West Tennessee Rehabilitation Center Jackson, Tennessee Saturday, December 6, 2003

Ethical Dilemmas in Rehabilitation Care Part 3 Bruce D. White, D.O., J.D., Director © www.ethicsconsultant.com

Part 3 Objectives Explain how conflicts between caregivers (family member v. family member; doctor v. doctor; doctor v. nurse) might be approached and resolved. Explain how conflicts between caregivers (family member v. family member; doctor v. doctor; doctor v. nurse) might be approached and resolved. Define medical futility. Define medical futility. Explain why medical futility is a clinical ethics problem and illustrate the concept of medical futility in the case. Explain why medical futility is a clinical ethics problem and illustrate the concept of medical futility in the case.

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

Conflict and Options Explore the possible conflict scenarios Explore the possible conflict scenarios Daughter v. daughter conflict Daughter v. daughter conflict Family member v. medical team Family member v. medical team Orthopedic consultants v. medical team Orthopedic consultants v. medical team Nurses v. physicians Nurses v. physicians Home health nurses v. hospital team Home health nurses v. hospital team How might one apply the Jonsen- Siegler-Winslade model to resolve the conflict? How might one apply the Jonsen- Siegler-Winslade model to resolve the conflict?

Institutional Preferences Policies & Procedures Shared Decision Making Model Modified from Jonsen AR, Siegler M, Winslade WJ.Clinical Ethics, 4th ed. New York: McGraw-Hill, Inc., Medical Indications-- Physician(s) Preferences Patient’s Representative Quality-of-Life Considerations Patient Preferences + decision making capacity - decision making capacity Contextual Features Delivery Systems Considerations Economic Considerations Legal Considerations Theological Considerations Psycho-social Considerations Informed Consent Justice Autonomy Beneficence Nonmaleficence Substituted judgment Best interests

Case Facts Continued The daughters accept that their mother would not have wanted the surgery The daughters accept that their mother would not have wanted the surgery After a few days--with pain control achieved with Percocet®--the patient is discharged home with the same pain control and home nursing and therapy plan as instituted at the previous discharge After a few days--with pain control achieved with Percocet®--the patient is discharged home with the same pain control and home nursing and therapy plan as instituted at the previous discharge At home, she fails to respond well and recover her baseline; she is often unresponsive, only takes sips, moves little At home, she fails to respond well and recover her baseline; she is often unresponsive, only takes sips, moves little

Case Facts Continued Three weeks later, the home health nurse calls to report that the patient is having respiratory difficulties Three weeks later, the home health nurse calls to report that the patient is having respiratory difficulties The patient is readmitted for evaluation and care The patient is readmitted for evaluation and care The medical team diagnoses a right middle lobe pneumonia and institutes antibiotic therapy and aggressive respiratory toilet The medical team diagnoses a right middle lobe pneumonia and institutes antibiotic therapy and aggressive respiratory toilet

Case Facts Continued After thorough evaluation, the medical team finds the patient has extremely poor cardiac and kidney function too and tells the older daughter that they plan to write a do-not-resuscitate (DNR) order based on medical indications After thorough evaluation, the medical team finds the patient has extremely poor cardiac and kidney function too and tells the older daughter that they plan to write a do-not-resuscitate (DNR) order based on medical indications The patient has very poor function The patient has very poor function She has more than three systems in failure She has more than three systems in failure See Bedell et al. New Engl J Med. 1983;309: See Bedell et al. New Engl J Med. 1983;309:

Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA. 1988;260: DNR order rationales: (1) Poor quality of life before resuscitation; (2) expected poor quality of life after resuscitation; (3) medical futility

Define Medical Futility Webster’s definition Webster’s definition Greek etymology of “futility” Greek etymology of “futility” Practical definitions Practical definitions Physiologically implausible Physiologically implausible Nonvalidated, but plausible Nonvalidated, but plausible Nonbeneficial Nonbeneficial Very unlikely Very unlikely

Institutional Preferences Policies & Procedures Shared Decision Making Model Modified from Jonsen AR, Siegler M, Winslade WJ.Clinical Ethics, 4th ed. New York: McGraw-Hill, Inc., Medical Indications-- Physician(s) Preferences Patient’s Representative Quality-of-Life Considerations Patient Preferences + decision making capacity - decision making capacity Contextual Features Delivery Systems Considerations Economic Considerations Legal Considerations Theological Considerations Psycho-social Considerations Informed Consent Justice Autonomy Beneficence Nonmaleficence Substituted judgment Best interests

Justice, Equity, Fairness Contextual Features Justice Delivery Systems Considerations Economic Considerations Legal Considerations Theological Considerations Psycho-social Considerations

Is this an ethical dilemma? Why?

How should the physician respond?

Case Facts Continued The daughters agree that a DNR order is appropriate; the medical team writes a DNR order The daughters agree that a DNR order is appropriate; the medical team writes a DNR order Medically-mediated nutrition is delivered via a intravenous line and nasogastric tube Medically-mediated nutrition is delivered via a intravenous line and nasogastric tube All agree that it is not necessary to remove the patient to the intensive care unit should her condition deteriorate All agree that it is not necessary to remove the patient to the intensive care unit should her condition deteriorate

Case Facts Conclusion A The patient dies from respiratory failure as a consequence of the pneumonia with sufficient morphine to relieve any discomfort The patient dies from respiratory failure as a consequence of the pneumonia with sufficient morphine to relieve any discomfort

Case Facts Conclusion B The patient recovers from the pneumonia The patient recovers from the pneumonia However, the patient remains unresponsive most of the time However, the patient remains unresponsive most of the time The daughters and team agree that the patient would not want a gastrostomy tube for more prolonged artificial feedings nor be discharged to a nursing home The daughters and team agree that the patient would not want a gastrostomy tube for more prolonged artificial feedings nor be discharged to a nursing home Hospice is contacted; she is discharged home; she dies a few days later Hospice is contacted; she is discharged home; she dies a few days later

Case Facts Conclusion C The patient begins to respond to treatment and recovers from the pneumonia The patient begins to respond to treatment and recovers from the pneumonia While in the hospital, she slowly regains her baseline, begins to take oral feedings well, regains some strength with aggressive physical and occupational therapy While in the hospital, she slowly regains her baseline, begins to take oral feedings well, regains some strength with aggressive physical and occupational therapy After twelve days, she is discharged home with careful attention to her pain control After twelve days, she is discharged home with careful attention to her pain control

Part 3 Objectives Reviewed Explain how conflicts between caregivers (family member v. family member; doctor v. doctor; doctor v. nurse) might be approached and resolved. Explain how conflicts between caregivers (family member v. family member; doctor v. doctor; doctor v. nurse) might be approached and resolved. Define medical futility. Define medical futility. Explain why medical futility is a clinical ethics problem and illustrate the concept of medical futility in the case. Explain why medical futility is a clinical ethics problem and illustrate the concept of medical futility in the case.

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