Beneficence & Autonomy Flashcards
Relationship-Centered Care:
Three relationships within PT = ?
“Don’t over think”
Beneficence & Autonomy
Relationship-Centered Care:
- Accents the importance of interactions among people as the foundation of any therapeutic activity.
- These relationships include:
- PT and patient (primary relationship).
- PT and co-workers / supervisors.
- PT and community.
- Emphasizes concern for patients, sensitivity totheir needs, empathy for their suffering,respect for their rights, and value of health(biopsychosocial).
Four important principles of Biomedical Ethics = ?
Beneficence & Autonomy
Principles of Biomedical Ethics:
(1) Beneficence:
- Promote good of others, besensitive topatients fears/needs related to their care; standards of excellence in care.
(2) Respect for autonomyof patients:
- Value the self-governance of the patient and use it as a guide when providing services.
(3) Nonmaleficence:
- Do no harm.
(4) Justice:
- Treat patients fairly; support fair procedures in health care.
“Acting in the patient’s best interest; being kind” = ?
Beneficence & Autonomy
Beneficence:
- Acting in the patient’s best interest; being kind.
- Cornerstone motive of professional healthcare
- “Helping others”
- This is an obligation for us.
Think:
- But….. how much help should we give
- Is there a limit to the obligation we have?
The “Beneficence Continuum” ranges from = ?
Beneficence & Autonomy
Beneficence:
In order to define the limits to the obligation, a continuum exists;
The “Beneficence Continuum”: Ranges from Obligation to Supererogation.
(a) Obligation:
- Strict Obligation:Honesty, don’t steal, don’t kill.
- Weak Obligation:Remaining civil despite disagreement; don’t cut in line.
(b) Supererogation:
- Beyond the obligatory;
- (1.) Optional
- (2.) They exceed common obligation.
- (3.) Intentionally undertaken to promote welfare of others.
- (4.) Morally good and praiseworthy , heroic.
- Most acts of supererogation do not put people at risk for harm or financial ruin
Specific vs. General Beneficence = ?
Beneficence & Autonomy
Beneficence:
(a) Specific Beneficence:
- Acts performed for family, partners, friends, loved ones.
(b) General Beneficence:
- Acts performed for strangers,
- Less intuitive
- Less well understood
Beneficence Laws:
- What are they = ?
- Give one example = ?
Beneficence & Autonomy
Beneficence Laws:
- Most states have Good Samaritan Laws.
- Protect off duty health care professionals from criminal & civil chargeswith negative outcomes during their attempt to help stranger(s). physicallyinjured or in danger.
- Laws do not reward beneficence, just prevent misfortune of providers.
- In most states there is no legal obligation to provide Good Samaritan care.
- These are not “hero” laws….In no case is a person expected to act if doing so puts him/her in harm’s way.
Why do we do what we do?
- Craft Motives = ?
- CompensationMotives = ?
- Moral concern = ?
Beneficence & Autonomy
Professional Motives - Why do we do what we do?:
(a) Craft Motives:
- Desires to meet the standards of technicalexcellence, as defined by state-of-the-artprofessionalism;
- Desire to seek creativesolutions to technical problems.
(b) CompensationMotives:
- Desires to earn a living, have job stability,gain professional recognition, exercisepower and authority, and other primarilyself-oriented desires.
(c) Moral concern:
- Desires tomeet one’s responsibility and maintainone’s moral integrity;
- Desires topromote the good of others for their sake.
Medical Paternalism = ?
Beneficence & Autonomy
Medical Paternalism:
(a) Paternalism: When someone fails to recognize another individual’s rights and autonomy.
(b) Medical Paternalism: When this practice occurs in the medical field.
- Old / past practice and mentality.
- Health care provider had authority to make treatment decisions on behalfof their patient.
- This occurred regardless of whether the patient provided consent.
- becausethe physician knew ‘what was best’
Notes:
- This practice is declining dramatically and moving toward an emphasis on respect for autonomy.
- Currently used in cases of emergency (unless DNR order).
____ requires that the wishes of competent individuals must be honored.
Beneficence & Autonomy
Respect for Autonomy:
(a) Autonomy: Self-determination
- Autonomy requires that the wishes of competent individuals must be honored.
- We have the responsibility to respect autonomy / self determination of each person.
- Locates control with the patient or designated representative rather thanthe provider.
- Pilot/co-pilot
“No principle is more important to health-care ethics, or indeed to allprofessional ethics”
Duties of Autonomy include = ?
