SECTION II CRITICAL THINKING FOR RESPIRATORY CARE PRACTITIONERS

SECTION II CRITICAL THINKING FOR RESPIRATORY CARE PRACTITIONERS Thinking is the hardest work there is, which is probably the reason why so few engage in it. Henry Ford 14 Critical thinking refers to a higher order thought process that questions assumptions and seeks to find truth. Objectives of critical thinking in truth seeking include the ability to ask pertinent questions, analyze multiple forms of evidence and evaluate options before arriving at a conclusion. Much has been written about critical thinking and there are many adjectives that describe the characteristics of a critical thinker. What adjectives do you think describes a critical thinker? Here are a few for thought: being open minded independent in thought honest curious organized and systematic logical data gatherer humble insightful proactive Components of critical thinking include specific knowledge, application of processes and procedures, as well as an organized approach to standards of care, policies and procedures, and protocols. In order to come to a conclusion and make a decision we need to be ready to collect all the needed information to be informed and analyze it carefully before coming to a conclusion. We need to think like this team. After gathering all pertinent data we need to take time to analyze the information and make sure we keep an open mind to see if there is any bias, or false data, and keep asking ourselves if we are letting any of our own emotions dictate our conclusion, and have we explored all the possibilities, before reaching any conclusion. But why must I think critically? The ability to think critically is essential if RCPs are to be able to resolve ethical dilemmas effectively. Critical thinking is a valuable skill to use in every aspect of our lives. It can help us to be more fair-minded, make better decisions, analyze journal articles, and reason more ethically. We will discuss how to critically think about difficult situations, explore principles of bioethics used today and see how they are used to support the thinking behind clinical practice and how ethical dilemmas are resolved. 14 Krieger, Richard; Civilization s Quotation: Life s Ideal, Algora, 2002 17

Because RCPs gather information and data from which they are expected to make decisions that can impact patient care, when we do not critically think, it can have serious consequences. The scenarios based on real life cases from the RCB, will be presented in the Law section and will demonstrate what happens when people fail to think critically, act ethically and morally, and violate the law. Another area that affects RCPs today is the subject of moral distress when applying ethical decisions. It can and does impact an RCP. When confronted with a conflict of ethics or morals, RCPs need to understand they do have recourse. In this section we will explore what recourse RCPs have when confronted with ethical and moral dilemmas. Have you ever had a time where your ethics conflicted with therapy you were ordered to complete? When this happened what did you do to advocate for the patient? Our AARC code of conduct and Respiratory Care Act address RCP s obligation as patient advocates and caregivers. As such, we have a responsibility to ensure patients receive the right treatment, drug, therapy, route, and frequency or time. Consequently we must know what actions to take when advocating for their proper care. RCPs are not to just keep doing what doesn t work for the patient or brings harm to the patient, because it is ethically wrong and RCPs can be held accountable. So what did you do when you were confronted with such a situation? Did you consult with, an RCP colleague, the bedside RN, the attending MD, the medical director, your immediate supervisor, or your manager? If none of these resources were helpful, did you utilize the Bio-ethics Committee? If contacting the chain of command does not yield productive results, RCPs should know how to activate a bio-ethics consult because no one should have to feel powerless to help a patient. All JACHO accredited facilities have a Bio-ethics Committee that will investigate and help bring conflict resolution. These groups may serve to advise on hospital polices and/or provide ethics consults. The consults are used to resolve conflicts that may arise between patients and physicians, and or family, and or hospital staff. In California, ethics team members are usually multidisciplinary and are educated in Bioethics, California Probate Codes, hospital policies and procedures, and conflict resolution. These consults can be called by anyone (a family member, the patient, physician, nurse, respiratory therapist, or housekeeper). Each committee is composed of a multidiscipline group, which is educated in the art of conflict resolution and the principles of ethics. The committee is guided by the institute s policy and procedure and it has monthly meetings, and continuing education. Any people, be they a RN, MD, RCP, housekeeper, family member, 18

or the patient themselves can ask for a Bio-ethics consult. Each facility should have contact information posted so it is easy to ask for a consult. While each facility will have their own format for gathering information and data one of the tools used by facilities is the Jonsen Grid. This tool will help to understand how a committee will collect information to come to conflict resolution. There is no one accepted method by which an ethics consult is achieved. Albert R. Jonsen Ph.D 15 developed a four topic question set regarding medical indications (medical history, diagnosis, prognosis and treatment), patient preferences for treatment and right to choose, quality of life (prospects with or without treatment), and contextual features (family issues, religion, etc.). The grid helps to organize facts and values into an orderly pattern for the purpose of discussion and resolution of ethical disagreements. The end purpose is to maintain the dignity of the patient and if possible to honor their wishes, when possible. These questions are the core of Clinical Ethics, Jonsen's book that is commonly used worldwide. Information is gathered for each section in a systematic, logical manner, and each section considered equally important in determining the final outcome of the consult. 15 Jonsen, Albert, Clinical Ethics, McGraw- Hill, 2006, 6 th edition 19

