Medical EthicsMedical EthicsMedical Decision MakingMedical Decision Making
Jeffrey J Kaufhold, MD FACPJeffrey J Kaufhold, MD FACPChair, Bioethics Advisory Chair, Bioethics Advisory Committee, Grandview Committee, Grandview
HospitalHospital
Factors to ConsiderFactors to Consider Medical IndicatorsMedical Indicators
DiagnosisDiagnosis PrognosisPrognosis TreatmentTreatment
Quality of LifeQuality of Life
Patient PreferencePatient Preference Advance DirectiveAdvance Directive Prior StatementsPrior Statements Prior Choices pt has Prior Choices pt has
made.made. ContextContext
SocialSocial CulturalCultural LegalLegal FinancialFinancial
Medical Decision MakingMedical Decision Making Heirarchy for decision makingHeirarchy for decision making
1. Competent Patient is always first1. Competent Patient is always first 2. Substituted judgment2. Substituted judgment
Family in rank order:Family in rank order: SpouseSpouse ParentsParents ChildrenChildren OthersOthers
3. Best Interest of the Patient3. Best Interest of the Patient Paternalistic approach by caregiversPaternalistic approach by caregivers
4. Ethics Committee.4. Ethics Committee.July 17, 2004 Robert Orr
SummarySummary History of Conflict in medicineHistory of Conflict in medicine Justice in MedicineJustice in Medicine Social responsibilities of PhysiciansSocial responsibilities of Physicians Medical FutilityMedical Futility
Justice in Clinical MedicineJustice in Clinical Medicine Edmund Pellegrino, MDEdmund Pellegrino, MD
Professor Emeritus of Medicine and Professor Emeritus of Medicine and Medical Ethics, Georgetown University Medical Ethics, Georgetown University Medical CenterMedical Center
Lecture from conference:Lecture from conference: Conflict and Conscience in HealthcareConflict and Conscience in Healthcare July 16, 2004July 16, 2004
History of Conflict in MedicineHistory of Conflict in Medicine Pre-Hippocrates: Self Interest of Pre-Hippocrates: Self Interest of
PhysicianPhysician Hippocrates dared to see pt as primary Hippocrates dared to see pt as primary
focusfocus This was taken up by all of the This was taken up by all of the
monotheistic religions, and preserved by monotheistic religions, and preserved by the Muslims during the middle agesthe Muslims during the middle ages
Adam Smith: Enlightened self interestAdam Smith: Enlightened self interest Bad outcome is bad advertisingBad outcome is bad advertising
Karl Marx: All serve societyKarl Marx: All serve society
History of Conflict in MedicineHistory of Conflict in Medicine Managed CareManaged Care
Limited Resources (Marx influence)Limited Resources (Marx influence) Are they really limited?Are they really limited?
Physician is steward of those resourcesPhysician is steward of those resources Inevitable ranking of the Worth of Inevitable ranking of the Worth of
PatientsPatients Healthy pt is good for societyHealthy pt is good for society Chronic illness is bad for societyChronic illness is bad for society Patient may not be the primary focusPatient may not be the primary focus
Justice in MedicineJustice in Medicine Assumptions:Assumptions:
Physician has competence, acts Physician has competence, acts professionally, and in the interest of the professionally, and in the interest of the patientpatient..
Implicit covenent with societyImplicit covenent with society We are allowed to do We are allowed to do Illegal actsIllegal acts, in order to , in order to
learn the art.learn the art.
Justice in MedicineJustice in Medicine Commutative JusticeCommutative Justice
Contract with patientContract with patient Distributive JusticeDistributive Justice
Allocation of resourcesAllocation of resources Charitable JusticeCharitable Justice
What we ought to do even if pt is abusing What we ought to do even if pt is abusing themselvesthemselves
General JusticeGeneral Justice What do we owe the common good?What do we owe the common good? What does the patient owe the common good?What does the patient owe the common good?
Justice in MedicineJustice in Medicine General JusticeGeneral Justice
Patient has obligation to follow the Patient has obligation to follow the recommendations of the physicianrecommendations of the physician
Physician must take responsibility to define Physician must take responsibility to define what the patient needswhat the patient needs
Not required to do what pt wantsNot required to do what pt wants What good can we do for the patient.What good can we do for the patient.
