Test 1 Flashcards
1
Q
Cardinal Virtues
A
- prudence (wisdom)
- justice
- fortitude
- temperance
2
Q
Non-cardinal virtues
A
Fidelity to Trust
Compassion
Integrity
Effacement of self-interest
3
Q
obstacles to moral ethical reasoning
A
- different facts
- Different values: (Culture & Religion)
- Different emotions: (Fear, Anger, Guilt, & Denial)
- Different reasoning: (Consequences & Liability)
- Different loyalties: (Patient, Institution, & Society)
- Different perceptions: (Personal or professional experiences)
4
Q
fundamental principles from AMA
A
- Primacy of patient welfare****
- Patient autonomy
- Social justice
5
Q
define virtue (ethics)
A
need to do good with our purpose (intent) and do good in perormance- not being told to do the right thing but WANTING to do the right thing
-what does my HEART tell me to do?
- Application of the Virtues
- Clinicians committed to Ethics of Care hold themselves accountable for well-being of patients
- Emphasis is on quality care as a distinct moral obligation
6
Q
goals of medicine
A
- Promotion of health and disease prevention
- Maintenance/improvement of quality of life by relief of symptoms, pain and suffering
- Cure of disease
- Prevention of untimely death
- Improvement of functional status/ maintenance of compromised status
- Education/counseling about condition/prognosis
- Avoidance of harm to patient in course of care
- Providing relief and support near time of death
7
Q
evaluating ethical problems things to think about
A
- Medical indications-beneficence and non-maleficence
- Patient preferences- respect autonomy, mental capacity
- Quality of Life-respect autonomy, beneficence and non-maleficence
- Contextual features-loyalty fairness
8
Q
Principle based ethics:
A
- Beneficence – Duty of health care providers to be of benefit to patient – healing – to make whole again
- Nonmaleficence – Requires caregivers to avoid causing patients harm
- Autonomy – Patient must indicate willingness to accept treatment; Relates to self-determination and informed consent
- Justice – Obligation to be fair;Fairness with goods and services in short supply
9
Q
central question of principle based?
A
what am i obligated to do?
10
Q
analysis of principle based:
A
Rational, analytic, problem-solving focus
Imposes no general conception of the good on individuals
Focus on action*
Central question – what am I obligated to do?”
Tends to reduce ethics to quandaries or dilemmas
11
Q
required reporting for public safety (break in confidentiality for good of whole)
A
STDs
gunshot/stab
child or elder abuse
12
Q
subpena purpose and what it is not
A
forced release of record BUT it is NOT A COURT ORDER (MUST have release from pateint) an atorney asks for the info - but can say no
13
Q
practical wisdom in med
A
- pursuit of worthwhile ( ends) goals
- accurate perception of concrete circumstances
- committment to morla principles and virtues
- deliberation that integrates end goals
- motivation to act in order to achieve the conclusions
14
Q
goals in med again but dif
A
- preventing diseases and injury and promoting health
- relieving pain and suffering caused by disease and injury
- caring and curing
- avoiding premature death and pursuing a peaceful death
15
Q
intervening
A
should not just straight to the intervention… we need to udnerstand the condition and WHAT THE GOAL IS PRIOR TO MAKING A MOVE
-intervention gets too much attention and the goal gets too little attention
16
Q
GOAL CAREs toward the end of life
A
1) be cured
2) live longer
3) improve or maintain function
4) be comfortable
5) achieve life goals
6) provide support for family/caregiver
7) clarify daignosis or prognosis
17
Q
good physicians with end of life
A
they know how t ogently transition the family into the process
18
Q
decision making needs to include talk about
A
probability of outcomes and willingness to endure suffering
19
Q
wise clinical judgement asks:
A
How will this help achieve the patient’s goals
20
Q
clinical judgement is a form of
A
practical wisdom
21
Q
What are judgements based on?
A
1) principles of duty = moral obligation (action may be rigt even if it doesnt promote greates balance of good over evil)
2) consequences=what goods are worth pursuiing (action is right if it promotes the greatest possible balance of good over evil)
3) virtues=about persons, motives, intetions,and traits of character (an action is right if it is what a virtuous person would do in the circumstances)
22
Q
compartmentatlization
A
we put on a different role when we need to… NOT GOOD. NEED TO BE WHOLE. Ex) Nazi doctors did horrible things at work and then went home to families to be good fathers… say whattt?