JONSEN GRID 16 Medical Indications The Principles of Beneficence and Non- maleficence Ø What is the patient s medical problem? Ø History, diagnosis and prognosis? Ø Is the problem acute chronic, critical, emergent reversible? Ø What are the goals of treatment? Ø What are the probabilities of success? Ø What are the plans in case of therapeutic failure? Ø In summary, how can this patient benefit from treatment and how can harm be avoided? Quality of Life The Principles of Beneficences and Non- Maleficence And Respect for Autonomy Ø What are the prospects, with or without aggressive treatment, for return to a functional or normal life? Ø What physical, mental or social deficits is the patient likely to experience if treatment succeeds? Ø Are there biases that might prejudice the provider s evaluation of the patient s quality of life? Ø Is the patient s present or future condition such that their continued life might be judged undesirable? Ø Is there any plan and rationale to forgo treatment? Ø Are there plans for comfort and palliative care? Patient Preferences Principles for Patient Autonomy Ø Is the patient mentally capable and legally competent? Ø Is there evidence of incapacity? Ø If competent what is the patient stating about preference for treatment? Ø Has the patient been informed of benefits/risks, understood the information, and given consent? Ø If incapacitated who is the surrogate? Is the surrogate using appropriate decision making standards? Ø Has the patient expressed prior preferences? e.g. Advance Directive or Intensity of Medical Treatment. Ø In summary is the patient s right to choose being respected to the extent possible by law and ethics? Contextual Features The Principles of Loyalty and Fairness Ø Are there family issues that might influence treatment decisions? Ø Are there provider (physician and nurse) issues that might influence treatment decisions? Ø Are there financial and economic factors? Ø Are there religious or cultural factors? Ø Are there limits to confidentiality? Ø Are there problems of allocation of resources? Ø How does the law affect treatment decision? Ø Is clinical research or teaching involved? Ø Is there any conflict of interest on the part of the provider or the institution? 16 ibid 20

Let s explore how a clinical ethics consultation is applied. Bio-ethics Case Study Mrs. Jones is a 90 year old female patient in impending respiratory failure who arrived at the hospital via medics from a SNF (Skilled Nursing Facility) in pending respiratory failure, where she was being cared for due to Dementia, with a history of CHF and COPD. This is the second time this year she has been admitted due to pulmonary infection. She has a feeding tube in place, is bed bound, contracted, and must have all activities of daily living attended to by others, and she no longer interacts with her surroundings. There was no POLST (Physician Ordered Life Sustaining Treatment), or Advanced Directive. Her daughter is listed as the family contact. The ER physician, stated that, She must want treatment or she would not have been brought to the ER but he does not want to intubate her due to her physical condition, and lack of ability to interact with her surroundings. He believes that to place her on invasive mechanical ventilation will prolong and increase her suffering. Because the patient does not have any advanced directives, he decides to place the patient on non-invasive ventilation (NIV) until family can be reached and a decision maker can decide what treatment course should be continued. The patient is transported to a Progressive Medical Unit that receives patients on NIV. You are the RCP assigned to this patient and you believe that this patient has many chronic conditions, and, given her age, should be placed on comfort care and the NIV removed. The RN at the bedside insists that the patient must keep the NIV in place as she might die, and she believes everything must be done at this time. The patient s husband died approximately 5 years ago and she has only one daughter. The daughter and grandson arrive, and the daughter thinks the NIV should be removed and her mother should be made comfortable and let nature take its course. The grandson, a lawyer, insists everything should be done to keep his grandmother alive. From a religious point of view he believes everything should be done to sustain life, and he doesn t want to pull the plug on his grandmother. His mother tries to explain grandma has had a good life and believed when God calls, we should answer. The grandson gives indication to the healthcare team he will sue if she does not receive full care. The family is at odds, and the attending doesn t want to end up in court. Two days later the patient is still on NIV and her skin is starting to degrade and every time the patient is repositioned she cries out in pain. While you are in the room to assist, you feel this full level of care is prolonging pain and suffering. As the patient s RCP you discuss the case with the attending physician who is frustrated with the family because they are unable to come to a consensus. The 21

