Skip redundant pieces
Landon Center on Aging
Landon Center on Aging  :  Geriatric Education & Training

Medical Ethics

Developed by: Daniel Swagerty, MD, MPH, CMD and
Sharee A. Wiggins, NP, Post-MS(N), ARNP, BC-GNP, BC-ANP
Revised 2012

Specific Learning Objectives

A. Introduction

Please review the Objectives, Content material, and Case Study before our Ethics Noon conference. We will apply the tasks in the Skills Objectives to the case study, and you should think about them ahead of time.

B.  Attitudes - Third year medical students should be able to:

  1. Acquire knowledge that will foster one's ability to combine excellent clinical skills with ethical behavior.
  2. Acquire the ability to confidently and effectively participate in patient care situations that present ethical challenges to the health care team, institution, patient, and/or family.
  3. Acquire an ability to recognize and respond appropriately to typical ethical challenges encountered in clinical situations.

C. Knowledge - Third year medical students should be able to:

    1. Discuss the principle of autonomy as an ethical standard, as it relates to medical decision making, and in contrast with the principle of beneficence.
    2. Define the medical ethics principle of justice.
    3. Relate examples of ambiguous distributive justice.
    4. Explain the principle of informed consent as an ethical standard, as it relates to medical decision making.
    5. Discuss the clinical situations in which life-sustaining treatment might alter one's choice of management.
    6. Describe the clinical situations in which medical futility might alter one's choice of management.
    7. Describe the important medical treatment options which must often be considered by older adults and their surrogate decision makers.

D. Readings

Required Reading

  • Gibson, R. M., & Ferrini, R.  (2010).  You let them do what??!!  Decision-making capacity and the exercise of patient autonomy in LTC.  [Ethical and Legal Issues in Long-Term Care].  Annals of Long-Term Care;18(10):25-30.  Accessed online February, 2011 at:  http://www.annalsoflongtermcare.com/print/852

Recommended Reading

E. Skills-Third year medical students should be able to:

  1. Define the principles of autonomy and beneficence.
  2. Describe the process and key components necessary to assess a patient for decision making capacity (decisional capacity) .
  3. Recommend appropriate courses of action for patients and family members as exemplified by the case studies.

F. Cases

  1. It's My Life, Isn't It?
  2. Three cases in the Required Reading article

 

There are four major principles that guide American Medical Ethics:  1) autonomy, 2) beneficence, 3) nonmaleficence, and 4) justice. These are considered guiding principles rather than moral imperatives. 

AUTONOMY

The principle of autonomy, or self-determination, entails respecting the choices and wishes of persons who have the capacity to decide and protecting those who lack this capacity. This principle would be used when a physician who has discussed preferences about life-sustaining treatment with a woman who has just been diagnosed with metastatic breast cancer is then guided by those wishes.

Competence and Capacity – competence is a legal term; determination of a person being “competent” or not, can only be decided in a court of law.  Decisional capacity is necessary to exercise the right of autonomy.  A patient who is able to make medical decisions possesses capacity. A patient who is not mentally or psychologically able to make medical decisions lacks capacity.  Decisional capacity is determined at the bedside, not a court of law. 

Assessment of decisional capacity involves 3 distinct components [adapted from J. Davenport]:

  1. Patients must demonstrate they understand the information provided about their condition, as well as its consequences.  This can be assessed by asking patients to paraphrase their understanding of these issues.
  2. Patients should be able to make decisions consistent with their own values. They can be asked what is most important to them in making their decision.
  3. Patients should demonstrate an ability to communicate consistent choices regarding their decisions.

 

Surrogacy – A surrogate stands in the place of another. In healthcare, we typically look to surrogates to help make decisions when patients lack medical decision making capacity.  This is an extension of the principle of autonomy. Patients do not lose the right to make decisions about their health care just because they lose capacity; the mechanism by which that right is expressed changes. [Davenport]

Informed Consent

The ethical foundation on informed consent can be traced to the promotion of two values: personal well-being and self-determination (autonomy). To ensure that these values are respected and enhanced, patients who have the capacity to decide their care must be permitted to do so voluntarily and must be provided all relevant information regarding their condition and alternative treatments.  This would include possible benefits, risks, costs, other consequences and significant uncertainties surrounding any of this information.

