Clinical ethics
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Clinical Ethics. Prepared by Peter Saul ICU John Hunter Hospital 13 th October 2006. Medicine is a contact sport…. Medicine is a contact sport…. People get hurt. A little history. JHH Clinical Ethics Committee Founded 1993 Survey 1995 ( J Qual Clin Prac 1998) CUEHL 1996

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Clinical Ethics

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Clinical Ethics

Prepared by Peter Saul

ICU

John Hunter Hospital

13th October 2006


Medicine is a contact sport…


Medicine is a contact sport…

People get hurt


A little history..

  • JHH Clinical Ethics Committee

    • Founded 1993

    • Survey 1995 (J Qual Clin Prac 1998)

    • CUEHL 1996

    • Became Area (HACEC) 2000

    • ACHS commendation 2001

    • Consultation service published 2004 (MJA 2004;181:204-206)


Macro and micro

  • Macro

    • Policy

    • Institutional change

    • Cultural change

  • Micro

    • The pointy end

    • Support for value-laden decisions at the bedside


Time to have a go

  • The Wandering Man

    • Elderly man found wandering around a park

    • Investigations showed brain tumour (inoperable, incurable)

    • Immigrant, no family or friends in Australia

    • CEC contacted six weeks after admission

    • Still wandering, vomiting blood


Questions

  • What can we do without consent?

    • Hide drugs in his food?

    • Do an endoscopy?

    • Restrain him?

    • Write a no-CPR order?


Time to have a go 2

  • Young woman with severe Crohn’s disease

  • Unable to give up smoking

  • New (expensive) drug available – evidence suggests drug much less effective if patients smoke.

  • Should the drug be withheld?


Ethics consultation

  • Formal and informal

  • Knowledge deficit or dilemma (values)

  • Expertise and accountability


“Can you tell me, Socrates - is virtue something that can be taught? Or does it come by practice? Or is it neither teaching nor practice that gives it to a man, but natural aptitude, or something else?”

Plato

Protagoras and Meno


Macro stuff

  • “Patient autonomy”

    • A short and undistinguished career

    • An issue of culture

  • Can patients become meaningfully involved in decisions about their care?

  • A worthy subject for experimentation


A few facts (AIHW 2002)

  • Life is still getting longer

    • But slower

    • At high cost

  • All the gain is at the end

    • Last 5-9yrs with disability

    • Extremes of age now common

  • > 90% of Australians now get to be old

  • Chronic illness now common


80 deaths a month

90% have no attempt at resuscitation

80% have no involvement in their own EOL decisions


80% die after a decision to withdraw or withhold treatment

Almost all these decisions are made by surrogates


Place of death

  • US data - 20% in ICU (60% in Miami)

    • Crit Care Med 2004;32:638-643

  • UK data - institutions 80% (hospitals 66.5%)

    • BMJ 2003;326:30-34

  • Bankstown data - > 60% have multiple hospital admissions during last year of life, av bed days 25

    • Age & Ageing 2004


Death in hospital is an actively managed event…


That doesn’t involve the patient


  • Principles of a good death

  • To know when death is coming, and to understand what can be expected

  • To be able to retain control of what happens

  • To be afforded dignity and privacy

  • To have control over pain relief and other symptoms

  • To have choice and control over where death occurs (at home or elsewhere)

  • To have access to information and expertise of whatever kind is necessary

  • To have access to any spiritual or emotional support required

  • To have access to hospice care in any location

  • To have control over who is present and who shares the end

  • To be able to issue advance directives which ensure wishes are respected

  • To have time to say goodbye, and control over other aspects of timing

  • To be able to leave when it is time to go, and not to have life prolonged pointlessly

  • Age Concern, London 1999


Advance care planning in residential care

  • Questionnaire study of 4625 residents of nursing homes and hostels in NSW

  • <0.2% had a written advance directive

  • 1% had a no-CPR order

  • decision making largely informal

    Aust NZ J Med 2000;30:339-343


“There is always an easy solution to every human problem - neat, plausible, and wrong”

H L Mencken 1917


Advance directives

  • Level 1 evidence that you can get people to write them

    • J Crit Care 2004;19:1-8

  • Level 1 evidence they don’t work

    • Arch Int Med 2004;164:1501-1506


End of life decision making in NSW

  • No legislation (unlike our neighbours)

  • A complex (and disputed) intersection of guidelines and perceptions about what the common law might say


An outline of the RPC Program

  • Born in LaCrosse Wisconsin in the 90’s

  • Adopted and adapted by Austin Health in Victoria in 2002 - trialed 02-03

  • Extended to acute care pilot hospitals in all states 2004-2006

  • Extended to residential aged care 2005

  • Rural pilot and GP’s 2006


The essence of RPC

  • Starts at the top

  • Changes hospital systems

  • Trains facilitators

  • Focuses on families/carers, not just patients

  • Aims to provoke documented discussions (not just AD’s)

  • Educates absolutely everybody


ACP pre RCP Program

  • Only 1% of in-patient notes included any reference to a plan or patient preferences (4 states)

  • Legislation not influential

  • 0.2% of notes in nursing homes in Hunter Region of NSW contained a plan


Surrogates pre RCP Program

  • No recognition of guardianship provisions in acute care (on admission or subsequently).

  • < 5% of residents in nursing homes in Hunter had a recorded guardian


Evaluation

  • “Program logic map”

  • Outsourced to a group at LaTrobe

  • Looked at several tiers, quantitative and qualitative

  • Tries to establish links between changes made and outcomes


Outcomes at JHH

  • Changes to hospital administration

  • Changes to processes of care in the pilot wards

  • 120 trained staff

  • High level of confidence in trained staff

  • Incorporated into routines of care

  • Extended into clinics


Early results at JHH

  • 2 plans and no identified proxies (PR) in 200 patients pre-implementation

  • 50/200 identified preferred proxy and 30/200 recorded preferences in evaluation period

  • A smorgasbord of documents produced

  • Impact evaluated Jan-Apr 2006


Outcomes at JHH

  • (1 in 50 told us to go away)

  • 15 in-patients/week introduced to RPC (4 wards) and lots of outpatients

  • 8 ask for follow-up

  • 3 identify or appoint a proxy

  • 2 request a no-CPR order

  • 1 writes a plan (may include an advance care directive). Takes about 2hrs.

  • All plans followed so far


Guidelines for end of life care and decision making

  • A “shared decision”

  • Based on “consensus”

  • Ethical principle

    • In the absence of a competent adult patient, nobody has the trump card


Patient wishes

doctors

family


Patient wishes

doctors

family

No trump card


Advance care planning in NSW

  • Identify who will make decisions for you

  • If not OK, appoint somebody else

  • Talk to them

  • Make sure everybody knows what you’ve said

  • Write something down and keep it with you


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