Ethics for Rehabilitation Professionals. Eric Gluck MD, FCCP, JD Claudia Ann Morehead PT April 5, 2016

Transcription

1 Ethics for Rehabilitation Professionals Eric Gluck MD, FCCP, JD Claudia Ann Morehead PT April 5, 2016

2 Course Objectives Upon completion of this course participants will be able to: Describe the four major ethical principles Describe the process of resolving ethical issues Identify three ethical issues that commonly arise in medicine

3 Whence Ethics? Ethics = Hearth minus the h Ethics and morality Overlap: what should I (we) do? Differences: Morality: good vs evil right vs wrong Ethics: What s important, what matters Deeply linked to spirituality, whether religious or not Law: series of statutes created to avoid chaos in civilized areas. Arbitrary, time dependent, location dependent.

4 Ethics in Health Care Arises out of: Nature of provider-pt. relationship: Imbalance of power Core Value: Trust: Fiduciary Relationship Placing pt s interest before self-interest Virtues and Vices Actions

5 Professonal Ethics in Health Care The Five Ethical Principles Duties Based on reason, not religious belief Derived from nature of professional-patient relationship Beneficence Autonomy Non-Maleficence Fidelity Justice

6 Principles = Guidelines Guide routine interactions Assist in addressing ethical problems Uncertainty/disagreement Give rise to Dilemmas Conflicts of interest Moral distress

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9 Autonomy Individuals have the right to know their diagnosis/prognosis and determine the best outcome for themselves, based on their beliefs and values For patients, leads to Informed Consent: avoidance of Medical Paternalism

10 Non-maleficence First, do no harm Prevent harm from happening Either doing or omitting actions Bottom line: ensure that balance of benefit and risk/harm is in the patient s favor

11 Justice Treating patients/clients fairly based on need No discrimination based on age, sex, race, religion, social factors Treat equals equally, unequals unequally When unequal tx, be clear about criteria and priorities and transparent about applications Distributive justice Fair distribution/allocation of benefits/resources

12 Fidelity Veracity: telling the truth Promise-keeping, for example Confidentiality: protecting harmful, shameful or embarrassing information about patients and colleagues, based on right to privacy Don t exploit sexually, don t cause or hasten death

13 One way to operationalize the four principles: the four boxes (Jonson, Siegler, Winslade) Medical Indications: BENEFICENCE 1.Pt s medical problem? History? Diagnosis? Prognosis? 2. Is problem acute? Chronic? Critical? Emergent? Irreversible? 3. What are goals of treatment? 4. What are probabilities of success? 5. What are plans in case of therapeutic failure? 6. In sum, how can this pt. be benefited by medical and nursing care, and how can harm be avoided? Patient Preferences: AUTONOMY 1.What has pt expressed re preferences for tx? 2.Has pt been informed of benefits & risks, understood, and given consent? 3.Is pt mentally capable & legally competent? What is the evidence of incapacity? 4.Has pt expressed prior treatment preferences, e.g., in an advance directive? 5.If hospitalized, who is the appropriate surrogate? Is the surrogate using appropriate standards? 6.Is pt unwilling or unwilling to cooperate with medical treatment? If so, why? 7.In sum, is pt s right to choose being respected to extent possible in ethics and the law? Quality of Life: NONMALEFICENCE 1.What are prospects, with or without tx, for a return to the pt s normal life? 2.Are there biases that might prejudice providers evaluation of the pt s quality of life? 3.What physical, mental, & social deficits is the pt likely to experience if the tx succeeds? 4.Is the pt s present or future condition such that to continue life might be judged as undesirable by him/her? 5.Is there a plan and rationale to forgo treatment? 6.What plans are there for comfort & palliative care? Contextual Features: JUSTICE 1.Are there family issues that might influence treatment decisions? 2.Are there provider issues that might influence treatment decisions? 3.Are there financial and economic factors? 4.Are there religious and/or cultural factors? 5.Any justification to breach pt confidentiality? 6.Are there problems of allocation of resources? 7.What are legal implications of treatment decisions? 8.Is clinical research or teaching involved? 9.Any provider or institutional conflicts of interest?

