Euthanasia abortion stem cell research cloning allocation of transplant organs how do you determine brain death? some people approach ethics by being passive (not doing anything and waiting for someone else) Going to talk about real stories case 1 90 year old female with hypertension and osteoporosis lives with son in Siler City EMS called because of acute onset of chest pain on arrival in ER, develops complete heart block and cardiogenic shock for successful resuscitation, she will need intubation temporary pacemaker
Euthanasia abortion stem cell research cloning allocation of transplant organs how do you determine brain death? some people approach ethics by being passive (not doing anything and waiting for someone else) Going to talk about real stories case 1 90 year old female with hypertension and osteoporosis lives with son in Siler City EMS called because of acute onset of chest pain on arrival in ER, develops complete heart block and cardiogenic shock for successful resuscitation, she will need intubation temporary pacemaker
Euthanasia abortion stem cell research cloning allocation of transplant organs how do you determine brain death? some people approach ethics by being passive (not doing anything and waiting for someone else) Going to talk about real stories case 1 90 year old female with hypertension and osteoporosis lives with son in Siler City EMS called because of acute onset of chest pain on arrival in ER, develops complete heart block and cardiogenic shock for successful resuscitation, she will need intubation temporary pacemaker
Bring forms Be ready to answer why you are interested in shadowing Dress professionally Dont be stressed
Medical Ethics Presentation Rick Stouffer
Medical ethics euthanasia abortion stem cell research cloning allocation of transplant organs how do you determine brain death? not what we are interested in here
Health Care Providers Doctors make ethical decisions every day Funny escalator movies o some people approach ethics by being passive (not doing anything at all and waiting for someone else)
Disclosures I dont not have all of the answers. And, on some days, Im not sure I have any of them. Going to talk about real stories
Case 1 90 year old female with hypertension and osteoporosis lives with son in Siler City EMS called because of acute onset of chest pain on arrival in ER, patient is confused and no family is available BP 85/50 and pulse 70 bpm EKG shows changes consistent with blood clot in right coronary artery
What do you do? within 10 mins of arrival in ER, develops complete heart block and cardiogenic shock for successful resuscitation, she will need intubation temporary pacemaker, IABP and emergent angioplasty. is this what she wants? o significant risks just to live another day would you put this 90 year old woman through a bunch of invasive procedures or let her die? most people went with resuscitationjob is to provide care and keep patient as healthy as possible until you know the patients wishes are otherwise
Who Decides? implied consentin an emergency, two physicians can document that the condition is threatening to life or limb Living Will Surrogate decision maker o Spouse o Parent or child o Other Relation Judicial reviewAMA recommends ethic committee or judicial review, ACP recommends judicial review Doctors went for surrogate decision making in this case (her son was around) Son says that he thinks the 90 year old would want the procedures done in order to live
Coronary Angiogram shown blockage is shown by the premature stopping of the catheter
The rest of the story admitted to hospital 2/14 Left foot embolus 2/16 Extubated 2/18 Re-intubated 2/19 Turned 91 on 2/25 Extubated on 3/1 Re-intubated later Died soon after No one seems to think this was the wrong decision. Consensus that you cant make decisions based on the history of one case.
Medical Ethics Principles that govern your behavior as a health care provider combination of o moralswhat is right/wrong o professional ethicsstandards of conduct that prescribe behavior o malpracticedoing what you do poorly, outside standard of care o Legallaws and regulation governing your actions HIPPA tells you what you can and cannot disclose about a patients records o Guidelines Hippocratic oath Geneva (1947) Sydney (1968)
Factors that Influence EthicsMaking the Right Choice Patient o Wishes o cultural values o religious values o family expectations o financial issues Legal issues o Law and regulation o insurance, etc.
Case of Patient Who Refused to Take Care of Himself September 2009 o 45 year old male with several weeks of shortness of breath o Echocardiogram shows dilated LV with an ejection fraction of 15-20% o diagnosed with Cardiomyopathy of unknown etiology o several likely contributing factors including heavy alcohol use and possibly untreated hypertension o using cocaine Clinic Visits o Early after diagnosis: Regularly attends cardiology clinic appointments medication adjustments he does seem to understand that he has a problem with substance abuse and smoking and agrees to a make an effort to quit o later patient begins to miss appointments and fall of the wagon September 2011 o CC: increased shortness of breath for past week. Can normally go up and down the stairs at work without problems, but has been getting more short of breath. o Returned to poor diet, smoking, cocaine use, etc. Non-Sustained Ventricular Tachycardiacommon in people with cardiomyopathies. Can cause sudden death AHA/ACC Guidelines for ICD o Class I ICD therapy is indicated in patients with non-ischemic dilated cardiomyopathy who have an LVEF les than or equal to 35% who are in NYHA functional Class 2 or 3 Patient is class 3 Should he get an ICD? o Class 1 indication o potentially lifesaving o but he doesnt take his medications o drug abuser o should the hospital give expensive treatments without holding patient accountable for his actions and that impact on the hospitals expenditure of resources? o doctor has loyalty to patient but not to society as a whole What about the cost? o Patient is unemployed o Average implantation costs are very expensive September 2012 o Implantation of a single coil, single lead, primary prevention ICD February 2013 o Patient is 49 now and feels 5 ICD shocks. Feeling well though continues to feel chronically fatigued and short of breath with exertion. The rest of the story o He has not taken his medications the past few days and is cocaine positive Did we do the right thing? o Apply a high degree of skill and knowledge o act for good of patient o remain objective and emotionally detached o respect the position of privilege Conflicts of Interest o Best interest of patient But How do you resolve conflicts of interest between patient vs. society? how do you resolve conflicts of interests between patient vs. other patients? how do you resolve conflicts of interest between patient vs. training environment? o Bedside Manner patients look for compassion how do you make the right medical decision with the compassion factor? they want someone who knows their wishes and will be available when they need them The Case of the Patient with an Unusual Past 62 year old white male prior history of myocardial infarction and stent in the left anterior descending coronary artery exertional chest pain nuclear study shows large anterior defect what do you do?
Not Your Typical Patient patient is on death row for a gruesome murder of his brother and two nephews? Do you treat him any differently?
Issues to Ponder do prisoners deserve the same level of medical care as others? Does the severity of crime matter? What level of care? o Basic medical needs o life saving treatment, etc.
What happens when family and physicians do not agree on patient care? 33 year old female with debilitating multiple sclerosis diagnosed 13 years ago normal mentation but severe physical disability from MS she had been on home hospice, but was stopped 1 week ago because doing better choked on biscuit, found by mother
Case of Unrealistic Family Fire department arrived and found pulse EMS arrived tem minute later and treated With CPR and establishment of airway, patient had circulation patient underwent intubation o patient was started on norepinephrine treatment patient prevents CNS damage
5 days later no return of any mental activity primary care doctors said that she didnt want to be kept on life support mother wants full life support (against patient wishes). family (primarily mother) said daughter would want full support ethics consult was requested
Ethics Consult different interpretations of patients wishes o it is clear that mothers understanding of patient wishes is not aligned with doctors. o the mother did not interpret the prognosis in the way that doctors meant. ethics consult sides with the doctor, but restates the situation. o they consider that the mother lacks understanding of the disease.
Mothers Diagnosis of Prognosis was told at last discharge that her daughter had only 2 weeks to live. hospice arranged her to leave because she was doing better. thought that daughter would recover because her brother hit his head and was predicted to be a vegetable. however, he ended up being fine.
Rest of Story mother decided that the daughter would not want to be kept alive if there was no hope of her getting better. patient survived for three months after extubation. feeding tube was put in.
You will be making many ethical decisionsBe Prepared!!