advertisement

Sicu Intro Bioethics

50 %
50 %
advertisement
Information about Sicu Intro Bioethics

Published on July 20, 2007

Author: shivabirdi

Source: slideshare.net

advertisement

Introduction to Bioethics Martin L. Smith, STD Director of Clinical Ethics Department of Bioethics

Department of Bioethics 6 Staff Consultants. Consult pager (22512). Separate from the Ethics Committee. Can help in situations where there is not a clear single best option. When values conflict or there is ethical or moral uncertainty. Open access: Available to healthcare teams, families, and patients. Advisory.

6 Staff Consultants. Consult pager (22512).

Separate from the Ethics Committee.

Can help in situations where there is not a clear single best option.

When values conflict or there is ethical or moral uncertainty.

Open access: Available to healthcare teams, families, and patients.

Advisory.

Content and Topics Informed Consent and Communication. Confidentiality. Advance Directives: Living Will Durable Power of Attorney for Health care Medical Futility. DNR Orders. Research.

Informed Consent and Communication.

Confidentiality.

Advance Directives:

Living Will

Durable Power of Attorney for Health care

Medical Futility.

DNR Orders.

Research.

Informed Consent Informed consent entails right to refuse. Generally, informed consent should be given by patient or surrogate. But there are exceptions…. And in the ICU, “blanket consent” covers many situations. Documentation: “RBAPC.”

Informed consent entails right to refuse.

Generally, informed consent should be given by patient or surrogate.

But there are exceptions….

And in the ICU, “blanket consent” covers many situations.

Documentation: “RBAPC.”

Communication Clear communication is part of good care. View self as an “educator” of patient and family (but not just raw data). Provide adequate time for family to talk. Listen for the underlying values and goals. Get comfortable with occasional silences. What is impact of family interests?

Clear communication is part of good care.

View self as an “educator” of patient and family (but not just raw data).

Provide adequate time for family to talk.

Listen for the underlying values and goals.

Get comfortable with occasional silences.

What is impact of family interests?

Communication Bloopers Do you want us to do everything? Should we stop everything? There is nothing more we can do. He failed all the treatments we’ve tried. What do you want us to do if s/he stops breathing? Others???

Do you want us to do everything?

Should we stop everything?

There is nothing more we can do.

He failed all the treatments we’ve tried.

What do you want us to do if s/he stops breathing?

Others???

Stereotyping of Patients/Families Generalizations are rarely useful. Individuals vary greatly. Find a balance. Avoid nick-names/jokes Can impact patient care May impact other MDs/RNs Patient/family overhears

Generalizations are rarely useful.

Individuals vary greatly.

Find a balance.

Avoid nick-names/jokes

Can impact patient care

May impact other MDs/RNs

Patient/family overhears

Confidentiality Patient’s reputation could be at stake. Establish to whom you are giving information. Rarely should patient information be withheld from the patient.

Patient’s reputation could be at stake.

Establish to whom you are giving information.

Rarely should patient information be withheld from the patient.

Advance Directives Oral or written expressions by an adult with decision making capacity conveying wishes related to medical care in anticipation of being unable to communicate wishes. Patient, not family, can revoke at any time (document in medical record) Verbal or written revocation Should have a witness Explicit documentation

Oral or written expressions by an adult with decision making capacity conveying wishes related to medical care in anticipation of being unable to communicate wishes.

Patient, not family, can revoke at any time (document in medical record)

Verbal or written revocation

Should have a witness

Explicit documentation

Living Will Terminal illness or PVS (documented by 2 physicians) AND patient lacks decision making capacity. Allows specific instructions: to receive or withhold/withdraw treatments. Under Ohio law, requires compliance. Involvement of surrogate is not needed. PVS and medically supplied nutrition and hydration: Initials needed.

Terminal illness or PVS (documented by 2 physicians) AND patient lacks decision making capacity.

Allows specific instructions: to receive or withhold/withdraw treatments.

Under Ohio law, requires compliance.

Involvement of surrogate is not needed.

PVS and medically supplied nutrition and hydration: Initials needed.

Durable Power of Attorney for Health Care Activated when decision making incapacity occurs. Names agent empowered to make medical decisions. Applies to any medical decision with limited exceptions. Allows specific instructions.

Activated when decision making incapacity occurs.

Names agent empowered to make medical decisions.

Applies to any medical decision with limited exceptions.

Allows specific instructions.

Procedures For Handling ADs Inquire about existence of AD. Social Work/EPIC maintains copies. Place newly acquired copies of AD on chart and inform Social Work. Social Work (and Pastoral Care) can assist patient in completing an AD.

Inquire about existence of AD.

Social Work/EPIC maintains copies.

Place newly acquired copies of AD on chart and inform Social Work.

Social Work (and Pastoral Care) can assist patient in completing an AD.

Ohio Order of Decision Makers Legal guardian Medical Power of Attorney Spouse Majority of adult children Parents Majority of adult siblings Nearest adult related by blood or adoption who is reasonably available

Legal guardian

Medical Power of Attorney

Spouse

Majority of adult children

Parents

Majority of adult siblings

Nearest adult related by blood or adoption who is reasonably available

Medical Futility - AMA Guidelines Patient has right to refuse treatment. Physicians can refuse to provide treatment judged to be medically futile. Advises physicians against non-medical value judgments that are inconsistent with patient autonomy. (JAMA 1991; 265:1868-1871)

Patient has right to refuse treatment.

Physicians can refuse to provide treatment judged to be medically futile.

Advises physicians against non-medical value judgments that are inconsistent with patient autonomy.

(JAMA 1991; 265:1868-1871)

Medical Futility - CC Policy Definition: Does not achieve its physiological objective Offers no benefit to the patient Violates reasonable medical standards No right to insist on futile treatment. Recognition of occasional need to continue such treatment for limited time.

Policy Definition:

Does not achieve its physiological objective

Offers no benefit to the patient

Violates reasonable medical standards

No right to insist on futile treatment.

Recognition of occasional need to continue such treatment for limited time.

CC Procedures for Medical Futility Shared decision making and consensus favored for conflict resolution. Support physician judgment within legal and ethical constraints, but need to address transfer options. Before unilateral withdrawal, Ethics Committee consult should be called.

Shared decision making and consensus favored for conflict resolution.

Support physician judgment within legal and ethical constraints, but need to address transfer options.

Before unilateral withdrawal, Ethics Committee consult should be called.

Patient/Family Care Conferences

Case Illustration: Nell Age 78, ovarian cancer, significant metastases to both lungs. Front-line combination chemotherapy could not be administered due to low platelet counts. A lower dose of a single agent was given. Hospitalized due to acute renal failure, hypotension, and respiratory distress. Dialysis. Admitted to ICU for respiratory failure. Ventilator. Massive GI bleed (blood transfusions) and growing signs of hepatic failure. Patient arousable and responds to commands.

Age 78, ovarian cancer, significant metastases to both lungs.

Front-line combination chemotherapy could not be administered due to low platelet counts. A lower dose of a single agent was given.

Hospitalized due to acute renal failure, hypotension, and respiratory distress. Dialysis.

Admitted to ICU for respiratory failure. Ventilator.

Massive GI bleed (blood transfusions) and growing signs of hepatic failure.

Patient arousable and responds to commands.

Case Illustration: Nell Texas Living Will (not typical): In the event of terminal condition, “I request that I be kept alive … using available life-sustaining treatment.” DNR order written after bedside discussion with patient and 2 daughters. DNR rescinded a few hours later when patient communicated to daughters 3 times, “I want to live,” in response to family question about CPR. Second DNR order written two days later, after ICU physician met with daughters, but then rescinded that evening at the family’s request. The family believes that Nell would want CPR.

Texas Living Will (not typical): In the event of terminal condition, “I request that I be kept alive … using available life-sustaining treatment.”

DNR order written after bedside discussion with patient and 2 daughters.

DNR rescinded a few hours later when patient communicated to daughters 3 times, “I want to live,” in response to family question about CPR.

Second DNR order written two days later, after ICU physician met with daughters, but then rescinded that evening at the family’s request.

The family believes that Nell would want CPR.

Ohio Portable DNR State-wide logo for Identification and Orders Allows 2 types: DNRCC & DNRCC-Arrest Provides immunity for compliance with law For patients arriving with portable DNR, rewrite on Cleveland Clinic DNR order form At Cleveland Clinic a DNR is an Attending’s order

State-wide logo for Identification and Orders

Allows 2 types: DNRCC & DNRCC-Arrest

Provides immunity for compliance with law

For patients arriving with portable DNR, rewrite on Cleveland Clinic DNR order form

At Cleveland Clinic a DNR is an Attending’s order

Ohio DNR Comfort Care You will: Suction the airway Administer oxygen Position for comfort Splint or immobilize Control bleeding Provide pain medication Contact other appropriate health care providers such as hospice, home health, attending physician/CNP/CNS Provide emotional support

You will:

Suction the airway

Administer oxygen

Position for comfort

Splint or immobilize

Control bleeding

Provide pain medication

Contact other appropriate health care providers such as hospice, home health, attending physician/CNP/CNS

Provide emotional support

DNR Comfort Care Protocol You will not : Administer chest compressions Insert an artificial airway Administer resuscitative drugs Defibrillate or cardiovert Provide respiratory assistance (other than suctioning the airway and administering oxygen) Initiate resuscitative IV, or Initiate cardiac monitoring

You will not :

Administer chest compressions

Insert an artificial airway

Administer resuscitative drugs

Defibrillate or cardiovert

Provide respiratory assistance (other than suctioning the airway and administering oxygen)

Initiate resuscitative IV, or Initiate cardiac monitoring

Activation of Ohio DNR Protocol DNR Comfort Care: At time order is given DNR Comfort Care—Arrest: At time of cardiac or respiratory arrest Cardiac arrest=absence palpable pulse. Respiratory arrest=absence of spontaneous respirations/presence of agonal breathing.

DNR Comfort Care:

At time order is given

DNR Comfort Care—Arrest:

At time of cardiac or respiratory arrest

Cardiac arrest=absence palpable pulse.

Respiratory arrest=absence of spontaneous respirations/presence of agonal breathing.

DNR - Specified Not portable outside of Cleveland Clinic Appropriate for patients that might not want CPR, but would like other medical interventions Raises questions about partial/limited CPR attempts. Should make “medical sense”

Not portable outside of Cleveland Clinic

Appropriate for patients that might not want CPR, but would like other medical interventions

Raises questions about partial/limited CPR attempts.

Should make “medical sense”

Consent for DNR Orders Ohio DNR law: presumes informed consent of patient or surrogate Cleveland Clinic Policy: No obligation to initiate CPR if resuscitation would be futile, i.e.,: If resuscitation would not achieve its physiological objective, would offer no benefit to the patient, and would violate reasonable medical standards

Ohio DNR law: presumes informed consent of patient or surrogate

Cleveland Clinic Policy: No obligation to initiate CPR if resuscitation would be futile, i.e.,:

If resuscitation would not achieve its physiological objective, would offer no benefit to the patient, and would violate reasonable medical standards

DNR in the OR Prior to any invasive procedure any existing DNR order should be reviewed with patient or patient’s surrogate. Changes should be documented in the patient’s medical record with a notation indicating when and if the original DNR order should be reinstated. When does a surgical procedure end?

Prior to any invasive procedure any existing DNR order should be reviewed with patient or patient’s surrogate.

Changes should be documented in the patient’s medical record with a notation indicating when and if the original DNR order should be reinstated.

When does a surgical procedure end?

Research Research and patient care are not the same. Different level and documentation of consent needed for research when it deviates from standard of care. ICU populations are often extremely vulnerable to coercion. Innovation?

Research and patient care are not the same.

Different level and documentation of consent needed for research when it deviates from standard of care.

ICU populations are often extremely vulnerable to coercion.

Innovation?

Contact/Acknowledgment Contact Department of Bioethics with comments or questions. Consult Pager: 22512 (24 hr/ 7day) Department Telephone: x4-8720

Contact Department of Bioethics with comments or questions.

Consult Pager: 22512 (24 hr/ 7day)

Department Telephone: x4-8720

Add a comment

Related pages

Sicu | LinkedIn

View 7466 Sicu posts, presentations, experts, and more. Get the professional knowledge you need on LinkedIn.
Read more

Carolyn E. Stevens | LinkedIn

View Carolyn E. Stevens's professional profile on LinkedIn. LinkedIn is the world's largest business network, helping professionals like Carolyn E. Stevens ...
Read more

Intro to 4th Year Presentation - Stritch School of Medicine

Intro to 4th Year Presentation ... time available пЃ¬ Bioethics Requirements пЃ ... пЃ¬ Examples of services: MICU, SICU, BICU ...
Read more

Loyola University Chicago Stritch School of Medicine

Bioethics Requirements. Completion of Ethics Case Paper (should be completed during third year) ... Examples of services: MICU, SICU, BICU, CCU, NICU, PICU.
Read more

Student introduction Jeremy Morall - YouTube

IMP2 Intro Jeremy Morall - Varighet: 2:02. ... Introduction to Bioethics | GeorgetownX on edX | Course About Video - Varighet: 1:29.
Read more