Ethics at the BedsideConflicts and Communication

Bernard Scoggins, M.D., F.A.C.P.

Ethical actions and decisions should reflect the values of your staff and

institution

How we decide can be as important as what we decide

Ethics often has tension with the law, risk management, regulations,

and institutional policies

Ethics properly applied should lead to patient centered medicineEthical decisions poorly communicated can lead to distress and staff burnout

Can good ethical practices improve patient care?

• Improve patient quality or satisfaction?• Reduce risks and malpractice?

First Clinical Case

• Questions - – What did she really tell the doctor?– Was she or is she competent?– If not competent, who can decide for her?– What about her advanced directives

CompetencyDecision-Making Capacity

Informed Consent

Competency is a legal decision

Decision Making CapacityClinical Judgment

Decision Making Capacity is task specific. The complexity and ambiguity of the

options affect it.

Four Standards for Decision-Making Capacity*

• Communicate a choice• Understand the relevant information• Appreciate the situation and its consequences• Reason about treatment options

- New England Journal of Medicine

Decision-making capacity may wax and wane

• Dementia does not mean lack of decision-making capacity

Myths about decision-making capacity

1. Decision-making capacity and competency are the same

2. Lack of decision-making capacity can be presumed when patients go against medical advice

3. There is no need to assess decision-making capacity unless patients go against medical advice

4. Decision-making capacity is an ‘all or nothing’ phenomenon

5. Cognitive impairment equals lack of decision-making capacity

JAMA

Myths about decision-making capacity

6. Lack of decision-making capacity is a permanent condition

7. Patients who have not been given relevant and consistent information about their treatment lack decision-making capacity

8. All patients with certain psychiatric disorders lack decision-making capacity

9. Patients who have been involuntarily committed lack decision-making capacity

10.Only mental health experts can assess decision-making capacity

JAMA

Informed Consent is the legal recognition that each individual has

the right to make decisions regarding his/her own healthcare

Information sharing is patient centered

• Decision-making in context of the physician patient relationship is building trust

“Trust me I’m a doctor”

If decision-making capacity is lacking, turn to the surrogate

1. Patient’s known wishes2. Substitute judgment 3. Patient’s best interest

Advanced Directives

In Georgia• 1980 - First Living Will Law• 1990 - First Law of Durable Power of Attorney

for Healthcare• In 2007, New law combined both

When does it apply?• Patient is terminable or permanently

unconscious• Requires two physicians to certify this

Part 1 – Healthcare AgentPart 2 – Treatment Options

• This must be properly signed and witnessed

Case 2 (involving brain death)

Criteria date back to Harvard Criteria 1968

• First Georgia Law 1975• Uniform Determination of Death Act

Georgia Law – Death can be declared if:

• There is irreversible cessation of circulation and respiratory function

or• Brain death involving the whole brain

Clinical Evaluation• Other tests not required• Two physicians not required but advised

American Academy of Neurology Standards

•Do not confuse with PVS, MCS, or Coma

1. Fuzzy language2. Don’t fight it out in the chart3. Communicate with staff and family4. Document, document, document5. Do not use the term “withdrawal of life

support”

3rd Case

DNR

• First Georgia law passed in 1991

Personal decision-making capacity can always decide

if no DMC (see list)

Must be a candidate for non-resuscitation with one attending and another physician

declaring this.

• Ethics Committee Role

Law expanded to include hospice in 1994 and DNR out of facility in 1999

with portability

• Documentation?• Communication with family, nursing, others

What is Futility?

Strictest sense – treatment is futile if it offers no benefit to the patient

Judgment of futility involves both values and scientific evaluation.

Patient autonomy and goals

We all recognize when resuscitation is futile but we cannot make unilateral

decisions

We are not obligated as providers to provide inappropriate treatment that

could be harmful or of no value or technically impossible

Question treatment for families that want everything done...

This can lead to moral distress

What is DNR Portability?

• To Home?• To Nursing Home?• Return to Hospital?• To Assisted Living?

Nutrition/HydrationThis is a medical procedure and can be

withdrawn just like any other procedure

This is a very sensitive topic with religious and moral beliefs involved

Must be discussed, shared, and documented

Laws do not address every option

There also are Georgia Laws or Case Law involving physician-assisted

suicide and withdrawing/withholding of life support

“What this patient needs is a doctor” (a quotation from Dr. Stead, Duke

University Medical School)

We will always have conflicts, tensions, doubts and uncertainties

Don’t forget to ask:

1. Nurses, yes - nurses2. Lawyers3. Risk managers4. Dieticians5. Chaplains6. Social Workers/Case Managers7. Patient Representatives8. Ethics Committee

Always listen to patients, nurses, and staff and coordinate their message

Ethical actions and decisions should reflect values of the institution, staff,

and profession.

We will always have stress, but we can reduce moral distress and conflict

Medical ethics should be proactive and preventive

“Hope begins in the dark, the stubborn hope that if you just show up and try to do the right thing, the dawn will come. You wait and watch

and work; you don’t give up”

-Anne Lamott

“In clinics, at the bedside where it counts, a health care system is people touching each

other. Everyone who touches anyone affects that person’s healing, and affects the further

demoralization of medicine – or its remoralization. In the moral moment of that

touch, there is no system.”

- Arthur Frank, University of Chicago

Post-test

1. What is the difference between competency and decision-making capacity?

2. Can a person with dementia still have decision-making capacity?

3. Can a person who is brain dead be removed from "life support" if the family objects?

4. If a person is DNR in the hospital, will he or she remain DNR at home or in assisted living?