ETHICS Part I

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ETHICSPart I

• June 5, 2003
• Moritz Haager PGY-2
• Dr. Carol Holmen

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Ethics vs.. Law

• ..ethics and law are not equivalent. Adherence
  to the law does not result in ethical behaviour,
  and ethical behaviour may not be covered by the
  law or may in fact be contrary to law or
  policy.ethical duties typically exceed legal
  duties, and in some cases, the law mandates
  unethical conduct
• Derse. Emerg Med Clin North Am. 1999 17(2)
  307-25

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Ethics vs. Law

• Law
• A formal expression of a social ethical consensus
  that sets a minimal standard of conduct
• Does not cover large areas of conduct
• Ethics
• Branch of philosophy dealing with human conduct
  which acts as a moral repository of societal
  norms
• Less formal but more pervasive than law

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What is unique about ED ethics?

• Most literature and discussion focused on
  non-acute setting
• Pts present w/ rapid change in health
• Little continuity of care / familiarity w/ pt
• Lack of reliable information
• Need to make rapid potential life or death
  decisions w/ limited information
• Pts often not in ED of their own volition
• Pts often impaired, noncompliant, or hostile

5
What is an Ethical Dilemma?

• Deciding which of 2 or more choices provides the
  greater overall good
• Autonomy vs. justice
• Confidentiality vs. public duty
• Beneficience vs. non-maleficience
• etc

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Ethical Models
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Fundamental Ethical Principles

• 1. Preservation of Life
• Beneficience
• Non-maleficience
• 2. Respect Autonomy
• 3. Justice
• 4. Truthfulness

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Preservation of Life

• Beneficience
• Acting in the pts benefit ( doing good)
• Alleviation of suffering
• Nonmaleficience
• Primum non nocere (first do no harm)

9
Autonomy

• From Greek for self-rule Patient right to
  self-determination
• Respecting vs.. creating autonomy
• Respecting following pts wishes
• Creating allowing pt to make a choice e.g.
  informed consent
• Autonomy vs. paternalism
• Benign paternalism
• Making therapeutic decisions for incompetent pts
  in good faith

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Justice

• Complex concept E.g. resource allocation
• 3 major types
• Egalitarian
• equal access for all
• Libertarian
• social or economic ability should be allowed to
  determine access
• Utilitarian
• combines features of above to maximize public
  utility (Canadian System)

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Case 1

• A 83 you Punjabi male is brought to the ED for
  constipation. He looks cachexic and dehydrated
  but is oriented and able to communicate.
• Physical exam reveals an enormous hard irregular
  mass in the abdomen which is almost certainly
  cancerous.

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Case 1

• You call the radiologist to arrange an abdominal
  CT. You dont realize the son is standing behind
  you as you relate your suspicion about the
  cancer.
• After you hang up the son approaches you and asks
  you not to tell his father the Dx because he is
  very afraid of death and would not want to know.
  In India the word Cancer is like a death sentence
  he tells you. He feels that telling him would
  destroy his fathers quality of life.

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Truthfulness

• Trust b/w pt and physician
• Is truth always best? Straightforward?
• Cultural differences
• Impact of disease
• Gradual vs.. immediate disclosure
• Therapeutic privilege
• Concept that a physician may withhold information
  if doing so would result in harm to the pt
  (non-maleficience)
• Becoming a historical concept
• Withholding information, at least temporarily,
  may be justified, BUT only if there are
  compelling defensible reasons

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McMaster Decision Model

• List the alternative courses of action
• Assess each alternative in 3 spheres
• Medical
• Patient
• Legal
• Apply relevant ethical principles to each
• Justify each choice as a moral statement
• Formulate a conclusion

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Iserson Model

1. Have you already dealt w/ a similar problem? Do
   you have a rule for it?
2. Is there a safe time-buying option?
3. If immediate decisions needed
4. Impartiality test would you want this done to
   you?
5. Universality test would you want this done in
   all similar situations?
6. Interpersonal Justifiability test can you
   strongly justify your actions to others?

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Case 2

• You are taking care of a 25 yo female suffering
  from acute traumatic C1 on 2 dislocation with
  complete cord transection. She is
  ventilator-dependant and a complete quadriplegic
  with no chance of recovery. She is alert enough
  to answer questions through eye opening and
  closing.