EpicayaEpicaya Preservation of equityPreservation of equity
Look at the big picture/everyone makes Look at the big picture/everyone makes mistakesmistakes
Social Responsibility of PhysiciansSocial Responsibility of Physicians
Best Medicine possible Best Medicine possible Stay up to dateStay up to date Participate in public debateParticipate in public debate
We have the knowledge needed to inform We have the knowledge needed to inform the debatethe debate
Advocacy for those who need helpAdvocacy for those who need help Legislators have the responsibility to Legislators have the responsibility to
make decisions about distribution of make decisions about distribution of resources.resources.
Medical FutilityMedical FutilityDaniel P Sulmasy, OFM, MD, PhDDaniel P Sulmasy, OFM, MD, PhDDirector, The Bioethics InstituteDirector, The Bioethics Institute
New York Medical CenterNew York Medical CenterJuly 17, 2004 July 17, 2004
CaseCase 76 y.o. female with Multiple Myeloma 76 y.o. female with Multiple Myeloma
admitted with Sepsis. admitted with Sepsis. Heavily pretreated, no further chemo Heavily pretreated, no further chemo
availableavailable On vent, PressorsOn vent, Pressors Daughter wants everything done.Daughter wants everything done.
The Basis for Medical FutilityThe Basis for Medical Futility History of FutilityHistory of Futility Religious PrinciplesReligious Principles Moral PrinciplesMoral Principles ProbabilityProbability Dealing with the case.Dealing with the case.
Futility, a HistoryFutility, a History Smith Papyrus, 1700 B.C.Smith Papyrus, 1700 B.C.
Entreaty to not intervene if spinal cord is Entreaty to not intervene if spinal cord is transectedtransected
This Egyptian papyrus, found in 1900’s, This Egyptian papyrus, found in 1900’s, references a much older text.references a much older text.
Futility, a HistoryFutility, a History Smith Papyrus, 1700 B.C.Smith Papyrus, 1700 B.C.
Entreaty to not intervene if spinal cord is Entreaty to not intervene if spinal cord is transectedtransected
Hippocrates, 460 – 377 B.C.Hippocrates, 460 – 377 B.C. ““On The Art” – the physician should On The Art” – the physician should
refuse to treat in cases where medicine refuse to treat in cases where medicine is powerlessis powerless
Social norms regarding cancerSocial norms regarding cancer 1950’s – call it something else.1950’s – call it something else. 1960’s – Inform pt of diagnosis1960’s – Inform pt of diagnosis 1970’s – Informed consent1970’s – Informed consent 1990’s - Informed Demand 1990’s - Informed Demand
Religious PrinciplesReligious Principles Intrinsic DignityIntrinsic Dignity
Made in the image of GodMade in the image of God Alien Dignity Alien Dignity
Relationships define our being.Relationships define our being. Also a fact that we are FiniteAlso a fact that we are Finite
Religious PrinciplesReligious Principles Life is a gift, and we are its stewardsLife is a gift, and we are its stewards Limits to stewardshipLimits to stewardship
Illness is a burdenIllness is a burden Costs and burden to family/caregiversCosts and burden to family/caregivers Futile care need not be given.Futile care need not be given.
Moral PrinciplesMoral Principles No moral obligation to provide futile No moral obligation to provide futile
Tx.Tx. What is Futile Treatment?What is Futile Treatment?
Non-beneficialNon-beneficial Inappropriate treatment at the end of Inappropriate treatment at the end of
lifelife What is the real goal?What is the real goal?
Free of pain and sufferingFree of pain and suffering
Moral PrinciplesMoral Principles What is Futile Treatment?What is Futile Treatment?
Subjective FutilitySubjective Futility Patient won’t be able to appreciate benefitPatient won’t be able to appreciate benefit This is This is not sufficientnot sufficient moral argument to moral argument to
withhold therapywithhold therapy Objective Futility (biomedical use)Objective Futility (biomedical use)
No objective benefit to any observerNo objective benefit to any observer
Moral PrinciplesMoral Principles Medical RealismMedical Realism
There are factsThere are facts Trained people can make judgementsTrained people can make judgements But we are fallibleBut we are fallible We have to relate the We have to relate the datadata to the to the
patientpatient This is the tricky part of the art.This is the tricky part of the art. Requires use of probability.Requires use of probability.