patient s day shift RN is in agreement with you that the patient should receive comfort care and have the NIV removed. The night shift RN, however, thinks this treatment should continue as it is keeping her stable. The nurses constantly call the on duty RCP because the patient is unable to maintain the oxygen saturation parameters above 90%. You too experience helplessness and frustration with this situation. What can you as the RCP do? You dialogue with the physician and recommend an ethics consult. The physician agrees. The Bio ethics committee meets and calls the MD asking for a family meeting. After researching all the data and information, the committee asks the grandson s pastor to be present, along with the physician, RCP, day shift RN, night shift RN, dietitian, social worker and palliative care team, along with the daughter and grandson. Let s use the Jonsen grid method and see how we might resolve the case. The Medical Indications section of the Jonsen Grid is concerned with the ethical principles of Beneficence (doing good for the patient) and Non-Maleficence (not harming the patient). Medical Indications questions may include: What is the current medical problem? Acute pulmonary infection for the second time in a year. What is the patient history? Dementia, with a history of CHF and COPD. What is the diagnosis? It appears to be terminal. What is the prognosis? The patient has repeated acute pulmonary infections and many chronic conditions, which lead to a poor prognosis. Is the problem acute, chronic, critical, emergent, reversible or non-reversible? Acute and chronic conditions. What are the goals of treatment? Keep patient stable and comfortable. Do the treatment burdens outweigh the benefits? California Probate Code Section 4735 states a physician is not required to provide treatment that does not benefit the patient. The patient has chronic dementia and heart and lung disease. The patient is also succumbing to repeated pulmonary infections, which may continue and lead to ultimate death. How can harm be avoided? No aggressive treatments that may exacerbate the chronic diseases. The Patient Preferences section of the Jonsen Grid is concerned with the ethical principle of Autonomy (patient making decisions about his/her medical treatment). Patient Preferences questions may include: Is the patient mentally capable and legally competent? Not at this time as she exhibits dementia. 22

What is the patient s preference for medical treatment? Patient s daughter states that patient would not want these medical measures based on religious beliefs. Has the patient given informed consent for the medical treatment? The patient is incapacitated and unable to do so at this time. Because there were no advance directives and the situation was life threatening, the health care team was obligated to provide full heroic measures. If the patient is incapacitated, who is the surrogate decision-maker? Since the patient did not previously assign a surrogate decision-maker, the physician must act per ethical (Nonmaleficence and beneficence) and legal duty. Is the surrogate making appropriate decisions? The physician is currently ethically and legally acting. Is there a Durable Medical Power of Attorney or an Advanced Directive? None. Is the patient s right to choose being respected to the extent possible by law and ethics? The ethics team would dialogue with the family to ascertain more information regarding wishes of the patient. Because there is no durable medical power of attorney or advance directive, the ethics committee now must intervene to formulate a directive. Physician Ordered Life Sustaining Treatment (POLST) POLST is a standardized medical order form that indicates the specific types of life-sustaining treatment a seriously ill patient does or does not want 17. What makes POLST powerful is that, unlike a health care directive, it is signed by the patient and physician and becomes a set of medical orders. And unlike a directive, the POLST form moves with the patient as part of the medical record. When used with an advance directive that names a proxy decision maker, POLST can reduce unwanted or ineffective care, reduce patient and family suffering, and ensure that patients' wishes are honored. Currently, 47 states have implemented POLST or are developing similar programs. A California law in effect since 2009 requires that POLST be honored in all care settings and gives immunity to providers who honor a POLST document in good faith. At the recommendation of the National POLST Task Force, the California Task Force reviews the California POLST form every two years and recommends changes, in response to feedback based on actual usage of the form in the field. Revisions were made and went into effect on April 1, 2011. General changes include: California s POLST form has changed from Pulsar Pink to Ultra Pink (still on 65# cardstock). Ultra Pink was tested to confirm a better result on a wider range of copiers and fax machines. 17 http://www.capolst.org/?for=providers#starts 23