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Case 2

• Her husband indicates to you that they wish for
  the ventilator to be turned off. They had
  discussed this hypothetical situation in the past
  as the family knows Christopher Reeves who used
  to ride horses at their ranch She confirms this
  when you ask her if this is true.

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Consent

• The pts right to agree to, OR refuse a medical
  treatment (autonomy)
• Requires physicians to inform pts about the
  potential consequences of both accepting and
  refusing a treatment

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Implied vs.. Explicit Consent

• Implied Consent
• Pts actions in keeping w/ agreeing to Tx
• E.g. Pt rolls onto side and pulls down pants when
  told of need to perform a DRE
• Explicit Consent
• Verbal or written, and documented on chart
• More involved discussion of risks, benefits, and
  alternatives
• Should be obtained by person doing procedure

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Components of Consent

1. Possession of decision-making capacity
2. Provision of pertinent information about the
   proposed therapy on which to base a decision
3. Consent is voluntary, and obtained w/o coercion
   or manipulation.

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Guidelines for informed consent

• Discuss procedure including anticipated impact,
  significant risks, and alternatives
• Encourage questions
• Explain likely outcome if treatment is not
  provided without resorting to coercion
• Specifically address individual concerns
• Adhere to above for all patients even if they
  seem prepared to accept any treatment

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Assault vs.. Battery

• Assault
• Threatening to touch someone
• Battery
• Touching someone without that persons agreement
• Any intervention in the ED provided w/o the pts
  consent in situations other than those where
  consent is not required

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Exceptions to Need for Consent

• Based on concept of beneficience
• Emergencies If immediate threat to life or limb,
  and unable to give consent
• Unconscious trauma victim
• Person lacking capacity and at acute risk
• Intoxicated drug OD pt wanting to leave
• May require invocation of Mental Health Act
• Treatment of minors
• 12 yo Jehovah's witness w/ acute blood loss
• Public Health Regulations
• Mandatory reporting laws

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Age of Consent

• No age of consent in Canadian tort law
• Provincial legislation for age of consent
• PEI
• 18 yo or married (for surgery)
• NB
• 16 yo or younger if competent
• PQ
• 14 yo
• SK
• 18 yo or married (for surgery)
• BC
• 16 yo if unable to obtain parental consent need
  2nd physician to provide written opinion of
  necessity of Tx

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Case 3

• 14 yo female is brought in by her mother. A
  friend of the girl has just phoned the mother to
  say that she had gotten drunk, done drugs, and
  then had sex with a nineteen year old. The pt
  denies all this. Mom demands a drug screen AND
  pelvic examination. She firmly states that as the
  pt is a minor, and she the parent, you must abide
  by her wishes. Do you? What if the girl refuses
  the blood and urine tests, and pelvic exam? Are
  you obliged to refer her to the sexual assault
  team? Are you obliged to notify the police?

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Case 4

• A 12 yo girl is brought to the ED by her mother
  c/o fever dysuria. The pt does not want her mom
  present during the interview or exam. She is
  pre-menarchal, and denies being sexually active,
  or sexual or physical contact against her will.
  Her temp is 38.0. Superficial genital exam
  reveals multiple labial ulcerations and
  malodorous vaginal discharge.

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Case 5

• A 16 yo female is brought to the ED by her mother
  for abd pain, vomiting, and PV bleeding. You
  examine her in private. She admits to consensual
  sexual activity. A urine pregnancy test is ve,
  and she has a tender R adnexal mass. U/S
  confirms a ectopic pregnancy. She understands the
  need for intervention and is willing to see O G
  but insists you not tell her mom.

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Case 6

• A 70 yo man with gangrene of R foot leg from a
  diabetic ulcer is in your ED. He is requesting a
  Rx for abx painkillers. You tell him that you
  think he should come into hospital and see a
  surgeon. He refuses this saying he does not want
  his leg amputated. better to die than lose your
  independence he tells you.
• His daughter is present and argues with him
  vehemently. At one point she tells him you cant
  go on like this, all cooped up by yourself in
  that house not taking care of yourself. She
  tells you he has been depressed since his wifes
  death 2 yrs ago.