Informed consent is a two-part process involving disclosure by the health care professional and a decision by the patient. If health care professionals support a patient's right to make informed choices, they must respect the patient's decision regarding whether to accept or decline treatment. The consent form provides written documentation of the patient's decision but it is not a substitute for a thorough discussion between their physician and the patient.

The U-CARE acronym and model to assess decision-making capacity has been used by Gibson and Ferrini (see required reading article).  The authors cite advantages of the model as being both practical and simple to use.  The ethical tension increases as the complexity of the decision increases relative to the ability of the patient.

  • Understanding of the relevant information
  • Consistency of opinions/responses within and between interviews
  • Appreciation of the significance of the information as it applies to the person’s own situation
  • Ability to Reason with relevant information and to engage in a logical process of weighing option
  • Ability to Express a choice

These elements must be present for informed consent:

  1. the information to be discussed, including the nature of the intervention described in sufficient detail,
  2. the patient's comprehension,
  3. the patient's decisional capacity and
  4. the voluntary nature of the decision.

The physician should carefully discuss the proposed purpose of the intervention, including how any knowledge gained from the procedure will change the treatment course or outcome. The likely risks of the proposed intervention must be fully disclosed together with a discussion of their severity and likelihood. The likely benefits of the proposed intervention should be explained.

BENEFICENCE  {bə-ˈne-fə-sən(t)s}  and  NONMALEFICENCE  {non′-ma-le’-fə-sən(t)s}

The principle of beneficence advises the healthcare provider to benefit patients and protect their interests, whereas the principle of nonmaleficence encompasses the Hippocratic duty to “do no harm." Physicians must balance the risks and benefits of any proposed treatment. Conflicts between these two ethical principles can be found in most clinical situations.  An example of beneficence would include a physician who refuses to provide a prophylactic mastectomy for a patient who fears cancer but does not have any unusual risk factor for the disease. Beneficence can come into conflict with autonomy.

JUSTICE

The principle of justice entails providing persons with that to which they are entitled and treating similar cases similarly. The duty to treat all fairly, distributing the risks and benefits equally.

Top of page

FIDELITY

The ethical principle of fidelity is a proposition that healthcare providers keep patients’ interests first in mind above all others. It requires maintenance of patient trust and confidences. It obligates them to carry out their promises to care for patients with faithful attention.

Top of page

VEARACITY

The duty to tell the truth.

RESPECT

The duty to honor others, their rights, and their responsibilities. Respecting others implies we do not treat them as a mere means to our end.  It is foundational to the principle of autonomy.

Top of page

MEDICAL FUTILITY

Situations in which a patient's underlying diagnosis or diagnoses impart a terminal or poor prognosis, thus rendering specific medical interventions unhelpful and possibly detrimental.

LIFE-SUSTAINING TREATMENT

Life-sustaining treatment may include, but is not limited to, a mechanical ventilator, renal dialysis, chemotherapy, antibiotic therapy and artificial nutrition or hydration. Physicians, ethicists and lawyers widely agree that withdrawing or withholding life-sustaining treatment is legally and ethically permissible under appropriate circumstances. In fact, ethical and legal principles require that physicians respect the decision to forego life-sustaining treatment by a patient who has decisional capacity. However, if a physician is morally opposed to the patient's treatment preferences, the physician may transfer care to another physician who is more comfortable with the patient's wishes.

In addition, a competent patient may make his/her wishes known in advance of losing the ability to make health care decisions.  Such Advance Directives include the Living Will and the Durable Power of Attorney for Health Care (DPOA-HC).  The latter is also known as “health care proxy” (HCP) because a surrogate has the power to make decisions but ONLY when the patient lacks decisional capacity.  In such cases, physicians are morally and legally required to follow these health care preferences to the extent permissible by law.

