LIN Sessions: Rapid Ethical Decision Making in the ED
Michelle Lin MD and Jill Barren MD
Take Home Points
We need to apply an ethical decision making framework to patient care.
Ethicists make no moral distinction between withholding and withdrawing treatment.
When a treatment is not effective, there is no moral obligation to continue with it.
Refusal of care is formally established in American case law and is considered part of the right to privacy.
If you are going to have an informed refusal of care conversation with a patient, make sure they demonstrate the components of decision making capacity
Barren has always had an interest in ethics and is drawn to the humanistic aspects of medical care. This is an antidote to physician burnout. She had already established an academic career when she decided to pursue a Master’s degree in Bioethics. This allowed her to connect with other like-minded physicians. It enhanced her teaching by adding another dimension to patient care.
In clinical medicine, we learn clinical reasoning and we apply it to our patients over and over again in a series of cases to solve diagnostic dilemmas. We need to do the same thing when it comes to ethical dilemmas. We need to apply an ethical decision making framework to patient care.
What is ethics?Ethics is the application of values and moral rules to human activities and behaviors. We are aiming to create good by doing right. In the field of bioethics, ethical principles are used to solve actual or anticipated dilemmas in medicine or biology.
Clinical bioethics is case based reasoning and relies on learned rules of clinical practice and takes into account prior decisions and recognition of unique factors found in each case.
A skilled nursing facility transported an 84 year old resident with a history of dementia for a change in mental status. Treatment was initiated with intubation, fluid hydration, antibiotics and diagnostics. A few minutes later, family arrived waving a piece of paper, furious that their mother’s wishes to remain DNR were ignored.
This is a frequent occurrence in the emergency department. Emergency physicians have a strong moral imperative to save lives. This is based on the presumption that the patient or family member would consent to preserve life and health if he or she were able to and there was sufficient time. When a patient arrives in extremis, there is not sufficient time to obtain that consent. We rely on advance directives.
Should you resuscitate if you are not sure about the existence of advanced directives? Yes, absolutely. If in doubt, resuscitate. However, this case raises the competing moral imperative to relieve pain and suffering. Emergency physicians should never overrule a valid advanced directives. In this case, once the family arrives, it is quite ethically permissible to withdraw care once more information is available and the goals of care can be determined.
This is the point when you switch from cure to care and begin to manage the dying process. Ethicists make no moral distinction between withholding and withdrawing treatment. However, conventional wisdom tells us that it is more difficult to withdraw once you have instituted care. The law does not require any kind of maintenance of life-sustaining therapy. When a treatment is not effective, there is no moral obligation to continue it. Many prolonged cardiac arrest situations are futile and should not be continued.
These scenarios may have a twist when family members are in disagreement about withdrawing life-sustaining treatment. In this case, you can continue to treat while establishing the prognosis, getting more information or until disputes are resolved. You can stop treatment if you are convinced that is the decision the patient would make. It is important to be truthful and disclose a poor prognosis. You are under no obligation to render futile treatment.
What phrases can you use in the discussion of withdrawal of care? We are busy and these conversations require being in the moment with the family. Go into a private space. Make sure that you are able to sit down, have eye contact and provide family members with tissues and water. This is a life-defining moment for them. It is important to set the environmental circumstances before the conversation. This is a resource issue as well. We need to take ownership of these issues rather than passing the buck to the ICU team.
Don’t use the phrase, “What would you like us to do?” This implies that our system of values and preferences are more important than that of the patient when the opposite is true. “What do you think your mother/father/brother would want us to do in this situation? Are there conversations that might have happened previously that might point us in the right direction and help us learn more about what your family member’s values and preferences would have been in this situation if they could speak for themselves?” You are trying to understand the person through substituted judgment by using members of their family who were close to them, understand them and can express their values.
A 25 year old male was involved in some interpersonal violence and presented with multiple facial lacerations. He was agitated. He didn’t want care, repair or cleaning of the wounds. He appears mildly intoxicated and smells of alcohol but denies drinking more than one beer. He was alert and oriented and stated he wanted to leave. He threatened to sue.
This is a difficult patient and can contribute to burnout. In many refusal of care situations, you need to take a step back and realize that patients may be unreasonable but not irrational. Consider what will get you out of the situation in the most civil, collegial and professional way possible.
Refusal of care is the corollary in ethical terms of the right to informed consent. Informed consent is when you present the patient with risks, alternatives and benefits of any procedure. If you do not do that, you are subjecting patients to coercion or forceful intrusion. The key to refusal of care is to make sure that there is an informed refusal conversation which should mirror a good informed consent conversation with all the essential components. Why would you recommend the procedure to the patient? What would happen if the patient didn’t have the procedure? What are the risks, benefits and alternatives to the procedure? Indicate to the patient that you will still care for the patient despite their choices.
Refusal of care is formally established in American case law and is considered part of the right to privacy. It is the prerogative of someone who is capable. We know that treatment without consent is warranted in a life-threatening emergency or when the patient is incapacitated. It is invalid when the patient demonstrates capacity.
If you are going to have an informed refusal of care conversation with a patient, make sure they demonstrate the components of decision making capacity; knowledge of the options, awareness of the consequences and appreciation of the personal costs and benefits depending on their decision.
The leaving against medical advice form is not as protective as people think. This is a starting point to document the conversation but the conversation itself is what is important and not a signature on a paper.
How can we be more confident in this area? There are an infinite number of ethical dilemmas encountered in emergency medicine. Decisions in the emergency department are often made with little or no time for reflection or consultation. You can’t usually call a stat consult to the ethics department. We need to feel comfortable with making rapid ethical decision making in the ED.
There is a simple ethical framework created by Kenneth Iserson MD, a well-known emergency physician and bioethicist. Iserson suggests that when you encounter an ethical dilemma in the ED that requires rapid decision making, ask yourself if you have encountered a similar dilemma in the past and if there was a clear way to act, you should follow a similar set of actions. Build upon case based reasoning to act similarly. If this is not the case, you can quickly ask yourself three questions. Would I be willing to have my physician act in this manner if I were in the patient’s place? Would I be comfortable if all clinicians with my background and in these same circumstances acted in this manner? Am I ready to state the reason for my proposed action openly to my peers, superiors and public? If you can say yes to all the questions, you are on good solid ground for your actions.
What does the law say? Focus on more patient-centered value-driven decisions. However, it is important to know the law regarding common practice situations. Sometimes the line between the law and ethics is blurred. Remember that bioethics responds rapidly to a changing healthcare environment whereas the law might remain silent, inconsistent or morally wrong on matters that are vitally important to the biomedical community. It takes longer to solve problems through cases. For example, all the landmark right to die cases went through the court system over decades before we were able to reach some conclusion. Consider the law but don’t take it as the only thing driving your actions. Good ethics often makes good law but good law does necessarily make good ethics.
When time is not a critical factor, you should draw upon your case based learning and review some of your crisis decisions with colleagues and ethicists to refine your skills. View a quality review or M and M through an ethical lens to go through how you made the decision you did, evaluate the outcomes and what could have been done differently. The more you practice rapid ethical decision making in the ED, the more comfortable you will become with it.
Emergency decisions are not removed from ethical considerations just because they are emergencies.
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