Post on 19-Mar-2018
1/13/2016
1
© 2015 NORCAL Mutual Insurance Company
Medical Ethics and Physician‐Patient Encounters
JANUARY 23, 2016TEXAS OSTEOPATHIC MEDICAL ASSOCIATION
DALLAS, TX
Presented by:BRADFORD S. DUNKIN, MHA
MARY‐LYNN RYANRISK MANAGEMENT SPECIALISTS
© 2015 NORCAL Mutual Insurance Company
DISCLAIMER
The information contained herein and presented by the speaker is based upon sources believed to be accurate at the time they were referenced.
The speaker is not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought.
This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation.
© 2015 NORCAL Mutual Insurance Company
Faculty and Planners
Faculty• Bradford S. Dunkin, MHA
Sr. Risk Management Specialist
• Mary‐Lynn RyanRisk Management Specialist
Planners• Jo Townson
CME Manager/NORCAL
The faculty and planners of this activity have no relevant financial relationships to disclose.
1/13/2016
2
© 2015 NORCAL Mutual Insurance Company
• Which one of the following is not a bioethical principle?
A. Autonomy
B. Beneficence
C. Non‐maleficence
D. Justice
E. Autonomy
• Working from an ethical framework always allows us to choose the one best way to solve an ethical dilemma.
A. True
B. False
Pre‐test questions:
4
© 2015 NORCAL Mutual Insurance Company
• Fundamentally, ethics is: (choose all that apply)
A. Moral courage
B. Dignity
C. Being right
D. Compassion
E. Collaboration
F. Managing complexity
• Ethics is a completely different and separate discipline from risk management.
A. True
B. False
Pre‐test questions:
5
© 2015 NORCAL Mutual Insurance Company
Learning Objectives
By reviewing common allegations and risk issues associated with ethics, this presentation will support your ability to:
• Differentiate and identify the behaviors that constitute ethical behavior, personal conflicts, and professionalism.
• Identify and apply bioethical principles in health care settings.
• Apply ethical best practices to improve patient safety and reduce overall liability that focuses on identifying, responding to, investigating, and monitoring ethical behaviors.
1/13/2016
3
© 2015 NORCAL Mutual Insurance Company
A. End of Life
B. Reproductive Issues (i.e. IVF, VBAC, contraception, etc.)
C. Genetic Information
D. Privacy of Information
E. Research Issues
F. Dealing with Minors and Parents and Pediatric Issues
G. Termination of Care
H. Personal Moral Conflicts(i.e. LGBT patients, abortion, etc.)
I. Communication of Informed Consent
J. Dealing with Surrogates and Guardians
K. Other
What is the Biggest Ethical Issue You Face in Your Practice?
7
© 2015 NORCAL Mutual Insurance Company
MEDICINE
SCIENCE• Technical Proficiency
• Clinical Skills
ART• Ethics
• Professionalism
• Decision Making
© 2015 NORCAL Mutual Insurance Company
Ethics, What it is:
• Moral courage
• Dignity
• Compassion
• Collaboration
• Managing Complexity © 2012, Josh Hyatt, Used with permission
THE ARTin the Art of Medicine
1/13/2016
4
© 2015 NORCAL Mutual Insurance Company
What Ethics is Not:
• The “morality” police
• The “thought” police
• The “pull‐the‐plug” police
• The “religious‐thought” police
• The “right‐and‐wrong” police
• The “how‐to‐treat‐your‐patient” police
• The “I'm‐in‐charge” police
• The “my‐way‐or‐the‐highway” police
© 2015 NORCAL Mutual Insurance Company
Ethics
RIGHT
WRONG
Ethics is often seen as:
Ethics is really about: Coming up with the better, more reasonable solution given the circumstances
© 2015 NORCAL Mutual Insurance Company
Basic Bioethics Principles
AUTONOMY
BENEFICENCE
NON‐MALEFICENCE
JUSTICE
1/13/2016
5
© 2015 NORCAL Mutual Insurance Company
Ethical Challenges of Medicine
• Patient/family expectations
• Community standards
• Sense of failure or surrender
© 2015 NORCAL Mutual Insurance Company
Goals of Medicine
• Return the patient to full quality of life
• Get the patient to an acceptable quality of life
• Provide comfort when quality of life goals cannot be achieved
Always Ask:WHAT IS THE GOAL?
© 2015 NORCAL Mutual Insurance Company
Benefit‐Risk Ratio
Beneficence and nonmaleficence are assessed.
1/13/2016
6
© 2015 NORCAL Mutual Insurance Company
Is it Medically Indicated?
• Acute, chronic, critical, reversible, emergent or terminal?
• Goals of treatment?
• Medically indicated?
• Probabilities of success?
• How can this patient benefit from care?
• How can harm be avoided?
Jonsen, Siegler, & Winslade. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed)
© 2015 NORCAL Mutual Insurance Company
Is it Medically Indicated?
• Acute, chronic, critical, reversible, emergent or terminal?
• Goals of treatment?
• Medically indicated?
• Probabilities of success?
• How can this patient benefit from care?
• How can harm be avoided?
