Course Materials

   

  Ethics: A Case Based Discussion

AARC Current Topics in Respiratory Care 2015 Program 6 – CT20156 ®

Approved for 1 contact hour of CRCE credit per participant who successfully completes the test.

© 2015 American Association for Respiratory Care

OVERVIEW Ethics: A Case Based Discussion AARC Current Topics in Respiratory Care 2015 – Program 6

Description Respiratory therapists are faced with challenging clinical situations on a daily basis. This session will present four cases in which respiratory therapists are faced with an ethical dilemma and work through the cases to arrive at the most ethically supported outcome. The presenters will share perspectives on these important scenarios.

Objectives Through four case scenarios, the learner will be able to: § Identify an ethical dilemma within a given situation § Discuss ethical principles involved within the dilemma § Consider the given dilemma from multiple perspectives § Develop ethically supported solutions for the dilemma

Lecturer Lewis Rubinson, MD, PhD Director, Critical Care Resuscitation Unit R Adams Cowley Shock Trauma Center Associate Professor of Medicine University of Maryland School of Medicine Baltimore, Maryland

Shawna Strickland PhD, RRT-NPS, RRT-ACCS, AE-C, FAARC Associate Executive Director-Education American Association for Respiratory Care Irving, Texas

CRCE® Credit To earn 1 CRCE credit for participating in today’s program: • View entire presentation • Take the 10-question test (available from Proctor/Site Coordinator) • Answer at least 7 questions correctly • Enter your name and AARC member number on the Attendance and CRCE Log (Please do not enter your Social Security Number) • Receive Certificate of Completion from the Proctor/Site Coordinator

   

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PROGRAM SLIDES and NOTES

Slide 1

Objectives • Through four case scenarios, the learner will be able to: – Identify an ethical dilemma within a given situation – Discuss ethical principles involved within the dilemma – Consider the given dilemma from multiple perspectives – Develop ethically supported solutions for the dilemma

Slide 2

Morality vs. Ethics • Morality – Shared beliefs about right and wrong conduct in a culture or society – Composed of our values, duties, character – Personal morality vs. shared/group morality

• Ethics – A discipline that studies and provides an analysis of morality

Ethics is how we should act in consideration of others, not how we feel or believe.

   

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Slide 3

Identifying the Ethical Conflict • Ethical issue: any situation that may have important ethical challenges • Ethical problem: any situation that may have serious negative implications regarding moral values and duties – 3 components : moral agent, course of action, desired outcomes

• Ethical distress: a situation in which the moral agent  knows  the  right  thing  to  do  but  can’t • Ethical dilemma: a situation in which there are two or more ethically correct courses of action but  you  can’t  do  them  all

Slide 4

Principles of Medical Ethics • Four basic principles – Autonomy – Justice – Beneficence – Non-maleficence • Major problem: – Which  principle  gets  “top  billing”? – Does one principle trump another?

Slide 5

Practitioner Biases • Prior experiences with similar patients • Prior experiences with physician • Personal feelings about end of life care – Religious beliefs – Moral obligations – Personal value system

   

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Slide 6

Barriers to Moral Agreement • Different sets of beliefs • Lack of understanding • Fluctuating role of physicians • Loss of relationship • Complexity of health care environment

• • • • •

Economic influences Racial and gender bias Defining futility Inflated expectations Fear and loss of trust

Slide 7

Ethical Dilemmas: What NOT to do • Collapsing moral dilemmas into medical or legal questions • Generalizing expertise in the clinical healthcare arena to ethics • Divorcing ethical and clinical reasoning

6 Step Process: Addressing Ethical Conflict

Slide 8

1. Gather relevant information 2. Identify the type of ethical conflict 3. Determine the ethics approach to be used and apply the code of ethics for the profession 4. Explore practical alternatives 5. Describe and support your intended action 6. Evaluate the outcomes and process

   

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Slide 9

Case #1: Joseph • A 15 year old male is admitted with end-stage chronic kidney disease – Past medical history: anoxic brain injury at birth, severe developmental delay, cerebral palsy, gastrostomy tube for feeding – Clinical presentation: fever, high heart rate, high respiratory rate, short of breath, work of breathing increased, bluish tinge to lips and nail beds – Diagnosis: acute respiratory failure due to pneumonia; kidney function nil – Advance directive on file: do not intubate • Joseph lives in a long-term care facility • Family rarely visits but retains guardianship • Advance directive written two years ago when Joseph was diagnosed with chronic kidney disease

