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CPS Statements > Bioethics > Flashcards

Bioethics Flashcards

1
Q

What is the problem or challenges with advance care planning for paediatrics?

A
  • lack of info
  • bias of beneficence over autonomy (or curative rather than palliative options)
  • kids usually outlive parents which leads to avoidance of difficult topics
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2
Q

When is palliative care appropriate to be introduced?

A

-at any point following the diagnosis of a life-limiting condition
-can introduce simultaneously with potentially curative treatment
-

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3
Q

What are the goals of palliative care?

A
  • relief of suffering
  • quality of life
  • bereavement support
  • early discussion avoids equating DNR with giving up
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4
Q

What are key things to remember when discussing palliative care or advance care planning for paediatrics?

A
  • most parents want initiation of discussion
  • be specific in terms of interventions
  • address physical, psychological and spiritual needs
  • be explicit about shift in focus from cure ad survival to comfort and well being
  • help parents talk to child about death
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5
Q

What are some barriers to implementation of advance care directives?

A
  • many provinces legal age for advance directives is 16 yrs below this usually advance directives have no legal validity even if made by a mature minors
  • legal age to be substitute decision maker varies
  • get variable acceptance by third parties about advance directives and lack legal status b/c most not drafted by the patient themselves
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6
Q

What is our role as paediatricians in advance care planning?

A
  • start discussions early and have them regularly (before a crisis)
  • our responsibility to start the discussions
  • plan regarding emergency and life-sustaining treatments should be well-documented
  • palliative care is a potential adjunct to care of all dis with conditions limiting life expectance
  • adovcate for uniform legislation across canada
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7
Q

What are some issues with kids participating in medical education (i.e. being examined by medical students)?

A
  • availability of parents
  • consent by parents/patients for exams
  • need for chaperones
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8
Q

What are the main ethical challenges in medical education?

A
  • truth telling
  • informed consent
  • respect for person and confidentiality

-medical schools have a responsibility to society to train clinically competent and professional physicians but need to balance this with the right so individual patients (non-maleficence); distributive justice

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9
Q

How do we achieve informed consent for medical education regarding kids?

A
  • by parent or guardian or mature minor is essential for participation of children in medical education
  • explicit verbal or written consent
  • fully informed of what is proposed and give voluntary, concerned concept
  • younger child needs to give assent and dissent and these should be respected
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10
Q

What do families need to know about trainees?

A
  • we need to let them know that trainees may be providing some care for them
  • explain the role of a trainee
  • they have a right to request no trainee but we need to advise them about the limits of this (esp given trainee involvement during call coverage)
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11
Q

What is the CPS recommendation regarding parental presence during exams of pts?

A

-they should be present for most encounters unless it is a teen or is clinically urgent

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12
Q

What are the requirements of educational rounds or teaching sessions?

A
  • reveal only relevant non identifying info
  • consent not required but should inform the family
  • need consent for photographs,
  • need written consent if plan to publish photos
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13
Q

What are some implications of having children play SPs for OSCEs?

A

-should clearly ask for informed consent and assent, as appropriate.
• When children, whether actual patients or volunteer SPs, are being used in an OSCE, they or their parents should provide informed consent and/or assent as appropriate. The well-being and comfort of the child should always be paramount and he/she should have the option to withdraw or be withdrawn from participating in the OSCE. Administrators of OSCEs should always be aware of the impact that portraying a sick or troubled child has on the volunteer child, and should provide appropriate limits and counselling.
• If other SPs are remunerated for their participation in an OSCE, children should also be compensated in a manner that does not constitute undue inducement

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14
Q

Why is research in children a moral duty based on the ethical principles?

A
  • distributive justice: making high-quality health care available to all populations
  • beneficence: evidenced based care
  • non-maleficence: avoiding harmful therapies
  • respect for informed consent: supports developing autonomy in kids
  • respect for privacy and confidentiality: within the legal requirements
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15
Q

What have been some challenges in paediatric research?

A
  • protective attitude
  • could not recruit enough kids for rare diseases
  • not financially beneficial to bring new drug to market for small population
  • fewer researchers looking into meds issues
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16
Q

What is the governing document for research in humans in Canada?

A

Tri-Council policy statement

  • must adhere to guidelines
  • need REB approval
  • assesses risk
  • disclosure of conflict of interests
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17
Q

What is the role of the REB and who sits on it?

