Ethics in Shadow of Uncertainty: Suggestions for Clinical Practice. Gary Goldsand Clinical Ethicist, Royal Alexandra Hospital, Edmonton. Assistant Clinical Professor, Faculty of Medicine and Dentistry, University of Alberta. Upcoming Lunchtime Ethics Oct. 16th Ethical and Cultural Issues in Discharge Planning Leanne Currie BScN Community Health Nurse. Nov. 6th Ethics and Nutrition at the End of Life - Gary Goldsand Nov. 20th Towards Culturally Responsive Care in Wabasca, Alberta in Dementia and End-of -Life Care, A Consensus Group Process Dr. Jean Triscott and Dr. Earle Waugh Dec. 4th Ethics in the Emergency Department Julija Kelecevic, Bioethicist, Thunder Bay Regional Health Sciences Centre and the Collaborative Group. Dec. 18th A Good Death for DNR? New Trends in Naming Treatment Goals. - Gary Goldsand 1
Great talk next week AHFMR VISITING LECTURER AND UNIVERSITY CENTENNIAL EVENT John Dossetor Health Ethics Centre presents Carl Elliott, MD, PhD Professor, Pediatrics and Philosophy Center for Bioethics, University of Minnesota White Coat, Black Hat: Subverting Medicine for Fun and Profit 2:00-3:00 pm Tuesday, 7 October 2008 Bernard Snell Hall, Walter Mackenzie Health Sciences Centre Refreshments: 3:00-4:00 pm Ethics Committees: What were they for again? Originally: allocating scarce resources - like dialysis. Now: Provides a neutral community of peers to assist with tough decisions. Aims to support hospitals and organizations with moral aspects of health care. Ongoing education and ethical capacity building of members. Big cases are rare. Better decisions, less moral distress, are hoped for. 2
Clinical Ethics Long tradition of ethics in clinical practice Modern version a response to effective technologies. Compelled to face difficult decisions. Goal is to facilitate sound decisions Goal is to reduce moral distress A plurality of methods of analysis. Famous Prayer God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. Reinhold Niebuhr 3
Update for the modern hospital? God grant me the wisdom to know the difference between what I know and what I don t know; courage to share this with my patients and colleagues, and serenity in the face of uncertainty. Epistemology Science of knowledge Asks how do we know what we know? How do we think? Thinking about thinking. Separating what we know, from what we don t yet know, from that which can t be known. 4
Uncertainty A normal state for many domains. Almost always applies in ethical issues. Characterizes the future, almost always. Can be difficult to admit to others. Can be difficult to admit to self. Often raises anxieties. Is not going away. Trust and uncertainty We want patients and their families to trust us. We want to demonstrate competency. Need to deliver health information with appropriate level of confidence. Too little confidence - patients perceive incompetence. Too much confidence - setting yourself up for being wrong, and losing trust. 5
Suggestion 1 Always be as clear as possible with patients about what we know, what we are trying to find out, and what we likely cannot know. Eg. -we know Joe had a stroke -we are trying to see how severe. For now, long term prospects are unknown. Doing this well can instill trust, and help patients and families to formulate hope reasonably. Uncertainty in Informed Consent In any calculation of risks and benefits, uncertainty will be a part of the equation. Patients with difficult decisions should have a good sense of how certain we are about potential risks and benefits. 6
Need for resistance against those who demand certainty Uncertain line between capacity and incapacity to make decisions. Uncertain when a patient has 6 months to live. Often initial uncertainty around diagnosis and prognosis. Uncertainty in ethical reflection Need for balance between relevant ethical principles. Respect for autonomy vs. beneficence Pt. liberty vs. maximal pt. safety Wide Reflective Equilibrium What is a reasonable compromise, all things considered? 7
Common domains of uncertainty in clinical settings: Reliability of Scientific data Good science vs. skewed science. The who is my primary caregiver phenomenon in patients. Appropriate times to shift goals of care from cure towards comfort. Is it really better to tell patients of the nearerror that could have harmed them? More common areas of uncertainty What was last week s attending physician thinking? Actual vs. perceived quality of life. Better models of healthcare delivery. What specific interventions you will want in your final days. Etc. 8
What to do about uncertainty? Reduce it whenever possible. Embrace it as normal. Understand that it can be hard to accept. Assist patients in managing it - help them to focus hopes appropriately. Be honest with self and others about it. Update for the modern hospital? God grant me the wisdom to know the difference between what I know and what I don t know; courage to share this with my patients and colleagues, and serenity in the face of uncertainty. 9
Thank - you. Gary Goldsand Clinical Ethicist, Royal Alexandra Hospital, and Assistant Clinical Professor, Faculty of Medicine and Dentistry, University of Alberta. gary.goldsand@capitalhealth.ca Ongoing Issues in Clinical Ethics Advance Care Planning How different are people s care goals at the end? Artificial Nutrition and Hydration. When appropriate and when not? Evolving Care Goals. From hope for cure to hope for comfort Capacity assessment How does it help the marginal patient? Discontinuity and Fragmentation in Patient Care. Who is my clinician anyway? Physician - patient, nurse - patient relationship is traditional model still possible? 10
Ongoing issues cont d Inter-clinician communications. Can you talk to others enough? Systemic Impediments to Doing Right. (organizational ethics) Professionalism, Duty, and rights. Why try to do good anyway? Ethics of pandemic planning. Health systems partnering with skilled staff? Abortion and assisted suicide. heart and soul of modern clinical ethics. Effecting change in complex systems Not an easy task, but necessary. 11