ProbabilityProbability Is this patient going to die?Is this patient going to die?
Probably.Probably. Even with treatment?Even with treatment?
Probably.Probably. Can you be more specific?Can you be more specific?
Probably.Probably.
ProbabilityProbability Prognosis is the probability that a Prognosis is the probability that a
patient will respond to tx, plus the patient will respond to tx, plus the probability that the disease will kill probability that the disease will kill them.them.
Probability that we use in individual Probability that we use in individual cases comes from objective data cases comes from objective data about the particulars of the case, plus about the particulars of the case, plus experience, plus common sense.experience, plus common sense. This process is fallible, but we do the This process is fallible, but we do the
best we can.best we can.
ProbabilityProbability Three factors:Three factors:
Frequency: Frequency: Prediction: Prediction: Strength of beliefStrength of belief
Lets apply to the case:Lets apply to the case:
Probability Probability Myeloma with sepsisMyeloma with sepsis
Frequency: (80% of myeloma pts do Frequency: (80% of myeloma pts do not wean from vent)not wean from vent)
Based on studiesBased on studies Prediction: (1% likelihood of survival Prediction: (1% likelihood of survival
for this pt)for this pt) Based on Karnovsky score in Onc literatureBased on Karnovsky score in Onc literature Based on APACHE score in ICU literatureBased on APACHE score in ICU literature
Strength of beliefStrength of belief P valueP value ““Reasonable degree of medical certitude”Reasonable degree of medical certitude”
““Ultimately, Ethics is Ultimately, Ethics is about What to Do”about What to Do”
Aristotle, 384 – 322 B.C.Aristotle, 384 – 322 B.C.
Morality of FutilityMorality of Futility Judgment enters Morality when Judgment enters Morality when
decision is made about taking action.decision is made about taking action. Actions:Actions:
Wean from vent?Wean from vent? Wean from pressors?Wean from pressors? Stop Antibiotics?Stop Antibiotics? Stop tube feedings/ IV fluids?Stop tube feedings/ IV fluids?
Morality of FutilityMorality of Futility Judgment enters Morality when Judgment enters Morality when
decision is made about taking action.decision is made about taking action. Approaches:Approaches:
Pragmatic – does this help the patient?Pragmatic – does this help the patient? Remember, removing pt from life support may kill Remember, removing pt from life support may kill
them, but might it also stop their suffering?them, but might it also stop their suffering? Moral (prudential) – is this the right thing to Moral (prudential) – is this the right thing to
do?do?
Back to the CaseBack to the CaseMyeloma with sepsisMyeloma with sepsis
Frequency: Frequency: (80% of myeloma pts do not wean from vent)(80% of myeloma pts do not wean from vent)
Prediction: Prediction: (1% likelihood of survival for this pt)(1% likelihood of survival for this pt)
Strength of beliefStrength of belief ““Reasonable degree of medical certitude”Reasonable degree of medical certitude”
Pragmatic approachPragmatic approach CPR will not help pt get betterCPR will not help pt get better
Prudential approachPrudential approach Morally wrong to provide inappropriate treatment.Morally wrong to provide inappropriate treatment.
Back to the CaseBack to the CaseMyeloma with sepsisMyeloma with sepsis
Pragmatic approachPragmatic approach CPR will not help pt get betterCPR will not help pt get better
Prudential approachPrudential approach Morally wrong to provide inappropriate Morally wrong to provide inappropriate
treatment.treatment. Recommendation:Recommendation:
Make the pt DNR – CC arrestMake the pt DNR – CC arrest Consider withdrawal of life supportConsider withdrawal of life support
How do we proceed with the family? How do we proceed with the family?
Back to the CaseBack to the CaseMyeloma with sepsisMyeloma with sepsis
The family in town wants to keep Mom The family in town wants to keep Mom comfortable, and see she is suffering on comfortable, and see she is suffering on life support.life support.
However, the out of town daughter is However, the out of town daughter is “in charge” and insists everything be “in charge” and insists everything be done.done.