Slide 10

Question #1 Does  “DNI”  mean  the  same  as  “no   mechanical  ventilation?” • Yes • No

Slide 11

The  Clinician’s  Dilemma • On  the  one  hand… – A conscious decision has been made to avoid mechanical life support – Using NIPPV is not going to cure Joseph or improve his long-term outcomes

• …but  on  the  other  hand… – – – –

   

The disease process is reversible I can help alleviate his shortness of breath We have the technology available Can I watch Joseph suffer?

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Slide 12

Definitions • DNI – Do not intubate

• DNAR – Do not attempt resuscitation – Why is this different from DNR?

• Living will – A document created by the patient prior to and in anticipation of end-of-life

• Power of attorney – Surrogate decision maker chosen by the patient prior to and in anticipation of end-of-life

Slide 13

Question #2 Is it ethically appropriate to use a noninvasive form of mechanical ventilation for and end of life patient with a DNAR or DNI? • Yes • No

Slide 14

The Ethical Debate • Ethical concern: Is it ethically appropriate to use a non-invasive form of mechanical ventilation to an end-of-life patient with a DNAR or DNI? – Futile treatment? – Beneficent? – Violation of DNI/DNAR order? – Burdens vs. Benefits?

   

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Slide 15

The Arguments Use NIPPV at end of life • Alleviates respiratory distress • No sedation necessary • Improve comfort • Provides additional time to finalize affairs • Improves communication

Do not use NIPPV at end of life

• Still a form of life support • Contraindicated in some situations • Will prolong the dying process • Patient elected to limit life support • False hope • System causes discomfort

Slide 16

Question #3 Would  you,  as  the  patient’s  respiratory   therapist, support the use of NIPPV for Joseph? • Yes • No

Slide 17

Ethicist’s  Recommendation • Identify treatment goals – Curative vs. palliative – Argument to use NIPPV for Joseph: • NIPPV may provide the healthcare team time to treat the reversible pneumonia • NIPPV may be able to provide a relief of shortness of breath • Treating kidney disease might be futile but alleviating shortness of breath is not – Arguments against the use of NIPPV for Joseph: » Side effects such as gastric distention and skin breakdowns may be painful » May prolong the dying process

• Consultant’s  Recommendation:  institute  NIPPV – Ethical justification: non-maleficence, beneficence (alleviating distress); no violation of autonomy because DNI/DNAR is not violated

   

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Slide 18

Case #2: Allocating Resources • January 2015: The CDC has estimated that approximately 400,000 Americans are afflicted with the flu and many will require ventilatory support. • Your community has been affected by the outbreak. You are at work at Community Regional Hospital. The emergency department is over capacity with flu victims and waiting for bed placement. Seven very ill patients require ventilatory support in order to survive, but there are only three ventilators not in use. There are no other ventilators available in the community

Slide 19 Meanwhile,  in  the  emergency  department… • Blake

• Dr. Joe

– 18 years old – College freshman

• Bob

– 63 years old – Pulmonary specialist

• Delores

– 52 years old – Cares for elderly mother

• Sheila – 35 years old – Leukemia remission for last 2 years

– 82 years old – “Don’t  treat  me” – Daughter insists on treatment

• Brenna and Brian – 10 years and 8 years – Deteriorating quickly

Slide 20

Question #1 What criterion is most useful in determining which of the 7 patients will receive mechanical ventilation? • Patient with worst physical condition • Patient with best potential outcome • Patient with the most life-years left • Patient with the highest quality of life-years left • Patient who contributes most to society

   

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Slide 21

Principles of Fair Distribution • • • • • • • •

Equality Efficiency Natural lifespan Age Justice (fairness) Medical need Quality of life Patient’s  responsibility  for  disease  (lifestyle)

Slide 22

Question #2 Which of the following criteria is most important to you when allocating the ventilator? • Equality (everyone treated equally) • Efficiency (which person will benefit the most) • Age • Medical need • Quality of life

Slide 23

Issues  with  “Fairness” • Fairness: allocations among individuals; every person is treated like every other person • Using resources for one patient may prevent someone else who also needs those resources • Cost associated with using resource for specific patient may be higher than using the same resource for a different patient

