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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

  • 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


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

Philosophical, theological and legal bias

in favor of acknowledging capacity


honoring personal decisions.

decision making1

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