Beneficence & Autonomy
Duties of Autonomy include:
- Informed consent
- Veracity (Honesty/Truth telling)
- Confidentiality (privacy)
Failure to obtain informed consent can result in = ?
Beneficence & Autonomy
Failure to Obtain Informed Consent:
- Failure to obtain informed consent is considered a form of helathcare malpratice.
- Equates to substandard care which is the essence of health care negligence.
Informed Consent = ?
Beneficence & Autonomy
Informed Consent:
- Patient right to know, accept and / or refuse intervention.
- Is one of the most important ethical and legal issues for health care professionals.
- This is an ongoing interaction with patients, not just at eval or beginning of eachsession, but throughout sessionsand plan of care.
Notes:
- Is paramount for the ethical principle of autonomy.
- This isn’t just a signature on the intake forms.
For patients to give informed consent, what three conditions mustbe met = ?
Beneficence & Autonomy
For patients to give informed consent, 3 conditions mustbe met:
(1) Information:
- Patients must be givenrelevant informationregarding their condition and treatment options in amanner they can understand to allow them an informed decision.
(2) Competence:
- Patient must be sufficiently rational or competent to understand and makehealth-care decisions.
(3) ** Voluntariness**:
- Patients must be free to make decisions without being coerced, intimidated or otherwisemanipulated.
Informed Consent - (1) Information:
- The information should include a clear explanation of = ?
Big list
Beneficence & Autonomy
Informed Consent - Information:
(a) The information should include a clear explanation of:
- The planned examination/assessment.
- The evaluation, diagnosis and prognosis/plan.
- The intervention/treatment to be provided.
- The risks which may be associated with the intervention.
- The expected benefits of the intervention (includes discussing the goals with the patient).
- The anticipated time frames.
- The anticipated costs.
- Any reasonable alternatives to the recommended intervention.
Informed Consent - (2) Competence:
- Legal competency = ?
Beneficence & Autonomy
Informed Consent - Competence:
(a) Patient must be sufficiently rational or competent to understand and makehealth-care decisions.
(b) Legal Competency:
- A person must have some threshold of substantial decision making capacity to be allowed to make health care decisions.
- Individuals 18years or older are presumed competent until courts declare otherwise.
(c) When the patient is not deemed competent or when the patient is a minor, a legal guardian or advocate may act as surrogate decision maker.
- Is often a spouse, close relative, durable power of attorney (DPOA)
Informed Consent - (3) Voluntariness:
- Violations may include = ?
Beneficence & Autonomy
Informed Consent - Voluntariness:
(a) Patients must be free to make decisions without being coerced, intimidated or otherwisemanipulated.
(b) Violations may include:
- Lying, intentionally misleading the patient, withholding information, exaggerating.
- Subtle threats or emotional manipulation.
- Physically forcing therapy on someone against their explicit desires.
- May constitute battery (I.g. ROM without consent).
(c) Fine line between substandard care and patient refusal.
A “Spectrum” of Strategies/Encouragements:
- Persuasion = ?
- Inducements = ?
- Interpersonal leverage = ?
- Threats = ?
- Compulsion = ?
Beneficence & Autonomy
A “Spectrum” of Strategies/Encouragements:
(1) Persuasion:
- Educating the patient of risks/benefits of proposed treatment and maybe patient will be more inclined to accept the treatment.
- Is the most ethical strategy to get a patient to participate.
- Respects autonomy and patient decision making.
- E.g. “You need to get up today; walking can help reduce risk for a blood clot”
(2) Inducements:
- Offering the patient an “incentive” to cooperate.
- Is usually ethically acceptable – but maybe infantilizes an adult patient.
- E.g. “If you walk to the door and back I’ll get you a Coke”
(3) Interpersonal leverage:
- Takes advantage of the trusting relationship we have with patients to pressure them.
- More problematic from an ethical standpoint; can be manipulative.
- E.g. “I counted on you to not let me down, Mrs. Scott; I’m disappointed in you…”
(4) Threats:
- Coercive statements; threats that the patient will be worse off if they don’t adhere.
- Ethically more problematic.
- E.g. “If you don’t get out of bed today I’ll make sure you don’t get any further PT services”
(5) Compulsion:
- Overriding a patient’s express wishes
Is the most ethically problematic treatment pressure.
E.g. Two people physically pulling a competent patient out of bed after she has refused.
Can be considered assault/battery
Patient Self-Determination Act = ?