23
Q
unifed people need to integrate…
A
personal views and professional views (… avoiding compartmentalization)
24
Q
being a doc means…
A
give info
make recommendation
persuasion can cross into manipulation and coercion (No-No’s)
25
conscientious practice need to recognize
- importance of individualy conscinece
- priority of the patient: intrinsic vulnerability, profess-ionals, pateints priority is not absolute
- our responsibilty to society
26
medicines social "contract"
a bunch of unwritten codes bw professions and society that are constantly evolving
27
legal regulation
state licensure
hospitals-restricting and limiting practice
professional organizations
malpractice legislation
28
confidentiality
cant give out sensitive patient info
29
priveledge
phys cant be forced to testify info about patient in course of treatmtnet
30
exceptions to duty of confidentiality
- patient permission( written release)
- danger to public or an indiv
- mandatory reporting statues
- legal process
- "treatment, payment, and health care operation (HIPPA)
- independent med eval
31
parent does not have a right to childs med record in divorce situation if
child is seeking care for addiction, contraception, or STI
32
minor definition
child under 18 who is unmarried and childless and is not living separately from parents with independaent financial support
33
care is owned to who?
the vulnerable regardless of anyones personal opinion
34
patient doctor relationship is part of a larger culture that frames relationship on
the consumer model
35
when is not preventing a preventable harm an injustice?
when basic human needs are not med - no food, clean water, education, safety...
36
what do we owe others?
we should help them out!
37
people behave in healthy ways when
they hang out with others who behave health
38
people do not behave morally because of
havibng the correct beliefs. All the same
39
key to bahving morlaly?
surround yourself with people who CHALLENGE you and your ideas.
40
three commonly encountered ehtical issues at end of life care:
withholding/withdrawin care
medical futility
assistnace with dying
41
Support Study:
- half of conscious patients had moderate to severe pain at least 1/2 of time before death
- 31% of pts did not wish to have CPR but physicians were not aware of DNR order pref
- nearly half of DNR orders were written within 2 days of pt death
- 40% of pt spent at least 10 days in ICU
- POOR SYMPTOM MANAGEMENT
- INCONSISTENT WITH PT PREFERENCES AND VALUES
- PROBLEMATIC COMMUNICATION AND DECISION MAKING
- LIFE-PROLONGING, INTENSIVE TREATMENT VS PALLIATIVE/HOSPICE CARE
42
Teno Study:
- 1/4 people who died did not receive enough pain meds or none at all.
- inadequate pain management was 1.6 times more likely in nursing home than hospice care
- 1/2 patients did not receive enough emotional support. 1.3x more likely if in an institution
- 1/4 respondents expressed concern over phys communication and treatment options
- 21% complained that the dying person was not always treated with respect.compared to homecare setting in a nursing home 2.6x higher and 3x higher in hospital
- 1/3 respondents said family members did not receive enoguh emotional support. 1.5x more likely in nursing home/hospital than at home
43
first questions to ask at PT end of life
- What is the patients GOAL?
- what else can we OFFER this patient?
- What else can we do here?
44
the object of all clinical decision making is first to:
secure the health, well-being or good dying of the pt and to do this in a manner that respects the integrity of all participants inthe decision making process
45
issues to address when thinnking of pt EOL goal?
risks, benefits, burdens, probabilities
Phys are good at talking about risks and benefits but not the other two.
46
euthanasia vs phys assisted suicide?
