Upload
luke-mcwilliams
View
222
Download
4
Tags:
Embed Size (px)
Citation preview
Ethics and Emergency Medicine Part II
Rebecca Burton-MacLeodPreceptor: Dr. Lisa CampfensDec. 4th, 2003
Ethics
Refer to Moritz’s presentation on Ethics in June 5th, 2003 for topics relating to consent, capacity, end of life issues, confidentiality, physician-assisted suicide
so that leaves us to talk about...
Today’s topicsPatient autonomyjusticehealth care rationingmoral decisions in disaster medicineethics in researchgender/cultural issues in EM careteaching of traineesbiomedical industry ethics
4 principles of health care ethics
Autonomybeneficence--doing good for your ptnonmaleficence--avoidance of harm
for your ptjustice
Patient autonomyGreek words autos and nomos
meaning “self rule”pt autonomy--”adults right to
accept/reject recommendations for medical care if capable of appropriate decision-making capacity” (Rosens)
Patient autonomy
major concept in last half of 20th centuryassociated with spreading democracy,
improvement in education, increase in diversity of values--encourages people to protect personal values
1914, USA Court Justice Cardoza, “any individual of sound mind has the right to determine what shall be done to his body…”
Violations of autonomy
Medical research performed on concentration camp victims in Nazi Germany
USA Tuskegee syphilis study
Case 1
“a 52y.o. gentleman presents to the ED complaining that he had a fall yesterday and hit his head. He denies any LOC, nor any symptoms since the event. However, he is concerned he may have ‘injured his brain’. He demands to have a CT head”. Is the pt ethically able to ask for possibly
superfluous tests? Does your answer to him depend on: time of
day, number of people waiting in dept, radiologist on call, strength of demand ?
Justice
One of 4 principles of western health care ethics
justice--”upholding of what is right and lawful, especially fair treatment or punishment in accordance with honour, standards, or law” (Webster’s dictionary)
distributive justice--”fairness in allocation of resources and obligations” (Rosens)
Why justice?
Aristotle--justice and prudence are primary virtues in “Niomachean Ethics”
Plato--justice principle theme in “Plato’s Republic”
Related to idea of human equalityprinciple evoked when interests of
individuals or groups compete
Theories of justice
Utilitarian should follow action
that creates greatest possible balance of good vs. harm
“the end justifies the means”
Deontological belief that actions
are either right or wrong, based on higher rule or rules
not based on consequence of action
Justice and EM
ACEP Ethic’s Manual, “emergency care is a fundamental individual right and should be available to all who seek it…Denial of emergency care or delay in providing emergency services based on race, religion, gender, ethnic background, social status, type of illness/injury, or ability to pay is unethical.”
Justice and EM
rationingaccesstriageresearch*may replace autonomy as ordering
principle in 21st century*
Health care rationing
Under distributive justice, require equitable (but not always equal) allocation of health care resources no information barriers, financial
barriers, supply anomalies which prevent decent basic minimum of health care (Daniels, 1985)
Health care rationing
3 levels of rationing: 1. societal interests
health care vs. education vs. defense vs. environment
effects of poor nutrition, inadequate housing, inadequate education, pollution, violence on an individual’s health
Health care rationing
2. health care resourcespublic health/preventative medicine vs.
child/maternal health vs. new technologies vs. prehospital/emergency care vs. comfort/palliation
distribution based on medical need, cost effectiveness, and sharing of benefits/burdens in society
Health care rationing
3. institutional/bedside leveltriage decisions in EMignoring cost considerations on one patient
ignores consequences on other patientsuse resources to benefit patient, without
causing undue burdenhow do we decide if specific treatment
produces benefit, marginal benefit, no benefit, harm ?
