slides ethics

7/25/2019 Slides Ethics

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Ethical and Legal Issuesin the Treatment of

Older AdultsRicardo Perez, DO, JDAssistant Professor ofMedicine

UMDJ!"OM


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Ethical and Legal Issues in theTreatment of Older Adults

This Care of the Aging MedicalPatient in the Emergency Room

(CAMPER)#resentation is o$ered%& the De#artment of Emergenc&Medicine in coordination 'ith the

e' Jerse& Institute for "uccessful

Aging(This lecture series is su##orted %& an educationalgrant from the Donald )( Re&nolds *oundation

Aging and +ualit& of Life #rogram(


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An - &ear old female 'ith mild dementia#resents in acute on chronic renal failure %& EM"

'ithout a famil& mem%er #resent( The #atient istold that she needs emergenc& hemodial&sis orshe 'ill die( .ou as/ her for #ermission to #lace#erm catheter to #roceed 'ith the treatment( In

terms of medical decision!ma/ing for the elderl&,'hich of the follo'ing should %e done 0rst1

A( 2a#acit& determination

3( 2om#etenc& hearing2( 2ontact famil&!a##ointed designate of

sur4i4ing children

D( Discuss 'ith E5ecutor of the #atient6s )ill

E( 2ontact Dura%le Po'er of Attorne& for 7ealth


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An emergenc& medicine attending and hissu%ordinate emergenc& medicine resident 'ere on a

8ight to Las 9egas for an annual medical conference(During the 8ight, an elderl& male %egan cho/ing onhis in!8ight meal( After multi#le failed attem#ts ofthe 7eimlich maneu4er, the resident uses a small#oc/et /nife to secure a #atent surgical air'a&(

Ultimatel&, the elderl& gentleman reco4ered, %utde4elo#ed an infection at the surgical site( As aresult of these actions, 'hich of the follo'ing is mostli/el&1

A( The attending #h&sician 'ill assume lia%ilit&(

3( The resident 'ill %e charged 'ith Assault(

2( The resident 'ill %e charged 'ith 3atter&(

D( The resident:s actions are #rotected through anemer enc e5ce tion(


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An ; &ear old male #resents to the ED 'ith#aramedics for res#irator& distress( 7e ma/es it

clear that he 'ants to return home after treatmentfor his shortness of %reath( .ou assess that he hasca#acit& to ma/e that decision( On e5am, he a##ears


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Medical Ethics

Informed 2onsent

DR Orders @Do ot Resuscitate

Li4ing)ills


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Dura%le Po'er of Attorne&

Buardianshi#

Elder A%use>eglect Ph&sician!AssistedDeath


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MedicalEthics!Princi#les

Autonomy:Patient is a%le to ma/e o'ndecisions

Benecence:Is treatment in the %estinterest of #atient

Nonmalecence: CDo no harm

! The la' tries to ca#ture the s#irit of these#rinci#les

! There are times 'hen legal and ethical#rinci#les do not coincide


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7othetical F

A G- &ear old female is ta/en to the EDafter a head!on M92

"he is unconscious and has se4eral

fractures "he %ecomes hotensi4e and a##ears to

%e in shoc/

The #h&sician 'ants to administer a %loodtransfusion

At the same time, a nurse disco4ers a cardthat states that #atient is a Jeho4ah6s

)itness


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7othetical ?

"ame #atient as #re4ious

"he is unconscious and no famil& is#resent

"he continues to %ecome #rofoundl&hotensi4e

.ou notice that the aforementioned card

has no date on it .ou also notice that it is not 'itnessed

and it is 'ritten in *rench

)ould &ou change &our mind on treatment1


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Informed 2onsent

True "tor&H Malette v. Shulman (1990)

The 2ourt decided in fa4or of the #atient

The 2ourt concluded that the transfusion

'as a 3atter& Informed 2onsent 'as not o%tained

Patient autonom& is #aramount

In this case, 3ene0cence andonmale0cence 'as not as im#ortant asthe #atient6s self!determination


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Origin of Informed 2onsent

Doctrine 'as concei4ed from theintentional tortof Battery! CLa&ing of hands 'ithout #ermission

! CE4er& human %eing of adult &ears and soundmind has a right to determine 'hat shall %edone 'ith his o'n %od& Judge @later

Justice 2ardozo @FFK

Intentional Tort No standard of care Informed 2onsent Standard of care

mayapply! Usuall& treated as negligent tort


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Torts

Torts

"trict

egligence

9icarious

Intentional


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"tandard of 2are

Torts

o"tandard of

2are

"tandard of2are

Intentional Tort

Res I#saLo


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o "tandard of 2are

"trict Lia%ilit&

*raud>Misre#resentation

Assault 3atter&


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Intentional Tort @o "tandardof 2are

