Understanding Conflict amp Seeking Resolution Rachelle Barina MTS PhDc Gateway Alliance Conference August 6 2015 9am 1230pm I hope the next three hours will Help you gain ID: 312504
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Slide1
Ethics at the End of Life:
Understanding Conflict & Seeking Resolution
Rachelle Barina, MTS, PhD(c)Gateway Alliance ConferenceAugust 6, 20159a.m. - 12:30p.m.Slide2
I hope the next three hours will…
Help
you gain awareness of how you tend to think about ethical issues and why you tend to think that way.Improve your capacity to understand the perspectives of others and articulate strong and relevant support for your views.
Deepen your moral imagination and give
you
insight about several ethically common or significant issuesSlide3
Outline
Intro to EthicsReflection on your own thought patterns & comparison to moral theoriesUS culture, death, and dying 5 CasesAdvance directives & end of life conversations
Treatment after a suicide attemptRelationship of law and ethicsCommunication strategies“Futility” impassesScope of clinicians’ responsibilities in helping patients live & die wellPolicy and physician assisted suicide or physician aid-in-dyingSlide4
What is ethics??Slide5
Being
(character)
Who we ought to become as persons5Ethics
doing
(action)
How we ought to act in relation to others
The ultimate good
The purpose and end of our lives:
Flourishing
Right
goods
Ethics is the study of the moral lives & actions of persons (or organizations)
against a normative basis
that provides insight into
who we ought to become & how we ought to act
in relation to othersSlide6
Ethics
LivedEthics is not a theory applied to life.
You develop your ethical perspective and a normative framework by which you make decisions throughout your life.As a clinician, you don’t (or shouldn’t) check your conscience at the door.Health Care Ethics: Define boundaries & advocate options that help people thriveThe stakes6Slide7
Ethics & Feelings of Moral Distress
Personal effectsQuantifiable decrease in well-being, withdrawal from social interactions, resentment & sadnessProfessional effectsQuantifiable impact on clinical care, communicationOrganizational effectsSignificant job turnover
You need intellectual tools and social support as you address difficult questions.Slide8
Assessing Your Approach to Ethics
This assessment is borrowed from Panicola et al Health Care Ethics: Theological Foundations, Contemporary Issues, and Controversial Cases
. It is based off the work of Brian O’Toole, first published as “Four Ways People Approach Ethics,” in Health Progress. Slide9
Being
(character)
9Theories & Approaches to Ethics
Doing
(Action)
Virtue
Principles
Utilitarian Consequentialism
These theories describe how you, your patients, and your co-workers probably already think.
You likely use different approaches as you negotiate and work through issues.Slide10
Principle-Based Approach
Decisions are made according to norms, rules, and principles. i.e., Be charitable, Do not harm, Be fair, Do not kill, Respect autonomy, Keep your promises, etc.)Principles come from a variety of sourcesThe ends do not justify the means (or action) Some are engrained in law and others are not.Bioethics and Principlism (Autonomy, Maleficence, Beneficence, and Justice)
What to do when principles conflict?Slide11
Utilitarian Consequentialism
Begin not with principles but with consequences and usefulness.What are the valued ends?What will happen if you pursue each option? CalculationGreatest good for the greatest number.Comparison of costs/burdens and gains/benefitsThe ends justify the meansSlide12
Virtue Approach
Ethics begins with the character and identity of a person, rather than the action or question at hand. Decisions come out of and shape who someone is/becomes.Ethical decisions are not simply about action, but about becoming virtuous people and helping others become virtuous too.The intention and disposition of a person is crucial. Slide13
Revised ANA Code of Ethics for Nurses
Provision 5:The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.Slide14
Discuss with one partner
Try to explain why you tend towards one approach or why your results are mixed. What in your life may have led you to these patterns of thinking?What has shaped the ways you approach ethics and your moral commitments?Can you think of a time where your moral commitments came up in your professional work? What happened, what did you think, and did your thinking have evidence of any of the approaches we discussed?
Remember: Text your questions to 661-523-2995Slide15
Wrap-up
Ethics is about helping people to flourish and to be able to pursue goods.Health care ethics acknowledges there are many stakeholders, so it seeks to define limits and boundaries that balances the goods of all involved. Your commitments and experiences color your professional judgment and your conscience. Being aware of how you tend to approach ethical issues and how others might approach them will help you gain understanding, build bridges, and explain differences.
Remember: Text your questions to 661-523-2995Slide16
Break!
Text your questions to 661-523-2995Slide17
Why ethics at the end of life??
Ethics & End of Life
Cost of Providing Treatment
Regulation and Policy
Religious Commitments
Technological intervention
Your personal, values, experiences and ideas
Family Dynamics
Organizational Values & Policies
Physician & care
team dynamics
Laws &
Fear of lawsuits
Medical culture and the default to treat
Miscommunication and Misconceptions
Professional GuidelinesSlide18
Pre-Modern Medicine
Modern MedicineLittle capacity to intervene in disease and death processes. People did all they could, usually without significantly affecting the timing of death.