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Capacity

• Ability to comprehend process
• Information about the treatment or test
• Potential consequences of acceptance or refusal
• Capacity can fluctuate with situation time
• Assess on sliding-scale the more serious the
  decision, the more competent the pt should be
• Age does not necessarily preclude capacity
• Assessment of capacity poorly studied subject
  to bias
• Few statutory laws other than those regarding
  formal admissions for psychiatric pts to guide
  you

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Impaired Capacity

• Examples of impaired capacity
• Intoxication
• Organic brain disease (e.g. Alzheimers)
• Minors
• Suicidal pts
• Other psychiatric illnesses

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Aid to Capacity Evaluation (ACE)

• Tool for systematic evaluation of capacity
  developed at U of T by experts in law, ethics,
  and medicine
• Scores 7 areas as yes, no, or unsure
• Requires identifying addressing any
  communication barriers
• Done in conjunction w/ discussing risks,
  benefits, alternatives of proposed Tx
• ACE questionnaire available at http//www.utoronto
  .ca/jcb/_ace/ace(fm).htm

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ACE Questions

• Ability to understand
• Current medical problem
• Proposed Tx
• Alternative therapies (if any)
• Option of refusing any Tx
• Reasonably foreseeable consequences of accepting
  proposed Tx
• Reasonably foreseeable consequences of refusing
  proposed Tx
• Is the persons decision influenced by
• Depression
• Delusions or psychosis

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ACE Conclusions

• Final assessment subjective, but based on score
  in prior areas
• Pt should demonstrate ability to understand
  relevant info AND possible consequences
• Clinician designates pt as one of
• Definitely capable
• Probably capable
• Probably incapable
• Definitely incapable

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Validity of ACE

• Cross-sectional study of 100 inpatients w/
  questionable capacity facing serious medical
  decisions
• Assessed by residents research nurse using ACE
  MMSE, general impression of attending
  physician, and formal assessments 2 separate
  experts
• Compared results of each

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Validity of ACE

• Results
• ACE took 15 min to administer
• Agreement b/w ACE and expert opinion was sig
  higher (k 0.90-95) than the general impression
  of attending physician (k 0.86)
• MMSE scores of 0-16 correlated sig w/ incapacity
  (k 0.93)
• A MMSE score of 0-16 combined w/ an ACE score of
  probably or definitely incapable resulted in
  post-test prob of 96 for incapacity
• A MMSE score of gt24 combined w/ an ACE score of
  probably or definitely capable resulted in
  post-test prob of incapacity of 3

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Validity of ACE

• Conclusions
• ACE MMSE both agree well w/ expert opinion
• Indeterminate results (probably capable or
  incapable MMSE score 17 23) correlate more
  poorly and should prompt alternative evaluation
• Combining ACE and MMSE preferable
• Etchells et al. J Gen Intern Med. 1999 14 27-34

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Case 7

• An ill-appearing 2-year-old with a fever and
  stiff neck appears to have meningitis. His
  parents refuse a lumbar puncture on the grounds
  that they have heard spinal taps are extremely
  dangerous and painful. They refuse treatment and
  investigation, saying, " We'd prefer to take him
  home and have our minister pray over him."

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Case 8

• A 5-year-old child has just had his second
  generalized tonic-clonic seizure in a 4 month
  period. You have recommended starting an
  anticonvulsant. The parents have concerns about
  the recommended medication and would prefer to
  wait and see if their son has more seizures. How
  should you respond to the parents request?

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Treatment Refusal

• A person of proper mental capacity has the right
  to refuse even life-saving Tx
• A parent or guardian may NOT make this same
  decision for a minor in their charge
• Written documentation corroborated by family
  members have been deemed sufficient grounds to
  withhold emergent therapy in an unconscious
  patient

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Treatment Refusal

• The key question in the ED regarding refusal of
  treatment is whether the patient is competent to
  make this decision
• Difficult area, but generally based on
• Set of values and goals
• Consistency in decision-making
• Ability to understand communicate info
• Linguistic conceptual skills
• Sufficient life experience
• Ability to reason
• Refusal of life-saving measures usually mandates
  assistance in determination of competency

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Case 9

• A 50 yo male receiving palliative care for
  metastatic stomach CA is brought in by his family
  b/c of poor pain control and inability to
  tolerate PO feeds
• His vitals are 37.4 / 110 / 96/70
• He looks cachectic, jaundiced, dry, is drowsy
  unable to answer Qs or cooperate with exam
• He has multiple metabolic abnormalities including
  renal failure on his lab work

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Case 9

• His wife states that he did not wish for
  life-prolonging measures or resuscitation, only
  for comfort and dignity
• His wife does not want you to start an IV,
  however his son daughter argue that he is
  dehydrated and should not starve to death
• How do you approach this?

