Ethics in the ICU presented on March 11 2019 at Spokane Chapter AACN Meeting

1. Ethics in the ICU
Andi Chatburn, DO, MA, HEC-C
Regional Director for Ethics
Providence St. Joseph Health, WAMT
Andrea.Chatburn@providence.org

2. No Financial Disclosures

3. Learning Objectives
• Introduce Clinical Ethics as a way of being with one another
in community
• Explore trends in Critical Care Ethics and case examples that
inform those trends
• Apply principles of ethics to cases through a 4-box analysis

4. Ways of “doing” Ethics
Traditional Principal-Based Approach:
• Autonomy
• Beneficence
• Nonmaleficence
• Justice

5. Ways of “doing” Ethics
•Virtue
•Ethic of Care – Reciprocity
•Narrative Ethics
•Capabilities Approach

6. JAMA Network. Accessed https://jamanetwork.com/collections/5584/critical-care-medicine

7. AP Photo/Manuel Balce Ceneta https://www.washingtonexaminer.com/shrinks-toss-aside-medical-ethics-to-protest-trump

9. http://www.kgh.on.ca/kghconnect/news/critical-care-program-launches-standardized-patient-bedside-handovers

10. Photo by: Staff Sgt. Katherine Spessa

11. Doctrine of Double Effect
Bad Effect
Good Effect
Cause & Effect
Cause & Effect
Action/
Object

12. ECLS / ECMO
• Who?
• When?
• For what end?

13. Kulkarni, RG. Emergency Medicine, Jan 27, 2012. Accessed at http://boards.medscape.com/forums/?128@@.2a2ee7fc!comment=1

15. When is something ‘Futile’?
Medically
Non-feasible
interventions
Medical
interventions:
“Questionable
benefit”
(“Non-
Manageable”)
Medically
Non-
beneficial
interventions
Objectively
Harmful
medical
interventions

16. Accessed Verarrier, L. 2018. https://www.acepnow.com/article/do-not-resuscitate-tattoos-are-they-valid/

17. Mr. C
0
Dementia, COPD
X
X

18. Disease Spectrum
http://www.med.umich.edu/geriatrics/patient/palliative-faq.htm

19. Views of Life: Basis of our obligations
Medical
Condition
Personal
Pursuit of
Values/Living
Quality
of Life

20. Diverse Communities

21. Cagle

22. Spectrum of Shared Decision Making
Diagnosis Death
Clinically
Directed
PaternalismPatient
Directed
Autonomy
Adaptive Coping Maladaptive Coping
Roeland et al. When Open-Ended Questions Don’t Work. J Palliative Medicine, Vol 17, No 4, 2014. DOI: 10.1089/jpm.2013.0408

23. Goldwasser, et al. Brazil. DOI: 10.5935/0103-507X.20180053 http://www.rbti.org.br/artigo/detalhes/0103507X-30-3-11

24. EXTREMIS

25. Ways of “doing” Ethics
Traditional Principal-Based Approach:
• Autonomy
• Beneficence
• Nonmaleficence
• Justice

26. Ways of “doing” Ethics
•Virtue
•Ethic of Care – Reciprocity
•Narrative Ethics
•Capabilities Approach

27. Providence Model for Ethics
Clinical Integrity Beneficence
Autonomy
Justice &
Non-Maleficence

28. Clinical
Integrity
Beneficence
Autonomy
Justice &
Nonmaleficence
Therapeutic relationship
between patient and provider

29. https://onbeing.org/blog/krista-tippett-good-conversation-is-an-adventure/

30. https://onbeing.org/civil-conversations-project/

31. Self Care
When you do the physically and emotionally hard
work of caregiving and bearing witness to
suffering.
You must cultivate tools to
nourish your soul.