Pom Ethics

Front 1

Why is it important for physicians to obtain patients’ consent to treatment?

Back 1

Legal - In law, physical contact without the person’s consent can be the basis of civil and criminal liability for assault and battery

Ethical -
1) respect for the individual’s freedom to make important personal choices requires giving them information about the consequences of those choices

2) The goal of promoting patient welfare (or best interests) is the second basis for the informed choice requirement

Front 2

Criteria for decision making?

Back 2

Patients should be able to

• Express a (reasonably stable) choice
• Understand basic information relevant to the specific decision

Front 3

How can you test decision making capacity?

Back 3

Have patient explain what they understand of the procedure

Front 4

When can adolescent patients make their own treatment choices?

Back 4

1) Normally parents in charge until 18. When child can communicate, usually get consent. Can be overridden.

2) Mature minor - most children by 14 can rationalize like an adult. Just don't have experience or emotional maturity

3) Other exceptions cover “emancipated” minors who are viewed as adults based on their status as members of the military, married persons, parents, or living apart from their parents

4) allow minors to consent to certain forms of care, such as treatment for drug or alcohol abuse and pregnancy-related care

Front 5

What are the basic ethical considerations in treatment decisions for premature newborns?

Back 5

• Parents’ freedom to make medical decisions for their children;
• The infant’s best interests;
• The family’s interests, including their need to provide adequate care to other children;
• The societal interest in protecting vulnerable persons;
• The societal interest in fair allocation of health care resources.

Front 6

What ethical considerations apply to parental decision-making?

Back 6

Parental autonomy, questionable survival, and probable low quality of life may justify honoring the parents’ treatment refusals.

Front 7

What do the Baby Doe rules say about treatment for premature and other at-risk infants?

Back 7

The rules require states receiving federal funds to adopt certain standards for child neglect.

the rules do permit withholding or withdrawing treatment in certain cases: chronic and irreversible coma; treatment would be futile in prolonging survival; treatment would merely prolong dying; treatment would not be effective for all infant’s life-threatening conditions; treatment would be “virtually futile” and “inhumane.”

Front 8

To whom do advance directives and family decision-making apply?

Back 8

Advance directives and family decision-making apply only to patients unable to make decisions contemporaneously

Front 9

What are the types of advance directives?

Back 9

• The instruction directive, in which the individual describes unacceptable and acceptable end-of-life care; and
• The proxy directive, in which the individual chooses a trusted relative or friend to make decisions on the patient’s behalf.

Front 10

What are the advantages of having an advance directive?

Back 10

• Protects patients’ rights; empowers patients
• Legal recognition; protects physicians from liability
• Promotes physician-patient communication
• Supported by medical ethicists; religious leaders; public
• Encourages planning about death
• Reduces emotional burdens on families

Front 11

What are the drawbacks to advance directives?

Back 11

• Patients might not understand choices they make in advance directive
• Their instructions might be vague, unclear or misinterpreted
• Proxies may not understand their role
• Not many people complete advance directives
• Directives can be too inflexible, can complicate care
• Patients might not discuss with physician
• Directives can be inaccessible when needed

Front 12

Why don’t more people make advance directives?

Back 12

• In surveys, the most common reason offered for failure to make a directive is that respondents expect physicians to bring up the topic

Front 13

What are some reasons why physicians may not ask patients whether they would like to make an advance directive?

Back 13

• Reluctance to bring up death;
• Lack of time;
• Lack of familiarity with advance directives as treatment tool

Front 14

What are the two standards to help families with treatment decisions when there are no advance directives or they fail to provide complete guidance?

Back 14

Substituted Judgment Standard

Best Interests

Front 15

What is goal of Substituted Judgment Standard?

Back 15

• To decide as patient would if competent, in light of patient’s former relevant statements, attitudes toward medical care, religious beliefs, and other values

Front 16

Questions and problems that may arise with Substituted Judgment Standard?

