Introduction to Bioethics Martin L. Smith, STD Director of Clinical Ethics Department of Bioethics
Department of Bioethics <ul><li>6 Staff Consultants. Consult pager (22512). </li></ul><ul><li>Separate from the Ethics Com...
Content and Topics <ul><li>Informed Consent and Communication. </li></ul><ul><li>Confidentiality. </li></ul><ul><li>Advanc...
Informed Consent <ul><li>Informed consent entails right to refuse. </li></ul><ul><li>Generally, informed consent should be...
Communication <ul><li>Clear communication is part of good care. </li></ul><ul><li>View self as an “educator” of patient an...
Communication Bloopers <ul><li>Do you want us to do everything? </li></ul><ul><li>Should we stop everything? </li></ul><ul...
Stereotyping of Patients/Families <ul><li>Generalizations are rarely useful.  </li></ul><ul><li>Individuals vary greatly. ...
Confidentiality <ul><li>Patient’s reputation could be at stake. </li></ul><ul><li>Establish to whom you are giving informa...
Advance Directives  <ul><li>Oral or written expressions by an adult with decision making capacity conveying wishes related...
Living Will <ul><li>Terminal illness or PVS (documented by 2 physicians) AND patient lacks decision making capacity. </li>...
Durable Power of Attorney for Health Care <ul><li>Activated when decision making incapacity occurs. </li></ul><ul><li>Name...
Procedures For Handling ADs <ul><li>Inquire about existence of AD. </li></ul><ul><li>Social Work/EPIC maintains copies.  <...
Ohio Order of Decision Makers <ul><li>Legal guardian </li></ul><ul><li>Medical Power of Attorney </li></ul><ul><li>Spouse ...
Medical Futility - AMA Guidelines <ul><li>Patient has right to refuse treatment. </li></ul><ul><li>Physicians can refuse t...
Medical Futility - CC <ul><li>Policy Definition:  </li></ul><ul><ul><li>Does not achieve its physiological objective </li>...
CC Procedures for Medical Futility <ul><li>Shared decision making and consensus favored for conflict resolution. </li></ul...
Patient/Family Care Conferences
Case Illustration: Nell <ul><li>Age 78, ovarian cancer, significant metastases to both lungs.  </li></ul><ul><li>Front-lin...
Case Illustration: Nell <ul><li>Texas Living Will (not typical): In the event of terminal condition, “I request that I be ...
Ohio Portable DNR <ul><li>State-wide logo for Identification and Orders </li></ul><ul><li>Allows 2 types: DNRCC & DNRCC-Ar...
Ohio DNR Comfort Care <ul><li>You will: </li></ul><ul><ul><li>Suction the airway </li></ul></ul><ul><ul><li>Administer oxy...
DNR Comfort Care Protocol <ul><li>You will  not : </li></ul><ul><ul><li>Administer chest compressions </li></ul></ul><ul><...
Activation of Ohio DNR Protocol <ul><li>DNR Comfort Care:  </li></ul><ul><ul><li>At time order is given </li></ul></ul><ul...
DNR - Specified <ul><li>Not portable outside of Cleveland Clinic </li></ul><ul><li>Appropriate for patients that might not...
Consent for DNR Orders <ul><li>Ohio DNR law: presumes informed consent of patient or surrogate </li></ul><ul><li>Cleveland...
DNR in the OR <ul><li>Prior to any invasive procedure any existing DNR order should be reviewed with patient or patient’s ...
Research <ul><li>Research and patient care are not the same. </li></ul><ul><li>Different level and documentation of consen...
Contact/Acknowledgment <ul><li>Contact Department of Bioethics with comments or questions. </li></ul><ul><li>Consult Pager...
