Medical Ethics for ED Docs

Meira LouisDr. Carol Holmen

With Thanks...

• Dr. Carol Holmen• Dr. Moritz Haager• Dr. Rebecca Burton-MacLeod

Goals

• To address practical ethical issues that arise in your daily shifts

• To discuss an approach to solving those issues• To raise awareness of resources you can use

Content

• Consent, Capacity, and Refusal of Care• Confidentiality• End of Life Care and Resuscitation

Negotiations

What’s different about the ED?

• Most literature focused on non-acute setting• Pts present with rapid change in health• Little continuity of care / familiarity with pt• Lack of reliable information• Need to make rapid potential life or death

decisions with limited information• Pts often not in ED of their own volition • Pts often impaired, noncompliant, or hostile

Overarching Principles

• Autonomy• Beneficence• Justice

Decision Framework

1. What is the dilemma?2. What are the alternatives?3. Principles:

1. What does the patient want?2. What can be done?3. What is fair?

4. Are there situational factors (context)?5. Propose a resolution

From: Doing Right. Philip C Hebert. 1995

Then...

• Consider your choice critically– Formulate your choice as a maxim• When would you use it? • When would you be uncomfortable using it?

– Talk to others– Use your resources

• Do the right thing!

Jonsen, Siegler, Winslade

• Medical Indications• Patient Preferences• Quality of Life• Context

Jonsen AR, Siegler M, Winslade WJ (eds): Clinical Ethics, 2nd ed. New York, MacMillan, 1992.

ED specific: Iserson1. Is this a type of ethics problem for which you have

already worked out a rule?1. Yes follow the rule

2. Can I buy some time?1. Yes buy some time

3. Follow these rules:1. Impartiality: Would you be willing to have this happen

to you?2. Universality: Would you use this in all similar cases?3. Interpersonal Justifiability: Would you defend this

decision in public?Iserson KV: Emergency medicine and bioethics: a plan for an expanded view. J Emerg Med 1991;9:65-66.

Cases

Case 1

• Mr. U is a 42-year-old professional who is living with his 14-year-old son and is involved in an acrimonious divorce. He is receiving drug therapy and weekly psychotherapy sessions for depression. Mr. U tells his psychiatrist that his wife makes him so crazy that at times he wants to kill her. He is concerned that in the heat of a confrontation he might act on this impulse. However, he recognizes that killing his wife would be devastating to his son, for whom he feels a great deal of affection and devotion.

Case 2

• 37yo male brought in for minor trauma• Was driving and ran off the road• Etoh level 76• Old charts show 6 prior MVC presentations,

all with elevated etoh

• Is this a reportable condition?

Confidentiality

Public Health Regulations– Mandatory reporting laws • unfit drivers• reportable infections• Gunshots• Stabbings• Child abuse• Dependent people abuse

Reportable InfectionsAcute Flaccid Paralysis, AIDS, Amoebiasis, Anthrax, Arboviral Encephaliditides, Botulism, Brucellosis, Campylobacteriosis, Chancroid, Chlamydia trachomatis, Cholera, Congenital Cytomegalovirus, Congenital Rubella Infection, Congenital Toxoplasmosis, Creutzfeldt-Jacob Disease, Cryptospodiosis, Cyclosporiasis, Dengue Fever, Diphtheria, E-coli O157:H7, Giardiasis, Gonococcal Infections, Hantavirus Pulmonary Syndrome, Hepatitis A, Hepatitis B (Acute or Chronic), Hepatitis C, HIV, Invasive Haemophilus Influenzae, Invasive Meningococcal Disease, Invasive Pneumococcal Disease, Invasive Group A Streptococcal Disease, Legionellosis, Leprosy, Leptospirosis, Listeriosis, Lyme Disease, Lymphogranuloma Venereum, Malaria, Measles, Muco-Purulent Cervicitis, Mumps, Neonatal Herpes Simplex Infection, Non-Gonococcal Urethritis, Pandemic (H1N1) 2009, Pertussis, Poliomyelitis, Psittacosis, Q-Fever, Rabies, Rocky Mountain Spotted Fever, Rubella, Salmonellosis, Shigellosis, Syphilis, Subacute Sclerosing Panencepahalitis, Tetanus, Trichinosis, Tuberculosis, Typhoid / Paratyphoid Fever, Typhus, Varicella (Chickenpox), Varicella Zoster, Vibrio Cholerae, Vibrio Parahemolyticus, West Nile Virus, Yellow Fever, Yersiniosis