Cultural barriers arise.Cultural barriers arise. Tilden. Nurs Res: 2001, 50;105-115.Tilden. Nurs Res: 2001, 50;105-115.
Its Stressful to be the surrogateIts Stressful to be the surrogate Guilt, Ambivalence, Depression, Anger.Guilt, Ambivalence, Depression, Anger.
How to proceed ClinicallyHow to proceed Clinically Establish relationship with familyEstablish relationship with family Review case (how did she get here)Review case (how did she get here) Describe level of illnessDescribe level of illness Lay out optionsLay out options Establish goals Establish goals
keep her alive until son gets herekeep her alive until son gets here Maintain comfort no matter what.Maintain comfort no matter what.
Establish LimitsEstablish Limits will not resuscitate her if heart stops.will not resuscitate her if heart stops.
Praying for a MiraclePraying for a Miracle Affirm that this is OKAffirm that this is OK Bear witness in faith, resurrectionBear witness in faith, resurrection God is present and answering all our God is present and answering all our
prayers, even if a miracle doesn’t prayers, even if a miracle doesn’t comecome
Hippocratic Oath Hippocratic Oath Now being admitted to the profession Now being admitted to the profession
of medicine, I solemnly pledge to of medicine, I solemnly pledge to consecrate my life to the service of consecrate my life to the service of humanity.humanity.
I will give respect and gratitude to my I will give respect and gratitude to my deserving teachers.deserving teachers.
I will practice medicine with conscience I will practice medicine with conscience and dignity.and dignity.
The health and life of my patients will The health and life of my patients will be my first consideration.be my first consideration.
Part 1
Hippocratic OathHippocratic Oath I will hold in confidence all that my patient I will hold in confidence all that my patient
confides in me.confides in me. I will maintain the honor and noble I will maintain the honor and noble
traditions of the medical profession.traditions of the medical profession. My colleagues will be as my brothers and My colleagues will be as my brothers and
sisters.sisters. I will not permit consideration of race, I will not permit consideration of race,
religion, nationality politics or social religion, nationality politics or social standing to intervene between my duty and standing to intervene between my duty and my patient.my patient. Part 2
Hippocratic OathHippocratic Oath I will maintain the utmost respect for I will maintain the utmost respect for
human life.human life. Even under threat I will not use my Even under threat I will not use my
knowledge contrary to the laws of knowledge contrary to the laws of humanity.humanity.
These promises I make freely and These promises I make freely and upon my honor.upon my honor.
Part 3
AesculpiusAesculpius Staff with single serpentStaff with single serpent ““Life is short, Art is long, experience Life is short, Art is long, experience
difficult.”difficult.”
Greek: Obi OE BpAXYE, HTEXNH MA Greek: Obi OE BpAXYE, HTEXNH MA KPH, O KAI POE OE YE.KPH, O KAI POE OE YE.
CompetencyCompetency Assessing Decision Making Assessing Decision Making
CapacityCapacity
Jeffrey J Kaufhold, MD FACPJeffrey J Kaufhold, MD FACP Chair, Bioethics Advisory Committee,Chair, Bioethics Advisory Committee,
Grandview HospitalGrandview Hospital
A Guide to assessing Decision Making A Guide to assessing Decision Making Capacity.Capacity.
Roger C. Jones, MD, Timothy Holden, Roger C. Jones, MD, Timothy Holden, MDMD
Cleveland Clinic Journal of MedicineCleveland Clinic Journal of Medicine Vol 71, December 2004, p 971-5.Vol 71, December 2004, p 971-5.
SummarySummary Physicians need an efficient way to Physicians need an efficient way to
determine a pts decision making determine a pts decision making capacitycapacity
This capacity must be assessed for This capacity must be assessed for each decision and not inferred on the each decision and not inferred on the basis of pts diagnosis.basis of pts diagnosis.
Documentation of the process used Documentation of the process used and decisions reached is necessary.and decisions reached is necessary.
Case 1Case 1 Pt admitted for sepsisPt admitted for sepsis Poor access for pressors and labsPoor access for pressors and labs Pt is confusedPt is confused No family is availableNo family is available Can pt consent to line placement?Can pt consent to line placement?