43
Case 10

• A 79 yo male is brought to the ED from a nursing
  home in acute resp distress.
• Recent admission records indicate COPD, end-stage
  RF, and dementia. He is non-ambulatory.
• On exam he is in sig resp distress. His vitals
  are 38.0 / 130 / 140/90 / 30 / 79 on 40 O2
• He is frail and unable to answer Qs.

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Case 10

• There is no documented code status anywhere
• The only family member you can reach is a son who
  lives in Miami. He last saw his father 8 mo ago.
  The son informs you that his father would not
  want any aggressive treatment.

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Substitute Decision Makers

• Person chosen to make medical decisions on behalf
  of an incompetent pt
• Role is to use Substituted Judgment to try and
  mirror what the pts wishes most likely would be

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Substitute Decision Maker

• Murky area in Canadian law
• family members probably not legally empowered to
  act as substitute decision makers unless
  specifically court appointed, although this is
  common practice
• If no appointed SDM, use in rank order
• Court-appointed guardian ? spouse / partner ?
  child ? parent ? sibling ? other relative
• If no one available need public guardian

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Minors

• Mature Minor
• Minor capable of understanding the risks
  benefits of a Tx are entitled to make autonomous
  decisions
• Emancipated Minors
• Sub-group of mature minors
• Those who support themselves independently and
  live separately from their parents, are married,
  and / or serve in the armed forces.

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Case

• A 45 yo male is brought in by EMS for polydrug
  OD. He is intubated and placed on a ventilator
  for resp failure.
• A suicide note is found on scene in which the pt
  claims he has the right to choose to die on his
  own terms given his Dx of ALS, that he is
  rational and not depressed, and that he will sue
  anyone resuscitating him.

49
Case

• His common-law wife arrives with his living
  will. It was formulated 6 mo prior, witnessed
  and notarized. In it the pt clearly states that
  if he is ..in a condition that is terminal with
  no reasonable hope of recovery I do not want
  heroic measures to prolong my dying..
• His wife states he would not want these
  interventions and demands you turn the ventilator
  off

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Case 11

• An elderly man with end-stage emphysema presents
  to the emergency room awake and alert and
  complaining of shortness of breath. An evaluation
  reveals that he has pneumonia. His condition
  deteriorates in the emergency room and he has
  impending respiratory failure, though he remains
  awake and alert. A copy of a signed and witnessed
  living will is in his chart stipulates that he
  wants no "invasive" medical procedures that would
  "serve only to prolong my death." No surrogate
  decision maker is available. Should mechanical
  ventilation be instituted? What if he presents
  confused and somnolent?

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Advance Directive

• Legal document outlining a pts wishes regarding
  their medical Tx in the event of becoming
  incapable of directing their care
• May assign a person to be SDM in which case it is
  a proxy directive or durable power of
  attorney
• Can be revoked by the pt at any time

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Case 12

• A 16 yo female presents w/ PV bleeding and abd
  pain. She came alone.
• By Hx exam she is 10 wks pregnant and is having
  an incomplete abortion with sig bleeding
• You discuss the situation with the pt and after
  discussing the options she states she wants a D
  C

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Case 12

• As you hang up the phone after talking to O G
  the mother identifies herself to you and asks
  what is going on with her daughter. You ask her
  to speak with the pt. She returns stating her
  daughter has no idea what is going on and as the
  parent she demands to know what is wrong.

54
Case 13

• A 24 yo male presents w/ penile d/c. He admits to
  using the services of a prostitute on a recent
  business trip to Thailand. You feel he likely has
  gonorrhoea and Tx him accordingly. His wife is in
  the waiting room. He demands you keep his Dx
  confidential stating that it was a one time
  thing and if she knew it would ruin their
  marriage. You buy yourself some time by going to
  grab a prescription padOutside you are approached
  by his wife who asks what is the matter with her
  husband.

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Case 14

• A 60-year-old man has a heart attack and is
  admitted to the medical floor with a very poor
  prognosis. He asks that you not share any of his
  medical information with his wife as he does not
  think she will be able to take it. His wife
  catches you in the hall and asks about her
  husband's prognosis. Would you tell his wife?