   

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Slide 24

Closure? • • • •

“Reverse  Triage” Utilitarianism vs. individual justice Justice and perceptions of fairness Potential guidance for maximizing outcomes – Cao & Huang, 2012

Slide 25

Case #3: Mrs. Casey • Mrs. Casey is a 68-year-old female patient with an extensive medical history of morbid obesity, end-stage primary biliary cirrhosis (MELD score 25), diabetes mellitus, and seizure disorder. Her primary disease processes has induced a hepatic encephalopathy and altered mental state. She has also been diagnosed with septic shock and multiple organ failure (liver, renal, respiratory, cardiovascular, and neurological). • Mrs. Casey has cultured positive for pseudomonas from PICC line (now removed). She is receiving antibiotics. She is mechanically ventilated with an increasing oxygen requirement.

Slide 26

Case #3: Mrs. Casey • Other pertinent medical information: – – – –

Necrotic, weeping pressure sores on legs and back 4+ pitting edema in lower extremities 24 hour I/O: 23,250/528 Increasing demand for vasopressor dosages to produce a marginal blood pressure

• Family agreed to a DNAR order based on medical futility yesterday but refuse to withdraw or limit medical therapy. • Family is convinced patient will recover from this event and return to prior quality of life.

   

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Slide 27

Question #1 Is continuing to provide Mrs. Casey with medical interventions (above comfort measures) causing further harm? • Yes • No

Slide 28

Medical Futility Futile Care • To a reasonable degree of medical certainty, it is not possible for the intervention to act as a bridge to: – Prevent/reduce the deterioration of the health of an individual – Prevent the impending death – Effectively or appreciably alter the course of the disease

Useful Care • Care that is beneficial to the patient’s  well-being and tolerable by the patient

Futile treatment is identified as treatment that is burdensome and harmful to the patient.

Slide 29

Question #2 What further support is necessary at this time? • Ethics consultation • Dialysis consultation • Surgical consultation • Neurology consultation

   

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Slide 30

Social Support • Social work – Provide social support, housing nearby, etc.

• Clergy – Provide spiritual/religious guidance in context with the current medical situation and decisions that need to be made

• Ethics committee – Facilitate communication between medical team and family – Provide ethical context and recommendation for situation based on medical ethics principles

Slide 31

Ethicist’s  Recommendation • Recommendation: – – – –

Maximize effective communication Involve clergy for social/religious/spiritual support Re-evaluate  patient’s  condition  with  family  every  24  hours Ethically supported through medical futility/non-maleficence to withdraw mechanical ventilation and other medical interventions

• Result: – Time allowed family to come to terms with the futility of intervention – Family consented to comfort care and withdrawal of mechanical ventilation and vasopressors the following morning – Patient expired within minutes of extubation

Slide 32

Case #4: Ebola Preparedness • Your hospital has been designated as a primary treatment center for patients infected with the Ebola virus. You are representing the respiratory care department  on  the  hospital’s  policy  development   team. One of the recommendations for the Ebola response policy is that persons who are infected with the Ebola virus will not receive cardiopulmonary resuscitation (CPR).

   

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Slide 33

Question #1 • What is the primary outcome upon which the team should focus? – Patient survival – Patient comfort – Protecting hospital staff from infection

Slide 34

How CPR Compromises Staff • Detailed donning/doffing procedures for PPE • “Code  Blue”  results  in  rushed,  panicked  staff • Rushed, panicked staff may not pay attention to PPE procedures • One missed step could compromise staff protection and result in infection

Changing our Desired Outcomes

Slide 35

• Why? – Protect the general population • How? – Mandatory interventions for health • Ethically? – Utilitarian perspective • Challenges? – Mostly reactionary responses (some proactive) – Infringes on personal liberty/autonomy

   

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Slide 36

Question #2 • Is it ethical to withhold CPR in order to protect the hospital staff? – Yes – No

Slide 37

The Ethical Argument Withhold CPR? No-not ethical

Withhold CPR? Yes-ethical

• Staff have duty to provide non-futile care to the maximal effort possible • Violate non-maleficence

• Uphold duty to protect hospital staff

– Will likely result in death

• Violate patient autonomy – Patient/family may desire CPR if it becomes necessary

