Post on 15-Mar-2020
What’s Hot?
Identify and discuss ethical aspects persistent and common issues.
Describe tools to deal with them. Examine side effects and responses to ethics
stressors.
Objectives
all ethical dilemmas are solved!
Once the patient gets to hospice…..
Principled Decision Making adapted from Robert Orr, MD
Sanctity of life Compassion
Service Meritorious suffering Redemptive suffering
Contentment
Mercy Grace Hope Scripture Eternity Ritual Social justice
Respect for life Truth telling Non-exploitation Advocacy Benefit/burden
Free will Obedience
Stewardship Faith
Sovereignty Dominion
God’s purpose
FAITH BASED
SECULAR
Diagnosis Prognosis
Treatment options
Values Goals Wishes
Social
Cultural Legal
Financial
Physical Psychological Social Spiritual
Patient Preferences
Contextual Features
Medical Indications
Quality of Life
Non-Maleficence
Beneficence Justice
Autonomy
Fidelity
The Ethics Iceberg VA National Center for Ethics
Cases Decisions and actions Crisis oriented
Patterns and trends Systems and processes Policies and procedures
What is really going on? Environment, culture Personal
Is there a moral or ethical issue?
Who are the stakeholders?
What are the relevant facts?
What values are at stake?
What are the options?
What resources might be helpful?
Are there legal or ethical norms at stake?
Am I comfortable with the decision?
Make a decision and evaluate its results.
Process
Conflict
An unavoidable aspect of group life
Any situation in which people have incompatible interests, goals, principles or feelings
Unmet expectations
A process that begins when one party perceives that another party has negatively affected, or is about to negatively affect something that the first party cares about.
Things we care about Ideas, Perspectives, Priorities, Preferences, Beliefs, Values,
Goals, People, Organizational Structures
What is conflict?
Go to Trial 2% of 29% File a Lawsuit 29% of 13% See a lawyer 13% of 25%
Claim of right 25% of all
Actionable injuries and wrongs
Overall, 0.25 x 0.13 x 0.29 x 0.02 = 0.000188, or 1/100 of 1% of all actionable injuries and wrongs ever go to trial.
The 'Rational' brain
Allows objectivity
Makes sense of any risk
The 'Emotional' brain
Quickly processes information
Filters for potential threat
Triggers fight or flight
Brain Power
“I can’t believe she
is visiting her dad
while I am here!!”
Result: rational
mind is swamped by the emotional mind.
Amygdala Hijacks
Stimulus
The other person’s behavior is caused by personality
or behavior (internal) rather than situational
(external) factors.
Person instead of group
Group instead of person
Fundamental Attribution Error
Status
Connection
Autonomy
Relationships
Fairness
SCARF
Moving from adrenalin Fight or Flight
Stress
Protect mode
Oxytocin production More relaxed, supported state, ‘humanized’ state
Pregnancy hormone
Connect mode
Feelings are stronger than thoughts
Chemistry
To Do
Seek the common goal Accountability
Infrastructure
Communication is primary Meet face to face
Conversation Get real data
Ask another question
Plan in advance if you can
Civility Maintain respect
Use “I” versus “You” language
Forgiveness & understanding
Find the workable solution Personal
Professional
Organizational
Culture
Language
Required translators
Words have power
Practices
Rituals at death, for remembering
Advocacy
For better death in hospice
Reflection
Culturally Coherent Care
Advance Care Planning
Applies when A person can’t make decisions
Judged to be in a terminal or irreversible condition
End of life document
Instructions Desire a natural death
Artificial nutrition (feeding tubes)
Organ donation
Completion Need two witnesses or a notary
Also known as Living will declaration, Advance Medical Directive or Direction, or
Instruction, Advance Care Plan
Living Will
Applies when Anytime a person can’t make decisions,
including end of life care Instructions Appoint a decision maker and alternate(s) Can make any medical decision the person could have
Completion Need two witnesses or a notary
Other names Durable Power of Attorney for Health Care Medical POA Health Care POA Health Care Agent
Proxy Directives
DNR Orders
Hospital
DOES NOT mean
“do not treat”
NOT automatic with
living will
Out of Hospital
Applies between facilities
Applies at home
Discharge planning
Universal DNR
POLST or POST
Mandatory for out of hospital limits, DNR
Meant for end of life CPR
01/25/05
PH-4193 (Rev 7/15) RDA-10137
A COPY OF THIS FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED
Tennessee Physician Orders for Scope of Treatment (POST, sometime called “POLST)
This is a Physician Order Sheet based on the medical conditions and wishes of the person identified at right (“patient”). Any section not completed indicates full treatment for that section. When need
occurs, first follow these orders, then contact physician.
Patient’s Last Name
First Name/Middle Initial
Date of Birth
Section A
Check One
Box Only
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.
! Resuscitate (CPR) ! Do Not Attempt Resuscitation (DNR / no CPR) (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B, C, and D.
Section B
Check
One Box Only
MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing. ! Comfort Measures. Relieve pain and suffering through the use of medication by any route, positioning,
wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location. Treatment Plan: Maximize comfort through symptom management.
! Limited Additional Interventions. In addition to care described in Comfort Measures Only above, use
medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support (e.g. CPAP, BiPAP). Transfer to hospital if indicated. Generally avoid the intensive care unit. Treatment Plan: basic medical treatment.
! Full Treatment. In addition to care described in Comfort Measures Only and Limited Additional
Interventions above, use intubation, advanced airway interventions mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. Treatment Plan: Full treatment including in the intensive care unit.