Back 16

• Different family members have different views of which treatment outcome is most consistent with patient’s former preferences and beliefs;
• High error rates (ie, surveys show relatives often do not know elderly patients’ actual preferences);
• Relatives may shape decision to reflect their own interests in avoiding emotional and financial burdens

Front 17

What is goal of Best Interests approach?

Back 17

• To choose what would be best for patient in current state;
• To protect vulnerable incompetent patients from harmful treatment decisions based on the interests of others

Front 18

What considerations should be evaluated to assess incompetent patient’s best interests?

Back 18

• Pain, distress, other burdens treatment and illness impose on patient;
• Whether death would be painful or uncomfortable if treatment forgone;
• Chances of treatment success;
• Pleasures, enjoyment, other positive benefits patients could gain with continued life

Front 19

Overall goal for best interests?

Back 19

Overall goal is to avoid imposing “inhumane” or pointless” treatment on patients, while at the same time avoiding discrimination, lack of respect for mentally disabled patients

Front 20

Define and distinguish withholding and withdrawing medical interventions

Back 20

Withholding and withdrawing medical interventions both involve forgoing life-sustaining measures and “letting nature take its course.” But withholding is a passive failure to act (an omission), while withdrawing is an affirmative act. In both situations, death has two primary factual causes: the underlying condition and the absence of affirmative life-preserving measures. In such cases, however, the underlying illness is considered the legal cause of death.

Front 21

What is voluntary cessation of nutrition and hydration?

Back 21

a patient with the capacity for independent decision-making refuses both oral and tube feeding and hydration. This involves forgoing an intervention that some people see as a basic form of care (or an “ordinary” measure), as opposed to a more burdensome intervention such as a ventilator (or an “extraordinary” measure). It is usually done with an explicit intent to cause death.

Front 22

What is risky pain management?

Back 22

Risky pain management involves terminally ill patients who need high doses of medication to relieve their pain. Sometimes giving a dose sufficient to relieve pain can hasten the patient’s death. Thus, the physician performs an action that could hasten death, but does so with the intent to relieve pain, not cause death. This is morally permissible under the traditional “double-effect” doctrine referred to in the JAMA article.

Front 23

What is palliative sedation?

Back 23

Palliative sedation (sometimes called terminal sedation) involves the administration of high doses of sedatives to relieve severe pain or distress that cannot be relieved through measures that allow consciousness to be maintained. In such cases, life-sustaining measures such as ventilators and tube feeding are withheld or withdrawn. These actions may be taken with the intent to relieve suffering and to allow (or cause?) the patient’s death.

Front 24

What is physician assisted suicide?

Back 24

Physician-assisted suicide occurs when a physician makes available to patients with decision-making capacity a medication or other means by which they may end their lives. In this situation, the patient must initiate the final act that causes death. In the US, Oregon and Washington are the only states with laws permitting this practice. Under those laws, eligible patients are those with a prognosis of six months or less to live.

Front 25

What is active euthanasia?

Back 25

Active euthanasia occurs when a physician, intending to cause death, administers a lethal agent that produces death independently of the patient’s illness or injury. This is not legally permitted anywhere in the US. The Netherlands and Belgium permit this practice. For some, the application of active euthanasia to infants is an appropriate way to relieve suffering, but for others it is a chilling indication that any steps toward allowing active assistance in dying put societies on a slippery slope to improper killing based on disability or social worth judgments.

Front 26

What are harms associated with the failure to discuss end-of-life issues?

Back 26

• Patients lose opportunities to have care consistent with their individual values and preferences;
• Patients’ pain and anxiety may be inadequately addressed;
• Patients may undergo aggressive treatment based on unrealistic understanding of the potential benefit;
• Patients lose opportunities to complete personal business and to say goodbye to loved ones;
• Families experience unnecessary burdens;
• Clinicians experience distress at delivering inappropriate interventions.

Front 27

What are the benefits from end-of-life discussion with patients?

Back 27

high-quality care and stronger relationships with patients and their families

Front 28

How can physicians express their own grief over losing a patient?

Back 28

Letters of condolence and other contact with families after a death allow physicians to express their own grief at the loss of a patient.