Monday, May 28, 2007

Ethical Principles

Advocacy: The asymmetrical power relationship of the caregiver and the patient requires that the caregiver take great care to protect the patient, and place the patient’s needs first.

Autonomy: The patient is free to express his/her own decisions in healthcare matters. In the event that a patient is unable or incompetent to express their wishes, two other standards can be applied, with substituted judgment taking precedence over best interests:

Substituted Judgement: if the patient is unable or incompetent to express their autonomous wishes, and a surrogate exists who knows the patient’s belief system well, they can express what they feel the patient would have wanted for himself

Best Interests: if the patient is unable to express their autonomous wishes, a surrogate can weigh the risks and benefits of treatment as they affect the patient’s quality of life, and try to make a treatment choice that would lead to the best quality of life based as much as possible on the values of the patient

Beneficence: Regardless of the patient’s ability to pay for services, the medical team is committed to providing whatever care the patient’s condition demands and which the team is competent to provide.

Compassion: The patient should be offered a quality of care that acknowledges the pain and suffering of the patient and offers forms of human connection which attempt to relieve suffering.

Justice: The healthcare team is responsible for balancing the appropriate resources and treatments with the knowledge of possible burdens they may place on the patient, the family, the hospital resources and society. The burdens should not outweigh the benefits

NonMalificence: When a medical treatment does not promote the patient’s well-being, either by relieving suffering or addressing and reversing a pathologic process, there is no longer an ethical obligation to provide it. This includes treatments that are deemed futile and those that may cause additional suffering. Communication with the family is most crucial in these instances so that a feeling of abandonment is not created

Principle of Double Effect: when a given act has two consequences, one good and intended, and the other bad and unintended although foreseen, it is ethically permissible to do this act if the four conditions are met:

The intended act itself is not immoral (murder, active euthanasia)
The act was undertaken with the intent only of achieving the good effect, even though the possibility of the bad effect could be foreseen
The act does not achieve the good effect by means of the bad effect
The act itself is undertaken only for a proportionately serious reason

Futility: a futile treatment either

cannot be performed because of the patient’s biologic condition
cannot produce the intended physiologic effect, or
cannot reasonably be expected to produce the benefit which is sought

A treatment who’s burdens, harms or costs outweigh the potential benefit is NOT futile

Competence: a person’s capacity to make rational decisions regarding their own well-being

Draft 5/28/07

Questions? Email barrymannmd@pacbell.net, fax 510-886-1613

Ethics Consult Procedure

If you are on-call for an ethics consult, you will work with the social worker who called you and one other committee member to do the consult. The purpose of the consult is to identify the conflict between the involved parties and help develop an understanding of the ethical issues involved so the impasse can be resolved.

The process of identifying the two parties’ positions and explaining them to the other will sometimes be all that is necessary to resolve the conflict. Other times a team conference is needed to discuss the principles of ethical care, including the possible treatment choices, possible outcomes, and goals of treatment.

It is not the purpose of an ethics consultant to DECIDE what will be done, or to TELL someone what they should do. We are there to help improve communication and identify the ethical principles that are causing the conflict. The parties involved in the conflict then have to determine which ethical principle will guide them. If a compromise cannot be found, and the treating physician cannot agree with the ethical position of the patient/family, then the physician may need to turn over care of the patient to another physician who feels comfortable with the ethical choice made by the patient/family.

It is only when one of the parties is following an ethically inappropriate path that the consultant would make an attempt to guide a decision. (for example, in the case of a woman in an irreversible coma whose Durable Power of Attorney document says no artificial life support, but the husband is pushing docs to continue aggressive interventions, the ethics consultant may need to re-emphasize the principle of autonomy to the husband, as well as trying to find out any other underlying reasons that the husband would want to go against his wife’s DPA).

At any time during the process of doing a consultation, other committee members can be called if consultants don’t feel comfortable with the way the consult is going. Specifically, the ethics committee chairperson would be called first (currently Barry Mann, cell 510-684-7270), and the chair can involve other members as they see fit.

Step 1: Assemble the Consult Team

The social worker who receives the request for the ethics consult will call the physician and layperson who are due up for the next consult. If possible, all three will meet in person to review the chart, discuss the case, and plan how to divide up the information gathering.

If a group meeting is not possible, the social worker will discuss the details of the case with the two consultants. Then, a phone contact between the layperson and physician should take place to plan how to divide up the information gathering.

Step 2: Gathering Information

The easiest way to gather information is to use the Ethics Consult Worksheet, which was handed out at the 1/25/2006 committee meeting, and is available from the social services department, and could be emailed or faxed when needed. The social worker may already have gathered some of the information, and the other consultant team members can decided how to divide up the rest.

Step 3: Consolidating the Information

Later that day the consultants should again meet, again in person if possible, otherwise by phone, to compare notes and find out if any information is missing. At this point, the ethical principles guiding the conflicted parties should be identified (the Ethics Consult Worksheet has a list of definitions of ethical principles attached).

Step 4: Planning the Correct Intervention

If there is only a communication problem between parties, suggesting a family conference may be all that is necessary. If the communication problem is explained to the involved parties prior to the family conference, the ethics consultants may not need to be present for the conference. If a family conference has already been held prior to the ethics consult, and the communication problem persists, a second family conference with an ethics committee member present may be helpful.

If the two parties have ethically appropriate but conflicting beliefs, then a family conference should be arranged to allow further discussion between the parties, with the goal being to find a compromise position that would not contradict the ethical principles of either party. The ethics consultants should be present for this conference if possible.

If one party does not seem to be guided by an appropriate ethical principle, then having the member of the consult team who knows that party the best go back and talk to them may help. (in the example given earlier, the consultant who had gathered information from the husband may go back now and discuss the ethical principle of autonomy further, explaining how the physicians want to honor the patient’s written request, not the husband’s current request, unless there is a clear reason to override it).

Step 5: Documenting the Consult

The physician member of the consult team is responsible for putting a consult note in the History and Physical section of the patient’s chart. Preferably this would be a dictated note using the Ethics Worksheet as a guide, and in the conclusion detailing the ethical principles involved and the outcome of the intervention.

Step 6: Presenting the Consult to the Committee

At the Ethics Committee meeting that month, one of the ethics consultants will present the consult to the committee, so that further feedback can be obtained from other committee members. The presentation should be 5-10 minutes maximum in order to allow time for discussion. The focus of the presentation should be on the ethical principles that are in conflict in the case, not the medical details. The social worker will invite the primary care doctor involved in the case to be present at the meeting if they can.

Bioethics Consultation Worksheet

Date: Patient:

Ethics Consultants: Consult Requested by:

Ethical Question:

Brief Medical History:

What are the possible treatment options and prognosis/outcomes

Patient/Family Ethical Position (and list people involved and relation to patient):

Physician/Staff Ethical Position:

Does the patient/family understand/believe the prognosis and the doctor’s position?

Does the doctor understand the patient/family’s position?

Conclusions:

Ethical Principles Definitions: