West TennesseeWest TennesseeRehabilitation CenterRehabilitation Center

Jackson, TennesseeJackson, Tennessee

Saturday, December 6, 2003Saturday, December 6, 2003

Ethical Dilemmas in Ethical Dilemmas in Rehabilitation CareRehabilitation Care

Part 3Part 3

Bruce D. White, Bruce D. White, D.O., J.D., D.O., J.D., DirectorDirector

www.ethicsconsultant.comwww.ethicsconsultant.com

© www.ethicsconsultant.com 2003

Part 3 ObjectivesPart 3 Objectives

Explain how conflicts between Explain how conflicts between caregivers (family member v. family caregivers (family member v. family member; doctor v. doctor; doctor v. member; doctor v. doctor; doctor v. nurse) might be approached and nurse) might be approached and resolved.resolved.

Define medical futility.Define medical futility. Explain why medical futility is a clinical Explain why medical futility is a clinical

ethics problem and illustrate the ethics problem and illustrate the concept of medical futility in the case.concept of medical futility in the case.

Case Facts ContinuedCase Facts Continued

The orthopedic consultants refuse to The orthopedic consultants refuse to operate: they say that they had operate: they say that they had conversations with the patient when she conversations with the patient when she clearly had decision making capacity, that clearly had decision making capacity, that she understood the benefits and burdens she understood the benefits and burdens of the operation and that she refused of the operation and that she refused surgery; they offer to withdraw from the surgery; they offer to withdraw from the case and suggest another orthopedic case and suggest another orthopedic team that can be consultedteam that can be consulted

Conflict and OptionsConflict and Options

Explore the possible conflict scenariosExplore the possible conflict scenarios Daughter v. daughter conflictDaughter v. daughter conflict Family member v. medical teamFamily member v. medical team Orthopedic consultants v. medical teamOrthopedic consultants v. medical team Nurses v. physiciansNurses v. physicians Home health nurses v. hospital teamHome health nurses v. hospital team

How might one apply the Jonsen-How might one apply the Jonsen-Siegler-Winslade model to resolve the Siegler-Winslade model to resolve the conflict?conflict?

InstitutionalPreferences

Policies & Procedures

Shared Decision Making Model

Modified from Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics, 4th ed. New York: McGraw-Hill, Inc., 1997.

MedicalIndications--Physician(s)Preferences

Patient’s Representative

Quality-of-LifeConsiderations

PatientPreferences

+ decision making capacity

- decision making capacity

Contextual FeaturesDelivery Systems ConsiderationsEconomic Considerations

Legal ConsiderationsTheological Considerations

Psycho-social Considerations

InformedConsent

Justice

AutonomyBeneficenceNonmaleficence

Substituted judgment

Best

inte

rest

s

Case Facts ContinuedCase Facts Continued The daughters accept that their mother The daughters accept that their mother

would not have wanted the surgerywould not have wanted the surgery After a few days--with pain control After a few days--with pain control

achieved with Percocet®--the patient is achieved with Percocet®--the patient is discharged home with the same pain discharged home with the same pain control and home nursing and therapy plan control and home nursing and therapy plan as instituted at the previous dischargeas instituted at the previous discharge

At home, she fails to respond well and At home, she fails to respond well and recover her baseline; she is often recover her baseline; she is often unresponsive, only takes sips, moves littleunresponsive, only takes sips, moves little

Case Facts ContinuedCase Facts Continued

Three weeks later, the home health nurse Three weeks later, the home health nurse calls to report that the patient is having calls to report that the patient is having respiratory difficultiesrespiratory difficulties

The patient is readmitted for evaluation The patient is readmitted for evaluation and careand care

The medical team diagnoses a right The medical team diagnoses a right middle lobe pneumonia and institutes middle lobe pneumonia and institutes antibiotic therapy and aggressive antibiotic therapy and aggressive respiratory toiletrespiratory toilet

Case Facts ContinuedCase Facts Continued

After thorough evaluation, the medical After thorough evaluation, the medical team finds the patient has extremely poor team finds the patient has extremely poor cardiac and kidney function too and tells cardiac and kidney function too and tells the older daughter that they plan to write a the older daughter that they plan to write a do-not-resuscitate (DNR) order based on do-not-resuscitate (DNR) order based on medical indicationsmedical indications The patient has very poor functionThe patient has very poor function She has more than three systems in failureShe has more than three systems in failure See Bedell et al. New Engl J Med. See Bedell et al. New Engl J Med.