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Sicu Intro Bioethics

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Sicu Intro Bioethics

  1. 1. Introduction to Bioethics Martin L. Smith, STD Director of Clinical Ethics Department of Bioethics
  2. 2. Department of Bioethics <ul><li>6 Staff Consultants. Consult pager (22512). </li></ul><ul><li>Separate from the Ethics Committee. </li></ul><ul><li>Can help in situations where there is not a clear single best option. </li></ul><ul><ul><li>When values conflict or there is ethical or moral uncertainty. </li></ul></ul><ul><li>Open access: Available to healthcare teams, families, and patients. </li></ul><ul><li>Advisory. </li></ul>
  3. 3. Content and Topics <ul><li>Informed Consent and Communication. </li></ul><ul><li>Confidentiality. </li></ul><ul><li>Advance Directives: </li></ul><ul><ul><li>Living Will </li></ul></ul><ul><ul><li>Durable Power of Attorney for Health care </li></ul></ul><ul><li>Medical Futility. </li></ul><ul><li>DNR Orders. </li></ul><ul><li>Research. </li></ul>
  4. 4. Informed Consent <ul><li>Informed consent entails right to refuse. </li></ul><ul><li>Generally, informed consent should be given by patient or surrogate. </li></ul><ul><ul><li>But there are exceptions…. </li></ul></ul><ul><ul><li>And in the ICU, “blanket consent” covers many situations. </li></ul></ul><ul><li>Documentation: “RBAPC.” </li></ul>
  5. 5. Communication <ul><li>Clear communication is part of good care. </li></ul><ul><li>View self as an “educator” of patient and family (but not just raw data). </li></ul><ul><li>Provide adequate time for family to talk. </li></ul><ul><li>Listen for the underlying values and goals. </li></ul><ul><li>Get comfortable with occasional silences. </li></ul><ul><li>What is impact of family interests? </li></ul>
  6. 6. Communication Bloopers <ul><li>Do you want us to do everything? </li></ul><ul><li>Should we stop everything? </li></ul><ul><li>There is nothing more we can do. </li></ul><ul><li>He failed all the treatments we’ve tried. </li></ul><ul><li>What do you want us to do if s/he stops breathing? </li></ul><ul><li>Others??? </li></ul>
  7. 7. Stereotyping of Patients/Families <ul><li>Generalizations are rarely useful. </li></ul><ul><li>Individuals vary greatly. </li></ul><ul><li>Find a balance. </li></ul><ul><li>Avoid nick-names/jokes </li></ul><ul><ul><li>Can impact patient care </li></ul></ul><ul><ul><ul><li>May impact other MDs/RNs </li></ul></ul></ul><ul><ul><ul><li>Patient/family overhears </li></ul></ul></ul>
  8. 8. Confidentiality <ul><li>Patient’s reputation could be at stake. </li></ul><ul><li>Establish to whom you are giving information. </li></ul><ul><li>Rarely should patient information be withheld from the patient. </li></ul>
  9. 9. Advance Directives <ul><li>Oral or written expressions by an adult with decision making capacity conveying wishes related to medical care in anticipation of being unable to communicate wishes. </li></ul><ul><li>Patient, not family, can revoke at any time (document in medical record) </li></ul><ul><ul><li>Verbal or written revocation </li></ul></ul><ul><ul><li>Should have a witness </li></ul></ul><ul><ul><li>Explicit documentation </li></ul></ul>
  10. 10. Living Will <ul><li>Terminal illness or PVS (documented by 2 physicians) AND patient lacks decision making capacity. </li></ul><ul><li>Allows specific instructions: to receive or withhold/withdraw treatments. </li></ul><ul><li>Under Ohio law, requires compliance. </li></ul><ul><li>Involvement of surrogate is not needed. </li></ul><ul><li>PVS and medically supplied nutrition and hydration: Initials needed. </li></ul>
  11. 11. Durable Power of Attorney for Health Care <ul><li>Activated when decision making incapacity occurs. </li></ul><ul><li>Names agent empowered to make medical decisions. </li></ul><ul><li>Applies to any medical decision with limited exceptions. </li></ul><ul><li>Allows specific instructions. </li></ul>
  12. 12. Procedures For Handling ADs <ul><li>Inquire about existence of AD. </li></ul><ul><li>Social Work/EPIC maintains copies. </li></ul><ul><li>Place newly acquired copies of AD on chart and inform Social Work. </li></ul><ul><li>Social Work (and Pastoral Care) can assist patient in completing an AD. </li></ul>
  13. 13. Ohio Order of Decision Makers <ul><li>Legal guardian </li></ul><ul><li>Medical Power of Attorney </li></ul><ul><li>Spouse </li></ul><ul><li>Majority of adult children </li></ul><ul><li>Parents </li></ul><ul><li>Majority of adult siblings </li></ul><ul><li>Nearest adult related by blood or adoption who is reasonably available </li></ul>
  14. 14. Medical Futility - AMA Guidelines <ul><li>Patient has right to refuse treatment. </li></ul><ul><li>Physicians can refuse to provide treatment judged to be medically futile. </li></ul><ul><li>Advises physicians against non-medical value judgments that are inconsistent with patient autonomy. </li></ul><ul><li>(JAMA 1991; 265:1868-1871) </li></ul>
  15. 15. Medical Futility - CC <ul><li>Policy Definition: </li></ul><ul><ul><li>Does not achieve its physiological objective </li></ul></ul><ul><ul><li>Offers no benefit to the patient </li></ul></ul><ul><ul><li>Violates reasonable medical standards </li></ul></ul><ul><li>No right to insist on futile treatment. </li></ul><ul><li>Recognition of occasional need to continue such treatment for limited time. </li></ul>