Other Instructions: ________________________________________________________________________
Section C
Check One
ARTIFICIALLY ADMINISTERED NUTRITION. Oral fluids & nutrition must be offered if feasible. ! No artificial nutrition by tube. ! Defined trial period of artificial nutrition by tube. ! Long-term artificial nutrition by tube. Other Instructions: _______________________________________________________________________
Section D
Must be Completed
Discussed with:
! Patient/Resident
! Health care agent
! Court-appointed guardian
! Health care surrogate
! Parent of minor
! Other: (Specify)
The Basis for These Orders Is: (Must be completed) ! Patient’s preferences
! Patient’s best interest (patient lacks capacity or preferences unknown) ! Medical indications ! (Other) _________________________________________________
Physician/NP/CNS/PA Name (Print)
Physician/NP/CNS/PA Signature Date
NP/CNS/PA (Signature at Discharge)
MD/NP/CNS/PA Phone Number:
( )
Signature of Patient, Parent of Minor, or Guardian/Health Care Representative
Preferences have been expressed to a physician and /or health care professional. It can be reviewed and updated at any time if your preferences change. If you are unable to make your own health care decisions, the orders should reflect your preferences as best understood by your surrogate.
Name (Print) Signature Relationship (write “self” if patient)
Agent/Surrogate
Relationship Phone Number ( )
Health Care Professional Preparing Form Preparer Title Phone Number ( )
Date Prepared
TDH, Division of Health Licensure and Regulation, Office of Health Care Facilities, 665 Mainstream Drive, Second Floor, Nashville, TN 37243
01/25/05
PH-4193 (Rev 7/15) RDA-10137
Directions for Health Care Professionals Completing POST
Must be completed by a health care professional based on patient preferences, patient best interest, and medical indications. To be valid. POST must be signed by a physician or, at discharge or transfer from a hospital or long term care facility, by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy. Photocopies/faxes of signed POST forms are legal and valid.
Using POST
Any incomplete section of POST implies full treatment for that section. No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation”. Oral fluids and nutrition must always be offered if medically feasible.
When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only”, should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only”. Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate “Limited Interventions” or “Full Treatment”.
A person with capacity, or the Health Care Agent or Surrogate of a person without capacity, can request alternative treatment.
Reviewing POST
This POST should be reviewed if:
(1) The patient is transferred from one care setting or care level to another, or (2) There is a substantial change in the patient’s health status, or (3) The patient’s treatment preferences change. Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.
COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.
TDH, Division of Health Licensure and Regulation, Office of Health Care Facilities, 665 Mainstream Drive, Second Floor, Nashville, TN 37243
Recurring conversation, over time, and with
changes in health
Check understanding
Include values, beliefs, preferences, goals
Document wishes and goals
Access to the documents
Best Planning
Document specific treatment preferences “do not place feeding tube” instead of “comfort care”
Consistent format and location in the medical record
Review and update preferences regularly as clinical conditions, family changes
Create data collection strategies to document decisions to withhold medical interventions
Implement a consistent measurement approach
Best Practices
Not a legal document; doesn’t distribute material wealth A heartfelt expression of what truly matters, what is right
Share values, blessings, lessons, hopes and dreams for the future,
love, and forgiveness with family, friends, and community
Shared when one is still alive
Helpful as a companion to other legal documents: last will,
healthcare decisions
Other names
Legacy letter, wisdom document, life legacies, celebration of life,
spiritual legacy, personal legacy
Ethical Will
1. An adult who has shown special care and
concern, who is familiar with the person’s values and who is reasonably available.
2. Preference for Spouse
Adult child
Parent
Sibling
Any other relative
Adult who satisfies #1
Health Care Surrogate Selection
Not Mandatory
Doctors decide with assistance from
Another doctor, not directly involved
Not residents
Ethics committee, or ethicists
Tremendous variation state to state
Types of decisions
Burden of proof
Difference between patient identified and MD identified related to feeding tubes
No people/No paperwork
http://deathoverdinner.org/
http://theconversationproject.org/
http://www.nhdd.org/#welcome
http://polst.org/
Helpful Sites
Kindler, gentler….
Early Risk Factors for Ethical Challenges
Crescendo Effect
Solid lines indicate moral distress
Dotted lines indicate moral residue Moral
Distress
Time Moral residue
crescendo
Moral residue
Moral distress
crescendo
Moral Distress
Pain and anguish that affects everything when one knows the right thing to do, but doesn’t do it, due to perceived constraints
Jading
A process leading to exhaustion from being overdriven, performing long, continued labor and/or severe or tedious tasks
Burn Out
Individual or group stress related to one’s relationship with the work environment
Grief out
Repeated, sustained and often unresolved grief and loss
Other/Related Distress
All share issues with empathy and engagement
Burnout
More related to mismatch between person and job
Organizational characteristics
Interpersonal action
Compassion fatigue
Psychological/emotional consequences
Change in beliefs and expectations
Vicarious traumatization
Personally traumatized
Anxiety, confusion, apathy, sadness
Burnout/CF/STS
Strategies…
Causal analysis
Self awareness/self monitoring
Limits, issues
Address issues in real time
Debriefing
“Talk about it”
Ethical dialog
Referral
Skill-building
Grief work
Engage in work of “letting go”
Funerals, journal, phone calls
Sacred/holy
Story telling
Self-care Balance
Appropriate boundaries
Spiritual practice
Find own voice/advocacy Courage
Develop sources of support Professional
Referral sources
Social
Play
…strategies
Contact
Kate Payne, JD, RN, NC-BC
The Center for Biomedical Ethics and Society Vanderbilt University Medical Center
2525 West End Ave, Suite 400
Nashville, TN 37203
615-936-2609
kate.payne@vanderbilt.edu