The dying process is lengthened by our technologies and capacity to intervene; common sentiment is that we should intervene and delay death when we can.Death was viewed through faith as a natural evil that couldn’t be affected. We were not immanently responsible for death.Death is viewed through science as a moral evil to fight against. We are responsible when we fail to overcome death.People accepted their finitude.We tend to be anxious and resistant of death, emphasizing our autonomy over death and a medical hope to overcome all diseasePeople thought about morality, even if not naming it as suchMore people experience end of life in institutions. Bioethics formalized in 60s-80s. Times Past and Present
Slide credit: Mike
PanicolaSlide19
Most people have numerous end of life options.
Are we dying in the ways we want? Are we thriving as health declines?Slide20
True or False
: Most people prefer to die in the hospital surrounded by an attentive group of health care professionals who will manage pain and other symptoms.False!
>80% of patients say that they wish to avoid hospitalization during the terminal phase of illness.Slide21
What percentage of people in the US die in a hospital? …In an ICU?
50% die in a hospital70-80% of deaths in the US occur in a hospital/institutional setting.
More than 68% of Medicare pts were hospitalized in their last 6 months.20% die in an ICUAre we dying in the ways we want? Slide22
Why does end of life continue to pose challenges?
PersonalInterpersonal
MedicalStructuralAccepting our mortality is REALLY HARD.Death and dying and often raise questions about the meaning of life, death, and flourishing.Preconceived ideas about hospice.
Differences are brought to light.
Long standing
conflicts and grudges come up.Spirituality or faith can be important and divisive.
Medicine almost always has another option to try.
The culture of medicine leads to a tendency to try it.
Technological interventions are
difficult to forego or withdraw.
US
culture tends to deny and avoid the realities of finitude and death.
Systematic challenges
from our health care system.Slide23
Problems of our HC System Shape End of Life
Current SystemCare Design
provider-centered
Care
Focus
individual sick care
Care Delivery
fragmented,
in silos
Care Setting
hospital,
office
Payment
fee-for-service
Financial Incentives
do more, make more $$
Primary Care
Diagnostics
The Patient
Specialist(s
)
More
Diagnostics, Terminal diagnosis
Event &
hospitalization
Nursing Home
Primary Care
Specialist(s)
Home
Slide credit: Mike
Panicola
Nursing Home
ICU
ED, AdmissionSlide24
The U.S. population is aging
– fast 40+ million people ≥65 years of age in 2010, By 2050 that number will be over 80 million
The 65+ population in the U.S. tends to be sicker than elderly adults in other industrialized nationsApproximately 92% of older adults have at least one chronic disease that leads to significant health decline prior to death.To Make the Situation Worse…
Slide credit: Mike
PanicolaSlide25
Dying in the US Today
How are we going to fix the conflict-ridden, expensive, and dissatisfying ways we die?
From “Let's talk about dying” - Peter Saul
Function
Time
Sudden Death
Terminal Illness
Organ Failure
Frailty
Remember: Text
your questions to 661-523-2995Slide26
Advance Directives
First proposed by a lawyer in 1967Surrogate DMs and treatment directivesAdvance Directives were born out of:1) Values of autonomy and self-determination (
Principlism)2) The practical need to have a process that would reduce court costs and conflicts at EOL. (Consequentialism) Slide27
We frequently overestimate how much treatment-based directives will advance patient autonomy and self-determination.Slide28
Concerns about Treatment Directives
Accurate prediction of situational preferencesMisunderstanding & lack of perspectiveTremendous cognitive bias in making treatment decisions in advance. (Recent experience, way of asking questions, the AD form itself)Stability of preferencesAdvance directives must be acknowledged and interpreted.They often fail to resolve difficult clinical situations.Slide29
What Can Advance Directives do?
Designate a surrogate decision maker.Treatment directives may help us know about a person’s anticipated preferences.Treatment directives can help alleviate the burdens of responsibility that families feel.
Most importantly, they are one tool for prompting our attention and having conversations. Slide30
End of Life Conversations
Our conversations are poor because: We usually don’t have them. (90 vs. 30%) We use sickness as the occasions to acknowledge that we die and advance directives to frame our conversations.Treatment directives can serve as proxies for bigger and more challenging ideas, emotions, and questions.Slide31
Our conversations should focus on
what matters most toward the end of life, not which treatments we may want.
All health care professionals have a role in encouraging advance care planning. Slide32
Better Questions to Start with
Theconversationproject.orgAdvance Care Planning: the process of thinking about your preferences for care at the end of life Get Ready, Get Set, Go, Keep Going (AD is option in the last phase)What are your priorities for living toward the end of your life?What
are your concerns about treatment? What are your preferences about where you want to be?How involved do you want your loved ones to be?When the death approaches rapidly, are you more inclined to be alone or surrounded by family?What do you feel are the three most important things that you want your friends, family and/or doctors to understand about your wishes for end-of-life care?**Might Katrina’s EOL turned out differently if she had a different kind of conversation?Slide33
End of Life Conversations & Culture ShiftSlide34
Better EOL conversations are not enough
Cultural shifts
Structural:Reimbursement, institutional practices, physician expectations, realistic advertising messages, access to and easier/earlier transitions to hospice, etc.Personal:Reflection and acceptance about end of life, Realistic expectations of medicine, Conversations with family & surrogate decision makers
Remember: Text
your questions to 661-523-2995Slide35
2 minute discussion
Personally or professionally, how might you be able to promote more substantive conversations about living toward the end of life?Remember: Text your questions to 661-523-2995Slide36
This talk included case presentations that are not available for distribution.Slide37
Questions? Thank you!