Bioethics 1

Question 1

Are verbal advanced directives ethically valid? What to note?

Answer 1

Yes

NOTE: should be documented in medical record by provider

Question 2

What are the 4 goals of advance care planning?

Answer 2

1. Maximize the likelihood that medical care serves the patient’s goals
2. Minimize the likelihood of over- or under-treatment
3. Reduce the likelihood of conflicts between a patient’s spokesperson, family members and health care providers
4. Minimize the burden of decision making on the spokesperson and/or family members

Question 3

What is patient autonomy? What does it depend on? 3

Answer 3

The right to self determination based on personal interests if an adult patient is competent.

1. Goals
2. Preferences
3. Concerns for one’s family

Question 4

What can you learn about your patients while engaging in advance care planning? Give examples.

Answer 4

1. Hopes: live longer, have quality relationships with loved ones
2. Fears: loss of dignity or cognitive functions

Question 5

With what patients should a doctor engage in advance care planning?

Answer 5

All or patients at higher risk for decisional incapacity, UNLESS the patient is severely depressed or suicidal

Question 6

How to raise advance care planning issues without scaring patients?

Answer 6

Be sure to tell them that me asking does NOT mean that there is something unspoken to worry about

Question 7

What are 2 good questions to ask when talking about advance care planning?

Answer 7

1. Who should speak on your behalf if you become so sick you can’t speak for yourself?
2. Are there any circumstances that you’ve heard about through the news or TV where you’ve said to yourself, “I hope that never happens to me” or “I would never want to live like that?” If so, what are they and why do you feel this way about them?

Question 8

What does it mean for a patient to be decisionally incapacitated?

Answer 8

Unable to make informed decisions

Question 9

Who is responsible for determining if a patient is decisionally competent?

Answer 9

Most often the doctor, but sometimes may require a psychiatric evaluation

Question 10

What should you do as a physician if a family disagrees with the living will of the patient?

Answer 10

Meet with the family and medical team to discuss and ask:

1. Do they have a different idea of what should be done (e.g., based on other communication from the patient)?
2. Do they have a different impression of what would be in the patient’s best interests, given her values and commitments?
3. Does the family disagree with the physician’s interpretation of the living will?
4. Is there a conflict of interest that may be fueling disagreement between the patient and family members?

Conclusion:
If the family merely does not like what the patient has requested, they do not have much ethical authority to sway the team.

If the disagreement is based on new knowledge, substituted judgment, or recognition that the medical team has misinterpreted the living will, the family has much more say in the situation and most hospitals would defer to the family in these situations.

If no agreement is reached, the hospital’s Ethics Committee should be consulted.

Question 11

What should you do if you are having difficulty interpreting a patient’s advance directive?

Answer 11

The health care agent (surrogate decision maker) or a close family member often can help the care team reach an understanding about what the patient would have wanted. Of course, physician-patient dialogue is the best guide for developing a personalized advance directive.

Question 12

What are the 6 steps in breaking bad news?

Answer 12

1. Make sure the setting is private and ask the patient who she wants there in the room
2. Find out how much the patient knows
3. Find out how much the patient wants to know by asking “Some patients want me to cover every medical detail, but other patients want only the big picture–what would you prefer now?”
4. Share the information: diagnosis, treatment, prognosis, and support or coping BUT stop in between each to ask if the patient has questions
5. Respond to the patient’s feelings or ask how they are feeling
6. Plan and follow-through: step-by-step plan and contact the patient needs if she has questions before step 1

Question 13

What should I do if the patient starts crying while I am delivering bad news?

Answer 13

Wait for the person to stop crying, ask how they are feeling, offer tissues

Question 14

I just saw another caregiver tell something to my patient in a really insensitive way. What should I do?

Answer 14

1. Examine what happened and ask yourself why the encounter went badly
2. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn’t slander the insensitive caregiver: “I thought you looked upset when we were talking earlier and I just thought I should follow up on that–was something bothering you?”

Question 15

What 5 factors need to be taken into account in evaluating the risks and benefits of any therapy?

Answer 15

1. Amount and quality of research that has been done on the intervention
2. Known risks and side effects of the therapy
3. Credential and competence of the practitioner
4. Seriousness of the condition being treated
5. Belief system and wishes of the patient.

Question 16

What are the physician’s professional obligations with respect to CAM?
3

Answer 16

1. Track the patient’s use of all CAM therapies (can interact with other therapies)
2. Be respectful of their use of CAM
3. Do not believe that because it is natural it is safe ==> be informed about risks

Question 17

Why is confidentiality between patient and physician important?