Intentional Tort

Assault 3atter&

Informed 2onsentN


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Origin of Informed 2onsent

Patient consents to an aortogram( Patientne4er ad4ised of ris/s associated 'ithcontrast medium( "hould s>he ha4e %een1

Salgo ! "eland Stanford# $r!#%nier&ity Board of 'ru&tee& (*+)! Esta%lished the Doctrine of Informed 2onsent

! o guidance as to the detail of 'hat com#rises

Cinformed consent


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Elements of Informed 2onsent

2ase la' has determined 'hat constitutesCInformed 2onsent

Elements

! ,e&cri-e procedure.treatment! E/plain ri&0&.-enet&

! ,i&cu&& alternatie treatment&

Ade


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"tandard of Informed 2onsent

!"o Standards for #sclosure! Physician-Based

! Patient-Based

$hyscan%Based! Natan&on ! 1line!Amount of disclosure

%ased on 'hat #h&sicians 'ould disclose gi4enthe same circumstances

! $ro&lems Plainti$ has to #roduce e5#ert testimon&

3ased solel& on #h&sician discretion


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o $atent%Basedo Canterbury v. Spence Amount of disclosure

determined %& 'hat the Creasona%le #atient'ould 'ant to /no' a%out the treatmentoE/pert te&timony no longer nece&&ary

oBy focu&ing on patient# court -elieed thatautonomy.&elf2determination pre&ered

o Be"are' "ome states use Csu%=ecti4e

standardo "tates ha4e used case la'>statutes to #ic/

one of these standards, or a h&%rid ofthem


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"ome states 'ith $hyscan%BasedStandard! Dela'are

! *lorida! e' .or/

! e4ada

"ome states 'ith $atent%BasedStandard

! 2alifornia!


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Presentation of Information

Modaltes! Verbal Presentation

! Discussion with physician (preferred)

! Written Information! Pamphlets

! VideoInternet

! Dia!ramsCharts


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Disclosure of Ris/s

Should #sclose! Severe "is#$ %ow Probability

! %ess Severe$ &i!her Incidence

! "is# speci'c to procedure

*ule of !hum&

! #eath

! Serous n+ury

! ,m&-r/an #ama/e! Mnor events that happen 2 of the tme

3eneral *s4

! 5nfecton6 vascular-neurolo/cal n+ury6

death


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DR Orders

This is an order gi4en %& a #h&sician tonot attem#t resuscitati4e #rotocol forsomeone in cardio#ulmonar& distress(

It can onl& %e 'ritten after a #h&siciandiscusses it 'ith the #atient or, if the&lac4 capacty, a #atient surrogate(


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DR Orders

!ypes of #N* orders-codedes/natons! #N* Do not resuscitate @o A2L" #rotocol

! #N5 Do not intu%ate @o in4asi4e air'a&esta%lishment

! Chemcal code Medications onl&

! 7ull codeAll su##orti4e measures

Remem%er DR Do not treat! umerous studies sho' that DR #atients get

less aggressi4e care and treatment, des#ite aPresidential Directi4e to discourage this


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Ad4ance Directi4es

2riteria for 2a#acit&! A%ilit& to communicate a choice

! %nder&tanding rele4ant information

! Appreciatethe situation>conse


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Ad4ance Directi4es

Tes of Ad4ance Directi4es! Li4ing )ill @Fst

! Dura%le Po'er of Attorne& for 7ealth 2are

@e5t Beneration Li4ing )ill

! Ta/es e$ect 'hen #atient lac/s ca#acit&

! Outlines the te of care the& 'ould li/e

! Usuall& addresses cardiac resuscitation,4entilator treatment, arti0cial nutrition, %lood#roducts, in4asi4e tests, dial&sis, anti%iotics


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Ad4ance Directi4es

Li4ing )ill @Pro%lems! It ma& not address the thera#& that needs to

%e instituted

! Language can %e 4ague! Ma& not clearl& indicate code status

CTerminal condition! Legal de0nition )ill result in death

regardless of treatment! Medical #ers#ecti4e If not treated, can result

in death

! Usuall& need ? #h&sicians to agree


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Ad4ance Directi4es

Dura%le Po'er of Attorne& for 7ealth2are! Pro4ides for a surrogate to ma/e acti4e

decisions! Patient can still outline 'hat the& #refer as faras treatment modalities

! Also called Medical POA, healthcare #ro5&,

healthcare POA! Regular dura%le POA!controls onl& 0nances

3uardanshp A #erson is stri##ed of alltheir rights and declared incompetent %&

the court


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"#ectrum of Autonom&

8utonomy

8dvance#rectves

3uardanshp


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7othetical

7 #atient comes into the ER( ">he is in8orid se#sis, hotensi4e, andunconscious( o li4ing 'ill, ad4ance

directi4e, or DR order( o health care#ro5& or medical POA(

2an6t reach famil&(

2an6t get consent(

)hat do &ou do1


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Emergenc& E5ce#tion

Courts allo" treatment &ecause tspresumed that patent "ould "ant tolve.