– Duty to protect staff from infection

• Violate non-maleficence toward hospital staff – Harm = infection

• Utilitarianism – Greatest good for greater number

Slide 38

Summary • Respiratory therapists cannot be excused from the ethical decision-making process • Multiple perspectives impact ethical decision-making • Practitioner bias is unavoidable; understanding personal bias is important to understanding the ethical implications • Effective communication among healthcare providers, patients, families, and other stakeholders is vital to arriving at an ethically supported action

   

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Slide 39

References •

•

• • •

Cuomo A, Delmastro M, Ceriana P, Nava S, Conti G, Antonelli M, Iacobone E. Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer. Palliat Med 2004;18(7):602-610. Curtis JR, Cook DJ, Sinuff T, White DB, Hill N, Keenan SP, et al. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med 2007;35(3):932-939. Fleming DA. Futility: Revisiting a concept of shared moral judgment. Hecforum 2005; 17(4):260-275. Jones GK, Brewer KL, Garrison HG. Public expectations of survival following cardiopulmonary resuscitation. Academic Emer Med 2000; 7(1):48-53. Kacmarek RM. Should noninvasive ventilation be used with the do-notintubate patient? Respir Care 2009;54(2):223-231.

Slide 40

References • •

• • •

   

Purtilo R. Ethical dimensions in the health professions, 4th ed. Elsevier/Saunders: St. Louis, MO, 2005. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation  reverses  acute  respiratory  failure  in  select  “do-not-intubate”   patients. Crit Care Med 2005;33(9):1976-1982. Sinuff T, Cook DJ, Keenan SP, Burns KE, Adhikari NKJ, Rocker GM, et al. Noninvasive ventilation for acute respiratory failure near end of life. Crit Care Med 2008;36(3):789-794. Thigpen K, Davis SP, Basol RTanvetyanon T. Which patient with a do-notintubate order is a candidate for noninvasive ventilation? Crit Care Med 2004;32(10):2148-2150. , Lange P, Jain SS, Olsen JD, et al. Implementing the 2005 American Heart Association guidelines, including use of the impedance threshold device, improves hospital discharge rate after in-hospital cardiac arrest. Resp Care 2010; 55(8):1014-1019.

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TEST Ethics: A Case Based Discussion AARC Current Topics in Respiratory Care 2015 – Program 6 Mark the Corresponding Box for your Response to each Question 7 Correct Out of 10 is Passing

Name: __________________

_____________________

AARC Mbr #: _______________

Email Address:___________________________________

Date: _____________________

(first)

(last)

(required for nonmembers)

1. Morality and ethics are the same concept. o True o False 2. A major criticism of using principlism to evaluate ethical issues and problems is that it is difficult to determine which principle should get “top billing” in any given situation. o True o False 3. There is one primary perspective from which every ethical situation should be evaluated. o True o False 4. The respiratory care practitioner should be able to be 100% neutral when dealing with ethical situations. o True o False 5. A situation in which the moral agent knows the right thing to do but is unable to complete the action is called an ethical issue. o True o False 6. The power of attorney document identifies a surrogate decision maker for the patient at a time when the patient is unable to communicate healthcare decisions. o True o False 7. The principle of fair distribution that places a high value on treating everyone the same is equality. o True o False 8. Futility is defined as interventions that are burdensome and harmful to the patient. o True o False 9. The principle of autonomy focuses on fair distribution of healthcare resources. o True o False 10. A vital component of arriving at an ethically supported action is effective communication among all stakeholders. o True o False

   

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PARTICIPANT EVALUATION Ethics: A Case Based Discussion AARC Current Topics in Respiratory Care 2015 – Program 6

Please help evaluate this program by taking a moment to answer the following questions. Thank you. 1. My current position is: _____Staff Therapist

_____RT Supervisor/Mgr

_____Student

_____RT Program Faculty

_____Other (please specify) ________________________________________________ 2. The content of today’s program was relevant and applicable to my job. _____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 3. Presenters were easily understood and presented the topic well. _____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 4. Slides on the video were effective in supporting the information presented. _____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 5. I achieved the learning objectives of today’s program. _____Strongly Disagree _____Disagree _____Neutral _____Agree _____Strongly Agree 6. Provide any comments you have about this program:

7. List any topics that you would like to see presented as future programs.

Participants: Please return this completed form to your Proctor/Site Coordinator.

   

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