Delirium: Ethical Considerations Valerie Violi-Satkoske, PhD Director of Ethics Wheeling Hospital Associate Director WVU Center for Health Ethics and Law University of Pittsburgh Medical Ethics Conference 2017 Friday, March 31, 2017

A Case 75 y/o male Independent with ADLs / Works full-time Anterior cervical discectomy and fusion 24 hours later confusion and agitation which would last for 20 days, 3 ICUs….patient doesn’t remember most of the following 4 months After the onset of the delirium, clinical staff began to point out all of the factors that put the patient at high risk for developing delirium Patient exhibits signs of PTSD and depression and reports had he known about delirium, the long term risks associated with developing it, and his level of risk he would never have consented to surgery

Informed Consent Should delirium become part of the informed consent discussion for patients at risk?

ACS Guideline Optimal Perioperative Management of the Geriatric Patient: Best Practices Guideline from ACS NSQIP/American Geriatrics Society Delirium prevention and treatment mentioned over 60 times in 53 pages Informed consent mentioned ‘0’ times

Threshold At what point is information relevant enough to obligate a professional to disclose it within the informed consent process?

Disclosure Professionals are generally obligated to disclose a core set of information, including: (1) those facts or descriptions that patients or subjects usually consider material in deciding whether to refuse or consent to the proposed intervention or research (2) information the professional believes to be material (3) the professional’s recommendations (4) the purpose of seeking consent (5) the nature and limits of consent as an act of authorization (Beauchamp & Childress, 2009, Principles of Biomedical Ethics sixth edition)

Infection 4% Magill et al (2014) Multistate Point-Prevalence Survey of Health Care –Associated Infections, The New England Journal of Medicine: 370 (13) p. 1198

Coding / underdiagnosing 75% of delirium unrecognized (kappel slide) Wheeling Hospital: 1 year retrospective chart review of coding for delirium….symptoms and symptom management listed and described

Framing “For centuries considered a transient and reversible condition, delirium in older people is still viewed by many to be a normal consequence of surgery, chronic disease, or infections.” https://www.nia.nih.gov/alzheimers/features/dilemma-delirium-older-patients “The biggest misconceptions are that delirium is inevitable and that it doesn’t matter,” said E. Wesley Ely, a professor of medicine at Vanderbilt University School of Medicine who founded its ICU Delirium and Cognitive Impairment Study Group.

Shared Decision Making Shared decision making is a key component of patient centered health care. It is a process in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values. https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf

HELP The Hospital Elder Life Program (HELP) is a comprehensive, evidence-based, patient-care program that provides optimal care for older persons in the hospital. Dr. Sharon K. Inouye and her colleagues at the Yale University School of Medicine originally designed HELP to prevent delirium among hospitalized older persons. HELP does this by keeping hospitalized older people oriented to their surroundings, meeting their needs for nutrition, fluids, and sleep and keeping them mobile within the limitations of their physical condition.

Patient Educational Video At St. John’s Hospital in St. Paul Minnesota patients being admitted for nonemergent surgeries are asked to watch a short video on delirium.

Professional Obligation To support informed consent and shared decision making process Educate staff so they understand not only the inpatient management but long term risks Give patients an opportunity to plan and prepare if they decide to assume the risk Appropriately prepare and support families