCAL Mutual Insurance Company

Medical Ethics and Physician‐Patient Encounters

JANUARY 23, 2016TEXAS OSTEOPATHIC MEDICAL ASSOCIATION

DALLAS, TX

Presented by:BRADFORD S. DUNKIN, MHA

MARY‐LYNN RYANRISK MANAGEMENT SPECIALISTS


DISCLAIMER

The information contained herein and presented by the speaker is based upon sources believed to be accurate at the time they were referenced.

The speaker is not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought.

This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation.


Faculty and Planners

Faculty• Bradford S. Dunkin, MHA

Sr. Risk Management Specialist

• Mary‐Lynn RyanRisk Management Specialist

Planners• Jo Townson

CME Manager/NORCAL

The faculty and planners of this activity have no relevant financial relationships to disclose.

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• Which one of the following is not a bioethical principle?

A. Autonomy

B. Beneficence

C. Non‐maleficence

D. Justice

E. Autonomy

• Working from an ethical framework always allows us to choose the one best way to solve an ethical dilemma.

A. True

B. False

Pre‐test questions:

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• Fundamentally, ethics is: (choose all that apply)

A. Moral courage

B. Dignity

C. Being right

D. Compassion

E. Collaboration

F. Managing complexity

• Ethics is a completely different and separate discipline from risk management.

A. True

B. False

Pre‐test questions:

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Learning Objectives

By reviewing common allegations and risk issues associated with ethics, this presentation will support your ability to:

• Differentiate and identify the behaviors that constitute ethical behavior, personal conflicts, and professionalism.

• Identify and apply bioethical principles in health care settings.

• Apply ethical best practices to improve patient safety and reduce overall liability that focuses on identifying, responding to, investigating, and monitoring ethical behaviors.

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A. End of Life

B. Reproductive Issues (i.e. IVF, VBAC, contraception, etc.)

C. Genetic Information

D. Privacy of Information

E. Research Issues

F. Dealing with Minors and Parents and Pediatric Issues

G. Termination of Care

H. Personal Moral Conflicts(i.e. LGBT patients, abortion, etc.)

I. Communication of Informed Consent

J. Dealing with Surrogates and Guardians

K. Other

What is the Biggest Ethical Issue You Face in Your Practice?

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MEDICINE

SCIENCE• Technical Proficiency

• Clinical Skills

ART• Ethics

• Professionalism

• Decision Making


Ethics, What it is:

• Moral courage

• Dignity

• Compassion

• Collaboration

• Managing Complexity © 2012, Josh Hyatt, Used with permission

THE ARTin the Art of Medicine

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What Ethics is Not:

• The “morality” police

• The “thought” police

• The “pull‐the‐plug” police

• The “religious‐thought” police

• The “right‐and‐wrong” police

• The “how‐to‐treat‐your‐patient” police

• The “I'm‐in‐charge” police

• The “my‐way‐or‐the‐highway” police


Ethics

RIGHT

WRONG

Ethics is often seen as:

Ethics is really about: Coming up with the better, more reasonable solution given the circumstances


Basic Bioethics Principles

AUTONOMY

BENEFICENCE

NON‐MALEFICENCE

JUSTICE

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Ethical Challenges of Medicine

• Patient/family expectations

• Community standards

• Sense of failure or surrender


Goals of Medicine

• Return the patient to full quality of life

• Get the patient to an acceptable quality of life

• Provide comfort when quality of life goals cannot be achieved

Always Ask:WHAT IS THE GOAL?


Benefit‐Risk Ratio

Beneficence and nonmaleficence are assessed.

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Is it Medically Indicated?

• Acute, chronic, critical, reversible, emergent or terminal?

• Goals of treatment?

• Medically indicated?

• Probabilities of success?

• How can this patient benefit from care?

• How can harm be avoided?

Jonsen, Siegler, & Winslade. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed)


Is it Medically Indicated?

• Acute, chronic, critical, reversible, emergent or terminal?

• Goals of treatment?

• Medically indicated?

• Probabilities of success?