Beneficence & Autonomy
Patient Self-Determination Act:
- Is a federal law to ensure that a patient’s right to self-determination in health care decisions be communicated and protected.
- Requires that hospitals, long term care facilities and other health organizations participating in Medicare and Medicaid inform patients of their right to accept/refuse treatment.
- Includes the right to control theuse of extraordinary treatment measures, suchas artificial lifesupport.
If a patient refuses treatment, what should we do = ?
We = Physical Therapist
Beneficence & Autonomy
Refusal of Treatment:
- If a patient refuses treatment, this fact and asummarization of the “informed refusal”prevention measures used on the patient’sbehalf should be well documented.
- Theclinician is legally and ethically responsible tocoordinate with any referring health careprofessional about the patient’s refusal ofcare.
- Show beneficence - patient’s best interests
- Respect patient autonomy
- Durable Power of Attorney
- Living Will
- Do Not Resuscitate (DNR)
Are examples of = ?
Beneficence & Autonomy
Common Advance Directives:
(a) Legal documents that provide instructions for medical care, that only go into effect if the patient cannot communicate their wishes.
(b) Common Advance Directives:
(1) Durable Power of Attorney:
- A type of advance directive in which you name another person to make health care decisions for you in the event that you are unable to do so.
- Can be a spouse, family member, clergy member, attorney, medical advocate…
(2) Living Will:
- A legal document used to state certain future health care decisions in case you become unable to make the decisions/choices on your own.
- Used only at the end of life.
- Describes what type of medical treatment you would want/not want to receive.
- Includes the use of dialysis, feeding tubes, life support, organ donation after death, Do Not Resuscitate (DNR) orders.
(3) Do Not Resuscitate (DNR):
- Written directives to health careprofessionals that preclude the otherwiseautomatic initiation of CPR efforts in the event ofpatient cardiorespiratory arrest.
- Needs to be at the request of a competent patient
- Or, at the request of a properly designated durable power of attorney for healthcare decision making.
Euthanasia:
- What is it = ?
- Three Types = ?
Beneficence & Autonomy
Euthanasia:
- “Good” or “easy” death; is the intentional ending of one person’s life by another, motivated solely by the best interest of the person who dies.
- Most often patients terminally ill or a persistent vegetative state.
Types:
(1) Passive:
- Intentionally letting a patient die by withholding/withdrawing artificial life support such as ventilator or feeding tube; “let the patient die”.
(2) Active:
- Involves deliberate intervention by health careproviders that facilitate or cause patients’ deathin ordertorelieve patient pain andsuffering. (sometimes called “aggressive” euthanasia).
(3) Physician-assisted suicide:
- The physician provides the means, but the patientactually administersthemeans of death (not the same as euthanasia) usually bymeans of lethalmedication.
- Currently legal in about 10 states.
Veracity = ?
Beneficence & Autonomy
Veracity:
- The duty to tell the truth = principle of truthfulness, honesty, or veracity.
- Truth is expected in fiduciary relationships (trust) in health careproviders.
- Transparency!!!!
- Applies to patient and provider relationships;colleagues / co-workers; employees and employers.
- Truth telling includes reporting medical errors.
Failure to tell the truth:
- Generates badconsequences, violates patient rights to truth, manifests dishonesty.
The duty to maintain the privacy of informationconcerning patientsby not disclosing it to unauthorized persons = ?
Beneficence & Autonomy
Confidentiality:
(a) We have a duty to maintainconfidentiality:
- The duty to maintain the privacy of informationconcerning patientsby not disclosing it to unauthorized persons.
- Divulging medical information on a “need-to-know” basis.
(b) Includes all information about patientsobtained during professional interactions with them.
(c) Violations can result in civil lawsuits for invading privacy, emotional distress;license could be at risk.
HIPPA ensures = ?
Beneficence & Autonomy
Confidentiality:
- Health and Insurance Portability and Accountability Act(HIPAA) regulations.
- HIPPA ensures patients their legal rights to privacy, accessto examine their records.
- HIPPA forbidsdisclosure of their medicalrecords without their consent, as well as limited access toother health care professionals without need-to-know.
- Is a Federal Statute
- Enforced by licensing board and Joint Commission.
Confidentiality:
- Two justifiable exceptions = ?
Beneficence & Autonomy
Confidentiality - Exceptions:
- Medical records may be ordered by the courts in criminal investigations.
- Health care workers must report; (see lecture on mandatory reporting).