Health care rationing
Macroallocation (at level of society) based on distributive justice
microallocation (level of individual) based on beneficence, relies on
distributive justice
Health care rationingEx: Oregon Health Plan
in 1987, 7y.o. Coby Howard died from leukemia after not receiving bone marrow transplant
Oregon tried to pass legislation restoring Medicaid funding for bone marrow transplants
John Kitzhaber (emerg doc and later Oregon governor) argued that better use of resources to expand insurance to cover everyone, instead of paying for costly services for few
Oregon Health Plan
Expanded Medicaid to cover all residents below poverty line, but in return would ration health care services
rank list compiled of condition/treatment pairs--based on community priorities, physicians opinions, data on effectiveness of treatment outcomes
delisting occurred if financial shortfall
Oregon health plan
Problems with the plan: little rationing actually took place
(physician noncompliance, political concessions to move medical services on the list)
no substantial savingspositive outcomes:
uninsured rate significantly reduced covers more people
Oregon health plan
Similar delisting experiences in Britain, New Zealand, Netherlands, Ontario
when rationing decisions made public, less likely to be able to ration services
Case 2
“A plane crashes, resulting in injury to many patients. Victims range in age from 1y.o. to 93y.o. One victim is Prime Minister’s son. One victim has 90% body burns. Some patients have blunt head, abdominal, or chest trauma. Eight patients are in cardiopulmonary arrest. A woman is in labour. Five patients are in shock. You are the sole physician.” how would you proceed to care for these patients?
Disaster medicine
Imbalance between needs and suppliesEx:
natural disasters war genocide (Rwanda, Yugoslavia, Cambodia) terrorist events large-scale accidents
Disaster medicine
1st principles of mass casualty care: triage
triage based on utilitarian principles to provide greatest benefit to largest number
Triage models
3 possible models: first-come, first-served patient’s best prognosis patient’s social worth
Triage models
1. First-come, first-servedpotential for less bias, but not equitable
resource distribution during catastrophesfavours population that has access to
media, transportation, health carediscriminates against those with
physical/mental disabilities or financial difficulties
Triage models
2. Patient’s best prognosistriage decisions based on patient
survivabilityrequires using clinical skills to provide
maximum benefit to most people from fewest resources
most favourable model in catastrophesmay be hard for the general public to
accept consequences of triage in their environment
Triage models
3. Patient’s social worthage, occupation, statusage should not be a triage factor in itself--
cannot predict individual life expectanciesselecting based on occupation/status uses
the limited resources to save a fewgeneral consensus--social worth is unfair
criteria for triage
Triage
What about health care workers priority for treatment and prophylaxis? Question of individual social worth
Ability to help others--multiplier effectas physicians, should look after own
safety first, then team’s, then patient’s
TriageFactors to consider
likelihood of benefit effect on improving
quality of life duration of benefit urgency of pt
condition direct multiplier effect amount of resources
required for successful treatment
Factors NOT to consider age, ethnicity, sex talents, abilities, disabilities,
deformities socioeconomic status, social
worth, political position coexistent conditions that
do not affect short-term prognosis
drug/alcohol abuse antisocial/aggressive
behaviour
Triage algorithm
Case 3
“You are at the scene of an accident, and only have 2 chest tubes with you. There are 3 accident victims…all of whom require chest tubes. 2 of the patients each only need one tube, while the 3rd patient requires bilateral chest tubes. To whom do you give your 2 chest tubes?”
Case 4 “a 39y.o. man took 30mg of lorazepam. He
was somnolent but arousable and his vitals were stable. He and his family were informed he would be transported to the medical center across town ‘since they have a medicine to treat this overdose’ (the center was conducting trials with a benzodiazepine antagonist).” is it appropriate for this pt to be transported
in order to enroll them in a research protocol?
