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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