"ame #atient intu%ated on the 4ent("ta%le 4ital signs( 7as t'o #eri#herallines for I9* and A%5( .ou 'ant to #ut ina central line, =ust in case #ressors are

going to %e needed( "till can6t reachfamil&(

Do &ou #lace the central line1


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Emergenc& E5ce#tion

At that #oint in time, a&solutely not'

The emergenc& e5ce#tion to informedconsent can onl& %e used in the

#reser4ation of life( N M*:6 N,:SS'


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7othetical K

"urgeon is doing an a##endectom& on a SG&ear old 'oman( "urgeon notes that#atient has an o4arian mass that should %e

ta/en out and %io#sied( Patient is underanesthesia and no one is a4aila%le to gi4econsent( The surgeon %elie4es that themass should %e e5cised(

2an the surgeon #erform the e5tra#rocedure1


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The CE5tension Doctrine

;:S'

(ennedy v. Parrott orth 2arolina"u#reme 2ourt held that the surgeon

acted in the %est interest of the #atientand the& had the Cdut& to do 'hat soundmedicine dictated(

"hould %e a life2threatening ri&0

#oesnot apply! )lective cases

! When *e+tension, should be anticipated


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7othetical -

A neurosurgeon does not tell a #atient thatthere is a ris/ of #aral&sis 'ith alaminectom&( The surgeon %elie4ed that the

#atient reall& needed the surger&, and didnot 'ant scare the #atient out of ha4ing the#rocedure(

2an s>he do this1


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Thera#eutic Pri4ilege

Say No.

Canterbury v. Spence The court held thata #h&sician cannot generalize that a

#atient 'ould not %e a%le to ma/e aninformed decision %ased on fear of theris/(

The #ri4ilege can onl& %e o%tained if it

can %e #ro4ed that an indi4idual #atientcould not handle that disclosure

Largel& Cdictum

9er& hard to #ro4e


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7othetical G

A #h&sician starts to e5#lain a #rocedure,the ris/s, consehe 'ould rather not /no'

an&thing a%out the treatment and truststhat the doctor is ma/ing the right decision(

Is the re


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)ai4er of 2onsent

May&e

he physician should provide at lea&tenou!h information$ so that the !eneral

nature of the treatment is e+pressed. Inthat way$ the patient can understand whatthey are for!oin!.! 7or e


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7othetical S

A GS &>o female #resented to her P2P 'ithcom#laints of increased a%dominal girth( "he is

4er& acti4e and has a 'ell %alanced diet(e4ertheless, her #ants size has increased in the

#ast &ear( The P2P o$ers a 2T scan to furtherin4estigate( The #atient refuses %ecause she doesnot 'ant to %e e5#osed to radiation =ust %ecauseshe has Cgained a little 'eight( The P2P does not

discuss the issue an& further( One &ear later, the#atient #resents to ED 'ith intense a%dominal#ain>ascites( A 2T re4eals #eritonealcarcinomatosis(

Is the P2P lia%le for failure of informed consent1


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Informed Refusal

8&solutely'

ruman v. homas In F;, the 2A"u#reme 2ourt de4elo#ed the #rinci#le of

nformed refusal The #atient should %e told the

ris/s>conse


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7othetical

7 #atient comes into the ER( ">he is in8orid se#sis @again, hotensi4e, andunconscious( "till no li4ing 'ill, ad4ance

directi4e, or DR order( o health care#ro5& or medical POA( This time, a relati4eis in the ED( The& do not 'ant an&thingdone( .ou are not sure if the rest of the

famil& 'ould agree 'ith this(

Do &ou acce#t their refusal of treatment1

OR


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Informed Refusal

;ou are stuc4'

Treatment can %e gi4en, %ut &ou shoulde5#ress the urgenc& of medical care to

the relati4e( If #ossi%le, get con0rmationof this from another physcan6 orethcs &oard.