doctor does the killing (NOT LEGAL) vs doc gives pt the stuff to kill themselves (OREGON MONTANTA WASHINGTON)
47
passive euthanasia
- not beginning treatment that would provide a benefit to pt
- withdrawing treatment that has been shown to be inffective
THE INTENT NEEDS TO BE TO KILL. IF YOURE WITHDRAWING TREATMENT=NO EUTHENASIA
48
principle of double effect 4 elements
NEED TO SHOW THAT INTENT WAS GOOD BUT EVEN THOUGH OUTCOME WAS BAD
- nature of the act (good or marally neutral)]]
- agents inentions (only need to intend good)
- distinction-means vs ends (bad effect not a means for a good effec)
- proportionality bw good effect and te bad.(good must outwieight bad)
49
medical futility defnition
- unacceptable likeliood of achieving a therapeuticbenefit for the patient
- effectiveness (CLINICIAL DETERMINES), benefit assessment of value/desireabilit yof the effect (PATEINT DETERMINES) , burden (PT AND CLINICIAN DECISION
- quantitative component: benefit is key: if hasnt worked it probably sint going to work
- qualitative component: pt must have capacity to appreciate benefit and shouldnt have to worry about illness
50
due process of medical futility
- earnest attempts
- joint decsion making
- negotiation of deisagreements
- involvenment of an institutional ethics committee
- transfer care to another phys
- transfer to another institution
51
whcih ahs higher standard? law or ethics?
ETHICS
law is only what you must/must not do
52
palliative care focuses on
releicvkng pAIN and suffering/improvoing qualitty of life
53
hospice is
a philosophyvof care...
| wherever the pt calls home
54
langauge of EOL
ill do everything to hep you msintain your indep.
i want to ensure your afather receives the kind of treatnent that he wants
your comfort and fdignity are my top priority
i will focuds on treating your symptoms
lets didscuss what we can do to dfulfil your wish to stay at home
55
wat is the goal of EIOL
c;larify goals / guide care
| treatment priorities
56
treatment priorities optimized by
INTENTIONAL LISTENING
57
mediacl ethicsquestions
medical question, ehtics question, and the legal question
58
oath of hippocrates is
virtue based ethic .. emphasixzes competence, moral integrtity, personal relationshiopn w/ nonmaleficence and beneficence
59
prudence
is practical wisdom - in the right circumstance you wil make the right choice
60
justice
how will i distribute these resources?
61
fortitude
sustained moral courage - resisting temptation
| advocating for the patient!
62
temperance
going to be tempted -
| be victorious about desire - wish to do somethnig bu conscience and morals tell you to do the right thing
63
fidelity to trust
develop trust with yout patients
64
compassion
cant be cold and heartless
- talk to them!
- co-suffering with the patient
65
integrity
avoid fraud and conflict of intrest and misconduct
intellectual ingtegrity - know what you know and admit what you do not know
66
effaceemnt of self interest
finding find line between family first and patients first]
67
libertariane
- healthcare is not a right
| - does not favor taxing the rich to fund welfare
68
utilitarianism
- goal is to maximize social welfare
| - what is right for society or the total NET good
69
communitarianism
- all for one and one for all concept
| - each citizen should care for the community and the community for the citizen
70
egalitarianism
- persons receive healthcare benefits but not equally
| - everyone eligible for adequate butnot maximal healthcare
71
virtue helps us
aim at the right target
72
practical wisdom helps us
use the right means
73
function of practical wisdom (cardinal virtue)
to use the right means to a good end
74
how do you teach a virtue?
by doing and practicing
75
goals of treatment
cure disease,
prolong life,
preserve function
pallaiate symptoms
76
clinical judgement is a process of informatio processing that...
transforms data into a differential diagnosis to identify the most likely diagnosis and justify an approach to its treatment
77
rationing by medical effectiveness means:
delivering care by the prop that treatment will max benefits and min harm
78
which of the four principles of med ethics would be used when referring to informed consent?
autonomy (let the patient chose) and benefiscence (help them choosesort and choose the best deicison)
79
recommendation of a plan is...
informational element
80
medical decision making capacity is...
threshold element
81
disclosure is ...
informational element
82
understanding is
informational element
83
authorization is
consent element
84
the professional standard guideline was replaced by the
reasonable person standard
85
steps of medical decision making capacity
engage conversation, observe beh, talk with 3rd party
86
best test for determinin medical decision making capacity?
MacArthur Competence Assessment Tool
87
legal, medical, ethical questions?
do we have to?
can we?
should we?
88
what act requires drug companies to report transfers of value to physicians/ (tells you whcih phys receive money from corporations)
sunshine act
89
error, delay, neglected results
diagnostic
90
communication, equpment, system failure
other
91
procedure dose delay unintended
treatment
92
prophylaxis, monitoring, screening
preventative
93
clincal ehtical reasoning steps:
1) state the problem clearly
2) gather and organize data (med facts and goals, patient goals and preferences
3) Is the problem ethical
4) is more information or dialogue needed?
