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OGOPEER Rounds: November 4th, 2008

“Is Ambulatory Care Ethics Unique?”(A review of the literature)

Moji Adurogbangba BDS; MPH; MA (Bioethics)

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• Background

• Definition and objectives

• Literature review

• Discussion

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Where is the care today?

• Major shift of healthcare from the hospital to the outpatient world

• Primary locus of care = Primary locus of moral action

• Ethics needs go where the patient-system encounter occurs, if it is to guide healthcare practice

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Follow the patient

• Outpatient setting is where the initial signs of most illnesses become apparent to the primary care provider

• The environment may blend highly technical application of diagnosis, treatment, symptom management with equal important functions of patient education and coordination of support network

• Considerations previously viewed as external are increasingly recognized as integral to outpatient ethical decision making

• Little research has been done to document ethical issues in ambulatory setting

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A 17-year-old Cambodian female presents at the

outpatient clinic with chief complaint of Dysmenorrhoea. Since her onset of menarche at age 16, menstrual periods have been irregular, of variable duration, and with minimal flow, and severe crampy lower abdominal pain. She denies any sexual activity.

The physical examination was unremarkable and the physician referred the patient to the gynaecology clinic for an initial pelvic exam and consult. The mother believed the speculum exam would “spoil” her virgin daughter, and the patient was afraid because her mother told her it was “painful and horrible.” Both the mother and the patient refused.

(Adapted: BEISER E.N, Rhodes Island Medicine 1992 Aug. 75(8):413)

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Ms J is a 48-year-old woman with a Hx of metastatic breast cancer who has been observed in the oncology clinic for 8 months.– Lung and bone metastases– Spinal cord impingement– Brain metastases – Non of the therapeutic options offered had a chance for cure

After discussing the merits of third-line chemotherapy in detail, the question to Ms J was whether she wanted to continue on a treatment break or restart therapy.– After much silence, she said she just did not know what to do– Her fear: “I just don’t want to make wrong decision.”– Left her caregivers in a similar position of uncertainty and

anxiety about how to proceed

(Adapted: J of Clin Oncology; 2008 May, 26 (13): 2219-20)

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What exactly is ambulatory care?

Ambulatory care is any medical care provided on

an outpatient basis (patients who are not admitted to hospital) Medical dictionary

Historically: One reserved for stable patients with little symptomatology; those requiring little supportive care

Now emerged as: a dynamic, fast paced, comprehensive system

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What exactly is ambulatory care?

e.g., defining characteristics of current oncology outpatient settings:

• coordination of consultation with multiple clinicians• high patient volume to nurse ratio• increase number of procedures and treatments• increase need for patient education with limited time

frame• high volume of patient phone calls• multiple interactions among diverse health care settings,

such as readmission to inpatient service, home care, palliative care and multiple collaboration

• ……….. (Hass 1998)

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What is Ambulatory care ethics?

• Ethics– generic term for various ways of

understanding and examining the moral life

• Some approaches– normative– nonnormative

• Ambulatory ethics: a normative approach to ethics

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What is Ambulatory care ethics?

• Normative: – is a form of inquiry that attempts to answer the

question, what norms for the guidance and evaluation of conduct should we accept and why?

• Nonnormative:– Descriptive ethics and metaethics – their objective is to establish what factually or

conceptually is the case, not what ethically ought to be the case

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Objectives

• To identify the ethical issues arising in ambulatory care

• To better describe ethics in ambulatory setting in order to support further research in this area

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Why ethics in ambulatory care?

• many of our clinical decisions involve one of the basic questions of ethics:

–What is the right thing to do?

• ethics is not a separate area to be dealt with by an ethicist alone – it’s an essential part of decision-making for us all, every day.

