ETHICS & DECISION MAKING ETHICS & DECISION MAKING SPOON - - PowerPoint PPT Presentation

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ETHICS & DECISION MAKING ETHICS & DECISION MAKING SPOON - - PowerPoint PPT Presentation

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ETHICS & DECISION MAKING ETHICS & DECISION MAKING SPOON FEEDING SPOON FEEDING Should we stop? Should we stop? Manitoba Provincial Health Ethics Network Manitoba Provincial Health Ethics Network May 2014 May 2014 Good News

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ETHICS & DECISION MAKING ETHICS & DECISION MAKING “ “SPOON FEEDING SPOON FEEDING” ”

Should we stop? Should we stop?

Manitoba Provincial Health Ethics Network Manitoba Provincial Health Ethics Network May 2014 May 2014

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Good News Good News

It was a normal day in Sharon Springs, Kansas, when a Union Pacific crew boarded a loaded coal train for the long trek to Salina.

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Bad News Bad News

Just a few miles into the trip a wheel bearing became overheated and melted, letting a metal support drop down and grind on the rail, creating white hot molten metal droppings spewing down to the rail.

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Good News Good News

A very alert crew noticed smoke about halfway back in the train and immediately stopped the train in compliance with the rules.

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Bad News Bad News

The train stopped with the hot wheel

  • ver a wooden bridge with creosote tiles

and trusses.

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The crew tried to explain this to Union Pacific higher‐ups, but were instructed not to move the train! They were informed that Rules prohibited moving the train when a part was found to be defective!

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The RULES are the RULES! Don’t ever let common sense get in the way of a good Disaster!

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ENGAGING ETHICALLY ENGAGING ETHICALLY

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GUIDING PRINCIPLES GUIDING PRINCIPLES

BEAUCHAMP & CHILDRESS BEAUCHAMP & CHILDRESS

Principles that govern ethical relationships between healthcare providers and patients.

(Beauchamp and Childress 6th ed)

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PRINCIPLES PRINCIPLES

  • Nonmaleficence
  • Beneficence
  • Justice
  • Autonomy
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FRAMEWORK FRAMEWORK

Facts ‐ Known, missing, conflicting info,

what’s needed to move forward?

Ethical issue – What is problem, legal

issue, standards of practice, personality conflict

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FRAMEWORK FRAMEWORK

Who are the stakeholders ‐ anyone

missing, roles & responsibilities, conflicting interpretations

Analyze your biases ‐ influence your

perception

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FRAMEWORK FRAMEWORK

Build best/worse case scenario Prepare risk analysis associated with alternative plans

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FRAMEWORK FRAMEWORK

Policies/guidelines Make a plan/include alternatives Evaluate

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WHAT TO DO? WHAT TO DO?

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MORAL DISTRESS MORAL DISTRESS

  • Is aware of the moral problem
  • Acknowledges moral responsibility
  • Makes a moral judgment about the correct action

but as a result of real or perceived constraints, participates in or allows the moral wrong‐doing to occur The pain or anguish affecting mind, body or relationships in response to a situation in which the person:

(Nathaniel. A., 2006)

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WHAT DOES IT FEEL LIKE? WHAT DOES IT FEEL LIKE?

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FACTORS GENERATING MORAL FACTORS GENERATING MORAL DISTRESS DISTRESS

  • 1. Clinical Situations
  • 2. Factors internal to

the caregiver

  • 3. Factors external to

the caregiver

  • 4. Inherent in the

environment

CLINICAL FACTORS

  • Unnecessary tests/treatment
  • Prolonging dying through aggressive

treatment

  • Inadequate informed consent
  • Caregiver competence
  • Lying to or deceiving patients
  • Inappropriate use of resources

INTERNAL FACTORS

  • Heuristics
  • Perceived powerlessness
  • Lack of Knowledge
  • Personal/professional value conflict
  • Lack understanding of full situation

EXTERNAL or ENVIRONMENTAL FACTORS

  • Lack of time
  • Measuring results replaces

relationships

  • Lack of Community resources
  • Compromised care due to pressure

to reduce costs

  • Co‐worker issues or differing

professional perspectives

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TYPICAL RESPONSE TYPICAL RESPONSE

Springboard into action Avoidance, judge/blame others Withdrawal Frustration Job dissatisfaction

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ETHICS IS NOT EASY ETHICS IS NOT EASY… …BUT IT IS EASIER BUT IT IS EASIER WHEN WE: WHEN WE:

Communicate Systematic approach Aware of biases Respect relationship dynamics

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Consent and Capacity Board Consent and Capacity Board

Independent body with Legal authority Review decisions and compliance of SDM Provide guidance

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Competent People have Competent People have Considerable Control & Legal Considerable Control & Legal Authority to Direct Care Authority to Direct Care Incompetent People Incompetent People Have Much Less! Have Much Less!

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HEALTH CARE CONSENT ACT HEALTH CARE CONSENT ACT

Dictates rules and guidelines regarding all forms of capacity and authorization to Substitute Decision Making

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ADVANCE CARE PLAN ADVANCE CARE PLAN

Legal document Sometimes made ten years prior Ambiguous writing / Black and White instructions often from a bank of lists provided by a lawyer

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SPECIFIC DETAILS SPECIFIC DETAILS

Regarding nutrition once I am in severe dementia Regarding Comfort Care, which I request in any phase of dementia Protocols for stopping food and water

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Surrogate Decision Making Surrogate Decision Making

  • Substituted Judgment Standard

“Don the mental mantel of the incompetent” Reliant on the decision maker’s familiarity with the client’s view and values Risk of substituting own values/needs What if the client has never been competent or discussed the issue literally?

Beauchamp & Childress (2009)

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Surrogate Decision Making Surrogate Decision Making

  • Pure Autonomy Standard

 Applies exclusively to formerly autonomous judgments even in the absence of a formal directive  Written documentation (Living Will) & Oral directive dictate decisions about care  Satisfactory evidence? – Risk misinterpretation of value judgments from past events

Beauchamp & Childress

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Surrogate Decision Making Surrogate Decision Making

  • Best Interest Standard

 Can validly override advance directives if the decision goes against their best interest.  Ability to anticipate a future state often challenge reliance of advance directives  Quality of life?

Beauchamp & Childress

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Do the patient’s current wishes align with her previous directive? If not, Which should we follow?

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Feeding or Force Feeding Feeding or Force Feeding

Should not Force Feed! How can we distinguish between these? When is it considered medical intervention? When you can no longer feed yourself?

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Margot Margot’ ’s Choice s Choice

 Retired nurse  1991‐ “Statement of Wishes” desired level of care should she become incapacitated.  Now in Nursing home unable to communicate. Mobility limited and depends on spoon feeding

  • f pureed foods for nourishment.
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Conflicting Interpretation Conflicting Interpretation

Family claim no emotional reaction when eating Care team say she does communicate small wishes when eating

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Margot Margot’ ’s Choice s Choice

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COURT RULING COURT RULING

MUST CONTINUE SPOON FEEDING, TO DO OTHERWISE WOULD BE DEEMED AS NEGLECT OF BASIC CARE

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Ethical Challenges Ethical Challenges

Patient & Family For Caregivers For the Health Care System

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