Bioethics Consultation at the Bedside
Adding Value in a High Tech World
David E. Taylor, M.D.
ICU Medical Director
Chairman, Pulmonary/Critical Care
Palliative Care
Bioethics Is Critical to ICU Care?
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20% of all Americans die in an ICU
10-20% of ICU patients will die
70 - 90% of ICU deaths occur in the context of
withholding or withdrawing life support
Most ICU patients are at risk of dying
Many ICU patients
– Live with significantly reduced quality of life after
the ICU
– Return to the ICU
Ethical Challenges in the ICU
• Denial
unrealistic expectations
• Prognostic uncertainty
paralysis
• Patient “autonomy”
burden / conflict
• “Silos” of disciplines / specialties
fragmented care
“Autonomous” Decision-Making
• Fewer than 10% of ICU patients can participate in
treatment decisions.
• “Easy to drown in a sea of surrogates, whose
levels of anxiety and depression impair their own
capacity for decision-making.”
-Pochard, CCM 2001; 29:1893
-Pochard, JCC 2005; 20:90
What is Bioethics?
•Medical Ethics and History Course Trailer.wmv
Bioethics Building Blocks
•Moral Theories - Principles
of Bioethics.wmv
Fundamentals in Bioethics
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Respect for Persons
– Autonomy
– Confidentiality
– Truth Telling
Act in the Best Interests of Patients
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Beneficence
Non-maleficence
Lack of Decision-making Capacity
Conflicts of Interest
Allocate Resources Justly
What is Bioethics Consultation?
• Service provided by an individual consultant,
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team or committee
To address ethical issues in a specific
clinical case
To improve the process and outcome of
patient care
To identify, analyze, and resolve ethical
problems
Why Request a Clinical
Ethics Consultation?
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Efforts to resolve an ethical issue have reached
an impasse
Life-sustaining treatment for a patient who lacks
decision-making capacity with no appropriate
surrogate decision-maker
Surrogate decision-maker is unable/unwilling to
provide substituted judgment
Why Request a Clinical
Ethics Consultation?
(cont)
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Heathcare team wants to discuss ethically
supportable strategies that could help prevent
an “ethics crisis”
Case that is ethically challenging, unusual,
unprecedented, or complex
Clinical Ethics Consultation
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CASES Approach
– Clarify the consultation request
– Assemble the relevant information
– Synthesize the information
– Explain the synthesis
– Support the consultation process
Bioethics Mediation
Clinical Ethics Consultation
Clarify the Consultation Request
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Process of requesting a consult
– https://academics.ochsner.org/bioethicsform.aspx
Uncertainty or conflict over which
decisions/actions are ethically justifiable
Does the request pertain to an active patient
case?
Formulate the ethics question as precisely as
possible
Clinical Ethics Consultation
Synthesize the Information
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Review relevant information
Apply ethics knowledge
Formal meeting vs. other communication
strategy
Identify and assist ethically appropriate
decision-maker in reaching decisions
Clinical Ethics Consultation
Explain the Synthesis
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Communicate findings to key participants
Document suggestions
Support the Consultation Process
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Follow up on the patient’s case
Critical self-review of the individual consult and
the consultative process
Clinical Ethics Consultation
Common Reasons to Request a Consult
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Advance Directives
Autonomy in Tension with Best Interest
Confidentiality
Decisional Capacity
Disclosure and Truth Telling
End-of-life Care
Clinical Ethics Consultation
Common Reasons to Request a Consult
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Forgoing Life-sustaining Treatment
Goals of Care
Informed Consent and Refusal
Medical Futility
Parental Decision Making
Surrogate Decision Making
Ethics Consultation at Mayo Clinic
• Most common diagnoses
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Malignancy
Neurologic disease
Cardiovascular disease
Multi-organ failure
Pneumonia
18%
18%
17%
11%
9%
Requested by
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Physicians
Nurses
Patient or Family
Social Workers
68%
19%
9%
5%
Site of care
– Non-ICU acute care
– ICU
– Outpatient
55%
40%
6%
Swetz et al. Mayo Clin Proc. 2007
Clinical Ethics Consultation
Primary Indications at Mayo Clinic
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Competency or decisional capacity
Staff or professional conflict
Quality of life / end of life care
Appropriateness of treatment / futility
Withdrawing or withholding treatment
Patient autonomy
Advance directives
Family conflict
82%
76%
60%
54%
52%
38%
24%
22%
Swetz et al. Mayo Clin Proc. 2007
Bioethics in a Modern World
•Star Trek_ Voyager Nothing
Human.wmv
Bioethics
The Quest for Goal Alignment
Patient
Family
Provider
Knowledge
“Think”
Prognosis
Emotion
“Feel”
Suffering
Action
“Do”
Plan of care
Practical Approach to Decision-Making in the ICU
Curtis and White, Chest 134 (2008)
Difficult Conversations
• Begin by listening …instead of talking
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– Open-ended questions
– Don’t interrupt
18 second rule
– Establish trust
Explore perceptions before defining reality
Legitimize emotions
End by summarizing
Patient / Family Conference
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Change in patient status or goals of care
Provider / family miscommunication or conflict
Long length of stay without clear discharge plan
“Blanket” family directions – “Do everything”
Differing messages from various family members
Need for further cultural and spiritual insight
Family conflict or mistrust of medical caregivers
Uninvolved family members – “Relative from Alaska”
Alternative sites of care to be considered
Provider Care Conference
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No clear physician leader – MD coordinator of care
Disagreement among healthcare team members
Inconsistent assignments of nurse to patient
Nurses request different patient assignments
Patient / family reported as “difficult” or “challenging”
Co-morbid acute or chronic mental health condition
Debriefing after a death
Steps to Improve Family Communication
• V ….. Value family statements
• A ….. Acknowlege family emotions
• L ….. Listen to the family
• U …. Understand the patient as a person
• E …. Elicit family questions
Domains of Palliative Care
Patient and Family-Centered Decision Making
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Assess patient competence
Identify family spokesperson
Pre-existing advance directives
 Living Will
 Healthcare Power of Attorney
Establish parameters of care (DNR status)
Share plan of care with patient / spokesperson daily
Formal family conference within 48 hours of admit
Provider care conference to determine care plan
A SyMPLE Approach to Palliative Care
• Symptoms
• Medical Problems / Prognosis
• Psychosocial (Spiritual)
• Legal
• Ethical
Why Bioethics?
Death and Taxes
•NHDD Speak Up
Video.wmv
Ethical Approach to Dilemmas
in Clinical Medicine
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Clarify the facts of the case
– What is the clinical situation?
– Who is the primary decision maker?
– What are the concerns, values, and preferences
of stakeholders?
Analyze the ethical issues
– What are the pertinent ethical issues?
– How should ethical guidelines be applied to
these issues?
Ethical Approach to Dilemmas
in Clinical Medicine
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Address psychosocial issues
– What pragmatic issues complicate the case?
– Hold a team meeting
– Meet with the patient and/or family
Negotiate to reach agreement
Seek assistance as needed