Jonsen, Siegler, & Winslade. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (7th Ed)
© 2015 NORCAL Mutual Insurance Company
Ethical problems can arise when goals are:
• Undefined
• Change
• Unclear
• Conflict
Conflicts
Image courtesy of jscreationzs at FreeDigitalPhotos.net
1/13/2016
7
© 2015 NORCAL Mutual Insurance Company
Personal Conflicts
COUCH ISSUE
VALUE CONFLICT
© 2015 NORCAL Mutual Insurance Company
Surgery: Couch Issue or Value Conflict?
Advanced heart failure surgeon wants to place a pacemaker in a 77 y.o. male with diminished physical capacity but intact mental capacity. Daughters are adamant about doing whatever it takes.
Resident stated he spoke with patient and wife the day before and they stated they did not want aggressive treatment. Patient and wife meek and quiet.
Surgeon stated that daughter was decision‐maker and she wanted the surgery done.
© 2015 NORCAL Mutual Insurance Company
A. Confirm with the patient their wishes and honor his request.
B. Perform the surgery, because failing to do so would result in a lawsuit from the daughters.
C. Consult with clinical team to determine the best course of action, then proceed with the final decision.
D. Bring the daughters into a family meeting with the patient to talk some sense into him and his wife about his decision.
What would you do?
22
1/13/2016
8
© 2015 NORCAL Mutual Insurance Company
Analyzing complex issues in a logical, ethical format
Ethics Decision‐Making
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Who? Intentions?
Ethical Principles
Which Principles?
Conflicts?
Medical Indications
Clincal Options
Consequences
24
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Husband & Wife,
Daughters, Surgeon, Resident
Dignity, Keep Alive, Ego, Meet family
wishes
Ethical Principles
Which Principles?
Conflicts?
Medical Indications
Clinical Options
Consequences
25
1/13/2016
9
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Who? Intentions?
Ethical Principles
Which Principles?
Conflicts?
Medical Indications
Clinical Options
Consequences
26
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Husband & Wife,
Daughters, Surgeon, Resident
Dignity, Keep Alive, Ego, Meet family
wishes
Ethical Principles
Autonomy? Beneficence?
Non‐Maleficence?
Social Benefit?
Autonomy v. Beneficence? Beneficence v.
Non‐Maleficence, Social Benefit
Medical Indications
Clinical Options
Consequences
27
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Who? Intentions?
Ethical Principles
Which Principles?
Conflicts?
Medical Indications
Clinical Options?
Consequences?
28
1/13/2016
10
© 2015 NORCAL Mutual Insurance Company
Ethics Decision Making
Key Individuals
Husband & Wife,
Daughters, Surgeon, Resident
Dignity, Keep Alive, Ego, Meet family
wishes
Ethical Principles
Autonomy? Beneficence?
Non‐Maleficence?
Social Benefit?
Autonomy v. Beneficence? Beneficence v.
Non‐Maleficence, Social Benefit
Medical Indications
Surgery, Do Nothing, Less Invasive,
Palliative or Hospice
What’s appropriate?
29
© 2015 NORCAL Mutual Insurance Company
Analysis
Key Individuals
Who? Intentions?
Ethical Principles
Which Principles?
Conflicts?
Medical Indications
Clinical Options?
Consequences?
Ethics Decision Making
30
© 2015 NORCAL Mutual Insurance Company
Risk Management and Law
RISKMANAGEMENT
“Choose To Do”
RISKMANAGEMENT
“Choose To Do”
1/13/2016
11
© 2015 NORCAL Mutual Insurance Company
Operational Considerations in Ethics:
Provider Refuses to Provide Services?
Conflicts of Interest?
Allocation and Allocation and Utilization of Services?
Privacy and Disclosures?
Culture of Ethics/Organizational
Ethics?
Resources/Finances?
Insurance Payment?
© 2015 NORCAL Mutual Insurance Company
Decision‐Making and Consent Issuesto Consider:
Provider Refuses to Provide Services?
Refusal of Treatment
Unclear Who Surrogate Is
Patient’s Wishes are Unclear
Competency v. Capacity
Informed Consent?
Advance Directives
© 2015 NORCAL Mutual Insurance Company
55 year‐old female, end‐stage COPD, admitted with SOB and unconscious. Patient placed on medical ventilation.
The patient in MICU for 1 month.
During the admission, DX anasarca and an ileus, resulting in the need for TPN, which was stopped at her request
Unable to determine surrogate
Patient likely to pass away from COPD in < 6 months or die if the TPN is not restarted
Patient Refusing TPN
1/13/2016
12
© 2015 NORCAL Mutual Insurance Company
Patient Refusing TPN
An ethics consult was requested because the patient:
No longer being sedated
Alert and oriented
Refusing TPN for 3 days
Wanted to go home.
© 2015 NORCAL Mutual Insurance Company
Analysis?
55 y.o. Woman, Daughter, Sisters,
Boyfriend/Husband, Intensivist
Ethical Principles?