1983;309:569-576.1983;309:569-576.

Tomlinson T, Brody H.Tomlinson T, Brody H.

Futility and the ethics of resuscitation.Futility and the ethics of resuscitation.

JAMA. 1988;260:2094-2095JAMA. 1988;260:2094-2095

DNR order rationales: (1) Poor quality of DNR order rationales: (1) Poor quality of life before resuscitation; (2) expected life before resuscitation; (2) expected poor quality of life after resuscitation; poor quality of life after resuscitation;

(3) medical futility(3) medical futility

Define Medical FutilityDefine Medical Futility

Webster’s definitionWebster’s definition Greek etymology of “futility”Greek etymology of “futility” Practical definitionsPractical definitions

Physiologically implausiblePhysiologically implausible Nonvalidated, but plausibleNonvalidated, but plausible NonbeneficialNonbeneficial Very unlikelyVery unlikely

InstitutionalPreferences

Policies & Procedures

Shared Decision Making Model

Modified from Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics, 4th ed. New York: McGraw-Hill, Inc., 1997.

MedicalIndications--Physician(s)Preferences

Patient’s Representative

Quality-of-LifeConsiderations

PatientPreferences

+ decision making capacity

- decision making capacity

Contextual FeaturesDelivery Systems ConsiderationsEconomic Considerations

Legal ConsiderationsTheological Considerations

Psycho-social Considerations

InformedConsent

Justice

AutonomyBeneficenceNonmaleficence

Substituted judgment

Best

inte

rest

s

Justice, Equity, FairnessJustice, Equity, Fairness

Contextual Features

Justice

Delivery Systems ConsiderationsEconomic Considerations

Legal ConsiderationsTheological Considerations

Psycho-social Considerations

Is this an ethical Is this an ethical dilemma? Why?dilemma? Why?

How should the How should the physician respond?physician respond?

Case Facts ContinuedCase Facts Continued

The daughters agree that a DNR order is The daughters agree that a DNR order is appropriate; the medical team writes a appropriate; the medical team writes a DNR orderDNR order

Medically-mediated nutrition is delivered Medically-mediated nutrition is delivered via a intravenous line and nasogastric tubevia a intravenous line and nasogastric tube

All agree that it is not necessary to remove All agree that it is not necessary to remove the patient to the intensive care unit the patient to the intensive care unit should her condition deteriorateshould her condition deteriorate

Case Facts Conclusion ACase Facts Conclusion A

The patient dies from respiratory failure as The patient dies from respiratory failure as a consequence of the pneumonia with a consequence of the pneumonia with sufficient morphine to relieve any sufficient morphine to relieve any discomfortdiscomfort

Case Facts Conclusion BCase Facts Conclusion B

The patient recovers from the pneumoniaThe patient recovers from the pneumonia However, the patient remains However, the patient remains

unresponsive most of the timeunresponsive most of the time The daughters and team agree that the The daughters and team agree that the

patient would not want a gastrostomy tube patient would not want a gastrostomy tube for more prolonged artificial feedings nor for more prolonged artificial feedings nor be discharged to a nursing homebe discharged to a nursing home

Hospice is contacted; she is discharged Hospice is contacted; she is discharged home; she dies a few days laterhome; she dies a few days later

Case Facts Conclusion CCase Facts Conclusion C

The patient begins to respond to treatment The patient begins to respond to treatment and recovers from the pneumoniaand recovers from the pneumonia

While in the hospital, she slowly regains While in the hospital, she slowly regains her baseline, begins to take oral feedings her baseline, begins to take oral feedings well, regains some strength with well, regains some strength with aggressive physical and occupational aggressive physical and occupational therapytherapy

After twelve days, she is discharged home After twelve days, she is discharged home with careful attention to her pain controlwith careful attention to her pain control

Part 3 Objectives ReviewedPart 3 Objectives Reviewed

Explain how conflicts between Explain how conflicts between caregivers (family member v. family caregivers (family member v. family member; doctor v. doctor; doctor v. member; doctor v. doctor; doctor v. nurse) might be approached and nurse) might be approached and resolved.resolved.

Define medical futility.Define medical futility. Explain why medical futility is a clinical Explain why medical futility is a clinical

ethics problem and illustrate the ethics problem and illustrate the concept of medical futility in the case.concept of medical futility in the case.

direct access to an direct access to an experienced healthcare experienced healthcare

ethics consultant on ethics consultant on the webthe web

www.ethicsconsultant.comwww.ethicsconsultant.com