Research
Ethical principles for biomedical research: respect for people as autonomous agents truth telling beneficence in maximizing the benefits and
minimizing the burdens for research subjects justice in equitably distributing the
benefits/burdens of research (participating as subject in research is altruistic act)
ACEP Code of Ethics, “accurate, compassionate, competent, impartial, honest conduct of scientific research”
Research
Ethical issues in research: scientific misconduct (plagiarism,
inappropriate stat tests, neglecting negative results, omitting missing data points, data dredging, fabrication of data)
unethical treatment of human/non-human subjects
conflict of interest responsibilities to
colleagues/students/trainees
Research in EM
Informed consent for resuscitation and other research when pt does not have capacity to decide deferred consent (illogical concept) waived consent
Waived consent
Requirements: necessity for research prospect for direct benefit to subjects informed consent from pt representatives
will be pursued f/u consent will be pursued community disclosures must be performed obtaining informed consent must not be
feasible
Waived consent
Community notification: does not protect personal preferences
of individual enhances community trust, signals
integrity on behalf of researcher
Waived consentFamily notification:who is defined as “family member”?
Related by blood or affinity whose close relationship is equivalent of family
How do you respect pts need for confidentiality? Careful balance of confidentiality and
disclosure is responsibility of researcherBest way to find out what pt may wantsafeguard
Waived consent
Independent physician and data monitoring committee: evaluates necessity/value of the
research composed of individuals with no
investment or connection to research increases integrity and fairness of study
Vulnerable populations
Particular circumstances that bring them as potential research subjects: medical condition limitation of intellectual function social setting psychosocial stressors
Cultural/gender issues in research
Tuskegee syphilis studies: 1930’s-1972, US Public Health Service black males with tertiary syphilis (mostly
poor and illiterate); no informed consent study natural course of disease; not
provide treatment even when penicillin available, decided
not to treat subjects
Cultural/gender issues in research concerned about racial bias in research /
treatments Seattle committee for kidney dialysis pts--pt with
productive jobs or family to support (middle class, white males)
trauma centers concentrated in inner cities where minority gps tend to live, more violent crime
black pts under care of white physicians, homosexuals involved in AIDS research (“socially franchised studied the socially disenfranchised”)
Cultural/gender issues in EM
2 studies shown that Hispanics and African-Americans receive fewer analgesics for extremity #, than white pts in ED; no difference in pain sensation
failure in communication, or racial profiling/discrimination?
Case 5
“A 19y.o. North African female presents to the ED with her husband. She speaks no English, and her husband is acting as interpreter. She is 8wks pregnant and is hemorrhaging vaginally. She is hemodynamically unstable. You think she needs an emergent D+C. After conversing with his wife, the husband refuses the procedure. “ what do you do?
Cultural/gender issues in EM
Interpreters: inadequate interpretation is form of
discrimination often only available if pt brings
family/friend (confidentiality issues) untrained medical translators give
translation errors (omissions, additions, substitutions)
Cultural/gender issues in EM
Ideal of culturally competent health care: demonstration of sensitivity valuing cultural differences self-awareness of cultural background
and biases
Case 6 “A hospitalized, elderly pt is being coded
(full CPR). The code has gone on for 20min without evidence of success. You believe the pt will not survive the attempt. There is adequate IV access. Someone asks if you, as junior resident, would like to attempt a femoral venous line for practice, ‘since the pt is going to die anyways’. “ Is this ethical?
Teaching issues
Ethical issues of who provides care: obligation of academic physicians to
ensure that residents have adequate skills to provide good medical care
resident must acquire knowledge, technical abilities before assuming full responsibility for pt care
pt’s right to be treated by fully qualified physician
Teaching issues
Options for teaching: animals--is it ethical to inflict suffering on
animals, when alternatives are available? Mannequins--an imperfect model cadavers--do not realistically mimic tissue
of real pt newly dead--respect for autonomy? Does
it apply? Living--pt autonomy and nonmaleficence?
