Arnold Mackles, MD, MBA, LHRM

Transcription

1 By Arnold Mackles, MD, MBA, LHRM

2 The Sullivan Group - Author of on line CME courses - Volunteer member of Advisory Board Innovative Healthcare Compliance Group, Inc. - CME speaker - Consultant

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6 I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University.

7 I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Above all, I must not play at God. I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

8 Do unto others as you would have others do unto you

9 However, these messages of provider fairness, compassion, quality, honesty and The Golden Rule are not always received by our patients

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11 Nightshift Nightmare - Readers Digest, 2007.

12 White Coat Confessions - December, Secrets Surgeons Won t Tell You - October, 2012

13 What Your Doctor s Really Thinking But Won t Say to Your Face - October, 2014

14 50 Secrets Hospitals Wont Tell You! - Reader s digest February, 2016

15 1) Autonomy 2) Beneficence 3) Nonmaleficence 4) Justice

16 The patient s independence, liberty. Capable adults have right to make decisions (without manipulation or coercion). Capable adult patients can accept or decline treatment.

17 Providers must act in patient s best interest. Promote patient healing, good health, and well being.

18 First, do no harm! Do not harm patients due to: Carelessness Distain, malice, vengeance Treatments intended to cure (benefits must outweigh risks)

19 Fair distribution of health care resources. Who should receive scarce medical resources? Goal of Justice Principle: - Fair healthcare system

20 The World Medical Association Declaration of Geneva (1948) Physician's Oath: I will not use my medical knowledge contrary to the laws of humanity Issued in response to the medical atrocities committed during WWII by physicians in Nazi Germany.

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23 The four Principles of Medical Ethics: Autonomy Beneficence Nonmaleficence Justice Can be applied to any practice situation. In complicated cases, it is often difficult to determine which of the principles should be given more weight in decision making.

24 Ethical decision making must always be based on: Principles of medical ethics. Standards of medical practice. Accepted medical guidelines, protocols, and The law.

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28 In 1975, Karen Quinlan sustained a respiratory arrest, received resuscitation, and was left in a comatose, vegetative state. Her parents requested removal of mechanical ventilation, in order to let her to die. Physicians refused to remove the ventilator. Fine, R. From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury. Baylor University Medical Center Proceedings October; 18(4): Accessed April 18, 2013

29 The New Jersey Supreme Court ruled in 1976 that the ventilator could be removed. The court stated that families are adequate surrogates for incapacitated patients who did not and could not make their wishes known. Fine, R. From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury. Baylor University Medical Center Proceedings October; 18(4): Accessed April 18, 2013

30 The ventilator was withdrawn, however Karen lived for 10 years, receiving nutrition via a feeding tube. Her Parents did not request removal of the feeding tube. Fine, R. From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury. Baylor University Medical Center Proceedings October; 18(4): Accessed April 18, 2013

31 In 1990, 26 y/o female sustained cardiac arrest with anoxic brain injury, leaving her in a severely damaged neurological condition, requiring tube feedings. Her husband requested that everything be done to sustain Terri. In 1998, eight years later, her husband (who had been appointed legal guardian) requested discontinuing the feeding tube, stating that Terri would not want to continue living in her present vegetative condition.

32 Terri s parents disagreed with husband. Case received national attention. Congressional hearings followed. Florida Legislature passed Terri s Law. Terri s Law declared unconstitutional.

33 Feeding tube removed by judge s order on March 18, Terri died 13 days later.

34 Underscores the need for Advance Directives. Advance Directive: Written instructions recognized under law relating to the provision of health care when an individual is incapacitated. Carroll, R. Risk Management Handbook for Health Care Organizations, Student Edition. American Society for Healthcare Risk Management San Francisco. P.P. 567

35 Types of Advanced Directives Living Will Medical or Health Care Power of Attorney (POA) Do Not Resuscitate (DNR) Order Mayo clinic staff Living wills and advance directives for medical decisions. Mayo Clinic. Accessed April 20, 2013

36 Living Will: Written legal document. Lists types of treatments/life sustaining measures patient does or does not want. - ex. mechanical ventilation, tube feedings, etc. Also called Health Care Declarations or Health Care Directives, in some states. Mayo clinic staff Living wills and advance directives for medical decisions. Mayo Clinic. Accessed April 20, 2013

37 Medical or Health Care Power of Attorney (POA): Legal document designating an individual as a health care agent or proxy for a patient. Agent or proxy can make medical decisions for patient in event that patient is unable to do so. Different from financial POA. Mayo clinic staff Living wills and advance directives for medical decisions. Mayo Clinic. Accessed April 20, 2013

38 California was first state to legally provide for living wills in In 1976, Texas became the second state to pass legislation allowing for Living Wills. Fine, R. From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury. Baylor University Medical Center Proceedings October; 18(4): Accessed April 18, 2013

39 1) Medical Indications 2) Patient Preferences 3) Quality of Life 4) Contextual Features Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

40 Principles: Beneficence, Nonmaleficience What is the patient s problem? (acute/chronic/critical/reversible/terminal)? What are the goals of treatment? In what circumstances is treatment not indicated? What are the probabilities of success? How can patient benefit from care and not be harmed? Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