What does the law say?

• Although such reporting is not mandatory under the Traffic Safety Act, physicians are protected from legal action when so doing.

• In provinces where physicians are required to report drivers who fail to meet generally accepted medical standards, physicians have been held liable for ignoring their statutory obligation.

From CPSA guidelines on reporting unfit drivers. www.cpsa.ab.ca

Small Groups

• Split into pairs and take a case• Discuss and prepare your suggestions for

handling the situation• Present your case and thoughts back to the

group

Case 1

• Mr N, aged 46• Presents intoxicated with an acute MI• Chronic opiate abuser• Consented for treatment in the ED and

transferred to the ward• Leaves AMA three days later• Was the initial consent valid?

Case 2

• 24yo woman comes to ED for pelvic pain and nausea• Routine labs are drawn and nursing sends a urine tox

screen as they feel pt “looks sketchy”• Beta is positive, US confirms viable 10 wk gestation• Urine tox screen is positive for cocaine• The patient becomes very angry when you try to discuss

the risks of cocaine use in pregnancy and states “That is none of your business. I didn’t agree to a drug test!”

• Should this woman have been formally consented for the drug screen?

Consent• Implied Consent– Patients actions in keeping with agreeing to test or

treatment– Easton et al: What ED procedures fall under

implied consent?• Explicit Consent– Verbal or written, and documented on chart– More involved discussion of risks, benefits, and

alternatives

Defining the Scope of Implied Consent in the Emergency DepartmentRaul B. Easton ; Mark A. Graber ; Jay Monnahan ; Jason Hughes. 2007.

Breaking the law

• Assault– Threatening to touch someone

• Battery– Touching someone without that persons agreement– Any intervention in the ED provided without consent

in situations other than those where consent is not required

• The case of Giovanna Ciarlariello (1993, Ontario)

Case 3

• Mr A, 85yo man who is sole caregiver to his demented wife

• Has a known 8.5cm AAA for which he has refused surgery after being told “he would never survive the operation”

• Presents with a rupture and no family can be contacted

• Can he be taken for emergency surgery?

When is consent not needed?

– Wavier: “please skip the gory details”– Emergencies: If immediate threat to life or limb,

and unable to give consent • Exception: previous refusal of same tx.• Suicide notes

– 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 child with non-accidental trauma

Case 4

• Mr B., a 69yo man with severe Alzheimers disease in a nursing home

• Brought in for suspected pneumonia• No documented LOC• Wife will arrive in 30 minutes• Should you proceed with treatment? If

intubation is needed, can his wife legally agree to that?

Capacity vs Competency

• Competency is a legal determination made by a judge and is all or nothing

• Capacity exists on a spectrum, varies with time and condition and is task specific.

• NOTE: Alberta has no clear legal precedent for our common practice of having the closest family member act as substitute decision maker

Case 5

• Mr H, 65yo man with manic depression, non-compliant with his lithium

• Brought to ED for acute stroke with a-fib• Refuses to start warfarin therapy• What questions do you need to ask to decide

if he is legally able to make that choice?

Approach to Capacity Assessment

• Clinical Assessment – illness, metabolic derangement, intoxicants?