Case 2Case 2 Elderly pt with Alzheimers and a Elderly pt with Alzheimers and a
MMSE score of 23 of 30 refuses MMSE score of 23 of 30 refuses elective Chole.elective Chole.
Daughter/DPAHC requests surgery.Daughter/DPAHC requests surgery. Can the pt refuse? Can the pt refuse? How can his competency be How can his competency be
evaluated?evaluated?
Case 3Case 3 Pt admitted with acute pneumoniaPt admitted with acute pneumonia Also diagnosed with severe depressionAlso diagnosed with severe depression
Many answers are “I don’t know/I don’t care”Many answers are “I don’t know/I don’t care” Pt refuses treatment, stating “ I don’t Pt refuses treatment, stating “ I don’t
care if I live or die”care if I live or die” Does pt have decision making capacity?Does pt have decision making capacity? If not how do you procede?If not how do you procede?
ConsentConsent Requirements:Requirements:
AutonomyAutonomy Capacity to understand and communicateCapacity to understand and communicate Ability to reasonAbility to reason Recognized set of values or goalsRecognized set of values or goals
Agreement with the physician does Agreement with the physician does not imply that pts capacity to give not imply that pts capacity to give consent is intact!consent is intact!
CompetencyCompetency Legal designations determined by the Legal designations determined by the
courts.courts. Decision making capacity is clinically Decision making capacity is clinically
determined by physician at the bedside.determined by physician at the bedside. Adults are presumed competent unless Adults are presumed competent unless
legally judged to be incompetent.legally judged to be incompetent. President’s commission for the study of President’s commission for the study of
Ethical Problems in Medicine 1982.Ethical Problems in Medicine 1982. Avoid Routine recourse to legal system. Avoid Routine recourse to legal system.
Clinical ApproachClinical Approach Urgency of the clinical situation Urgency of the clinical situation
determines how to procede.determines how to procede. Urgent situationUrgent situation Pt not able to communicate / no Pt not able to communicate / no
spokespersonspokesperson Assume that a reasonable person would Assume that a reasonable person would
not want to be denied life saving not want to be denied life saving treatment.treatment.
““Implied Consent”Implied Consent”
Clinical approachClinical approach Nonemergent situationNonemergent situation
What are the risks and benefits?What are the risks and benefits? Low risk may not require much decision Low risk may not require much decision
making capacity.making capacity. I’m here to draw your blood for a hct.I’m here to draw your blood for a hct.
High risk may require significant High risk may require significant deliberation.deliberation.
Should a pt with lung cancer and severe CAD Should a pt with lung cancer and severe CAD undergo pneumonectomy for possible cure?undergo pneumonectomy for possible cure?
Algorithm for assessmentAlgorithm for assessment Miller and Marin, Emergency Med Miller and Marin, Emergency Med
Clinic North Am, 2000; 18: 233-241.Clinic North Am, 2000; 18: 233-241. Series of simple questionsSeries of simple questions Doesn’t take into account the level of Doesn’t take into account the level of
risk or benefit of a treatment.risk or benefit of a treatment.
AlgorithmAlgorithm 1. Do the history and physical confirm 1. Do the history and physical confirm
that the pt can communicate a choice?that the pt can communicate a choice? Is their memory good?Is their memory good? Is judgement appropriate?Is judgement appropriate? Can they maintain a conversation/follow Can they maintain a conversation/follow
your line of questioning?your line of questioning? Are their answers consistent?Are their answers consistent? If yes: procede to question 2If yes: procede to question 2 If No: pt needs help with decision making. If No: pt needs help with decision making.
AlgorithmAlgorithm 2. Can the pt understand the essential 2. Can the pt understand the essential
elements of informed consent?elements of informed consent? What is your present condition?What is your present condition? What treatment is being recommended?What treatment is being recommended? What might happen to you if you agree to the What might happen to you if you agree to the
treatment?treatment? What might happen to you if you refuse the What might happen to you if you refuse the
treatment?treatment? What are the alternatives available?What are the alternatives available?
Test of pts understanding of the discussion.Test of pts understanding of the discussion.
