Chapter Three Indications for medical intervention

The principles of Beneficence and Nonmaleficence What is the patient’s medical problem? Is the problem acute? chronic? critical? emergent? reversible? What are the goals of treatment? What are the probabilities of success? What are the plans in case of therapeutic failure? In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?

Definition of medical indications Medical indications are the facts, opinions, and interpretations about the patient’s physical and/or psychological condition that provide a reasonable justification for diagnostic and therapeutic interventions.

The goals and benefits of medicine Cure sometimes, support frequently, comfort always.

The essential point of clinical ethics is to know when cure is possible, how long support should be continued, and when comfort should become the primary mode of care. To understand the ethical issues in a case, it is necessary to consider the clinical situation of the patient, that is, the nature of the disease, the treatment proposed, and the goals of intervention.

The disease A disease may be acute (rapid onset and short course) or chronic (persistent and progressive). It can be emergent (causing immediate disability unless treated) or nonemergent (slowly progressive). Finally, a disease can be curable( the primary cause is known and treatable by definitive therapy) or incurable. These clinical distinctions are relevant in the ethical analysis of any case.

The treatment Patients’ decisions about treatment will vary based on their goals, desires, and values. A medical intervention may cause serious adverse effects. Both patients and physicians should consider it when agreeing on a treatment plan.

The goals of medicine Promotion of health and prevention of disease Maintenance or improvement quality of life through relief of symptom, pain, and suffering Cure of disease Prevention of untimely death

Improvement of functional status or maintenance of compromised status Education and counseling of patients regarding their condition and prognosis Avoidance of harm to the patient in the course of care Assisting in a peaceful death The goals of medicine

Clinical judgment and clinical uncertainty “What are we accomplishing?” “Is the expected outcome worth the effort?” “Do the benefit justify the risks?” “A science of uncertainty and an art of probability.”

clinical judgment. The process by which a clinician attempts to make consistently good decisions in the face of uncertainty is called clinical judgment.

clinical uncertainty Clinical medicine was described as “A science of uncertainty and an art of probability.” Although evidence-based medicine and practice guidelines aim to reduce the “uncertainty” and the “probability” of which Osler spoke, some degree of uncertainty always remains.

The shared decision making that constitutes an appropriate professional relationship.

Shared decision making Paternalistic The doctor made a diagnosis, prescribed treatment, and gave “orders”, providing minimal information to the patient. Patient autonomy The patient was seen as the authoritative decision maker.

Shared decision making a collaboration in which the physician shares with the patient medical knowledge and opinion, and the patient shares with the physician values and preferences. The best medical decision for an individual patient will depend on how the patient evaluates different risks and benefits.

Even when the physician’s recommendation is based on sound evidence, the patient should be the final decision maker, because only patients can assess the risks, benefits, goals, and costs of treatment in their own lives.

Medical error A 1999 Institute of Medicine (IOM) report on medical error estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors, as many as those who die of vehicular accidents, breast cancer, or AIDS.

Medical error Medical error was defined as the failure of a planned action to be completed as intended, or as the use of a wrong plan to achieve an aim.

Some errors resulted from incompetence or mistake judgment by competent physicians. Other errors were caused by system failure that often went unrecognized and uncorrected. When medical error occurs as a result of incompetence or negligence, it constitutes a serious breach of the physician’s professional responsibility.

Indicated and Nonindicated Interventions Innumerable interventions are available to modern medicine, from advice to drugs to surgery. Interventions are indicated, then, when the patient’s physical or mental condition may be benefited by them. Interventions may be nonindicated for a variety of reasons.

Case Mrs. Care, a 48-year-old married woman ; was diagnosed with MS 15 years ago ; is confined to a wheelchair ; is blind in one eye ; she has become profoundly depressed, is uncommunicative even with close family, and refuses to leave her bed.

The moribund patient “Moribund” means “about to die”, that is, the patient’s death is inevitable and will soon take place. The patient’s organ systems are disintegrating rapidly and irreversibly. Death can be expected within hours.

The terminal patient The prognosis of any patient with a lethal disease. “Terminal” is defined as having 6months or less to live. The benefits of accurate prognostication include informing patients and families about the situation, allowing them to plan their remaining time and arrange appropriate forms of care.

Medical futility The Oxford English Dictionary defines it as “incapable of producing any result, failing utterly of the desired and through intrinsic defect.” Many commentators prefer to use “medically ineffective or non-beneficial treatment” rather than “futility”.

What level of statistical or experiential evidence is required to support a judgment of futility?

Who decides whether an intervention is futile, physicians or patients?

What process should be used to resolve disagreements between patients (or their surrogates) and the medical team about whether a particular treatment is futile?

Is probabilistic futility a substantive or procedural norm for clinical judgment?

Orders not to resuscitate (DNR)

3.3 Legal implications of forgoing treatment

Determination of death cardiorespiratory criterion ----irreversible cessation of circulation and respiration Brain Death

In 1968, this concept was clarified in the Harvard Report on Brain Death. Unreceptivity and unresponsivity to external stimuli, no movements or breathing, no relaxes, and no discernible electrical activity in the cerebral cortex as shown by EEG.

The physician has the authority to declare the patient dead. Certain philosophical problems about the adequacy of the definition of death by brain criteria remain open to debate.

Working in groups of 3 or 4, describe values you feel are important in directing professional behavior

Good Behaviors Honesty Altruism Excellence Empathy Compassion Responsibility Accountability Integrity Respect Self-Regulation Confidentiality Apply Principles

Excellence Be the best physician possible Commitment to continued learning throughout your career Give all patients best care possible

Altruism Act for the good of others Act for the good of your community Do NOT act for your own personal gain

Respect Recognize the feelings and rights of  Patients  Families  Other physicians  All members of the health care team

Self-regulation Know the limits of your knowledge and skill Seek help from colleagues when needed Refer patients to a capable colleague

Confidentiality Keep patient and other information confidential Be careful when, where, and with whom you talk about patients Get permission before sharing confidential information with others

Integrity Defend what is the best practice Expect your self to meet the highest standards Act fairly with others Acknowledge the work of others

Relationships With Patients Respect beliefs and cultural differences Include patients and families in making decisions  Identify alternatives for treatment  Help patients understand, make choices

Relationships With Colleagues Respect and courtesy Learn how to work well with other members of the health care team

Acting for the Good of society Adopt these good behaviors in all aspects of your life Recognize physician ’ s responsibilities in society

Dealing With Dying Patients Continue to care for a patient even when cure is not possible Provide care to reduce pain and suffering of the dying patient Do NOT abandon or “ give up ” on a patient

Empathy Ability understand the experience or viewpoints of others  What are the concerns of an adult who parent is dying?  What are the feelings of a patient who is dealing with a diagnosis of cancer?

Compassion Act with concern for others’ feelings Act to improve others’ well being Act to end suffering

Responsibility Do what you are expected to do  Get to clinic on time  Complete tasks assigned Keep promises to individual patients and their care Keep promises to colleagues and other health care professionals

Accountability Take responsibility for your own actions  Admit to errors or bad decisions you have made  Accept the consequences of your behavior Do not make unnecessary excuses