Answer 17

1. If the confidentiality of this information were not protected, trust in the physician-patient relationship would be diminished ==> patients would be less likely to share sensitive information, which could negatively impact their care.
2. Creating a trusting environment by respecting patient privacy ==> encourages the patient to seek care and to be as honest as possible during the course of a health care visit

Question 18

Can I share patient information with another member of the clinical care team?

Answer 18

YUP, but needs to be done in private where others cannot hear

Question 19

What do I do if family member asks how the patient is doing?

Answer 19

If there is not explicit permission from the patient to share information with family member, it is generally not ethically justifiable to do so.

Except in cases where the spouse is at specific risk of harm directly related to the diagnosis, it remains the patient’s (and sometimes local public health officers’), rather than the physician’s, obligation to inform the spouse.

Question 20

What are 2 exceptions when patient confidentiality can be breached? Provide examples for each and issues.

Answer 20

1. Concern for the safety of other specific persons: homicidal ideation
   Issue: hard to determine the seriousness of a threat
2. Legal requirements to report certain conditions or circumstances: communicable/infectious diseases to protect public health (STDs, anthrax, TB), abuse, and gunshot wounds

Question 21

How do you test if a breach of confidentiality is the right thing to do?

Answer 21

Ask myself: will lack of this specific patient information put another person or group I can identify at high risk of serious harm?

Question 22

What to do before breaching confidentiality?

Answer 22

Seek legal advice

Question 23

Can you breach confidentiality with adolescents’ parents?

Answer 23

In many states adolescents may seek treatment without the permission of their parents for certain conditions, such as treatment for pregnancy, contraception, sexually transmitted infections, mental health concerns, and substance abuse. Familiarize yourself with state and local laws, as well as institutional policies, regarding adolescents and healthcare.

Question 24

Why should a physician respect the beliefs of his patients? 2

Answer 24

1. Failure to take those beliefs seriously can undermine the patient’s ability to trust you as her physician
2. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care when they need it

Question 25

What is the responsibility of the physician when a patient refuses a life-saving treatment? 3

Answer 25

1. Make sure that the patient understands the possible and probable outcomes of refusing the proposed treatment 2. Attempt to understand the basis for the patient's refusal and address those concerns and any misperceptions the patient may have 3. In some cases, enlisting the aid of a leader in the patient's cultural or religious community may be helpful

Question 26

Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs? What is the role of the physician here?

Answer 26

Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a significant risk of serious harm to the child's health ==> parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering Role of physician: may need to pursue a court order or seek the involvement of child protective services in order to provide treatment against the wishes of the parents + must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family

Question 27

What kinds of treatment can parents choose not to provide to their children?

Answer 27

Routine immunizations for their children on religious or cultural grounds (treatments that do not place the child at significant risk of substantial harm or suffering) EXCEPTION: an unvaccinated child who has suffered a puncture would from a dirty nail. In the latter case, the risk of tetanus (a serious and almost always fatal disease if not prevented) has become significant, and the provider would be justified in seeking the power of the State (through a court order or involvement of child protective services) to assure that the child receives the vaccination and treatment necessary to prevent tetanus in a high risk situation.

Question 28

Can a patient demand that I provide them with a form of treatment that I am uncomfortable providing? Explain.

Answer 28

NO A physician is not morally obligated to provide treatment modalities that they do not believe offer a benefit to the patient or which may harm the patient. Physicians should also not offer treatments that they do not feel competent to provide or prescribe. However, it is important to take the patient's request seriously, consider accommodating requests that will not harm the patient or others, and attempt to formulate a plan that would be acceptable to both the physician and patient.

Question 29

What are strategies to handle a "difficult patient"? 10 and overall

Answer 29

1. Because clinicians often find these relationships exhausting and frustrating, they should identify trusted colleagues with whom they can share their frustrations 2. Employ strategies that allow the best in the relationship to prevail 3. Use a team approach 4. Address or manage their own attitudes and behaviors that contribute to the problem, recognizing that the patient’s behaviors and attitudes may not change 5. Recognize the source of frustration and remember that you are likely a vital part of the patient’s support system even if the patient appears ungrateful or aggressive 6. Be compassionate and empathic. Keep in mind that most patients whom you find frustrating to deal with have experienced significant adversity in their lives 7. Set clear expectations, ground rules, and boundaries and stick to them. Have regular visits, which helps convey confidence that the patient can deal with transient flare-ups without an emergency visit. 8. Prioritize the patient’s immediate concerns and elicit the patient’s expectations of the visit and their relationship with you. 9. Recognize my own biases 10. Avoid being directive ==> tentative communication style will work better OVERALL: The clinicians should do everything they can to maintain a therapeutic relationship (even one that is not ideal), however in some circumstances they may need to transfer care to another provider. This transfer can be done without threatening the patient.

