4/28/2018. The Unsafe Discharge: What s my Responsibility? Objectives: Objectives: Susan I. Belanger, PhD, MA, RN, NEA BC

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1 The Unsafe Discharge: What s my Responsibility? Susan I. Belanger, PhD, MA, RN, NEA BC System Ethicist, Covenant Health Susan_Belanger@covenanthealth.net Objectives: 1. Describe three ethical principles to consider when caring for hospitalized patients. 2. Define decision making capacity and the process to determine whether a patient has capacity. 3. Identify four approaches to ethical decision making. 4. Describe the considerations in determining the best course of action when a patient makes a poor decision. Objectives: 5. Apply ethical principles to resolve a case with the goal of respecting patient autonomy and maintaining objectivity in determining the best disposition for the patient, in accord with the principles identified in the CCMC Code of Professional Conduct. 1

2 Irene Robitaille Belanger What is Ethics? Ethics is the formal study of who we ought to be, and how we should make decisions and behave, in light of our identity Four Principles Beauchamp & Childress (2001) Respect for Autonomy Informed consent Beneficence Obligation to provide beneficial treatment Nonmaleficense Prevent or reduce the risk of harm Justice Fairness in the allocation of resources 2

3 Principle of Respect for Autonomy Persons deserve respect Persons have dignity Basis for privacy & confidentiality Grounds for truth telling Patient right to self determination Informed consent Patient choice is a right, not a duty Advance Directives (AD) Definition Healthcare proxy or living will Capable person states medical care wishes and treatment preferences Implemented in lapsed capacity Patient Self Determination Act (PSDA) Gives patients right of healthcare decisions Types of Advance Directives Durable Power of Attorney for Healthcare Living Will Five Wishes Document Physician Orders for Life Sustaining Treatment (POLST) Comfort Measures Antibiotics Artificial Nutrition & Hydration CPR 3

4 Decisional Capacity: Definitions Clinical Determination: Determining if a person can understand, make, and be responsible for the consequences of healthcare decisions Competence: Legal presumption that an adult has the mental ability to negotiate legal tasks (entering into contract, making will, standing for trial) Incompetence: Judicial determination that because a person lacks this ability, he or she should be prevented from doing certain things Components of Informed Consent An individual s autonomous authorization of a medical intervention or of participation in research Disclosure Comprehension Voluntariness Consistency Communicating a choice Beauchamp & Childress, 2001 Decisional Capacity Elements Understand and process information about diagnosis, prognosis, and treatment options Weigh benefits, burdens, and risks of care options Apply personal values to the analysis Arrive at decision that is consistent over time Communicate decision The threshold for determination of decisional capacity is an assessment of an individual s ability to make decisions about healthcare and treatment Jones & Holden (2004) 4

5 Jones & Holden s Algorithm (2004) 1. Do the history and physical examination confirm that the patient can communicate a choice? 2. Can the patient understand the essential elements of informed consent? 3. Can the patient assign personal values to the risks and benefits of intervention? 4. Can the patient manipulate the information rationally and logically? 5. Is the patient s decision making capacity stable over time? John Glaser s Beneficence Model of Ethics (1994) Societal Realm Institutional Realm Individual Realm Beneficence / Nonmaleficense Obligation to maximize possible benefits and do no harm Benefit requires a clinician s best judgment discernment Beneficence includes protecting, defending, helping, rescuing as well as preventing and removing conditions that will cause harm to the individual Advocacy Beauchamp,

6 Justice Fairness in distribution or what is deserved Injustice occurs when an entitled person is denied or an undue burden is imposed without good reason To each person: (1) an equal share, (2) according to individual need, (3) according to individual effort, (4) according to societal contribution, and (5) according to merit. Belmont report, 1979 Approaches to Ethical Decision Making Bonde & Firenze, 2013 Three frameworks for ethical decision making: Consequentialist Utilitarian & common good approaches Duty based Duty & rights based, fairness or justice approaches Virtue Aristotelian & feminist approaches Consequentialist Based on philosophy of John Stuart Mills Deals with consequences & outcomes Greatest balance of good over harm Quarantine, war Chooses the best option for all concerned Can be seen as cold and uncaring 6

7 Consequentialist cont d Deliberative process What kind of outcomes do I want? Focus What are the future effects of my action? Who will be affected? Definition of ethical conduct Choosing action to achieve the best outcome Motivation Do what will yield the most good Duty Approach Developed by philosopher Immanuel Kant Respects moral rights & implies duties and obligations Belief that humans have dignity and have the right to choose freely Autonomy is at the heart of decision making Considers duty, intention and dignity & respect Duty Approach Deliberative process Do I have any obligations in this situation? What should I never do? Focus What are my duties and obligations? Definition of ethical conduct Doing what is right and dutiful Motivation Do what s right 7

8 Virtue Approach Based on the philosophy of Aristotle Concerned with individual character & virtue Relies on the individual to act properly in any situation What do you do when no one is watching? Virtue Approach Deliberative process What kind of person am I or do I want to be? Focus What character traits/virtues are motivating people to act? Definition of ethical conduct Doing what a virtuous person would do Motivation Developing one s moral character Ethical Hotspots Balance of benefits and harms Disclosure, informed consent & shared decision making Norms of family life Patient provider relationships Professional integrity Cost effectiveness & resource allocation Cultural differences Considerations of power 8

9 Discharge Challenges Swidler, Seastrum & Shelton, 2007; Jankowski, Seastrum, Swidler & Shelton, 2009 Patient focused Delays due to rejection of the plan Patient not ready Patient doesn t want to leave Rejection of the facility that would accept Specific facility request that is not available Discharge Challenges Swidler, Seastrum & Shelton, 2007; Jankowski, Seastrum, Swidler & Shelton, 2009 Person Focused cont d Conduct issues Patient/Family undermining efforts to find a facility Lack of family action Discharge Challenges Swidler, Seastrum & Shelton, 2007; Jankowski, Seastrum, Swidler & Shelton, 2009 System Problems Payment issues Patient lacks coverage and means Delay in prior approval Service gap delays Patient is homeless delay in finding residence Multiple diagnoses few suitable facilities Intensive service requirement payment& staffing issues 9

10 Discharge Challenges Swidler, Seastrum & Shelton, 2007; Jankowski, Seastrum, Swidler & Shelton, 2009 Blended categories Lack of capacity and no decision maker Refusal by a facility to take a patient with a particular condition, i.e. hx. of violence Refusal by a facility due to difficult family members Case of Mrs. B. Case Discussion Share your thoughts with those around you What are the next steps in the care of Mrs. B? What recommendations would you make to the clinicians involved in her care? What ethical approach are you considering in determining Mrs. B. s disposition? What would you consider a good outcome in this case? 10

11 References Beauchamp, T. L. & Childress, J. F. (2001). Principles of biomedical ethics (5 th ed.). NY: Oxford University Press. Bonde, S. & Firenze, P. (2013). A framework for making ethical decisions. Retrieved 4/10/18 from andtechnology studies/framework making ethical decisions References Jankowski, J., Seastrum, T., Swidler, R. N., & Shelton, W. (2009). For lack of a better plan: A framework for ethical, legal, and clinical challenges in complex inpatient discharge planning. HEC Forum, 21(4), Jones, R. C. & Holden, T. (2004). A guide to assessing decisionmaking capacity. Cleveland Clinic Journal of Medicine, 71(12), References Swidler, R. N., Seastrum, T., & Shelton, W. (2007). Difficult hospital inpatient discharge decisions: Ethical, legal and clinical practice issues. AJOB, 7(3), The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont Report. Washington, DC: US Government Printing Office. 11