Ethics at the Bedside
Conflicts and Communication
Bernard Scoggins, M.D., F.A.C.P.
Ethical actions and decisions should
reflect the values of your staff and
institution
How we decide can be as
important as what we decide
Ethics often has tension with the
law, risk management, regulations,
and institutional policies
Ethics properly applied should lead to patient
centered medicine
Ethical decisions poorly communicated can
lead to distress and staff burnout
Can good ethical practices improve
patient care?
• Improve patient quality or satisfaction?
• Reduce risks and malpractice?
First Clinical Case
• Questions – What did she really tell the doctor?
– Was she or is she competent?
– If not competent, who can decide for her?
– What about her advanced directives
Competency
Decision-Making Capacity
Informed Consent
Competency is a legal decision
Decision Making Capacity
Clinical Judgment
Decision Making Capacity is task specific.
The complexity and ambiguity of the
options affect it.
Four Standards for Decision-Making
Capacity*
•
•
•
•
Communicate a choice
Understand the relevant information
Appreciate the situation and its consequences
Reason about treatment options
- New England Journal of Medicine
Decision-making capacity
may wax and wane
• Dementia does not mean lack of decisionmaking capacity
Myths about decision-making capacity
1. Decision-making capacity and competency are the
same
2. Lack of decision-making capacity can be presumed
when patients go against medical advice
3. There is no need to assess decision-making capacity
unless patients go against medical advice
4. Decision-making capacity is an ‘all or nothing’
phenomenon
5. Cognitive impairment equals lack of decision-making
capacity
JAMA
Myths about decision-making capacity
6. Lack of decision-making capacity is a permanent
condition
7. Patients who have not been given relevant and
consistent information about their treatment
lack decision-making capacity
8. All patients with certain psychiatric disorders
lack decision-making capacity
9. Patients who have been involuntarily committed
lack decision-making capacity
10.Only mental health experts can assess decisionmaking capacity
JAMA
Informed Consent is the legal
recognition that each individual has
the right to make decisions regarding
his/her own healthcare
Information sharing is patient centered
• Decision-making in context of the physician
patient relationship is building trust
“Trust me I’m a doctor”
If decision-making capacity is
lacking, turn to the surrogate
1. Patient’s known wishes
2. Substitute judgment
3. Patient’s best interest
Advanced Directives
In Georgia
• 1980 - First Living Will Law
• 1990 - First Law of Durable Power of Attorney
for Healthcare
• In 2007, New law combined both
When does it apply?
• Patient is terminable or permanently
unconscious
• Requires two physicians to certify this
Part 1 – Healthcare Agent
Part 2 – Treatment Options
• This must be properly signed and witnessed
Case 2 (involving brain death)
Criteria date back to
Harvard Criteria 1968
• First Georgia Law 1975
• Uniform Determination of Death Act
Georgia Law – Death can be declared if:
• There is irreversible cessation of circulation
and respiratory function
or
• Brain death involving the whole brain
Clinical Evaluation
• Other tests not required
• Two physicians not required but advised
American Academy of
Neurology Standards
•Do not confuse with PVS, MCS, or Coma
1.
2.
3.
4.
5.
Fuzzy language
Don’t fight it out in the chart
Communicate with staff and family
Document, document, document
Do not use the term “withdrawal of life
support”
3rd Case
DNR
• First Georgia law passed in 1991
Personal decision-making capacity can
always decide
if no DMC (see list)
Must be a candidate for non-resuscitation
with one attending and another physician
declaring this.
• Ethics Committee Role
Law expanded to include hospice in
1994 and DNR out of facility in 1999
with portability
• Documentation?
• Communication with family, nursing, others
What is Futility?
Strictest sense – treatment is futile
if it offers no benefit to the patient
Judgment of futility involves both values and
scientific evaluation.
Patient autonomy and goals
We all recognize when resuscitation is
futile but we cannot make unilateral
decisions
We are not obligated as providers to
provide inappropriate treatment that
could be harmful or of no value or
technically impossible
Question treatment for families that
want everything done...
This can lead to moral distress
What is DNR Portability?
•
•
•
•
To Home?
To Nursing Home?
Return to Hospital?
To Assisted Living?
Nutrition/Hydration
This is a medical procedure and can be
withdrawn just like any other procedure
This is a very sensitive topic with
religious and moral beliefs involved
Must be discussed, shared, and
documented
Laws do not address every option
There also are Georgia Laws or
Case Law involving physician-assisted
suicide and withdrawing/withholding
of life support
“What this patient needs is a doctor”
(a quotation from Dr. Stead, Duke
University Medical School)
We will always have conflicts, tensions,
doubts and uncertainties
Don’t forget to ask:
1.
2.
3.
4.
5.
6.
7.
8.
Nurses, yes - nurses
Lawyers
Risk managers
Dieticians
Chaplains
Social Workers/Case Managers
Patient Representatives
Ethics Committee
Always listen to patients, nurses, and
staff and coordinate their message
Ethical actions and decisions should
reflect values of the institution, staff,
and profession.
We will always have stress, but we can
reduce moral distress and conflict
Medical ethics should be
proactive and preventive
“Hope begins in the dark, the stubborn hope
that if you just show up and try to do the right
thing, the dawn will come. You wait and watch
and work; you don’t give up”
-Anne Lamott
“In clinics, at the bedside where it counts, a
health care system is people touching each
other. Everyone who touches anyone affects
that person’s healing, and affects the further
demoralization of medicine – or its
remoralization. In the moral moment of that
touch, there is no system.”
- Arthur Frank, University of Chicago
Post-test
1.
What is the difference between competency and
decision-making capacity?
2. Can a person with dementia still have decisionmaking capacity?
3. Can a person who is brain dead be removed from
"life support" if the family objects?
4. If a person is DNR in the hospital, will he or she
remain DNR at home or in assisted living?