Post-mortem teaching
Pros: “construed
consent” unable to obtain
consent in ED setting
social ethics
Cons: individual
autonomy family possess
“rights of ownership” over deceased’s body
Teaching issues--back to case Survey of 234 house officers (47% 1st yr
postgrad training) 34% thought sometimes appropriate to insert
FVC for practice during CPR 26% had observed someone insert FVC for
practice during CPR 16% had attempted this significant association b/w the experience of
inserting FVC during CPR for practice and subsequent belief it may be appropriate to perform this
Case 7 “A drug company rep in the ED asks to speak with
Sr. resident. They discuss value of his company’s new antibiotic for ED use, vs. others on the market. He distributes promotional material to the Sr. resident and other residents in the area. Then passes out company pens, note pads, penlights, and gives a ‘textbook’ on infectious diseases for the residents library. Leaves his card and says he can bring food to future conferences, pay for guest speaker to come and present on infectious diseases.” any ethical issues involved with this visit?
Biomedical industryEthical concerns:
biomedical industry is a business and is allowed to “advertise”
physicians must base practice on scientific literature
biomedical industry presentations are fundamentally biased
physicians may not be aware of the influence of promotional materials/gifts, on their clinical decisions
Biomedical industry
ACEP guidelines for research: avoid conflicts of interest must disclose financial relationships in research must not allow investments from sponsors to
jeopardize rights of subjects, compromise integrity of results
financial compensation must be at fair market value
must establish agreements in writing before initiating research
Biomedical industry ACEP guidelines for gifts/subsidies:
should be of minimal value and either benefit pts, or serve educational purpose
EP must be willing to disclose all gifts received conference attendees should not accept direct
subsidies to pay for costs of personal expenses academic training programs may accept
subsidies to enable physicians to attend appropriately accredited programs
conference faculty should disclose all financial, material, or research support from industry
References Marx. Rosen’s Textbook of Emergency Medicine. Www.saem.org/download/ethics.doc larkin, G et al. Essential ethics for EMS: cardinal virtues and core principles. Emerg
Med Clin North Am. 2002. 20(4). Oberlander, J et al. Rationing medical care: rhetoric and reality in the Oregon Health
Plan. CMAJ. 2001. 164(11). Iserson, K et al. Are emergency departments really a “safety net” for the medically
indigent? AJEM. 1996. 14:1-5. Marco, C et al. Determination of “futility” in emergency medicine. Ann Emerg Med.
2000. 35(6):604-612. Domres, B. Ethics and triage. Prehospital Disaster Med. 2001. 16(1):53-8. Pesik, N et al. Terrorism and the ethics of emergency medical care. Ann Emerg Med.
2001. 37;642-646. Burkle, F. Mass casualty management of a large-scale bioterrorist event: an
epidemiological approach that shapes triage decisions. 2002. 20(2). Milzman, D. Pre-existing disease in trauma patients: a predictor of fate independent of
age and injury severity score. J Trauma. 1992. 32(2):236-43. Marco, C. Research ethics: ethical issues of data reporting and the quest for
authenticity. Acad Emerg med. 2000. 7(6):691-4
References Adams, J et al. Acting without asking: an ethical analysis of the Food and Drug
Administration waiver of informed consent for emergency research. Ann Emerg Med. 1999. 33(2)218-223.
Quest, T. Ethics seminars: vulnerable populations in emergency medicine research. Acad Emerg Med. 2003. 10(11);1294-8.
Schmidt, T. The legacy of the Tuskegee syphilis experiments for emergency exception from informed consent. Ann Emerg Med. 2003. 41(1).
Multiculturalism and cultural competency. Www.mdconsult.com iserson, K. Postmortem procedures in the emergency department: using the
recently dead to practise and teach. J Med Ethics. 1993. 19(2):92-8. Iserson, K. Law versus life: the ethical imperative to practice and teach using the
newly dead emergency department patient. Ann Emerg Med. 1995. 25;91-94. Moore, G. Ethics seminars: the practice of medical procedures on newly dead
patients--is consent warranted? Acad Emerg Med. 2001. 8(4):389-92. Kaldjian, L et al. Insertion of femoral vein catheters for practice by medical house
officers during cardiopulmonary resuscitation. NEJM. 1999. 341:2088-2091. ACEP. Financial conflicts of interest in biomedical research. Ann Emerg Med. 2002.
40:546-7.
Questions ?