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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

Clinical Ethics

Prepared by Peter Saul

ICU

John Hunter Hospital

13th October 2006




A little history
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 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
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
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
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
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
Macro stuff 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?”

  • “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
A few facts 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?”(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 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?”

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 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?”

Almost all these decisions are made by surrogates


Place of death
Place of death 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?”

  • 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… 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?”


That doesn’t involve the patient 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?”


  • Principles of a good death 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?”

  • 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
Advance care planning in residential care 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?”

  • 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
Advance directives neat, plausible, and wrong”

  • 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
End of life decision making in NSW neat, plausible, and wrong”

  • 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
An outline of the RPC Program neat, plausible, and wrong”

  • 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
The essence of RPC neat, plausible, and wrong”

  • 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
ACP pre RCP Program neat, plausible, and wrong”

  • 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
Surrogates pre RCP Program neat, plausible, and wrong”

  • 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
Evaluation neat, plausible, and wrong”

  • “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
Outcomes at JHH neat, plausible, and wrong”

  • 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
Early results at JHH neat, plausible, and wrong”

  • 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 jhh1
Outcomes at JHH neat, plausible, and wrong”

  • (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
Guidelines for end of life care and decision making neat, plausible, and wrong”

  • A “shared decision”

  • Based on “consensus”

  • Ethical principle

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


Patient wishes neat, plausible, and wrong”

doctors

family


Patient wishes neat, plausible, and wrong”

doctors

family

No trump card


Advance care planning in nsw
Advance care planning in NSW neat, plausible, and wrong”

  • 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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