If &ou decide to acce#t the refusal of

treatment, %e sure to document that therelati4e 'as informed of theris/s>conse


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7othetical

- &>o male 'as %rought into the ED forse4ere #ain

7e 'as diagnosed 'ith multi#le

com#ression fractures It 'as sus#ected that he might ha4e

ad4anced lung cancer

Patient su$ered se4ere #ain @!F; range,he 'as onl& gi4en PO 9icodin #rn

7is #ain meds 'ere not changed for 04eda&s


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Elder A%use

Ber/man v. Chn @F

The 2ourt ruled that the #h&sician6s lac/of action 'as egregious

The =ur& ruled that this 'as an e5am#le ofelder a%use

Damages 'ere F(- millionH


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7othetical F;

An ; &>o demented male #resents to ED'ith #aramedics for res#irator& distress(On e5am, he a##ears


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Elder eglect>A%use

;es'

Adult Protecti4e "er4ices stated thata%out ;Q of their re#orts 'ere%ased on a%use, S;Q on neglect

eglect is highl& underre#ortedH

e' .or/!one in ?(- a%use casesre#orted! *inancial a%use One in KK

! *or neglect ne n >'


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Resources

Ad4ance Directi4es for 7ealth 2are @J! htt#>>'''(state(n=(us>health>healthfacilities>

documents>ltc>ad4ancedirecti4es(#df! htt#>>'''(lsn=la'(org>english>healthcare>li4in

g'ills>ad4ancedirecti4es>
http://www.state.nj.us/health/healthfacilities/documents/ltc/advance_directives.pdfhttp://www.state.nj.us/health/healthfacilities/documents/ltc/advance_directives.pdfhttp://www.lsnjlaw.org/english/healthcare/livingwills/advancedirectives/http://www.lsnjlaw.org/english/healthcare/livingwills/advancedirectives/http://www.lsnjlaw.org/english/healthcare/livingwills/advancedirectives/http://www.lsnjlaw.org/english/healthcare/livingwills/advancedirectives/http://www.state.nj.us/health/healthfacilities/documents/ltc/advance_directives.pdfhttp://www.state.nj.us/health/healthfacilities/documents/ltc/advance_directives.pdf


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References

F( American 2ollege of Legal MedicineTe5t%oo/ 2ommittee( %e!al edicine$ /thed. Philadel#hia, PA Mos%&!Else4ier,

?;;SFG-!FS(?( alette v. Shulman$ G;( R( ?d, ?K, S?;(

R( ?d, KFS @O2A(

( "u#ra ote F, S(

K( Schoendorf v. Society of 0ew 1or#&ospital$ FFK, F;- (E( ? @(.(2(A((

-( Sal!o v. %eland Stanford$ 2r.$ 3niv. Bd. 4f

rustees$ FS P( ?d FS;, FF @2al( A##( 2t(


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References

G( "u#ra ote F, (

S( 0atanson v. (line$ -; P( ?d F; @an(FG;(

( Canterbury v. Spence$ KGK *( ?d SS?@D(2( 2ir( FS?(

( "u#ra ote F, KK!K-(

F;( "u#ra ote F, ?K;!?KF(FF( Mirarchi *L( Does a li4ing 'ill e


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References

F?( Magauran 3B( Ris/ management forthe emergenc& #h&sician 2om#etenc&and decision!ma/ing ca#acit&, informed

consent, and refusal of care againstmedical ad4ice( )mer! ed Clin 0 5m?;;V?S@KG;-!GFK(

F( Billic/ MR( Re4ersing the code status of

ad4ance directi4es1 0 )n!l 2 ed?;F;VG?@FF?!F?K;(

FK( "u#ra ote F, ?KF(

F-("u#ra ote FF, ;;(


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References

F( "u#ra ote F, -G;!F(

F( "u#ra ote F, (

?;( (ennedy v. Parrott$ ; "(E( ?d S-K @(2(

F-G(?F( Canterbury$ KGK *( ?d at S(

??( "u#ra ote F, (

?( ruman v. homas$ GFF P( ?d ;? @2al(F;(

?K( "u#ra ote F, KF!?(

?-( Ber!man v. Chin$ o( 7?;-S?!F

@"u#er( 2t( Alameda 2o( *e%( FG, F(


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References

?G( *ulmer T, Pa4eza B, 9ande'eerd 2, etal( eglect assessment in ur%anemergenc& de#artments and con0rmation%& an e5#ert clinical team( 2 6erontol 5

Biol Sci ed Sci?;;-VG;@F;;?!F;;G(?S( Lifes#an of Breater Rochester, Inc(

3nder the "adar7 0ew 1or# State )lder5buse Prevalence Study 8inal "eport$Self-"eported Prevalence and

Documented Case Surveys 8inal "eport.e' .or/, . )eill 2ornell Medical

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