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Confidentiality

• Pts has the right to hold the physician to
  secrecy regarding personal info
• EXCEPT where
• Doing so contravenes legal obligations
• Doing so may result in harm to others
• Doing so may result in harm to the pt AND the pt
  is incompetent
• All reasonable steps must be taken to inform pt
  of intended breach of confidentiality

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Case 15

• A 55 yo female is brought to the ED for decreased
  colostomy output and abdominal pain. She has a Hx
  of TAH BSO for ovarian CA 5 yrs ago. She looks
  mildly unwell and has generalized abdominal
  tenderness, but is otherwise stable. An U/S shows
  peritoneal carcinomatosis. Your staff surgeon who
  has not seen the pt, shrugs and tells you to
  send her back to the peripheral hospital from
  where she came. When you ask him about what you
  should tell her he says Nothing. Let the GP
  handle it

58
Case 16

• You are about to go see your next pt who is here
  after a minor MVA when you are intercepted by her
  daughter in the hall
• She tells you that her mother has cancer, but she
  has not told her of this and asks you to keep
  this secret.
• On exam there is an obvious mass lesion on the
  left breast. As you are auscultating the pt asks
  you about the mass.

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Case 17

• A 89 yo male is brought to the ED for cough
  resp distress.
• You find he has b/l pneumonia, chronic pulmonary
  edema, as well as a UTI
• He was discharged 3 wks ago for CHF exacerbation
  with multiple complications
• He was a full code status at that time

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Case 17

• Despite treating him with Abx, diuretics, and O2
  his breathing continues to deteriorate. He starts
  to look more septic so you start him on biPAP and
  dopamine.
• You discuss the situation w/ his wife. When you
  bring up code status she becomes upset and
  insists everything be done
• Just then you are called into the resus room
  your pt is in PEA

61
Case 18

• A 45 yo female of is brought to the ED w/ fever
  cough. She is in a persistent vegetative state x
  2 yrs following an MVA, lives in a nursing home
  and depends on a G-tube for nutrition. She is
  tachypneic and her O2 sats are 86 on RA. You Dx
  her w/ pneumonia and start her on abx and O2. As
  she looks unwell you broach the topic of code
  status. The family, who are Orthodox Jews, insist
  that she receive all measures including
  intubation ICU care if necessary. Is this
  appropriate?

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Medical Futility

• Futility
• action that is ineffective or w/o useful purpose
• Medical futility
• Variety of definitions but none widely accepted
• based on largely subjective opinions as we often
  dont really know the true efficacy of a
  treatment, nor can predict its success in a
  particular patient

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Medical Futility

• AHA ACLS guidelines for terminating
  resuscitation
• BLS ALS have been attempted appropriately w/o
  ROSC or breathing
• Deteriorating pt condition despite maximal
  therapy precludes likelihood of recovery (e.g.
  septic shock in ICU)
• Disease states from which no successful
  resuscitation has been reported in well-designed
  studies (e.g. metastatic CA)

64
Medical Futility

• Schneidermann et al 1990
• A treatment is futile if merely preserves
  permanent unconsciousness or fails to end total
  dependence of intensive medical care
• Efforts can be terminated, or care withdrawn w/o
  pt approval ..when physicians conclude (either
  through personal experience, experiences shared
  with colleagues, or consideration of empiric
  data) that in the last 100 cases, a medical
  treatment has been useless

65
Medical Futility

• Brody and Halevy 1995
• Physiologic futility
• failure to produce a physiologic response
• Imminent demise futility
• failure to prevent death in the very near future
• Lethal condition futility
• intervention not expected to impact fatal outcome
  in near future due to underlying condition
• Qualitative futility
• intervention not expected to result in an
  acceptable quality of life

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Pro-futility arguments

• Professional Integrity
• Physicians should not be forced into providing
  treatments they believe offer no benefit or are
  potentially harmful
• Professional Expertise
• Pts seek the advice of a physician regarding
  diagnosis and treatment options and would not
  normally expect to be offered Tx w/ little or no
  benefit
• Resource Stewardship
• Selective use of limited resources to maximize
  societal benefit

