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Hospital Medicine > Ethics and Legal Issues > Flashcards

Ethics and Legal Issues Flashcards

1
Q

What does the Joint commision require of hospitals regarding ethics?

A
  • Development of process to handle ethical issues
  • Typically ethics consultant -alone or in team- or full ethics committee
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1
Q

Who can be on ethics committees?

A
  • Physicians
  • APP
  • Nurses
  • Social workers
  • Attorneys
  • Theologians
  • Representatives of community
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2
Q

What is the role of the ethics committee?

A

Advisory

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3
Q

Indications for ethics consult

A
  • Advanced directive
  • Brain death
  • Capacity/informed consent
  • Confidentiality
  • Futility
  • Discharge/placement
  • DNR orders
  • Isolated incapacitated patient
  • Maternal/fetal conflict
  • Medical error
  • Pain management
  • Refusal of recommended treatment
  • Research ethics
  • Resource allocation
  • Surrogate decision making
  • Transplant issues
  • Truth telling
  • Withdrawal of ventilator or other life sustaining therapy
  • Quality of life
  • Cultural/ethnic/religious
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4
Q

What is required to give informed consent and refusal?

A
  • Ability to communicate a choice
  • Understand the natures and consequences of the choice
  • Manipulate rationally the information necessary to make the choice
  • Reason consistently with previously expressed values and goals
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5
Q

What does informed consent depend upon?

A

Mutual respect and good communication, shared agreement about course of medical care

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6
Q

What is the importance of informed consent process?

A

Deliberation in making a sound medical choice (not goal to just gain consent)

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7
Q

What are patient rights regarding informed consent?

A
  • Informed consent is a right and refusal is an option
  • Not all patients retain right, predicated on ability to be self-determining, which requires capacity
  • Must have decision making capacity to give informed consent
  • Patients without capacity need surrogate decision maker
  • Urgent care can be provided under emergency presumption
  • Well informed refusal should be respected
  • Every effort made to discern rationale for refusal and counter misinformation with appropriate facts
  • Ethics consultation may help resolve ethical issues when refusal made by surrogate on behalf of incapacitated
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8
Q

What are ethical principles regarding truth telling?

A
  • Provider must communicate specific information necessary for informed and deliberate choices
  • Most providers adhere to “reasonable person” standard by providing information that average person would need to make informed choice
  • Full medical disclosure is norm for western people
  • Burdens and benefits of truth telling and breaking bad news weighed against information necessary to make informed treatment choice
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9
Q

What is therapeutic privilege/exception?

A
  • Risks associated with disclosure outweight benefits and practitioners deliberately withhold information counter to patient’s self-determination and right to know
  • Thorough documentation critical
  • Patient’s family, and/or psychiatrist and local ethical participation is recommended to participate in determining need to limit disclosure
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10
Q

What percent of seriously ill patients are unable to decide treatment options at end oflife?

A

70%
Majority of these do not have advanced directives at time of hospitalization

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11
Q

Benefits of advanced directives?

A
  • Incapacitated patient can be treated in accordance with prior wishes, instead of speculation
  • Considered extension of patient’s voice under patient self-determination act of 1990
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12
Q

What does the patient self-determination act of 1990 require?

A

Health care institutions that participate in medicare and medicaid program ask patients whether they have an advanced direction, inform patients of their right to complete advanced directive, and incorporate into the medical record

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13
Q

What is a surrogate?

A
  • Person who makes decisions for patient when incapacitated
  • Make decisions according to three distinct decision-making standards: patients expressed wishes, substituted judgements, and best interests
  • May be designated as part of advanced directives
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14
Q

How is surrogate assigned if not assigned in advanced directive in WV

A
  • Spouse
  • Adult children
  • Own parents
  • Adult siblings
  • Adult grandchildren
  • Close friend
  • DHHR makes decision
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15
Q

What conflicts can arise with a surrogate?

A
  • Stress of surrogate role and family dynamics and imprecise prior patient wishes can lead to morally ambiguous situations
  • Conflicts can arise between surrogates of equal standing
  • When 2 surrogates disagree, ask to put aside own preferences and articulate what believe is in patient’s best interest
  • When this fails, hospitalists may give ethical and legal precedence to that surrogate who has been assuming more of the care responsibilities
16
Q

What is withholding life-sustaining therapy?

