1. © 2010 Jones and Bartlett Publishers, LLC A Practical Approach For Decision Makers SECOND EDITION EILEEN E. MORRISON

2. © 2010 Jones and Bartlett Publishers, LLC Class Twelve: Patient Issues and Ethics

3. © 2010 Jones and Bartlett Publishers, LLC Agenda Discussion of paternalism and its roots Discussion of paternalism and its roots Definition of the patient experience Definition of the patient experience Discussion of the product of health care Discussion of the product of health care Review the ethics of measurement Review the ethics of measurement Dialogue on patient-centered care Dialogue on patient-centered care Group reports on patient-experience Group reports on patient-experience Summary Summary

4. © 2010 Jones and Bartlett Publishers, LLC Paternalism Comes from the Latin “pater” meaning father. Comes from the Latin “pater” meaning father. Goes back to Aristotle and others. Goes back to Aristotle and others. Style or approach to relationships were you tell people what is best for them. Style or approach to relationships were you tell people what is best for them. Where do you find paternalism? Where do you find paternalism? Experiences with paternalism? Experiences with paternalism?

5. © 2010 Jones and Bartlett Publishers, LLC Paternalism Roots of health care dominated by professionals especially physicians. Roots of health care dominated by professionals especially physicians. After WW I, medical profession became very powerful. After WW I, medical profession became very powerful. Paternalism increased Paternalism increased –Moral duty to avoid harm –Beneficence and superior knowledge used to decide the “patient’s good”.

6. © 2010 Jones and Bartlett Publishers, LLC Why a change in Paternalism? Increase in insurance decreased overall control by physicians. Increase in insurance decreased overall control by physicians. Others began to define quality care. Others began to define quality care. Technology increase also changed physician power. Technology increase also changed physician power. Consumerism is on the rise and integrated medicine changed views. Consumerism is on the rise and integrated medicine changed views. Paternalism is still present but it is challenged. Paternalism is still present but it is challenged.

7. © 2010 Jones and Bartlett Publishers, LLC Patient experience.. You are not a patient until the system says you are. What are you? You are not a patient until the system says you are. What are you? For example, think about the last time you had a headache. What does it feel like? For example, think about the last time you had a headache. What does it feel like? What do you do? What do you do?

8. © 2010 Jones and Bartlett Publishers, LLC Patient experience.. If it did not go away, what did you do? If it did not go away, what did you do? When YOU decide what to do, it is self treatment. When YOU decide what to do, it is self treatment. What if self treatment did not work. What if self treatment did not work. You decide that you are SICK. You decide that you are SICK.

9. © 2010 Jones and Bartlett Publishers, LLC You assume the sick role? What are the benefits of the sick role? What are the benefits of the sick role? What are the disadvantages? What are the disadvantages? Seeking care is a process that is influenced by culture, experience and knowledge. Seeking care is a process that is influenced by culture, experience and knowledge. If you have a chronic problem, the sick role gets old and people may not support you. If you have a chronic problem, the sick role gets old and people may not support you.

10. © 2010 Jones and Bartlett Publishers, LLC Health Care System is a Strange Land You decide to enter the healthcare system, and You decide to enter the healthcare system, and You get a DX and a RX if we in health care can assign you a disease. You get a DX and a RX if we in health care can assign you a disease. Professional sees you as a disease that needs treatment and has an outcome. Professional sees you as a disease that needs treatment and has an outcome. Like you to be a “good patient” Like you to be a “good patient”

11. © 2010 Jones and Bartlett Publishers, LLC Health Care System is a Strange Land For patients, disease is personal. For patients, disease is personal. Societal stigma exists for some disease treatment. Societal stigma exists for some disease treatment. Culture clashes occur between professionals and patients. Culture clashes occur between professionals and patients. Remember that patients judge you from their system not yours. Remember that patients judge you from their system not yours.