14 Professional Conduct As healthcare professionals what guides our decision making? What documents are available to guide us? Illinois Physical Therapy Practice Act Physical Therapy Rules APTA Code of Conduct APTA Guide for Professional Conduct APTA Core Values

15 Professional Conduct Illinois Department of Financial and Professional Regulation (IDFPR) is responsible for licensing and regulating over 1 million professional and firms in Illinois. Regulation includes investigating complaints against a regulated professional and taking disciplinary action.

16 Professional Conduct IDFPR Disciplinary action taken PT license placed in refused to renew status for deficient recordkeeping and improper billing of physical therapy services. PT license placed on probation which terminates on June 12, 2017, as a result of Excessive Use of Alcohol in April, 2012, which resulted in physical therapist being unable to practice until June, PT license fined $1000 as result of Unprofessional Conduct Respondent mistakenly faxed a 2009 physical examination record of her son, to a job recruiter for submission to a prospective employer of license holder. PT license placed in refuse to renew status for a minimum of two renewal cycles for deficiencies in maintaining adequate communication with a minor fourteen year old female patient throughout the course of physical therapy treatment.

17 Professional Conduct IDFPR Disciplinary action taken (unlicensed) ordered to cease and desist unlicensed practice of physical therapy due to respondent using physical therapy related abbreviations on his business cards not recognized under the Illinois Physical Therapy Act and by the respondent not having met the requirements under the Illinois Physical Therapy Act that would allow him to hold himself out as able to practice physical therapy. PTA license issued and placed on one year non-reporting probation as a result of a criminal felony conviction for Mail Fraud. SLP license placed in refuse to renew status as a result of reporting to provide speech, language, pathology services for two patients without actually providing such services to those patients. OT license issued with reprimand as a result of a 2013 criminal misdemeanor conviction related to alcohol abuse (March 2015)

18 Ethics Committees & Clinical Ethics Case Consultation Ethics Committees--mission and functions Clinical Ethics consultation: conceptual tools, consultation process

19 Clinical Ethics Program at SCH Committee Functions 1. Policy Development 2. Education Education = DNA of All clinical ethics activities Ethics for Lunch: Bi-Monthly Residents Ethics Rounds Nursing Ethics Sessions 3. Case Consultation (25 per month) 4. Practice Improvement Initiatives Palliative Care Service (since 1999) Appropriate Use of G-Tubes Medically nonbeneficial as basis for code status orders Nursing Ethics Assessment Ethics History at Admission (Residents) Process for decision-making in care of unbefriended elders/ptsethics History as part of H&P

20 Ethics History

21 Ethics in Health Care Clinical Ethics Consultation Clinical Ethics asks What should or ought we do when we are uncertain or when we disagree? What are our professional obligations to one another? Requires knowledge base and communication skill set Knowledge base includes Ethical principles: guidance for thinking Pertinent state laws and institutional policies

22 Articulating the ethics problem Vocabularies of clinical ethics decision-making 1. Principles. Are core responsibilities of health care professionals to patients/families, each expressing a central value. Respect for autonomy, beneficence, non-maleficence, fidelity, and justice are the five pillar principles. 2. Utilitarianism or Consequentialism. Do that which produces the greatest benefits and the least harm to all involved. 3. Rights. Human persons have dignity based on their ability to choose freely what they will do with their lives, and have a fundamental moral right to have these choices respected. Persons are never to be treated merely as means, but as ends in themselves. E.g.,rights to: the truth, privacy 4. Fairness or Justice. Equals should be treated equally and unequals unequally according to clear standards. No favoritism or discrimination. Society s benefits and burdens should be distributed fairly. 5. Common Good. Persons flourish in community. Society comprises individuals whose own good is linked to the good of the community. Obligation to recognize and further those goals we share in common 6. Virtue. Traits of character reflecting ideals toward which we should strive, which provide for the full development of our humanity. E.g., honesty, promise-keeping, compassion 7. Care. Tend to the process. Include everyone involved; support and nurture relationships. Seek consensus.

23 Ethics Consultation Service Who can request Ethics Committee-Resource Team assistance? 1. Physicians (attendings, consultants, residents, fellows): assistance with communications with peers/ patients and/or families experiencing discomfort because of uncertainty or disagreement regarding treatment decisions; impasses in communication. 2. Nursing and other hospital staff; and 3. Patients and families: sounding board--resource to help sort out thoughts, feelings, options.