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Literature review method

Studies of research in the field of ethical

issues in ambulatory care were identified by: Pub Med & CINAHL search using the term “ethical issues/ethics in any of the following:– ambulatory care - primary care– medical office - managed care – outpatient clinics/outpatient setting

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Literature review method

Results• About 350 citations identified• Approx 150 abstracts were examined• 41 abstracts met the inclusion criteria• The full articles of the 41 abstracts from 1983 to

2008 form the basis of this review.• Articles were of empirical research, commentary

or discursive• Most of the studies were descriptive and

evaluative, making use of brief scenarios or statements and actual cases

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Follow the patient1. Connelly & Dallemura describe ethical problems in the

medical office (1998)2. La Puma and Schiedermayer feature a taxonomy of

outpatient clinical ethics (1989)3. Christensen and Tucker, with a companion article by

Ernle Young, point to managed care and cost-containment as forces that challenge ethics committees to follow patients out of the hospital (1997)

4. Fetters and Brody clarify that most of the medical care is outpatient, as are most of the ethical issues that need to be addressed (199)

5. Sugerman edits a book that extensively reviews 20 ethical issues common to primary care (200)

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Findings: Connelly & DalleMura (1998)

• Findings note ability of physicians to recognize ethical dilemmas in day to day aspects of medical practice

• There was a strong orientation to institutional expectations

• Methods of, and rationale for decision making appear to be inconsistent, non-universal and individualistic without evidence of specific models or criteria

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Ethical issues in “ambulatory care”:

A survey of practitioner’s perceptions (Robillard et al; 1989)

• To measure the perception of the practitioners who provide “ambulatory care” regarding the relative frequency of occurrence of ethical issues in practice.

• 391 physicians and 311 non-physician health care professionals.

• 12 most frequently encountered issues, selected by more than 50% of the respondents, centered on – patient self determination – adequacy of care and professional responsibility– distribution of resources

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Are inpatient and outpatient ethics different?

• Moral problems different and can be framed in different ways.

• Main distinguishing feature: Balance of power between the patient and healthcare professionals

• Differing power dynamic = can shift the balance in relationships, but same ethical guidance system do apply

• Conclusions in ethical problem solving = may be different

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Are inpatient and outpatient ethics different?• Moral world life: the person is primary

• Beliefs and preferences

• Concerns : medical and moral

• Moral problems not as easily recognized or classified

• First step in solving the moral problem: identifying and defining it

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Ethics in the ambulatory setting

Failure to recognize the existence of outpatient

ethical concerns may:• Jeopardize the care of patient• Encourage disruption of the long-term

relationship between patient and physician/HCP• Leave HCP’s who practice in ambulatory care

settings alone without guidance to face complex ethical questions whose answers call for thoughtful reflective analysis

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Ethics in the ambulatory setting

• Allotment of patient care time• Psychological factors that influence the patient’s

preferences• Lack of service continuity which compromise

care• Cultural sensitivity• Physicians expected to combine appropriate

medical care with psychological and moral sensitivity to patients’ values

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Ethics in the ambulatory setting

Attention to ethical issues in ambulatory care will assist HCP’s in providing more informed, rational, and consistent responses to patients, as well as continuing with critical thinking and compassionate caring

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A 17-year-old Cambodian female presents at the

outpatient clinic with chief complaint of Dysmenorrhoea. Since her onset of menarche at age 16, menstrual periods have been irregular, of variable duration, and with minimal flow, and severe crampy lower abdominal pain. She denies any sexual activity.

The physical examination was unremarkable and the physician referred the patient to the gynaecology clinic for an initial pelvic exam and consult. The mother believed the speculum exam would “spoil” her virgin daughter, and the patient was afraid because her mother told her it was “painful and horrible.” Both the mother and the patient refused.

(Adapted: BEISER E.N, Rhodes Island Medicine 1992 Aug. 75(8):413)

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Ethics in the ambulatory setting

Instead of: “how best can we get the Cambodian patient population to accept routine pelvic examinations,”

one might ask: Is it (and why is it) appropriate for health care professionals to try to modify the beliefs and behaviour of their patients?

More over, one might well ask, whether (and if so why) health care professionals should be required to seek to modify their patients’ behaviour.