• Provide Information – nature of problem, tests/treatment, alternatives, outcomes of both accepting and refusing care

• Assess patient’s knowledge –understand consequences• Ask why?• Set the threshold – more serious consequences

requires clearer understanding• Make a decision

Case 6

• 43yo male with a toxic ethylene glycol ingestion

• Being held on a Form 1 • Needs dialysis, but will not agree to have the

catheter placed unless his form is cancelled and he is allowed out for a cigarette

• What do you do?

Case 7

• Mr S, 51yo man with ACS• Initial management is done and the pain

disappears• He wants to leave AMA as he is pain free and

his brother died in hospital• What should you do?

End of Life Care

• Roleplaying situations that can complicate good end of life care

Discussing Life Sustaining Treatments

– Clarify Understanding • premorbid condition, acute problem

– Ask about prior wishes • advance directive, substitute decision maker

– Focus on goals • talk about goals as opposed to treatments, outcomes acceptable to

the patient

– Match treatments with goals– Finish strong – offer an opinion, a reasonable plan, and

emphasize that symptomatic care will be provided regardless

“Include a statement that they are not responsible for the outcome”

Case One

• Mr Peterson, a 90yo male with asystole secondary to choking

• He has no advance directive• You have gotten back a pulse and weak

pressure• Discussion between the wife and the clinician

Case Two

• Ms V, a 98 yr old female • witnessed cardiac arrest by her son, who

immediately performed CPR on scene.• no ROSC• they were unable to obtain IV access en route• Family members are present and are

requesting that everything be done• Discussion between the son and clinician

Case Three

• Ms F, 18yo girl with massive SAH• Neurosx recommends withdrawing care• Family approaches you at handover re:mvmts

she is making• Discussion between the family and clinician re:

possibilities of meaningful recovery

Case Four• 94yo man who lives at home with minimal support• Labs suspicious for ascending colangitis• GI comes to FMC at 3am for emergent ERCP Prior to ERCP, R1 level of

care.• During procedure, sats drop to 60s, started on non-rebreather and

sent back to ED• On arrival in ED, ER doc who has been handed over pt declares “I’m

not tubing a 94yo”• ER doc calls family and states “his condition is poor, he would not

survive the ICU. I recommend simply making him comfortable.”• Post-phone call, pt level of care made C1• ICU not called, pt gets 2L of fluid and abx over next 4 hours, down to

2L by NP within one hour• Grandson is confused as to whether he is being treated or not

Case Five

• Ms Y, 60yo woman with end stage pulmonary fibrosis

• Previous transplant candidate• Previous intubations and stay in ICU 6 months

ago• She wishes to be reintubated• Discussion between the husband and clinician

about the best course of action

Case Six• 85yo male found down at his lodge• GCS 7• RR 26, HR 110, BP 90/60, Sats 92% on 6L• SCM discharge summary from one month ago reveals

end stage COPD on 3L home O2• M1 level of care at that time (As per SCM)• Staff states “That was then, this is now. Let’s tube him,

they can always take it out later”• Discussion between daughter and clinician about

whether to withdraw care now that he is tubed

Life Sustaining Treatment

1. You are turning a passive process into what will need to be an active withdrawal of care.

2. You have a small window of time.3. Are you sure of your sources?

Good End of Life Care

• Control of pain and other symptoms• Decisions on the use of life sustaining treatment/

Avoiding inappropriate prolongation of dying• Support of dying patients and their families– Relieving burdens

• What is the patient most concerned about?

– Achieving a sense of control• Focus on treatment goals

– Strengthening relationships with loved ones

How good are we at knowing?• Prospective cohort study in Chicago hospices• Only 20% of predictions about length of life

were accurate• Overall doctors overestimated survival by a

factor of 5• Literature suggests a combination of clinical

gestalt and objective tests

• Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ 2000;320(7233):469–72.• Glare P, Sinclair C, Downing M, Stone P, Maltoni M, Vigano A. Predicting survival in patients with advanced disease. Eur J Cancer. 2008 May;44(8):1146-56.

Resuscitation

• NEJM case study, May 2010

Questions?