67
Anti-futility Arguments

• Respect for Pt Autonomy
• Where the goals of Tx, or odds of success worth
  pursuing are perceived differently by the
  physician and the pt or substitute decision
  makers, the latters wishes should be respected
• Prognostic Uncertainty
• Literature of critically ill pts suggests
  physicians are not good at accurately predicting
  outcomes making it difficult to justify
  withholding care based on this
• Lack of Societal Consensus on Futility
• Unless universally agreed upon, no futility
  judgments should be imposed on unwilling subjects

68
Approach to Futility

• Patient Preferences
• Likelihood of medical benefit
• Based on literature
• Likelihood of non-medical benefits
• Includes family needs, grieving process etc
• Family Wishes
• Potential Risks of Intervention
• Risks to pt and healthcare workers

69
Demands for Inappropriate Care

• Three groups
• Demands for ineffective Tx
• E.g. antibiotics for common cold
• Demands for effective Tx that supports a
  controversial goal
• E.g. liver transplant for 104 yo pt w/ end-stage
  liver dz
• Cases at the fringe of standard medical care
• E.g. chelation therapy

70
Demands for Inappropriate Care

• You are under no obligation to provide Tx that
  falls outside the standard of care, or those for
  which there is very poor evidence but which may
  be used by a small number of physicians
• If an acute situation is complex, possibly
  inappropriate requests for life-saving measures
  should be respected

71
Demands for Inappropriate Care

• Demands for effective Tx that supports a
  controversial goal
• Most difficult situation
• Values of physician vs.. family / pt
• Autonomy vs.. distributive justice
• Often requires extensive discussions help
• Hospital ethics committee
• Social workers
• Clergy

72
Case 19

• A 75 yo male is brought in by EMS. He was found
  comatose in his bed next to an empty bottle of
  barbiturates by a home care nurse. His son
  arrives and tells you his father has advanced
  lung CA with extensive bony mets which cause him
  intractable pain despite massive narcotic use.
  He is expected to die within the next 6 mo and
  has repeatedly stated the he is ready to face
  the maker. Your pt at that point goes into resp
  arrest. The son pleads with you not to intervene.
  Please, just let him go. He wants to die..has
  he not suffered enough?

73
The BIG Question

• Are some suicides reasonable decisions rooted in
  the concept of autonomy?
• 90 of suicides felt to be associated w/ some
  form of mental illness on post-mortem review
• Beneficience in the form of intervention
  overrules pt autonomy in these cases based on the
  idea that the mentally impaired pt the lacks
  capacity
• Situations where an otherwise competent pt
  chooses suicide are less straightforward

74
Are there good reasons for a pt to commit
suicide? Should these be respected?

• Pro
• A pt who has capacity has the right to
  self-determination should not suffer the
  imposition of others moral beliefs
• If all other medical options (beneficience) have
  been exhausted then our next duty should be to
  avoid further harm (maleficience)
• We must clearly differentiate between our own
  moral belief system and the choices we would make
  for ourselves, and those of our pts

75
Are there good reasons for a pt to commit
suicide? Should these be respected?

• Con
• Suicide is counter to the principle of preserving
  life
• Controversial whether suicide can truly represent
  a rational choice
• Not legally recognized as a right
• Rejected by most major religions
• In the ED in particular knowledge of the pt and
  their circumstances limited

76
Physician Assisted Suicide

• Legal in Netherlands Oregon
• Not legal in Canadayet
• Impact on ED
• Failed suicide attempts who do we resuscitate?
• Family members demanding resuscitation
• Staff unable to comply with pts wish to die
• Conflict b/w members of health care team
• Conflict w/ institutional policy

77
Intervening in Suicide

• Catch 22 the need to avoid 2 mistakes
• Intervening when it is not warranted
• Not intervening when it is warranted
• Bottom line
• 90 will have mental illness, combined with the
  lack of prior intimate knowledge of the pt alone
  should prompt intervention given the
  irreversibility of suicide

78
And finallythe biggest question
Is this ethical, for healthcare workers to
smoke?
79

• THE END

80
Case 20

• 51 yo male presents w/ 2 hr CP
• 2 mm STE in ant leads
• Tx w/ ASA, nitro r/o contraindications to
  thrombolysis
• During risks benefits discussion his pain
  resolves ECG normalizes CCU consult
• 2 hrs later nurse tells you pt is attempting to
  leave b/c his pain has resolved and he is tired
  of waiting around