These formulations suggest that what is at stake is not a value-neutral argument about what works best,

but rather an explicit clash of values as to what “best” means.

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Ms J is a 48-year-old woman with a Hx of metastatic breast cancer who has been observed in the oncology clinic for 8 months.– Lung and bone metastases– Spinal cord impingement– Brain metastases – Non of the therapeutic options offered had a chance for cure

After discussing the merits of third-line chemotherapy in detail, the question to Ms J was whether she wanted to continue on a treatment break or restart therapy.– After much silence, she said she just did not know what to do– Her fear: “I just don’t want to make wrong decision.”– Left her caregivers in a similar position of uncertainty and

anxiety about how to proceed(Adapted: J of Clin Oncology 26 (13): 2219-20)

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Ethics in the ambulatory setting

Physician’s concern:– How much of decision-making burden can the patient

bear emotionally or psychologically?– How to ensure that the patient understands the goals

of care and the potential benefits and risks of each management option?

– Patient continues to remain reluctant to voice an opinion regarding her care

– Can a patient be unburdened the role of primary decision maker?

– How best can physician guide a patient through challenging times of existential pain and anxiety that affects care?

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Ethics in the ambulatory setting

Patients, clinicians and other health

care professionals are making decisions in ambulatory care every day that depend on implicit answers to controversial, poorly defined, and unresolved questions about health care (Povar et al; 2004)

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Ethics in the ambulatory setting

• The art of recognizing and caring for overall clinical and ethical problems of the patients’ rather than simply naming the disease forms the basis of excellent medical practice

• Recognition of such clinical and ethical problems is an important part of good-quality medical care, because the problems can only be considered in decision making after it is recognized

Connelly & DalleMura (1998)

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Themes that emerged

• Paucity of research in ambulatory care ethics• Qualitative studies that describe the ethical

concerns of HCP and ways in which decisions are made may help to clarify some issues

• Studies grounded in daily practice will be able to take account of other possibly significant variables such as length of physician-patient relationship

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Way Forward

• Adhering to a clear, workable definition of ambulatory care will be important to moving this initiative forward

• Study to document characteristics and frequency of occurrence of ethical issues (prevalence and range of ethical issues)

• Qualitative research to confirm, disconfirm or compare the trend of ethical issues with previous studies (Descriptive study)

• Developing an accountability framework for ambulatory care ethics

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Concluding thought!

Empirical research in ambulatory care and ethics has much to offer, in terms of opening actual practice to ethical scrutiny, thus enriching both theoretical ethics and ambulatory care.

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Selected References:

• Jacobson JA; keeping the patient in the loop: ethical issues in out patient referral and consultation. J. Clin. E; 2002 winter 13 (4); 301-9

• Pugno PA. Medical errors in out patient setting: ethics in practice. J. Clin Ethics 2002. Winter(4) 324-9

• Young EW. Ethics in the out patient setting, new challenges and opportunities. Camb. Q health ethics: 19997 summer 6 (3); 293-8

• Montoya ID, Richard AJ. A case for the code of ethics in an ambulatory care setting. J. Ambul Care Manage 1995, July,18 (3):68-76

• Beiser EN. Medical ethics in an out patient setting: Conflicting Cultural values. R I Med.1992. Aug. 75(8):413-6

• Pume LA; Schiedermayer DL. Out patient Clinical Ethics. J. Gen Inter. Med. 1986. Sep-oct; 4 (5):413-20

• Mill MJ, O’Keefe AM. Issues in out patient treatment. J. Clin. Psychiatry. 1983. Jun 44(6 pt 2):33-40.

• Connelly J.E, DalleMura S. Ethical Problems in the Medical Office. JAMA. Aug 12, 1988 vol 260 (6): 812-815

• Robbilard H. M et al.; Ethical Issues in Primary Health: A Survey of Practitioners’ Perceptions. J. of Comm Health Vol.14 (1): 9-17

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