MEDICAL TREATMENT OPTIONS

Cardiopulmonary Resuscitation (CPR) in Older Persons
The indications for CPR have changed considerably since its inception in 1960. Initially a treatment for sudden death in the setting of an acute myocardial infarction, CPR has become a procedure utilized in death from any cause. In the absence of a Do Not Resuscitate (DNR) order, CPR is often done by default, despite a growing body of literature that indicates CPR is often ineffective, particularly in persons dying of non-cardiac, multi-system diseases.

Several studies have evaluated the efficacy of CPR in older persons. In frail older persons who are dependent in their activities of daily living, CPR is usually not effective. Less than 2% of patients living in nursing facilities who receive resuscitation survive. Those who do survive are often more debilitated than before the cardiac arrest. The outcomes of older adults in the community who have a cardiac arrest are equally poor.

Functionally active older persons with primarily cardiac disease, who suffer a witnessed arrest in the hospital, may fare better. Hospitalized older patients suffering cardiac arrest have a survival rate of 26%. Some patients are more functionally dependent after the arrest. When people begin to develop functional disability and accrue chronic illnesses, their survival drops precipitously, regardless of age.

ANH: Artificial Nutrition and Hydration -- Near the End of Life
Nutrition is an essential requirement of life and without it death is certain. The symbolic nature of food is very powerful and firmly rooted in our culture and religious beliefs. As such, the decision to not provide food is often a difficult one.

The delivery of nutrition through a medical device (artificial means) is a medical therapy. Although commonly known as “tube feeding,” it is not “feeding” or “eating” in any form.  ANH may be instituted, withdrawn or refused like any other medical treatment. However, a person must declare clearly that they do not want artificial nutrition.  This statement can be as simple as: "If I were to become so ill that I could not talk meaningfully with my family and the hope of me regaining that ability was small, I would not want artificial nutrition (or: “to be fed by a tube”).   It is useful to have statements like this included in the Health Care Proxy form (HCP), or to state in the form that the health care agent/proxy knows the person’s wishes regarding artificial nutrition. 

If a person feels strongly that they would always want to have artificial nutrition, they should make sure their health care agent knows their wishes (and if they have a HCP they should note this on the form).  In discussions with patients and families it may be helpful to divorce the conversation from the emotionally laden term “feeding” and use the more accurate term “nutrition” or “liquid nutrition,”

Much of the information about what happens to people when they decide to forego artificial nutrition comes from Hospice and Oncology literature. People working in hospice have noted that patients suffer very little due to not eating. Dying patients who choose not to have nutrition of fluid delivered by artificial means (ANH), do not suffer from hunger and thirst. Patients who do experience hunger and thirst, can have their symptoms relieved with excellent mouth care, and small amounts of food and fluids that they chose to eat. Sometimes this is referred to as “pleasure eating” since it satisfies a desire, but does not supply adequate nutrition to sustain life. 

Studies in the oncology literature have shown that cancer patients have a higher mortality and morbidity who when they receive aggressive artificial nutrition (such as via PEG tube – percutaneous endoscopic gastrostomy), in comparison with those who do not. In patients with strokes who are nourished with gastrostomy tubes, the median time of survival is only 53 days (range 2 - 528 days), with only 12% of the patients surviving for more than three months. No study has shown that dying patients live longer or are more comfortable as a result of artificial nutrition. Enteral tube nutrition therapy is not without side effects. Placement of a PEG tube is a highly successful procedure and One of these side effects is aspiration pneumonia, which occurs in 50% of patients. When enteral tubes are used in patients with confusion or dementia, self-extubation is common and secondary consequences can occur. For additional thoughts on the ethical use of long-term “feeding tubes” the student may enjoy reflecting on this four-page position from the North Carolina Medical Society available online at the URL below.  The concept of “informed refusal” is included.  http://www.ncmedsoc.org/non_members/longterm_feedingtube_physician.pdf

Some basic guidelines to consider:

  1. Dying patients should choose what they want to eat, when they want to eat and the amounts of food that they want to eat.
  2. Food should never be withheld from a dying patient who desires it.
  3. For some patients, the act of eating is still important even though they may eat only very small amounts of the food presented to them (pleasure eating).
  4. Almost all dietary restrictions should be lifted in older adults, and especially for dying persons.
  5. Food can be fed, but never forced.
  6. Education of family and caregivers concerning artificial nutrition is very important.
  7. Nutrition via enteral tube has substantial risks, especially aspiration and self-extubation that often results in the use of restraints.
  8. To date, no studies have demonstrated that artificial nutrition improves morbidity or mortality in dying patients.
  9. None of the predominant religions in the USA demand that artificial nutrition be administered to dying patients. All are firm however, that food never be withheld from a patient who wants it, or with the intent to cause pain or death.
  10. Severe anorexia and loss of thirst is often part of the dying process, no matter what the cause. Organ function slows and metabolic processes shut down.

Top of page

 

SMALL GROUP CASE

IT'S MY LIFE, ISN'T IT?

During your geriatric rotation you are asked to see a patient making her first office visit in years. Mrs. W is an 89 year old- female who had been bedridden for one week following a fall in which she fractured her hip. Following the fracture diagnosis she declined surgical repair or physical therapy. According to Mrs. W, she "had walked long enough and was ready for a rest." Mrs. W has the financial resources to obtain 24-hour personal care and this is already in place.

Mrs. W is brought to the office by her son. The son and extended family are very upset by the course of events and insist that the physicians "talk her into surgery for her own good." The attending you are working with asks you to assess her situation and see what you think should be done.

You review her medical history and find the following:

Medical problems:

  1. Hypertension -Well controlled on a diuretic.
  2. Diabetes - Fair control on an oral agent. She has peripheral neuropathy which is often painful and limits her ambulation.
  3. Osteoporosis - This is her fifth fracture after a wrist fracture and three vertebral body compression fractures.

Review of Functional Status: problems identified

  • Mild visual impairment: wears corrective lenses but has mild macular degeneration
  • Mild hearing impairment: does not use any type of assistive device
  • Gait instability:  ambulates with a walker and has had numerous falls
  • Independent in all other basic activities of daily living (dressing, eating, transfers, toileting, hygiene)
  • Dependent on her family and neighbors for grocery shopping, transportation, and some meal preparation
  • Urinary incontinence daily for which she wears disposable briefs (adult “pull-ups”)
  • Memory loss by self-report
  • Mood has been down lately given multiple illnesses and persistent pain

Process:

You have a long talk with Mrs. W and come to understand her point of view. You sympathize with her current impression of her quality of life but… you too are somewhat reluctant to let her wishes stand. It seems that surgery could give her a reasonable chance at walking again.

What is your recommendation to your attending?

How would you establish medical decisional capacity in this patient right now?

You have now established that Mrs. W has reasonable cognitive skills and is not emotionally impaired. You also discuss with her the implications of her decision and she is able to clearly outline the risk her decision places her at. She realizes she is at risk for greater medical complications and death. She clearly conveys an interest in enjoying her remaining time and pursuing only comfort measures at such time as they are appropriate. She does not want to return to the hospital setting. Based on this, you feel Mrs. W has full decisional capacity (cognition, emotion, insight and judgment intact) and should be allowed to make her own decisions. You and the attending relay this to the family.

The family is outraged. Mrs. W’s son pulls out his copy of the durable power of attorney for health care. He states that he wants to invoke his right to make decisions. He insists you remove the DNR and make a referral for surgical repair.

How do you respond to Mrs. W's son?

Though the family is still upset, Mrs. W is quite pleased with her current status. She is able to assist with transfers into a wheelchair and then propel herself throughout several rooms of her home. She has been accepting of transportation assistance that allows her to continue attending a senior center three times a week. She is appreciative of the health care providers who "listened to an old woman and let her have her way."

CASES 1-3 IN REQUIRED READING ARTICLE as time allows

Top of page

Back