5) determine the best course of action and support it with reference to source of ethical value
94
informed consent is borken if the phys
violates his duty to the patient and subjects himself to liability if he withholds facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment
95
two meanings of informed consent
autonomous authorization (patient or surrogate gives consent) and instituational/policy rules of censent (social rules = requirements that an org or institution fulfill prior to preoceeding with treatment
96
purpose of informed consent
-collaborative decision-making process=creating an ongoing partnership bw healthcare prof and patinet
-designed to prevent coercion or deception
-opportunity to assess patients udnerstanding and to review risks and benefits
DO THEY UDNERSTAND THE BURDENS AND THE OUTCOMES? (ANDS ONTO RISKS AND BENEFITS)
97
elements of informed consent -
1) threshhold elements (preconditions)-med decision making capacity=ability to understand and decide & voluntariness=not coerced into decison
2) informational elements -disclosure (discussion of material info); recommendation of a plan;undersnading disclosure or recommendation
3) consent elements-decision in favor of the proposed plan & authorization of chosen plan
98
issues with informed consent
- phys consistently fail to cunduct it ethically and legally
- dont use effective communication skills
- dif to interpret to patient uncertainty with med information
- dont want to overload or alarm patient
- time pressure
- diminishing the process as bureaucratic and unnecessary
99
patients andtheir informed consent
- they may not understand it
- pt usually distracted
- voercome by fear and anxiety
100
studies show that patients who give informed consent usually
cant even remember what they consented to the next day
101
informed consent is a
PROCESS -NEED A DISCUSSION AND DOCUMENT ATION
102
standards for consent laws
professional standard OLD days when phys relies on a judgement about what colleagues in similar situations would disclose....
NOW: reasonable person standard - one is required to disclose what a reasonable person would want to or need to know to make a good decidison
103
implied consent laws
- clinical sit when person CANNOT give consent bc of their situation
- (NO SURROGATE - DOCUMENT WHAT YOU DID TO CONFIRM NO SURROGATE
- first need to do what ever necessary to preserve life and function. THATS IT.
104
Danforth Act
- need to see medicare and medicaid
- need to give patietns what their RIGHTS are.
- cant discriminate if people dont have adv dir
1) right to participate and direct their own healthcare
2) the right to accept or refuse medical or surgical treatment
3) the right to prepare an advance directive
4) the receipt of info on the provider's policies that govern the utilization of these rights
105
decision making capacity
medical piece determined by a physician
this person has the capacity to make a reasonable decision about their health
THEY HAVE IT UNTIL SOMEONE DETERMINES THAT THEY DONT (determined as a CONTINUUM (more or less) rahter than a threshold (eitehr/or)
MORE about SPECIFICS rather than GLOBAL decisions
106
competency
the JUDGE DETERMINES this
| for example: can they handle their check book
107
assessing medical capacity is part of
informed consent - if the patient doesnt have medical assessing capacity then probably shouldnt be asking them for informed consent
108
patients (OR SURROGATE) and their med decison making
need to understand relevant info
appreciate med situation and consequences
-communicate choice
-engage in rational delibberation about values in relation to phys recommendation and treatment options
109
first question with patients who lack med decision making cpacity due to their medical circumstance...
Can medical decision capacity be restored? If not, find surrogate
110
med decisino makin capacity that REQUIRES fruteher eval...
PATEINTS WHO REFUSE LOW RISK HIGH BENEFIT TREATMENT
111
factors to consider with med decison making...
mental d isorders --- these people can still make decisions in some cases!
112
technology is
neutral. Its how we use it gives it its moral valance
113
nonvoluntary euthenasia
pt made no request or consent for death but was killed
114
involuntary euthenasia
pt expressed no euthenasia but killed
115
established practice
- can refuse treatment
- withholding and withdrawing treatment
- palliative and hospice care
116
controversial issues
- voluntary stopping eating and drinking
- palliative sedation (terminal sedation - soft euthenasia)
- phys assistance in dying
- patient surrogate demands for futile therapies
117
circle of decision making
indiv
directions from indiv (living will or power of attorney
-best interests
-court
118
hospice IS NOT
A PLACE TO GO TO DIE