  16. 16. CC Procedures for Medical Futility <ul><li>Shared decision making and consensus favored for conflict resolution. </li></ul><ul><li>Support physician judgment within legal and ethical constraints, but need to address transfer options. </li></ul><ul><li>Before unilateral withdrawal, Ethics Committee consult should be called. </li></ul>
  17. 17. Patient/Family Care Conferences
  18. 18. Case Illustration: Nell <ul><li>Age 78, ovarian cancer, significant metastases to both lungs. </li></ul><ul><li>Front-line combination chemotherapy could not be administered due to low platelet counts. A lower dose of a single agent was given. </li></ul><ul><li>Hospitalized due to acute renal failure, hypotension, and respiratory distress. Dialysis. </li></ul><ul><li>Admitted to ICU for respiratory failure. Ventilator. </li></ul><ul><li>Massive GI bleed (blood transfusions) and growing signs of hepatic failure. </li></ul><ul><li>Patient arousable and responds to commands. </li></ul>
  19. 19. Case Illustration: Nell <ul><li>Texas Living Will (not typical): In the event of terminal condition, “I request that I be kept alive … using available life-sustaining treatment.” </li></ul><ul><li>DNR order written after bedside discussion with patient and 2 daughters. </li></ul><ul><li>DNR rescinded a few hours later when patient communicated to daughters 3 times, “I want to live,” in response to family question about CPR. </li></ul><ul><li>Second DNR order written two days later, after ICU physician met with daughters, but then rescinded that evening at the family’s request. </li></ul><ul><li>The family believes that Nell would want CPR. </li></ul>
  20. 20. Ohio Portable DNR <ul><li>State-wide logo for Identification and Orders </li></ul><ul><li>Allows 2 types: DNRCC & DNRCC-Arrest </li></ul><ul><li>Provides immunity for compliance with law </li></ul><ul><li>For patients arriving with portable DNR, rewrite on Cleveland Clinic DNR order form </li></ul><ul><li>At Cleveland Clinic a DNR is an Attending’s order </li></ul>
  21. 21. Ohio DNR Comfort Care <ul><li>You will: </li></ul><ul><ul><li>Suction the airway </li></ul></ul><ul><ul><li>Administer oxygen </li></ul></ul><ul><ul><li>Position for comfort </li></ul></ul><ul><ul><li>Splint or immobilize </li></ul></ul><ul><ul><li>Control bleeding </li></ul></ul><ul><ul><li>Provide pain medication </li></ul></ul><ul><ul><li>Contact other appropriate health care providers such as hospice, home health, attending physician/CNP/CNS </li></ul></ul><ul><ul><li>Provide emotional support </li></ul></ul>
  22. 22. DNR Comfort Care Protocol <ul><li>You will not : </li></ul><ul><ul><li>Administer chest compressions </li></ul></ul><ul><ul><li>Insert an artificial airway </li></ul></ul><ul><ul><li>Administer resuscitative drugs </li></ul></ul><ul><ul><li>Defibrillate or cardiovert </li></ul></ul><ul><ul><li>Provide respiratory assistance (other than suctioning the airway and administering oxygen) </li></ul></ul><ul><ul><li>Initiate resuscitative IV, or Initiate cardiac monitoring </li></ul></ul>
  23. 23. Activation of Ohio DNR Protocol <ul><li>DNR Comfort Care: </li></ul><ul><ul><li>At time order is given </li></ul></ul><ul><li>DNR Comfort Care—Arrest: </li></ul><ul><ul><li>At time of cardiac or respiratory arrest </li></ul></ul><ul><ul><ul><li>Cardiac arrest=absence palpable pulse. </li></ul></ul></ul><ul><ul><ul><li>Respiratory arrest=absence of spontaneous respirations/presence of agonal breathing. </li></ul></ul></ul>
  24. 24. DNR - Specified <ul><li>Not portable outside of Cleveland Clinic </li></ul><ul><li>Appropriate for patients that might not want CPR, but would like other medical interventions </li></ul><ul><li>Raises questions about partial/limited CPR attempts. </li></ul><ul><li>Should make “medical sense” </li></ul>
  25. 25. Consent for DNR Orders <ul><li>Ohio DNR law: presumes informed consent of patient or surrogate </li></ul><ul><li>Cleveland Clinic Policy: No obligation to initiate CPR if resuscitation would be futile, i.e.,: </li></ul><ul><ul><li>If resuscitation would not achieve its physiological objective, would offer no benefit to the patient, and would violate reasonable medical standards </li></ul></ul>
  26. 26. DNR in the OR <ul><li>Prior to any invasive procedure any existing DNR order should be reviewed with patient or patient’s surrogate. </li></ul><ul><li>Changes should be documented in the patient’s medical record with a notation indicating when and if the original DNR order should be reinstated. </li></ul><ul><li>When does a surgical procedure end? </li></ul>
  27. 27. Research <ul><li>Research and patient care are not the same. </li></ul><ul><li>Different level and documentation of consent needed for research when it deviates from standard of care. </li></ul><ul><li>ICU populations are often extremely vulnerable to coercion. </li></ul><ul><li>Innovation? </li></ul>
  28. 28. Contact/Acknowledgment <ul><li>Contact Department of Bioethics with comments or questions. </li></ul><ul><li>Consult Pager: 22512 (24 hr/ 7day) </li></ul><ul><li>Department Telephone: x4-8720 </li></ul>

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