A
  • Decision not to institute intervention that could prevent death or prolong dying process
17
Q

What is prototypic reason for witholding life-sustaining therapy?

A
  • DNR order
  • DNI or partial DNR orders compromise integrity of practitioners because imply resuscitation without intubation as medically efficacious intervention despite marginal effectiveness of CPR itself
18
Q

What is protocol when DNR filled out?

A
  • Order placed into medical record and medical and nursing teams informed
  • DNR should travel with patient when he or she goes off floor and be readily available for consult should event occur
  • DNR reviewed periodically and may be reversed by patient at any time
  • DNR does not preclude other treatments or interventions
  • Patients can receive care in ICU or operating room
  • DNR honored across specialties and not impede access to appropriate palliative care if it can only be offered through intensive care or operative intervention

according to date, DNR at time of MICU consult associated with decision to refuse patient to MICU

19
Q

How are DNR orders handled in OR

A
  • Any arrest during surgery could be considered reversible so DNR should be discussed
  • American College of Surgeons calls for required reconsideration of preexisting DNR as part of informed consent process for surgery
  • If patient rescinds DNR perioperately, decision can be made to reinstate upon arrival to recovery room
  • If patient or surrogate wants to maintain DNR status during procedure must be documented in perioperative consent
  • If patient dies in OR, considered expected death
  • In some situations, clinicans may find intraoperative DNR order against their conscience and may remove themselves from the case after ensuring care transitioned to another provider
20
Q

DNR considerations regarding risks of CPR

A
  • Can cause serious bruising, broken bones, etc
  • Even if initially successful, another arrest may follow
  • Intubation may initiate life-support situation that may generate ethical problem of futility
  • Likelihood of being successfully resuscitated and being discharged from hospital is essential component of ethical decision to refrain from resuscitation
21
Q

What is the difference between witholding and withdrawing treatment ethically?

A
  • No difference dating from President’s Commission for study of ethical problems in medicine and biomedical and behavioral research
22
Q

Considerations of withdrawing life-sustaining therapy

A
  • Withdrawal of LST simply removes impediment to death with intent of freedom from interventions that are perceived as burdensome
  • Includes mechanical ventilation, hydration, and artificial nutrition
23
Q

Why might decision to withdraw life-sustaining therapy be challenging?

A
  • Transference and counter transference often embedded in end-of-life decisions
  • Physician’s reluctance due to a misconstrued view that there is an ethical, and certainly psychological, difference between withholding and withdrawal of LST
  • Sense of failure or sense of culpability
  • Uncertainty about prognostication
  • Inadequate communication with patients and/or surrogates about goals of care
  • Differences between how physicians and lay people view these decisions
24
Q

What happened in the Terri Schiavo case?

A
  • Irreversible persistent vegetative state
  • Husband and legal guardian argued that Schiavo would not have wanted prolonged artificial life support without prospect of recovery, and elected to remove feeding tube
  • Parents disputed assertions and challenged Schiavo’s medical diagnosis, arguing in favor of continued artificial nutrition and hydration
  • Highly publicized and prolonged series of legal challenges presented by parents, which ultimately involved state and federal politicians up to George W Bush, caused 7 year delay before feeding tube removed
25
Q

Why are medical devices at end-of-life tough ethically?

A
  • Can be viewed as treatment, such as dialysis machines or ventilators, or as biologic transplant like liver or lung transplant
  • The patient or surrogate retains ability to deactivate or remove devices under rubric of informed refusal as form of withholding or withdrawing therapy
26
Q

What is physiologic futility?

A

Absolutely - or to a reasonable degree of medical certainty- impossible to achieve a physiologic effect such as CPR in setting of persistent acidosis

27
Q

What is qualitative futility?

A

When patient’s physiology may improve, but there is no patient-centered benefit

28
Q

What is quantitative futility?

A

When intervention has not worked in similar patients within an accepted confidence interval

29
Q

How should clinicians try to dispute futility claims?

A
  • Ongoing communication during course of illness
  • Reflection about implicit force of one’s countertransference
  • Avoid mixed messages from different physicians by ensuring coherent co-management

Hospital Medicine (7 decks)

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