Throughout the POLST form, the term health care professional was changed to health care provider to be consistent with language in the POLST law. A few points to remember regardless of the most recent changes in 2011: Previously completed POLST forms remain valid Best practice suggests using the revised 2011 POLST form beginning April 1, 2011, rather than trying to use up old POLST form supplies POLST forms are valid regardless of the color paper used Copies and faxes of POLST forms are as valid as the original Although the POLST is similar, it does not replace an Advance Health Care Directive. It is recommended that a seriously ill patient have both a signed POLST form and an Advance Directive. The POLST law gives immunity from civil or criminal liability to those who comply in good faith with a patient s POLST request. Click on the following link to review the POLST form: http://www.capolst.org/documents/capolstform2011v13web_005.pdf The Quality of Life section of the Jonsen Grid is concerned with the ethical principles of Beneficence, Non-Maleficence and Autonomy. Quality of Life questions may include: What is the probability the patient may return to a normal life? Very unlikely. The patient does not interact with her surroundings What physical, mental or social deficits is the patient likely to experience after recovery? Unable to care for herself and will continue to be bedridden. What biases may prejudice the health care provider s evaluation of patient quality of life? Is the ethics team allowing for open minds? Is the patient s future condition judged undesirable? The health care team determines the persistent vegetative state to be a poor quality of life. The family is split in judging future condition. What did the patient express in living his life? Patient s religious views were expressed through her daughter and grandson and are conflicting. Is there any rationale to forgo treatment? Yes, the patient is exhibiting a recurring pulmonary infection, which may likely continue in the future. Are there plans for comfort/palliative care? Currently no, however, given the chronic conditions and recurring pulmonary infections, a poor prognosis is likely. The Contextual Features section of the Jonsen Grid is concerned with the ethical principle of Fairness and brings diverse moral and ethical issues for consideration. Contextual Features questions may include: Are there family issues that might influence medical treatment decisions? The husband is deceased. The daughter and grandson need help to see what their 24

elder might have wanted as an outcome. They currently have varying opinions about their loved one s outcome. Are there health care provider issues that might influence medical treatment decisions? Are there financial factors to be considered? Was someone in the family profiting from keeping their father on mechanical support? Was the hospital pushing to relieve a debt of no insurance? Are there religious or cultural factors to be considered? The family s religion allows for natural death. Are there problems with allocation of resources? Did another patient who was viable need the ventilator? How does the law affect medical treatment decisions? California probate code states a physician is not required to provide treatment that does not benefit the patient. Is clinical research or teaching involved? In this case no. Is there any conflict of interest on the part of the health care provider or medical institution? In this case no. After all the information is gathered, the team reconvenes. At the meeting the physician states all that could be done has been done and the patient is in steady decline and has a limited number of days of survivability, and he would suggest palliative care. The palliative care team explains their goals would be to provide all the medications and care plans necessary to keep the patient as pain free as possible without hastening the patient s death. If the patient should survive beyond the hospital stay they recommend hospice which would utilize the same goals. The dietician shares that the feeding tube is not helping the patient as the food is not being absorbed and places the patient at risk for aspiration and could lead to aspiration pneumonia. The pastor tells the team his church believes that people should be allowed to die a natural death, as God intended, as free of pain as allowed by medical treatment, which includes the removal of any mechanical devices including ventilators and feeding tubes. Next the RCP explained that by wearing the non-invasive mask, the skin is incurring damage and pain caused by the break down and the patient does struggle due to the discomfort. This is noted regularly in agitation, change in vital signs and desaturations. The RCP explained if NIV were removed, and she were to be kept comfortable, she would not struggle as hard and would decrease her oxygen demands. 25

The RNs relate how the patient reacts in pain and great distress every time she is moved, and how they can only give so much pain medication because they must keep the blood pressure and heart rate within certain parameters. The social worker states should the patient go into hospice care expenses such as medications and medical equipment needed for the patient to be comfortable would be covered. The family was in attendance and listened to all the information. Each health care provider asked the daughter and grandson if they had any questions or if they could do anything to help them understand all the information that was given. They thanked everyone for their information and requested the pastor and physician to stay for a moment as they talked over their decision. The daughter decided she would not want her mother to suffer more pain when she could be helped to be comfortable. While not completely resolved, the grandson wanted to make sure that God would want his grandmother to have a natural death. The pastor reassured the grandson, that God would have the final say no matter what decision was made. However, we could affect how the patient would leave this world and he encouraged the grandson to allow for a natural death. With everyone now in agreement, the patient was placed in palliative care and the NIV removed. The family gathered with the pastor, remembered and shared good stories of their loved one, and prayed for God s will to be done. The patient survived to be transferred to Hospice, where she passed peacefully and free of pain. In this case scenario we find that all parties came to resolution. Sometimes issues are very complex, and as such, there is no consensus to resolution. In these situations, a bio-ethics committee becomes an important tool to help guide the best outcome possible. Going back to your facilities, make sure to identify the pathway for invoking a Bio-ethics consult. 26