24 Ethics Consultation Service Situations to consider asking for Ethics Consult: Examples Informed Consent Assessment of Decisional Capacity No CPR/DNAR Order: No partial codes, slow codes, etc. Intubation/re-intubation Hemodialysis: initiating, discontinuing Withholding of Life Support Withdrawal of Life Support Determination of surrogate decision-maker Advance Directive: Validity, Interpretation Artificial nutrition/hydration Aggressive tx vs supportive care Terminal Care Treatment plan Communication Problem Confidentiality Futile Treatment Disagreements Deception and Truthtelling Pain Management: Placebos, Life-shortening medications Total Brain Failure (Brain Death) Organ Procurement dilemmas Discharge Issues: AMA, pt-family refusal of transfer order

25 Ethics Consultant or Team Process: Steps A) Assessment. The Consultant or Chair of Consultation Team: 1. identifies the problem(s) in discussion with requester. 2. names the ethical issues, screening out non-ethical problems. 3. identifies the participants in the situation. 4. informs/involves the primary physician of request for ethics consultation. (B) Intervention: 1. Interviews 2. Reviews records, legal and policy parameters 3. Care conference--articulates consensus (C) Documentation: ethical issues, pertinent considerations, ethically defensible options, next steps in process (D) Follow-up (E) Record-keeping (F) Evaluation. The consultation service should maintain ongoing evaluation of its effectiveness for continuous quality improvement (CQI).

26 Source of Ethics Requests Hospital Unit Nearly one half of the ethics consultation requests came from the critical care areas of ICU and IMCU. The breakdown of patient care units requesting consultations is as follows: The next most frequent contributors to consultation requests are the medical/surgical units of the Hospital, including AP 5, 5 East, 7 East, 4 East, and 5 South.

27 Ethics Issues A wide variety of issues give rise to requests for ethics consultation. The following graph summarizes the top fourteen reasons for consultation request: Not surprisingly, requests for assistance with goals clarification and communication comprised nearly one-third of all ethics consultation requests. Issues underlying these two categories include resource use, attending/consultant communication and need for consensus around diagnosis/prognosis, and aggressive vs supportive care. Nearly all of the requests for assistance with determining code status were for patients who arrived at the Hospital with no known or documented preferences regarding CPR. Most requests for clarification as to whether to pursue aggressive or supportive care resulted in a shift to supportive or comfort care. The treatments category includes ethics consult requests in response to a variety of proposed treatments including surgery, dialysis, artificial nutrition and hydration, intubation, PEG tube insertion, and tracheostomy.

28 References Sample Ethical Decision Making Models - The Ethics Network - Ryerson University.Ryersonca Available at: Forester-Miller, PhD H, Davis, Ph.D T. A Practitioner's Guide to Ethical Decision Making. Virginia: American Counseling Association; Available at: Accessed March 29, Slosar, PhD J. Ethical Decisions in Health Care. The Catholic Health Association of the United States; Available at: Velasquez M, Moberg D, Meyer M et al. Making Choices: A Framework For Ethical Decision Making. Markula Center for Applied Ethics at Santa Clara University; Available at: Glaser, JW. Three Realms of Ethics: Individual, Institutional, Societal. Kansas City, Missouri: Rowman and Littlefield, Kirsch N. Ethical decision-making: Terminology and context. PTmagazine of Physical Therapy. 2006;(14(2): Swisher, LL, et al. The Realm-Individual-Process Situation (RIPs) Model of Ethical Decision making. HPA Resource.2005; (5(3); 1,3-8 American Physical Therapy Association Code of Ethics for The Physical Therapist Available at: American Occupational Therapy Association. (in press). Occupational Therapy Code of Ethics(2015). American Journal of Occupational Therapy, 69(Suppl.3). Available at: American Speech-Language-Hearing Association. Code of Ethics Available at: The Illinois Department of Financial and Professional Regulation. PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS (225 ILCS 90/) Illinois Physical Therapy Act. The State of Illinois General Assembly; signed The Illinois Department of Financial and Professional Regulation. PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS (225 ILCS 75/) Illinois Occupational Therapy Act. The State of Illinois General Assembly; signed The Illinois Department of Financial and Professional Regulation. PROFESSIONS, OCCUPATIONS, AND BUSINESS OPERATIONS (225 ILCS 110/) Illinois Speech-Language and Audiology Practice Act. The State of Illinois General Assembly; signed 2015.