in clinical decisionmaking Jill Ann Jarrell MD MPH Complex Care Program Academic General Pediatrics Texas Childrens Hospital Baylor College of Medicine Dr Jarrell has no relevant conflicts of interest to disclose ID: 678867
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Slide1
Medical Ethics 101
Balancing obligation, outcomes, and risk
in
clinical decision-making
Jill Ann Jarrell, MD, MPH
Complex Care Program, Academic General Pediatrics
Texas Children’s Hospital, Baylor College of MedicineSlide2
Dr
. Jarrell has no relevant conflicts of interest to disclose
DisclosuresSlide3
Patient-Provider
RelationshipSlide4
Patient-Healthcare
Team RelationshipSlide5
“Ethics is a branch of philosophy; the formal, rational, systemic examination of the rightness and wrongness of human actions.”
1What is “Ethics”?Slide6
Evaluating the rightness and wrongness of human actions
in medicineBioethicsWhat is “Medical Ethics”Slide7
Principles and Duties of Medical EthicsSlide8
Autonomy
Individual liberty, dignity, and capacityJustice
What is fair or deserved
Beneficence
An obligation to do good
Nonmaleficence
An obligation to not harm
Ethical PrinciplesSlide9
Veracity
Truth telling
Privacy and Confidentiality
Role Fidelity
Professional responsibility and autonomy
Respect for Societal
I
nstitutions
Life, culture, family, religion
Ethical DutiesSlide10
Surrogate or
substitute decision-making
Advanced care planning
Principle of double effect
Informed consent
Futility
Hot Topics in EthicsSlide11
Able
to understand medical treatment and make informed decisions.
Decision-Making Capacity Slide12
Unable to understand the
benefits, risks, alternatives to treatment.
IncapacitatedSlide13
Individual with authority
to consent to medical treatment for an incapacitated patient.
Surrogate
Decision-Maker Slide14
Spouse
Adult child with POA or majority of adult children
Parents
Clearly identified individual
Nearest living relative
Patient’s clergy
Surrogate Decision-MakersSlide15
Parents available
Natural parents
Adoptive parents
Sole managing conservator
Possessory conservator (non-invasive procedures during possession)
Surrogacy in MinorsSlide16
Parents not available
Grandparent
Adult sibling
Adult aunt/uncle
Educational institution with written authorization
Surrogacy in MinorsSlide17
Parents not available (cont’d)
Adult with custody and written authorization
Court with jurisdiction
Adult with care of child subject to juvenile court
Peace officer
Surrogacy in MinorsSlide18
Schizophrenic Child
W
ith
A
bsent
F
amilySlide19
17
yo
male with paranoid schizophrenia
Attempted
suicide
Survived - multiple
orthopedic and internal injuries
HistorySlide20
Poorly compensated from a psychiatric perspective
Mother quit visiting/answering
calls
Patient turned 18
during care
ConflictSlide21
Who is the decision-maker?
Patient
Mom
CPS/APS
Legal Guardian
Who is in charge?Slide22
Beneficence
Autonomy
Social Responsibility
Ethical challengesSlide23
Pregnant
patient with terminal cancerSlide24
30
yo
woman
24
weeks gestation
Stage
IV
b
reast cancer
Pregnant Patient With CancerSlide25
Intractable
pain
Progressive encephalopathy
Previously told her
OB/GYN
she wanted to “have
this
baby”
Pregnant Patient With CancerSlide26
Patient’s condition declined
Patient’s mother
asked for hospice care for
her daughter
Pregnant Patient
W
ith
C
ancerSlide27
Pregnant Patient With Cancer
Two patients?Slide28
Pregnant Patient With Cancer
Who is the decision-maker?
Patient
Mother
Healthcare teamSlide29
Pregnant Patient
With Cancer
Ethical Challenges?
Beneficence
Nonmaleficence
S
ocial responsibility
Role FidelitySlide30
To
trach
or not to
trach
…Slide31
5
yo
with Trisomy 21, repaired CHD, CP admitted for pneumonia
PICU, intubated, difficult wean,
trach
was discussed with family
Palliative care consulted on HD 55 to discuss “options”
HistorySlide32
Palliative care recommended not to
trach
and for medical team to collectively advise palliation
ENT “just a technician” and uncomfortable
PCP and CCM wish to proceed with
trach
Ethics committee consult requested
ConflictSlide33
Benificence
Non-maleficence
Respect
for
family
Autonomy (but how much?)
Role fidelity
Ethical challengesSlide34
Listening
Conflict resolution
Tolerance for ambiguity
Ability to apply ethical principles and carry out duties
Skills for Resolving Ethical Dilemmas
2Slide35
Medical indications
Patient preferences
Quality of life
Contextual features
Framework for Ethical Decisions
3Slide36
Continue
to LEARN about your discipline and
the
ever-changing milieu in which it is
practiced
COMMUNICATION
and COLLABORATION
between
care team members and
decision-makers is
key to success
Take Home MessagesSlide37
Questions?Slide38
Pellegrino, E. Toward a Reconstruction of Medical Morality. The American Journal of Bioethics 2006; 6-65-71
“Legal and Ethical Issues” Physician Board Review Course in Hospice and Palliative Medicine, MD Anderson Cancer Center, 10/12/2010.
Jonson A,
Seigler
M,
Winslade
W.
Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine
. 6
th
ed
, page 11.
References