• How can this patient benefit from care?

• How can harm be avoided?

Jonsen, Siegler, & Winslade. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed)


Ethical problems can arise when goals are:

• Undefined

• Change

• Unclear

• Conflict

Conflicts

Image courtesy of jscreationzs at FreeDigitalPhotos.net

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Personal Conflicts

COUCH ISSUE

VALUE CONFLICT


Surgery: Couch Issue or Value Conflict?

Advanced heart failure surgeon wants to place a pacemaker in a 77 y.o. male with diminished physical capacity but intact mental capacity. Daughters are adamant about doing whatever it takes.

Resident stated he spoke with patient and wife the day before and they stated they did not want aggressive treatment. Patient and wife meek and quiet.

Surgeon stated that daughter was decision‐maker and she wanted the surgery done.


A. Confirm with the patient their wishes and honor his request.

B. Perform the surgery, because failing to do so would result in a lawsuit from the daughters.

C. Consult with clinical team to determine the best course of action, then proceed with the final decision.

D. Bring the daughters into a family meeting with the patient to talk some sense into him and his wife about his decision.

What would you do?

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Analyzing complex issues in a logical, ethical format

Ethics Decision‐Making


Ethics Decision Making

Key Individuals

Who? Intentions?

Ethical Principles

Which Principles?

Conflicts?

Medical Indications

Clincal Options

Consequences

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Key Individuals

Husband & Wife,

Daughters, Surgeon, Resident

Dignity, Keep Alive, Ego, Meet family

wishes

Ethical Principles

Which Principles?

Conflicts?

Medical Indications

Clinical Options

Consequences

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Key Individuals

Who? Intentions?

Ethical Principles

Which Principles?

Conflicts?

Medical Indications

Clinical Options

Consequences

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Key Individuals

Husband & Wife,



wishes

Ethical Principles

Autonomy? Beneficence?

Non‐Maleficence?

Social Benefit?

Autonomy v. Beneficence? Beneficence v.

Non‐Maleficence, Social Benefit

Medical Indications

Clinical Options

Consequences

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Key Individuals

Who? Intentions?

Ethical Principles

Which Principles?

Conflicts?

Medical Indications

Clinical Options?

Consequences?

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Key Individuals

Husband & Wife,



wishes

Ethical Principles

Autonomy? Beneficence?

Non‐Maleficence?

Social Benefit?

Autonomy v. Beneficence? Beneficence v.

Non‐Maleficence, Social Benefit

Medical Indications

Surgery, Do Nothing, Less Invasive,

Palliative or Hospice

What’s appropriate?

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Analysis

Key Individuals

Who? Intentions?

Ethical Principles

Which Principles?

Conflicts?

Medical Indications

Clinical Options?

Consequences?


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Risk Management and Law

RISKMANAGEMENT

“Choose To Do”

RISKMANAGEMENT

“Choose To Do”

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Operational Considerations in Ethics:

Provider Refuses to Provide Services?

Conflicts of Interest?

Allocation and Allocation and Utilization of Services?

Privacy and Disclosures?

Culture of Ethics/Organizational

Ethics?

Resources/Finances?

Insurance Payment?


Decision‐Making and Consent Issuesto Consider:

Provider Refuses to Provide Services?

Refusal of Treatment

Unclear Who Surrogate Is

Patient’s Wishes are Unclear

Competency v. Capacity

Informed Consent?

Advance Directives


55 year‐old female, end‐stage COPD, admitted with SOB and unconscious. Patient placed on medical ventilation.

The patient in MICU for 1 month.

During the admission, DX anasarca and an ileus, resulting in the need for TPN, which was stopped at her request

Unable to determine surrogate

Patient likely to pass away from COPD in < 6 months or die if the TPN is not restarted

Patient Refusing TPN

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An ethics consult was requested because the patient:

No longer being sedated

Alert and oriented

Refusing TPN for 3 days

Wanted to go home.


Analysis?

55 y.o. Woman, Daughter, Sisters,

Boyfriend/Husband, Intensivist

Ethical Principles?

