Ethics CBM + truth telling/consent oxford Flashcards
1
Q
What is applied medical ethics?
A
- helps individuals apply moral theory and reasoning to specific cases
- informs larger field of bioethics about evolving standards of clinical practice
2
Q
List sources of ethical conflict in clinical environment
A
- among clinical team members
- patients family’s and friends
- between patient and care team
- between patient and family/friends
- between clinical team members and existing norms (standards of practice, professional guidelines, institutional policies, etc)
- within same individual - moral angst
3
Q
Outline the 4 steps in clinical ethics methodological approach (CBM)
A
- Identify the ethical dilemma
- Gather pertinent information
- Analyse the information in context of the dilemma
- Prioritize recommendations and articular supporting argumentation
4
Q
What are the advantages of proposed methodology?
A
- similar to problem solving approaches in clinical medicine
- comprehensive integrated nature
- stepwise approach useful framework for complex problems
- focuses on resolution of ethical questions in specific clinical case
- goal is to enhance clinical judgment
5
Q
What are the limitations of this methodology?
A
- presumption of good faith intent
- assumption that stepwise approach will produce better outcome
- presumes rational analysis is most effectice
- unable to provide mechanism to construct single, unequivocal moral judgment / consensus
6
Q
What is characteristic of a clinical dilemma?
A
- choice between competing goods or harms
- choose the best of several options or avoid worst of several harmful ones
7
Q
What are the four fundamental principles of bioethics ?
Beauchamp and Childress
A
- Autonomy
- Non maleficence
- Beneficence
- Justice
8
Q
CBM ethics case:
54 F with metastatic colon cancer. She has never been told her diagnosis and prognosis. Family demand to not tell her how ill she is. Health care team deeply troubled, think it is unethical.
Step 1: What are the ethical dilemmas?
A
- Do I advocate for my professional judgment of this patient’s best interests or give in to family’s understanding of patient’s best interests?
- Do I advocate for patient autonomy through informed consent to care or in terms of family relationships?
- Do I protect my professional integrity by insisting on explicit informed consent or do I accept integrity of patient’s and family’s construct of dying?
9
Q
Step 2 : Gather all pertinent information
A
- Clinical
- diagnosis
- nature of illness
- prognosis with and without treatment
- to what extent can the patient be involved in decision making?
- Personal:
- views of all involved need to be taken into consideration in ethics analysis
- patient preferences
- SDM preferences
- caregiver (clincal team) preferences
- Social:
- law
- codes of ethics
- policies
- social norms
10
Q
What is fiduciary duty?
A
- physicians are bound by our responsibility to our patients
- palliative care ethics emphasize importance of care of surviving family members as well
11
Q
Step 2 : gather all pertinent information #2
A
- ascertain what the patient actually knows and understands
- what are her expectations as to whether she should provide consent?
- what are her expectations about the need to know?
- does her life narrative reflect an independent, autonomous person?
- How much does she want to know? When does she want to know it?
- How would she like that information to be communicated?
- To what extent would she like to be involved?
12
Q
Step 3: Analyze the information in the context of the dilemma
A
- Generate all realistic options
- Assess underlying principles and consequences that support and undermine each option
- Compare and contrast burdens and benefits of each option
- Judge which option brings best consensus
- rarely dichotomous options
- look for creative best scenario negotiated consensus options
- goal is to agree on option that is morally acceptable for all
13
Q
Describe 2 philosophical schools of thought:
A
-
Deontological
- driven by value, principles, norms
-
Teleological
- driven by consequences
14
Q
Define Casuistry
A
- traditional method of case-based analysis for the practical resolution of moral issues.
- considers principles and values and consquences
- references specific context of particular situation
- ethics equivalent of legal jurisprudence
15
Q
Step 3 : CBM case
Generate all realistic options
A
- Override family’s objections and involve patient in explicit consent process
- Concede to family demands and accept them as SDM
- Do not initiate discussions but answer direct questions honestly
- Indicate to family that patient has to be told, but they can do it their own way
- Offer info in gently progressive manner to assess patient preferences about her involvement in decision making.
16
Q
Step 3: Analyse info : Option 1
A
Override family’s objections and involve the patient in explicity consent process
- Principles and values
- self determination
- autonomy
- informed consent
- medical beneificence
- professional integrity
- family beneficence
- Consequences
- emotional, psychological, spiritual distress if not given opportunity to deal with unfinished business
- may be based on family;s own preferences for EOL
- patient may be subjected to clinical interventions she does not want
17
Q
Step 3 : Analyze option 2
A
- Concede to family demands and accept them as SDM without patient confirmation
Principles and Values:
- non maleficence
- long standing family values
- self protection as path of least resistance
Consequences:
- burnout, conspiracy of silences
- patient and family never get chance to have explicit conversation
*
18
Q
Step 3: Analyze Option 5 : offer information in a gently progressive manner
A
- Offer info gently progressive manner, to asses patient preferences in involvement in decision making.
Principles and Values:
- Gentle approach, over time with sequential questions
- respects family concerns about protecting from undue harms
- seeks to understand how much patient wants to know and be involved
- patient’s self deterination, autonomy, informed consent, professional integrity, family protection all intact.
Consequences:
- greatest likelihood of reasonable consensus.
- approach is consistent with family concerns
- would have greater difficulty insisting on non disclosure if patient indicates otherwise.
- consistent with team’s philosophy, goals and expertise.
19
Q
Step 4: Prioritize recommendations and articulate supporting argumentation
A
- limitations:
- based on assumptions, moral arguments
- based on risk assessments
- individuals applying this framework may arrive at different judgements
- applying recommendations may result in unanticipated results.
- rank order options
- substantiate recommendations with supporting arguments
- What?
- Why?
- How?
- Qualifiers?
20
Q
Truth-telling : 6 communciation tools
A
- Enabling patient self management
- making decision
- managing uncertainty
- responding to emotion
- exchanging information
- fostering healing relationships
21
Q
What is truth telling?
A
- Western concept:
- The way information is communicated about:
- futility of treatment,
- a person’s impending death,
- possible clinical pathways to death and
- possible impact of EOL decisions
22
Q
SPIKES approach to truthtelling / breaking bad news
A
- Setting
- Perception
- Invitation
- Knowledge
- Empathy/emotion
- Strategy / Plan
DO:
- set agenda
- pay attention to language of person
- obtain a clear invite
- use same words/language as person
- note gaps in understanding
- be empathetic
- explain treatment strategy
DON’T
- interrupt
- make assumptions
- blunt disclosure
- medical jargon
- destroy hope
- ignore unit of care (family) input
23
Q
Cultural considerations in truth telling/disclosure
A
- important factor but cannot assume
- ask each individual - much variation
- avoid cultural stereotyping
- Range of options:
- “Explain the results to me”
- “Explain results to me and family”
- “Explain them first to my family and then to me”
- “Explain results to family and let them decide what I should be told”