A
  • multiD panel with scientific peers, bioethics, law experts, lay community
  • role to uphold the Tri-council policy statement
  • ensure well designed study to ensure reliable and valid results
  • ensure researcher has control over the data
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18
Q

What are the 3 main elements required for informed consent for participation in research?

A
  • adequate information
  • voluntariness
  • capacity to understand the information

-for kids who cannot consent we should seek assent

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19
Q

What are some examples of conflict of interest as it relates to health research?

A
  • financial gains
  • personal academic gain/stature within community
  • institutional gain of pharm company to drive academic agenda

-conflicts of interest must be disclosed

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20
Q

What do you need to explain to parents about research results?

A

-offer to give them to them if they want
-make them aware that potentially sensitive info acquired will be documented in the health record
-give other physicians caring for the kid the relevant info you learn from the research
-

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21
Q

What are phase 1 trials?

A

tested in tissue culture/animal/human - focus on establishing safety profile and toxicity information of new drug in patients with advanced disease with no effective treatment

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22
Q

What are phase 2 trials?

A

-drugs found to be safe, now testing for efficacy, expand toxicity profile (patient with advanced disease)

23
Q

What is the CPS’ stance on use of anencephalic newborns as organ donors?

A
  • not appropriate organ donors
  • need to declare them brain dead or pronounced somatically dead before donation with standard cardiorespiratory criteria can be applied, but difficult to declare these kids brain dead
24
Q

What is anencephaly?

A
  • CNS abnormality that is characterized by congenital absence of the forebrain, skull and call
  • some rudimentary forebrain tissue may exist and a functioning brainstem is usually present
  • most die within days or week without life supporting interventions
25
Q

When can organ donation be considered in anencephalic infants?

A
  • only when it has satisfied the criteria for brain death or somatic death:
  • they will not usually satisfy the standard brain death criteria b/c of adequate brainstem function that maintains spontaneous reps and HR after birth
  • when brain death has been declared the organs will have undergone ischemic damage making them unsuitable for transplant
  • CV and resp functions deteriorate gradually in anencephalic infants before a terminal event
26
Q

Does life support improve the chance of successful organ donation from anencephalic infants?

A
  • no

- as brainstem function deteriorates, multi system organ failure develops before sudden death

27
Q

Under what conditions might a parent not be the appropriate substitute decision maker for a child?

A
  • lack capacity
  • irresolvable differences between parents
  • parents relinquish responsibility
  • legal guardian
28
Q

What do you do in acute situations when there is a question about decision making?

A

-presumption in favour of life sustaining treatment, if possible to deter treatment then do so to try and get clarification

29
Q

How do you give kids information about treatment decisions?

A
  • give developmentally appropriate info to understand what is happening to their bodies
  • seek assent
  • give some appropriate level choices in their treatment
30
Q

Do we always have a duty to provide life-sustaining care?

A
  • not if there is a consensus of irreversible progression to imminent death, treatment is clearly ineffective/harmful, life severely shortened regardless of Rx and limitation/withdrawal will allow greater palliative/comfort care
  • patient will face intolerable suffering/distress that cannot be prevented/alleviated
31
Q

Are there scenarios where it is appropriate to withhold or withdraw life-sustaining care?

A

-yes it can be appropriate if it is not clear it will benefit the child (eg. CPR, ventilation, etc); harder with artificial nutrition, etc

32
Q

Is it ok to use sedatives/analgesics to hasten death?

A

no it is unethical and illegal

33
Q

What should you do if you disagree with the parental decision being made related to a treatment decision for their child?

A
  • if there is risk of harm to the child then must provide a referral for 2nd opinion with uninvolved medical consults
  • with this level of disagreement, assistance of ethics consultant is recommended
  • if not resolved then child protection and/or legal system involvement may be necessary
34
Q

When is it ok to test children for genetic conditions?

A
  • for better medical care
  • to confirm a medical diagnosis
  • to enhance medical monitoring

-for genetic conditions that will not present until adulthood (predictive testing) testing should be deferred until the child is competent to decide whether they want that info

35
Q

Do children need to consent to undergo genetic testing?

A

-not necessarily but ideally testing should be done when a child is competent

36
Q

What are some of the concerns around genetic testing?

A
  • could be biased against by insurance companies
  • can be positive or negative effects of knowing one’s status
  • can feel guilt, cause depression
37
Q

What are the recommendations around testing kids for carrier status?

A

-this will be important only for reproductive decision-making so testing should be discouraged until the kid can decide if they want it

38
Q

What do you do if a family insists on testing a child where there is no benefit to the child?

