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