AlgorithmAlgorithm 3. Can the pt assign personal values 3. Can the pt assign personal values
to the risks and benefits of to the risks and benefits of intervention?intervention? Jehovahs witness refusal to accept Jehovahs witness refusal to accept
transfusion reflects different set of transfusion reflects different set of values.values.
AlgorithmAlgorithm 4. Can the pt manipulate the 4. Can the pt manipulate the
information rationally and logically?information rationally and logically? Can you follow how the patient got to Can you follow how the patient got to
their decision?their decision?
AlgorithmAlgorithm 5. Is the patients decision making 5. Is the patients decision making
capacity stable over time?capacity stable over time? Repeat the question several minutes Repeat the question several minutes
later/ after more discussion.later/ after more discussion.
AlgorithmAlgorithm Benefits of this approach:Benefits of this approach:
Avoids the tendency to devalue capacity Avoids the tendency to devalue capacity of chronically ill ptsof chronically ill pts
Reduces reliance on surrogate decision Reduces reliance on surrogate decision makers when not necessarymakers when not necessary
Avoids judgement based on whether pt Avoids judgement based on whether pt agrees with Doctor.agrees with Doctor.
AlgorithmAlgorithm Limitations:Limitations:
Language barriersLanguage barriers Cultural barriersCultural barriers
African Americans tendency to not look at African Americans tendency to not look at speaker, distrust of system leading to speaker, distrust of system leading to misinterpretation of options providedmisinterpretation of options provided
Some of the assessment questions are Some of the assessment questions are subjective.subjective.
When surrogate must be consultedWhen surrogate must be consulted
If the pt is incompetent as If the pt is incompetent as determined by the courtdetermined by the court
If the pts decision making capacity is If the pts decision making capacity is in doubtin doubt
If the pt is unable to understand If the pt is unable to understand options or is unable to decide.options or is unable to decide.
Case 1Case 1 Pt admitted for sepsisPt admitted for sepsis Poor access for pressors and labsPoor access for pressors and labs Pt is confusedPt is confused No family is availableNo family is available Does pt have to consent to line Does pt have to consent to line
placement?placement?
No, use implied consent.No, use implied consent.
Case 2Case 2 Elderly pt with Alzheimers and a MMSE Elderly pt with Alzheimers and a MMSE
score of 23 of 30 refuses elective Chole.score of 23 of 30 refuses elective Chole. Daughter/DPAHC requests surgery.Daughter/DPAHC requests surgery. Can the pt refuse? Can the pt refuse?
MMSE can miss cognitive deficitsMMSE can miss cognitive deficits How can his competency be evaluated?How can his competency be evaluated?
Psychiatry consult, ethics consult if needed.Psychiatry consult, ethics consult if needed. In this case, daughter served as decision maker.In this case, daughter served as decision maker.
Case 3Case 3 Pt admitted with acute pneumoniaPt admitted with acute pneumonia Also diagnosed with severe depressionAlso diagnosed with severe depression
Many answers are “I don’t know/I don’t care”Many answers are “I don’t know/I don’t care” Pt refuses treatment, stating “ I don’t care Pt refuses treatment, stating “ I don’t care
if I live or die”if I live or die” Does pt have decision making capacity?Does pt have decision making capacity?
Physician determined that pt does not, due to Physician determined that pt does not, due to depression.depression.
Treat depression and pneumonia.Treat depression and pneumonia. Capacity may return once depression treated.Capacity may return once depression treated.
SummarySummary Physicians must determine decision Physicians must determine decision
making capacity every day.making capacity every day. Diagnosis does not imply impaired Diagnosis does not imply impaired
capacity, nor does good MMSE imply capacity, nor does good MMSE imply that pt has capacity.that pt has capacity.
Agreement or disagreement with Agreement or disagreement with physicians recommendation does not physicians recommendation does not imply capacity is intact or impaired.imply capacity is intact or impaired.
SummarySummary Differing pt values may result in Differing pt values may result in
conflict and raise questions about pts conflict and raise questions about pts capacity.capacity.
Algorithm provides a simple method Algorithm provides a simple method to determine D.M. capacityto determine D.M. capacity
Competency is legal determinationCompetency is legal determination DMC is clinical determination.DMC is clinical determination.