Options:

A.TPN and hope the ileus resolves and stay at the hospital,

B. discharge home on medical ventilation,

C. provide her reasonable efforts to make her comfortable, and

D. home hospice

Ethics Decision Making: Patient Refusing TPN

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Ethical Issues:

Patient’s capacity and autonomy

Determining surrogate decision maker in the event she

becomes incompetent

Patient choosing something that will result in her death

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A. Utilize the family to encourage the patient into taking to the TPN so she can live as long as possible.

B. Recommend a palliative care consultation because the patient is actively dying and is refusing necessary services.

C. Get a court order to preserve the patient long enough to be transferred from the facility.

D. Become a conscientious objector to the patient’s decision, sign‐off on the care, and transfer care to another physician.

What would you recommend?

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Recommendations:

Palliative care consult

Not curative, patient is actively dying

Discussion of the available options

Decision:

The family opted for going home and having hospice provide care there.


Clinical Considerations in Ethics:

Pain?

MultipleCo‐Morbidities?

Life Sustaining Technologies?

Non‐Compliance?

Curative v. Futile Treatment?

Frequent Admissions?

Ethical Concerns Ethical Concerns About Current Treatment?

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End of Life Issues in Ethics:

Withdraw or Withhold Treatment?

Life Sustaining Treatment v.

Comfort Care

Allow Natural Death?


Anoxic Brain Injury

47 y.o. male, found unresponsive for approximately 20 minutes, now in ICU for a week

DX: Anoxic brain injury, drug overdose, close to brain death, on ventilator, minor episodes of over‐breathing

Physician recommending removal from ventilator, mother and sister do not want that and kept patient full code, no advanced directive


Anoxic Brain Injury

An ethics consult was requested because:

Not going to recover from the brain injury

No advanced directives or documented wishes

Family requesting care that was not medically indicated

Family wanted to take the patient home

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Analysis?

47 Y.O. Man, Mother, Sisters, Intensivist,

Palliative Care Physician

Ethical Principles?

Options:

A. Remove ventilator and allow natural death,

B. Continue the ventilator and life sustaining efforts

Ethics Decision Making: Anoxic Brain Injury

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Anoxic Brain Injury

Ethical Issues:

Surrogate’s decision‐making, best interest of the patient?

Providing scientifically futile care

Full code status

Unrealistic expectations


A. Explain the clinical condition and likelihood of recovery.

B. Consider palliative care.

C. Allow the family time to grieve.

D. Empathize with the complexity of making this decision.

E. Attempt to frame the conversation with positive language.

F. All of the Above.

How would you respond to the family?

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Anoxic Brain Injury

Recommendations:

Discuss curative versus futile care

Consider palliative care

Time to grieve

Decision‐maker not “killing the patient”

Positive language to frame discussion


Communication Issues in Ethics:

Patient

Providers

Family


Synopsis

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Synopsis

Finding best option in a given circumstance


Synopsis


Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication


Synopsis



Rooted in conflict

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Synopsis



Rooted in conflict

Requires difficult conversations and even more difficult choices


Synopsis



Rooted in conflict


Ethics is not for the faint of heart


Synopsis



Rooted in conflict


Ethics is not for the faint of heart

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• Which one of the following is not a bioethical principle?

A. Autonomy

B. Beneficence

C. Non‐maleficence

D. Justice

E. Autonomy

• Working from an ethical framework always allows us to choose the one best way to solve an ethical dilemma.

A. True

B. False

Answers:

56


• Fundamentally, ethics is: (choose all that apply)

A. Moral courage

B. Dignity

C. Being right

D. Compassion

E. Collaboration

F. Managing complexity

• Ethics is a completely different and separate discipline from risk management.

A. True

B. False

Answers:

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Q & A

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Bradford S. Dunkin, MHASr. Risk Management Specialist

NORCAL Mutual855‐882‐3412, ext. 1580

bdunkin@norcal‐group.com

Mary‐Lynn RyanRisk Management Specialist

NORCAL Mutual855‐882‐3412, ext. 2045mryan@norcal‐group.com

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