Question 30

How to understand what a "good" death means for a patient? 3

Answer 30

1. Be sincere and patient and interested 2. Listen more and talk less 3. Ask: "Knowing that all of us have to think about dying at some point, what would be a good death for you?"

Question 31

What can patients choose as a good death that physicians cannot provide? 3 examples.

Answer 31

1. Affirmation of love 2. Completion of important work 3. Last visit from an important person

Question 32

What goals should I have in mind when working towards a decent death for my patient? 5

Answer 32

1. Control of pain and other physical symptoms 2. Involvement of people important to the patient 3. A degree of acceptance by the patient (being realistic) 4. A medical understanding of the patient's disease 5. A process of care that guides patient understanding and decision making aka a coordinated system of providers

Question 33

What are the 4 aspects of hospice care?

Answer 33

1. Pain control 2. Symptom control 3. Psychological issues 4. Spiritual or existential issues

Question 34

Why is hospice care underutilized?

Answer 34

Because connecting hospice care to acute medical care is difficult because that referral implies a "switch" from curative to palliative medicine - a model that does not fit comfortably in many illnesses

Question 35

What 4 things should you know in order to care for a dying patient?

Answer 35

1. The patient's story 2. The body 3. The medical care system available for this particular patient 4. Yourself because you, as a physician, can be an instrument of healing, or an instrument that does damage

Question 36

What is medical futility?

Answer 36

Interventions that are unlikely to produce any significant benefit for the patient

Question 37

What are the 2 types of medical futilities? Describe each.

Answer 37

1. Quantitative futility, where the likelihood that an intervention will benefit the patient is exceedingly poor 2. Qualitative futility, where the quality of benefit an intervention will produce is exceedingly poor

Question 38

What are the ethical obligations of physicians when a health care provider judges an intervention is futile?

Answer 38

Physicians have no obligation to offer treatments that do not benefit patients

Question 39

How can medical futilities cause damage?

Answer 39

1. May increase a patient's pain and discomfort in the final days and weeks of life 2. Give patients and family false hope 3. Delay palliative and comfort care 4. Expend finite medical resources

Question 40

Can a patient ask for whatever treatment they want? Explain.

Answer 40

No! Patients can choose from among medically acceptable treatment options (or to reject all options), but physicians are limited to offering treatments that are consistent with professional standards of care and that confer benefit to the patient

Question 41

Who decides when a particular treatment is futile?

Answer 41

Generally the term medical futility applies when, based on medical data and professional experience, a treating health care provider determines that an intervention is no longer beneficial. BUT, because health professionals may reasonably disagree about when an intervention is futile, all members of the health care team would ideally reach consensus

Question 42

What if the patient or family requests an intervention that the health care team considers futile? What do you do? 3

Answer 42

1. Explain the rationale for such decisions 2. In some instances, it may be appropriate to continue temporarily to make a futile intervention available in order to assist the patient or family in coming to terms with the gravity of their situation and reaching closure (eg: to allow time for a loved one arriving from another state to see the patient for the last time). However, futile interventions should not be used for the benefit of family members if this is likely to cause the patient substantial suffering, or if the family’s interests are clearly at odds with those of the patient. 3. If intractable conflict arises, a fair process for conflict resolution should occur. Involvement of an ethics consultation service is desirable in such situations. The 1999 Texas Advance Directives Act provides one model for designing a fair process for conflict resolution.

Question 43

What should you say instead of "there is nothing I can do for you"?

Answer 43

"Everything possible will be done to ensure the patient's comfort and dignity."

Question 44

What is the difference between futility and rationing?

Answer 44

Futility refers to the benefit of a particular intervention for a particular patient. With futility, the central question is not, "How much money does this treatment cost?" or, "Who else might benefit from it?" but instead, "Does the intervention have any reasonable prospect of helping this patient?"

Question 45

Is an intervention more likely to be futile if a patient is elderly?

Answer 45

NOPE

Question 46

Why is medical futility controversial?

Answer 46

1. The exact definition of medical futility continues to be debated in the scholarly literature 2. An appeal to medical futility is sometimes understood as giving unilateral decision-making authority to physicians at the bedside (BUT proponents of medical futility reject this interpretation, and argue that properly understood futility should reflect a professional consensus, which ultimately is accepted by the wider society that physicians serve) 3. In the clinical setting, an appeal to “futility” can sometimes function as a conversation stopper so some clinicians find that even when the concept applies, the language of “futility” is best avoided in discussions with patients and families and replace it with other language, such as “medically inappropriate” 4. An appeal to medical futility can create the false impression that medical decisions are value-neutral and based solely on the physician’s scientific expertise, yet clearly this is not the case