12. © 2010 Jones and Bartlett Publishers, LLC Measuring Patient Experience What are you selling in health care from the patient’s view? What are you selling in health care from the patient’s view? A patient dies; is this a good outcome? A patient dies; is this a good outcome? How will you decide if the patient has had a excellent experience with you? How will you decide if the patient has had a excellent experience with you? What would you do with this information? What would you do with this information? Why is this important to your business? Why is this important to your business?

13. © 2010 Jones and Bartlett Publishers, LLC Measurement and Ethics As administrators, evaluation is good for business; why? As administrators, evaluation is good for business; why? Kant: Moral duty to treat patients with respect. Patients are not numbers; they are real. Kant: Moral duty to treat patients with respect. Patients are not numbers; they are real. Mill: Greatest good for the greatest number through knowing the consequences of your actions. Mill: Greatest good for the greatest number through knowing the consequences of your actions. Do your policies and practices work? Do your policies and practices work?

14. © 2010 Jones and Bartlett Publishers, LLC Measurement and Ethics Rawls: Protect the least well off and still treat them with dignity. Rawls: Protect the least well off and still treat them with dignity. Social justice also means paying attention to patient’s views. Social justice also means paying attention to patient’s views. Principles like autonomy, nonmaleficience and beneficence apply; how? Principles like autonomy, nonmaleficience and beneficence apply; how?

15. © 2010 Jones and Bartlett Publishers, LLC Measuring Patient Experience Numbers are used and report cards are created. Numbers are used and report cards are created. Surveys have limits. Surveys have limits. Remember design limitations. Remember design limitations. Ethics of data collection needs to be considered. Ethics of data collection needs to be considered. Use techniques other than questionnaires for a complete picture. Use techniques other than questionnaires for a complete picture.

16. © 2010 Jones and Bartlett Publishers, LLC Measurement and Ethics Moral duty to treat patients with respect. Moral duty to treat patients with respect. Greatest good for the greatest number through policies and practices. Greatest good for the greatest number through policies and practices. Social justice means paying attention to patient’s views. Social justice means paying attention to patient’s views. Principles like autonomy, nonmaleficience and beneficence apply. Principles like autonomy, nonmaleficience and beneficence apply.

17. © 2010 Jones and Bartlett Publishers, LLC What is Patient-Centered Care? An example is the Planetree Model founded by Angela Thieriot. An example is the Planetree Model founded by Angela Thieriot. She named Planetree in honor of Hippocrates. She named Planetree in honor of Hippocrates. It was a response to her treatment at a large hospital. It was a response to her treatment at a large hospital. She felt tortured and humiliated as a person. She felt tortured and humiliated as a person. Created a non-profit foundation to change health care. Created a non-profit foundation to change health care. First Planetree Hospital was a med/surg unit in San Francisco. First Planetree Hospital was a med/surg unit in San Francisco.

18. © 2010 Jones and Bartlett Publishers, LLC Features of Planetree Human interaction is essential. Human interaction is essential. Health information and patient knowledge are needed. Health information and patient knowledge are needed. Recognizes the family connection. Recognizes the family connection. Food and nutrition important. Food and nutrition important. Power of spirituality recognized. Power of spirituality recognized. Human touch included. Human touch included. The Arts are part of healing. The Arts are part of healing. IM (CAM) is part of its options. IM (CAM) is part of its options. The total healing environment is emphasized. The total healing environment is emphasized.

19. © 2010 Jones and Bartlett Publishers, LLC What has been the Response? From the clinical staff? From the clinical staff? From the management staff? From the management staff? What about patients and families? What about patients and families?

20. © 2010 Jones and Bartlett Publishers, LLC ‘What if” Exercise Suppose you had to spend eight days in the hospital. Suppose you had to spend eight days in the hospital. What would you want your experience to be like? What would you want your experience to be like?

21. © 2010 Jones and Bartlett Publishers, LLC In summary… Do you think patient-focused care is good business and good ethics? Why? Do you think patient-focused care is good business and good ethics? Why?