Flashcards in Medical Ethics Deck (29):
4 Elements of Principle-Based Model of Ethics:
-Self-determination - must know pt's wishes with respect to his/her illness and must respect pt's autonomy
-Pts are entitled to informed consent and confidentiality
-Autonomy can be compromised if pt has diminished decision-making capacity (ie. psychiatric illness, cognitive impairment)
-Physician must do the most good for the pt and act in the pt's best interest (Usually, respect for pt autonomy SUPERCEDES benificence if pt has capacity)
-Sometimes invoked as reason to limit pt's autonomy if pt cannot make decisions for or care for self
-First do no harm -> benefits must outweigh known risks/harms of any intervention
-Involves physician and pt weighing risks and benefits of a given procedure
-Physicians must offer care that carries the least chance of illness/death
-Must consider fairness/equality in distribution/delivery of a proposed tx or intervention.
-Must consider costs to society and weigh that with benefits to pt
Other factors to consider in Ethics Consults:
Capacity to give informed consent depends on:
-Pt's ability to understand illness, prognosis and proposed tx and alternatives, as well as ability to weigh risks and benefits of having tx
Mneumonic = BRAIN (Benefits, Risks, Alternatives, Indications, Nature)
-Willing or voluntary acceptance of a medical intervention by a pt after adequate discussion with doctor about Nature of intervention, Indications, Risks, Benefits and potential Alternatives.
When is Informed Consent required?
-Required for any significant procedure unless:
1) Emergency Tx is required
2) Pt lacks Decision Making Capacity (must obtain consent from a surrogate)
-For minors, consent OF ONE PARENT is sufficient, even if other parent disagrees.
When do minors (<18) not require parent/guardian to give consent on their behalf:
1) Life-threatening emergencies - when parents can't be contacted
2) Legal emancipation of minors (d/t marriage, in military, financially independent and obtained emancipation)
3) STIs and Substance Abuse Tx - Consent rules for Contraception/Abortion/Pregnancy/Drug & Alcohol Tx vary by state.
4) Refusal of Tx - If a parent's decision to refuse tx for child is not in best interest of child and poses a serious threat to child's wellbeing, doctor may provide tx AGAINST parents' wishes
When must ethics committees be consulted? When are court orders needed?
1) Pt lacks capacity AND/OR Pt has no proxy or advanced directive
2) Disagreement among family OR between family and providers about tx/care
In absence of a living will or DPOA, who can make decisions for pt?
In order of preference:
1) Spouse - 1st choice
-A person's global and legal capacity to make decisions and be held accountable in a court of law.
-Assessed by courts
-DIFFERENT than decision-making capacity
-Pt's ability to understand relevant information, appreciate severity of the medical situation and its consequences, communicate a choice, and deliberate rationally about his/her values in relation to the decision being made.
-Assessed by doctors
-Pts who have capacity have the right to refuse or stop tx
When can a pt's decision to refuse tx be overruled?
-When it endangers the health and welfare of others
Ex: Pt w/active TB must take Abx
-Addresses pt's wishes to maintain, withhold or withdraw life-saving tx in event of terminal disease or persistent vegitative state
-States pt's preferences for CPR and Intubation ONLY
DPOA for Health Care
-Legally designates a surrogate healthcare decision maker if a pt lacks capacity to make decisions. More flexible than a living will
Doctors may refuse a pt or family member's request for further tx/intervention on grounds of futility under these circumstances:
1) No evidence of pathophysiologic rationale for tx
2) Intervention has already failed
3) Maximal intervention is currently failing
4) Tx will not achieve the goals of care
Signs of elder abuse:
1) Cuts, bruises, pressure ulcers, burns
2) Uncommon fractures
3) Malnutrition or dehydration
4) Anogenital injury or infection
5) Evidence of poor caretaking or financial exploitation
Signs of suspected child abuse:
1) Hx given not consistent with injury
2) Delay in seeking medical care
3) Subdural hematomas
4) Retinal hemorrhages
5) Spiral, bucket-handle or rib fractures
6) Injuries in different stages of healing
7) Unusual child or parent behavior
When can a physician without info. from a patient?
-Only if pt requests not to be told, or in the rare case in which a physician determines that disclosure would cause severe and immediate harm to the patients (Therapeutic Privilege).
-Info cannot be withheld upon family request only
What are doctors' obligations regarding medical errors?
-Doctors are OBLIGATED to inform pts of mistakes made and if the cause of the error is not known, the doctor should communicate this with family and pt.
When can doctors override pt confidentiality?
MNEUMONIC: WAIT SEC (Wounds, Automobile driving impairment, Inftxns, Tarasoff - violent crimes, Suicide, Elder abuse, Child abuse)
In these circumstances:
1) Pt intent to commit a violent crime (Tarasoff decision) - due to duty to protect the intended victim by notifying police or warning victim
2) Suicidal pts
3) Child abuse/neglect or Elder abuse
4) Reportable infxtns (HIV, STIs, TB) - must warn public officials and people at risk - best to firs encourage pts to inform loved ones though.
5) Gunshot or knife wounds (duty to notify police)
6) Pt is a danger to others (ie. impaired drivers) - only mandatory in 6 states
How should doctors respond to IPV?
-Not required to report without pt's consent
-Doctors should document injuries, offer support, have resources for assistance if pt desires
Guiding principles for overriding pt confidentiality:
1. Identifiable 3rd party at risk for harm
2. Harm is significant and probable
3. Disclosure will help prevent or mitigate harm
4. Other measures, like convincing pt to self-disclose, have failed
What is a conflict of interet for a doctor?
-When doctors have a personal interest in a given situation that influences their professional obligations.
-Doctors must disclose existing conflicts of interest to affected parties
What are requirements for a civil malpractice lawsuit?
1) Duty - Physician has duty to pt
2) Derelection of duty occurs
3) Damage occurs to pt
4) Direct cause of damage is due to dereliction
Burden of proof = "a preponderance of evidence"