Options:
A.TPN and hope the ileus resolves and stay at the hospital,
B. discharge home on medical ventilation,
C. provide her reasonable efforts to make her comfortable, and
D. home hospice
Ethics Decision Making: Patient Refusing TPN
36
© 2015 NORCAL Mutual Insurance Company
Patient Refusing TPN
Ethical Issues:
Patient’s capacity and autonomy
Determining surrogate decision maker in the event she
becomes incompetent
Patient choosing something that will result in her death
1/13/2016
13
© 2015 NORCAL Mutual Insurance Company
A. Utilize the family to encourage the patient into taking to the TPN so she can live as long as possible.
B. Recommend a palliative care consultation because the patient is actively dying and is refusing necessary services.
C. Get a court order to preserve the patient long enough to be transferred from the facility.
D. Become a conscientious objector to the patient’s decision, sign‐off on the care, and transfer care to another physician.
What would you recommend?
38
© 2015 NORCAL Mutual Insurance Company
Patient Refusing TPN
Recommendations:
Palliative care consult
Not curative, patient is actively dying
Discussion of the available options
Decision:
The family opted for going home and having hospice provide care there.
© 2015 NORCAL Mutual Insurance Company
Clinical Considerations in Ethics:
Pain?
MultipleCo‐Morbidities?
Life Sustaining Technologies?
Non‐Compliance?
Curative v. Futile Treatment?
Frequent Admissions?
Ethical Concerns Ethical Concerns About Current Treatment?
1/13/2016
14
© 2015 NORCAL Mutual Insurance Company
End of Life Issues in Ethics:
Withdraw or Withhold Treatment?
Life Sustaining Treatment v.
Comfort Care
Allow Natural Death?
© 2015 NORCAL Mutual Insurance Company
Anoxic Brain Injury
47 y.o. male, found unresponsive for approximately 20 minutes, now in ICU for a week
DX: Anoxic brain injury, drug overdose, close to brain death, on ventilator, minor episodes of over‐breathing
Physician recommending removal from ventilator, mother and sister do not want that and kept patient full code, no advanced directive
© 2015 NORCAL Mutual Insurance Company
Anoxic Brain Injury
An ethics consult was requested because:
Not going to recover from the brain injury
No advanced directives or documented wishes
Family requesting care that was not medically indicated
Family wanted to take the patient home
1/13/2016
15
© 2015 NORCAL Mutual Insurance Company
Analysis?
47 Y.O. Man, Mother, Sisters, Intensivist,
Palliative Care Physician
Ethical Principles?
Options:
A. Remove ventilator and allow natural death,
B. Continue the ventilator and life sustaining efforts
Ethics Decision Making: Anoxic Brain Injury
44
© 2015 NORCAL Mutual Insurance Company
Anoxic Brain Injury
Ethical Issues:
Surrogate’s decision‐making, best interest of the patient?
Providing scientifically futile care
Full code status
Unrealistic expectations
© 2015 NORCAL Mutual Insurance Company
A. Explain the clinical condition and likelihood of recovery.
B. Consider palliative care.
C. Allow the family time to grieve.
D. Empathize with the complexity of making this decision.
E. Attempt to frame the conversation with positive language.
F. All of the Above.
How would you respond to the family?
46
1/13/2016
16
© 2015 NORCAL Mutual Insurance Company
Anoxic Brain Injury
Recommendations:
Discuss curative versus futile care
Consider palliative care
Time to grieve
Decision‐maker not “killing the patient”
Positive language to frame discussion
© 2015 NORCAL Mutual Insurance Company
Communication Issues in Ethics:
Patient
Providers
Family
© 2015 NORCAL Mutual Insurance Company
Synopsis
1/13/2016
17
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication
Rooted in conflict
1/13/2016
18
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication
Rooted in conflict
Requires difficult conversations and even more difficult choices
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication
Rooted in conflict
Requires difficult conversations and even more difficult choices
Ethics is not for the faint of heart
© 2015 NORCAL Mutual Insurance Company
Synopsis
Finding best option in a given circumstance
Taking into account the science of medicine, the art of compassion, listening to the patient, and excellent two‐way communication
Rooted in conflict
Requires difficult conversations and even more difficult choices
Ethics is not for the faint of heart
1/13/2016
19
© 2015 NORCAL Mutual Insurance Company
• Which one of the following is not a bioethical principle?
A. Autonomy
B. Beneficence
C. Non‐maleficence
D. Justice
E. Autonomy
• Working from an ethical framework always allows us to choose the one best way to solve an ethical dilemma.
A. True
B. False
Answers:
56
© 2015 NORCAL Mutual Insurance Company
• Fundamentally, ethics is: (choose all that apply)
A. Moral courage
B. Dignity
C. Being right
D. Compassion
E. Collaboration
F. Managing complexity
• Ethics is a completely different and separate discipline from risk management.
A. True
B. False
Answers:
57
© 2015 NORCAL Mutual Insurance Company
Q & A
1/13/2016
20
© 2015 NORCAL Mutual Insurance Company
Bradford S. Dunkin, MHASr. Risk Management Specialist
NORCAL Mutual855‐882‐3412, ext. 1580
bdunkin@norcal‐group.com
Mary‐Lynn RyanRisk Management Specialist
NORCAL Mutual855‐882‐3412, ext. 2045mryan@norcal‐group.com
CONTACT INFORMATION