Ethics exam 2

moral distress

one has clear sense of morality, ability to act morally is thwarted

4 aspects of ethical dilemma

• competing values

• its unclear what to do

• cannot obey one set of values without violating the others

autonomy

self-governance or self-control (to be in control of one’s actions)

paternalism

someone in authority making decisions on behalf of subordinate based on what they think is in the “best interest” of the subordinate

is choice synonymous with autonomy?

NO

autonomy and paternalism are not about the RANGE of choices open to someone

• prisoners can be autonomous

• royals can lack autonomy despite many choices

real definition of autonomy

ability to make informed choices ABSENT of manipulation or coercion

what does autonomy require (3 things)

1. ability (cognitive and psychological)

2. having information about available choices/options

3. accounting for limitations (awareness of AND freedom from coercion or manipulation)

real definition of paternalism

directly making choices for others based on YOUR personal values, without considering their beliefs/values

paternalism is unacceptable when:

• subordinate is considered autonomous

• VALUES are driven by the authority vs the subordinate

acceptable paternalism

• subordinate either:

• 1. endorses relationship

• 2. subordinate lacks autonomy

what is “understanding”?

intersection of facts and subjective interpretation of those facts

Does the legal bar for being one’s own decision maker require being “right”?

no

does autonomy require understanding?

YES

US law says you can be ignorant as long as (2 things)

1. thinking processes aren’t impaired (no manipulation/coercion)

2. and its possible to imagine others making similar decisions

standards of decision making (gold, silver, bronze)

patient themselves, authorized surrogates, medical best-interests

What does patient need to have to make decision themselves? (2)

1. informed consent

2. capacity

good standards for informed consent

tailored conversation at patient’s level of understanding (more than yes or no convo)

concerns with highest standard for IC

may be too rigorous to do in all circumstances

Valid informed consent

a PROCESS, requires more than a yes or no, demonstrates understanding by subject or patient

3 levels to get to valid informed consent

1. threshold elements

2. information elements

3. consent elements

Threshold elements for VIC

1. competence/capacity

2. voluntariness (no coercion)

Information elements for VIC

1. disclosure

2. recommendation of a plan

3. understanding of the above

Consent elements of VIC

1. decision for or against a plan

2. authorization for the plan

Incompetence- legally

• determined by a JUDGE

• clear and convincing evidence

• unable to care for self or carry out important decisions

• relatively black/white

Incapacity/incapable

• determined by a clinical evaluation

• person does not understand, cannot evaluate medical information needed to make an informed decision

• agent cannot override all decisions

• many shades of gray

how is the standard for DMC (decision making capability) determined (2 things)

1. risk-to-benefit ratio

2. whether patient consents or refuses

bar for DMC lowers when:

• high benefit, low risk, patient consents

• low benefit, high risk, patient refuses

bar for DMC raises when:

• high benefit, low risk, patient refuses

• low benefit, high risk, patient consents

Mini-mental state exam

• limited “global” screening tool

• scores less than 19 highly likely to be associated with lack of DMC

MoCA

• ranked as one of the most accurate in assessing cognitive abilities

• useful in detecting mild cognitive impairment

clinical triggers for assessment of DMC

• abrupt changes in mood

• refusals of reccomended treatment

• risky treatment accepted too hastily

• one or more risk factors for impaired decision making

challenges with assessing for DMC

• mental status can wax and wane

• conflicting opinions by assessors

• potentially reversible factors can impact (infection, sickness, etc)

• communication barriers (intubation)

• urgent decisions

2 legally recognized decision makers

• guardian

• power of attorney for healthcare

guardian vs POA

guardians override

guardians

• appointed by a judge

• can override patients known treatment preferences if they believe doing so is in the best interest of the patient

POAs

• person appointed

• cannot override patients’ known treatment preferences or refusals

what to look for in non-legally recognized surrogates

• knowledgable about the patient

• has the patients best interests in mind

red flags about surrogates

• unknowledgeable

• unwilling to accept truth/reality of situation

• apparent conflict of interest (could be financial)

• lack of consensus

when is “bronze” standard activated?

no treatment decision-making capacity, no known surrogates, treatment goals are unknown

what is meant by “medical best interests”

• standard medical practices and professional guidelines

• institutional frameworks (could be dependent on state)

what is meant by life-sustaining treatment (LST)

treatment needed to prevent imminent death

are withdrawing and withholding treatment both morally equivalent?

yes, but they can feel different

medical futility

treatment that will never reach its goal

withdrawing treatment

decisions not to START treatment

withdrawing treatment

decisions to STOP treatments once they are started

outcomes after Nancy Cruzan case

creation of Advance Directives and patient self-determination act of 1990

is right to refuse LST dependent on life expectancy?

no

reasons for withholding/withdrawing treatment

1. respect for autonomy

2. get rid of burden of unwanted treatments

3. relieve suffering

4. get rid of burden from ineffective treatment

conflict between providers and surrogates with LST (sometimes)

• surrogates would rather try and fail

• providers would rather not start treatment than start and fail (withdrawing feels like causing the death)

what about “wanting to die?”

intent does not matter regarding decisions to withhold/withdraw LST

futility

failure to reach objectives, now or low benefit to risk, violates reasonable med standards, fails to align with patient goals

is it required to provide futile treatment?

no. there is no moral, ethical or legal obligation to provide futile treatment

death elasticity

prolonging decisions to withdraw treatment in attempt to prevent death until after date/event— UNETHICAL in most cases

CPR unique why?

rather than opting in for treatment you must opt OUT

“slow” codes

not getting there quickly… deceptive, paternalistic and unjust

when was DNR order created and what is it

1970s, medical order that gives consent NOT to be touched, purpose is to allow a natural death

probable survival rate from car after cardiac arrest in hospital

18%

providers must offer treatment interventions that are not medically viable

FALSE