41 Principles: Autonomy Did you inform patient of risks and benefits? Was consent obtained? Does the patient understand the information? Is the patient mentally capable and competent? - If so, what are the patient s treatment preferences? If not capable or incapacitated, what were prior wishes? Who is the medical proxy or surrogate? Is the patient unable / unwilling to receive treatment? Why? Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

42 Principles: Beneficence, Nonmaleficience, Autonomy What are prospects for return to normal life w/wo treatment? What deficits may persist with treatment? How (on what grounds) can you judge what is quality of life for the patient? Do you have biases in evaluating patient s quality of life? Do quality of life evaluations suggest changing treatment plans? What is rationale and plan if you forgo life sustaining measures? Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

43 Principles: Justice, Fairness Are there business, professional or financial interests that could create a conflict of interests with treatment plan? Do other parties (family, friends, etc.) have an interest in clinical decisions? Is the allocation of scarce resources effecting decisions? Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

44 Principles: Justice, Fairness Are there religious or legal issues that might influence decisions? Are there medical research or educational factors that could effect decisions? Jonsen, A., Siegler, M.,Winslade, W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine McGraw Hill. New York.

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46 Mrs. J, a 59 y/o female with a documented history of gastric carcinoma is a patient in your hospital. 1 ½ years prior to this admission, she was diagnosed via biopsy obtained during a esophagogastroduodenoscopy. Following this diagnosis, despite numerous and documented discussions with physicians she refused all suggested interventions and treatment options. She missed follow up appointments and did not return phone calls.

47 Two months prior to this admission, Mrs. J was seen by a new gastroenterologist and she requested a second biopsy, which again revealed the diagnosis of gastric carcinoma. The patient developed gastric bleeding several days later, had emergency surgery at which time a partial gastric resection was performed and a stoma was created for decompression. The patient suffered a stroke at the time of surgery and was sent to recover in a rehabilitation facility. The surgeon documented lengthy discussions with family members concerning the patient s condition.

48 Three weeks later Mrs. J was readmitted to the hospital with bowel obstruction. A CT scan of abdomen and pelvis showed widespread liver metastases. The GI obstruction was felt to be secondary to the metastatic lesions. The hospitalist had many discussions with the patient and family stating that all doctors involved felt that no further intervention would be helpful (other than placing a PEG tube and comfort measures). The patient demanded further treatment and requested a meeting with all physicians involved.

49 The hospitalist then requested assistance from the Ethics Committee

50 1) Refuse to offer further treatment due to futility. 3) Offer one course of chemotherapy. 2) Offer to transfer patient to a tertiary center if accepted. 5) None of the above. 4) Suggest sending the patient to hospice.

51 The Ethics Committee recommendations: Await the outcome of the family meeting with all providers. Psychiatric consultation to determine patient s capacity for decision making due to earlier denial of condition.

52 Prior to family meeting, the Oncologist met privately with patient and offered one course of chemotherapy, warning that treatment could precipitate demise. Patient did well for one week, then decompensated with hypotension and septic shock.

53 After multiple discussions, 3 days later the family agreed to remove patient from intensive care and institute comfort measures only. The patient expired the following day.

54 Autonomy A competent patient or proxy has the right to accept or deny treatment. Providers have the right not to perform procedures or treatment felt to be to more dangerous than beneficial. Providers cannot force medical treatment against a competent patient s will.

55 Beneficence Physicians initially felt that no benefit would be obtained by further treatment. The oncologist did change position but warned of dangers.

56 Non-maleficence Physicians initially all agreed that risks of treatment outweighed benefits.

57 Justice Access to scarce resources did not appear to be an issue in this case.

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59 Provider Responsibilities: Fiduciary Duty - An obligation to act in the best interest of the patient. - A legal relationship based on trust and confidentiality. Accessed May 5, 2013

60 Provider Responsibilities: Provide the best care possible.

61 Provider Responsibilities: Confidentiality and Privacy HIPPA regulations. EMR, Internet issues. Privacy concerns in healthcare settings (discussions in hallways, elevators).

62 Provider Responsibilities: Avoid conflicts of interest Self referrals. Bias due to financial ties and incentives.

63 Provider Responsibilities: Communicate in a clear and ethical manner so that individual patients can understand.

64 Start with a warm introduction Greet patient by name Make eye contact Review the chart before entering room - First impressions count - Patients do not want to see the top of your head as you read the chart!

65 Remember, patients may be anxious Take a seat after entering room Face the patient Listen to patient concerns; acknowledge Avoid interrupting patient if possible

66 Focus on patient Do not talk too much about yourself Avoid asking Do you understand? Confirm understanding via teach-back Provide patients with written instructions

67 Ask Me 3 1) What is my main problem? 2) What do I need to do? 3) Why is it important for me to do this? Partnership for Clear Health Communication Accessed August 13, 2007

68 Provider Responsibilities: Full disclosure: Patient s condition. All accepted treatments (meds/ surgeries/ therapy, etc.). Risks and benefits of treatment. What to expect without treatment.

69 Provider Responsibilities: Full disclosure (continued): Informed consent. Research protocols. Medical errors.

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71 Cost of medical care? Healthcare reform? Allocation of scarce resources? Rationing of care? Shortage of trained providers?

72 Privacy, confidentiality issues with: - Electronic medical records? - Use of internet, texting, social media for treatment, care, consultations?

73 Cloning, genetic engineering? Clinical research oversight?

74 Autonomy Justice Beneficence Nonmaleficence

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