A

-MD is not obligated to do the testing if it is not in the best interest of the child

39
Q

What are the recommendations around genetic testing for infants who are going to be adopted?

A

should not be subject to genetic testing where there is no timely medical benefit

40
Q

What are 3 major problems with patient blogs?

A
  • pt’s or care providers are well described which breaches confidentiality
  • patient may share info they they may not realize is sensitive
  • HCP may be offended by pt comments and that may impact care
41
Q

How should physicians approach websites?

A
  • avoid recommending therapies or meds in a public forum as they may be perceived as advertising, conflict of interests should be disclosed
  • must be kept up to date and respond to questions in a timely fashion
  • may be time-consuming, interfere with office care
42
Q

What are the biggest issues with social networking sites?

A
  • users cannot fully control who has access to their profile
  • issues of civil liability relating to breaches of pt confidentiality
  • posting of unprofessional content
  • jo loss b/c of damaging disclosure by a profiled individual or 3rd party
  • physicians have not always applied appropriate privacy options
43
Q

What are the CPS recommendations regarding social media and blog use?

A

• Protecting patient confidentiality and privacy by:
◦ Not posting identifiable patient information online
◦ Not accessing a patient’s blog without their permission
◦ Exercising caution because ulterior motives, personal justifications and hidden agendas may be less evident online than when communicating in person.
• Preserving physician privacy by:
◦ Use high privacy settings and understand this does not completely protect
◦ Avoid online friendships with patients
◦ Keep business and personal websites separate
◦ Use same ethical and professional principles online as in person (i.e. avoid risky material and inappropriate communications)
◦ Use only accurate, current and evidence based information
◦ Not promoting any therapy for personal gain.

44
Q

What do you need to keep in mind regarding electronic consults?

A
  • keep professional, ethical and legal duties
  • confidentiality is paramount
  • use clear patient identifiers but be cognizant of the security of our email network
  • remember that written email record may be viewed as a formal consult even though it is not
45
Q

What are the problems with electronic discussion groups?

A
  • often anecdotal, include personal observations or clinical intuitions
  • not peer-reviewed
  • adice should be limited to general comments about a disease, treatment modality or recent research if you have not seen the patient, consider including a disclaimer
46
Q

What are recommendations around emailing patients?

A
  • if wrong advice is given it may erode trust and result in litigation
  • should be reserved for simple, non-urgent issues for previously diagnosed conditions and not involve sensitive or confidential information
  • • Review your current licensing body policies including liability insurance provider on email
47
Q

How should you communicate with individuals who seek medical advice who are not your patients?

A

do not advise them if they are not your patients

48
Q

When is artificial nutrition and hydration beneficial?

A
  • if will enhance quality of life and health (e.g. malabosption, increased caloric requirements)
  • should not be done with the sole purpose of prolonging survival,
  • if artificial nutrition is not improving health or QoL it should be re-evaluated
49
Q

Is there a difference between withholding and withdrawing artificial nutrition or other life-sustaining therapies?

A

no, important to recognize that life-sustaining treatments do not cure/change the course of the underlying disease

50
Q

What are some common objections from families regarding forgoing artificial nutrition and hydration?

A
  • often seen as ‘food and drink’ and not a medical intervention
  • they may see it more as providing care/compassion compared to things like vents
51
Q

What are some examples of when it is morally permissible to withhold or withdraw artificial nutrient and hydration?

A
  • child who permanently lacks awareness and ability to interact with environment (e.g. anencephaly, persistent vegetative state)
  • if it only prolongs and adds morbidity to the process of dying (e.g. terminal illness in the final stages of dying)
52
Q

What are some important things to ensure with families when withholding artificial hydration and nutrition?

A
  • shared decision making with parents fully involved
  • reassure them that the kid will be kept comfortable
  • comprehensive palliative care measures including appropriate sedation, treatment of pan or dyspnea, oral hygiene, swabs for dry mouth etc
  • attention to psychosocial cues is important as it may be weeks before the child dies and do not want parents to feel abandoned
  • ethics involvement if things get controversial
53
Q

What can you do if a member of the health care team has personal objections to withdrawal of artificial hydration and nutrition?

A
  • helpful to request external legal or ethics consultation
  • arrange for team conferences to clarify misconceptions and openly discuss difference of opinion
  • individual providers can recuse themselves so that plan can be followed in accordance to child/family wishes

CPS Statements (14 decks)

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