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Patients without Spokespersons. Ethics Champions Program January 6, 2010. John F. Wallenhorst, Ph.D. Vice President, Mission & Ethics Bon Secours Health System. Purpose. Discuss some of the ethical issues related to care for patients without spokespersons

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Patients without spokespersons
Patients without Spokespersons

Ethics Champions Program

January 6, 2010

John F. Wallenhorst, Ph.D.

Vice President, Mission & Ethics

Bon Secours Health System


Purpose
Purpose

  • Discuss some of the ethical issues related to care for patients without spokespersons

  • Relate those issues to patient self-determination, autonomy, and special protection for vulnerable persons

  • Explore practical applications for the Catholic health ministry


Case study mr smith
Case Study – Mr. Smith

  • 74 year-old man hospitalized for respiratory distress; multiple chronic medical problems

  • Recurrent aspiration; need for suctioning and intubation

  • Refuses feeding tube, but asks for a normal diet

  • Would like to go home, but there is no one to care for him

  • No family or known friends

  • No nursing home will accept him in his current condition


Patient autonomy
Patient Autonomy

Right to make one’s own informed decisions about treatment.


Patient autonomy1
Patient Autonomy

  • Competent and free

  • Information and understanding

  • Decision and authorization

Principle of informed consent.


Principle of informed consent
Principle of Informed Consent

  • The right and responsibility of every competent person to advance his or her own welfare


Self determination in health care
Self-Determination in Health Care

  • Persons have the right to make decisions and provide informed consent about the medical treatment they receive

  • Based on philosophical and theological grounds for respecting the autonomy and dignity of persons

  • Protected by law

    • Common law

    • Patient Self-Determination Act, 1990


Patient self determination act
Patient Self-Determination Act

  • Organizational structures for protecting patient self-determination

  • Specific acknowledgement of right to:

    • Guide health care decision making

    • Accept or refuse treatment

    • Make an advance health care directive


Decision making capacity
Decision-Making Capacity

  • Ability to express choice

  • Ability to understand information

  • Ability to understand one’s situation

  • Ability to weigh information

    Situation-specific

    Not the same as legal competency.


Other forms of consent
Other Forms of Consent

  • Presumed

    • In rare, emergent situations in which person is unconscious or otherwise does not have capacity

    • Limited to those medical interventions that cannot be safely postponed

  • Vicarious

    • Incompetent or incapacitated persons

    • Regulated by state and federal laws


Special considerations
Special Considerations

  • Psychiatric Evaluation

    • Best interests of patient

    • Possibly more than one evaluation

  • Conservatorship

    • Probate court appointed

    • Best interests of patient

    • Given specific levels of authority

    • Reviewed periodically

    • Special review for psychiatric care


Decision making
Decision-Making

Philosophical, theological and legal bias

in favor of acknowledging capacity

and

honoring personal decisions.


Decision making1
Decision-Making

Putting the person’s preferences at

the center of deliberation.

Reflection of values, beliefs,

personality, culture, lifestyle.


Catholic health care
Catholic Health Care

  • Dignity of the Person

  • Justice

  • Prudence

  • Benefit - Burden


Catholic health care1
Catholic Health Care

  • Ethical & Religious Directives

    • Part Three: The Professional-Patient Relationship

    • Promote mutual respect, trust, honesty

    • Avoid manipulation, intimidation, condescension

    • Directives 26-28

      • Free and informed consent

      • Benefit – burden calculation


Adequate disclosure standard
Adequate Disclosure Standard

  • Carefully apply “adequate disclosure” standard

    • Diagnosis

    • Nature and purpose of treatment

    • Risks of treatment

    • Treatment alternatives


Best interests standard
Best Interests Standard

  • Aware of “best interests” standard

    • Current level of functioning

    • Degree of pain

    • Amount of dependence, humiliation or offense against human dignity

    • Life expectancy and chance of recovery

    • Treatment options

    • Risks and benefits of treatment


Ethical issues
Ethical Issues

  • Sometimes evaluation of capacity is not completely clear

  • A continuum of vulnerability

    • Potentially

    • Circumstantially

    • Temporarily

    • Episodically

    • Permanently


Ethical issues1
Ethical Issues

  • Impossible to delineate all imaginable scenarios

  • Professional judgment and personal ethical reflection are almost always required


Some cases
Some Cases

  • 63 year old man on vent with stage four cancer

    • Disagreements among family members, physicians, ethics committee members

  • 27 year old woman with paraplegia and history of drug addiction

    • Dropped at ER; no resources; no diagnosis warranting admission


Some practical rules of thumb
Some Practical Rules of Thumb

  • Maintaining personal dignity

  • Bias in favor of honoring the person’s choice

  • Building relationships that support discussion and sound decision-making

    • Full care team, including Pastoral Care

  • Acknowledging that care is not simply about medical treatment/intervention


Some practical rules of thumb1
Some Practical Rules of Thumb

  • Avoiding paternalism

  • Avoiding applying one’s own preferences

  • Prudently using ethics committees/consult teams

  • Involvement of Social Worker, community resources, and other support networks


Back to mr smith
Back to Mr. Smith

  • What are the key ethical issues?

  • What are the alternatives?

  • What support mechanisms are there?

  • What do you do?


About holistic care
About Holistic Care

  • Based on respect

  • Context of loving relationships

  • Acknowledging moral ambiguity

  • Rarely easy, expedient, clear



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