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CPMA Minutes 2 9/24/2014 4:03:00 PM

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Medical Ethics Presentation
Rick Stouffer

Medical ethics
euthanasia
abortion
stem cell research
cloning
allocation of transplant organs
how do you determine brain death?
not what we are interested in here

Health Care Providers
Doctors make ethical decisions every day
Funny escalator movies
o some people approach ethics by being passive (not doing
anything at all and waiting for someone else)

Disclosures
I dont not have all of the answers.
And, on some days, Im not sure I have any of them.
Going to talk about real stories

Case 1
90 year old female with hypertension and osteoporosis
lives with son in Siler City
EMS called because of acute onset of chest pain
on arrival in ER, patient is confused and no family is available
BP 85/50 and pulse 70 bpm
EKG shows changes consistent with blood clot in right coronary
artery

What do you do?
within 10 mins of arrival in ER, develops complete heart block and
cardiogenic shock
for successful resuscitation, she will need intubation temporary
pacemaker, IABP and emergent angioplasty. is this what she
wants?
o significant risks just to live another day
would you put this 90 year old woman through a bunch of invasive
procedures or let her die?
most people went with resuscitationjob is to provide care and
keep patient as healthy as possible until you know the patients
wishes are otherwise

Who Decides?
implied consentin an emergency, two physicians can document
that the condition is threatening to life or limb
Living Will
Surrogate decision maker
o Spouse
o Parent or child
o Other Relation
Judicial reviewAMA recommends ethic committee or judicial
review, ACP recommends judicial review
Doctors went for surrogate decision making in this case (her son
was around)
Son says that he thinks the 90 year old would want the procedures
done in order to live

Coronary Angiogram shown
blockage is shown by the premature stopping of the catheter

The rest of the story
admitted to hospital 2/14
Left foot embolus 2/16
Extubated 2/18
Re-intubated 2/19
Turned 91 on 2/25
Extubated on 3/1
Re-intubated later
Died soon after
No one seems to think this was the wrong decision. Consensus that
you cant make decisions based on the history of one case.

Medical Ethics
Principles that govern your behavior as a health care provider
combination of
o moralswhat is right/wrong
o professional ethicsstandards of conduct that prescribe
behavior
o malpracticedoing what you do poorly, outside standard of
care
o Legallaws and regulation governing your actions
HIPPA tells you what you can and cannot disclose about
a patients records
o Guidelines
Hippocratic oath
Geneva (1947)
Sydney (1968)

Factors that Influence EthicsMaking the Right Choice
Patient
o Wishes
o cultural values
o religious values
o family expectations
o financial issues
Legal issues
o Law and regulation
o insurance, etc.

Case of Patient Who Refused to Take Care of Himself
September 2009
o 45 year old male with several weeks of shortness of breath
o Echocardiogram shows dilated LV with an ejection fraction of
15-20%
o diagnosed with Cardiomyopathy of unknown etiology
o several likely contributing factors including heavy alcohol use
and possibly untreated hypertension
o using cocaine
Clinic Visits
o Early after diagnosis:
Regularly attends cardiology clinic appointments
medication adjustments
he does seem to understand that he has a problem with
substance abuse and smoking and agrees to a make an
effort to quit
o later
patient begins to miss appointments and fall of the
wagon
September 2011
o CC: increased shortness of breath for past week. Can
normally go up and down the stairs at work without problems,
but has been getting more short of breath.
o Returned to poor diet, smoking, cocaine use, etc.
Non-Sustained Ventricular Tachycardiacommon in people with
cardiomyopathies. Can cause sudden death
AHA/ACC Guidelines for ICD
o Class I
ICD therapy is indicated in patients with non-ischemic
dilated cardiomyopathy who have an LVEF les than or
equal to 35% who are in NYHA functional Class 2 or 3
Patient is class 3
Should he get an ICD?
o Class 1 indication
o potentially lifesaving
o but he doesnt take his medications
o drug abuser
o should the hospital give expensive treatments without holding
patient accountable for his actions and that impact on the
hospitals expenditure of resources?
o doctor has loyalty to patient but not to society as a whole
What about the cost?
o Patient is unemployed
o Average implantation costs are very expensive
September 2012
o Implantation of a single coil, single lead, primary prevention
ICD
February 2013
o Patient is 49 now and feels 5 ICD shocks. Feeling well though
continues to feel chronically fatigued and short of breath with
exertion.
The rest of the story
o He has not taken his medications the past few days and is
cocaine positive
Did we do the right thing?
o Apply a high degree of skill and knowledge
o act for good of patient
o remain objective and emotionally detached
o respect the position of privilege
Conflicts of Interest
o Best interest of patient
But
How do you resolve conflicts of interest between patient
vs. society?
how do you resolve conflicts of interests between
patient vs. other patients?
how do you resolve conflicts of interest between patient
vs. training environment?
o Bedside Manner
patients look for compassion
how do you make the right medical decision with the
compassion factor?
they want someone who knows their wishes and will be
available when they need them
The Case of the Patient with an Unusual Past
62 year old white male
prior history of myocardial infarction and stent in the left anterior
descending coronary artery
exertional chest pain
nuclear study shows large anterior defect
what do you do?

Not Your Typical Patient
patient is on death row for a gruesome murder of his brother and
two nephews?
Do you treat him any differently?

Issues to Ponder
do prisoners deserve the same level of medical care as others?
Does the severity of crime matter?
What level of care?
o Basic medical needs
o life saving treatment, etc.

What happens when family and physicians do not agree on patient care?
33 year old female with debilitating multiple sclerosis diagnosed 13
years ago
normal mentation but severe physical disability from MS
she had been on home hospice, but was stopped 1 week ago
because doing better
choked on biscuit, found by mother

Case of Unrealistic Family
Fire department arrived and found pulse
EMS arrived tem minute later and treated
With CPR and establishment of airway, patient had circulation
patient underwent intubation
o patient was started on norepinephrine treatment patient
prevents CNS damage

5 days later
no return of any mental activity
primary care doctors said that she didnt want to be kept on life
support
mother wants full life support (against patient wishes).
family (primarily mother) said daughter would want full support
ethics consult was requested

Ethics Consult
different interpretations of patients wishes
o it is clear that mothers understanding of patient wishes is not
aligned with doctors.
o the mother did not interpret the prognosis in the way that
doctors meant.
ethics consult sides with the doctor, but restates the situation.
o they consider that the mother lacks understanding of the
disease.

Mothers Diagnosis of Prognosis
was told at last discharge that her daughter had only 2 weeks to
live.
hospice arranged her to leave because she was doing better.
thought that daughter would recover because her brother hit his
head and was predicted to be a vegetable.
however, he ended up being fine.

Rest of Story
mother decided that the daughter would not want to be kept alive if
there was no hope of her getting better.
patient survived for three months after extubation.
feeding tube was put in.

You will be making many ethical decisionsBe Prepared!!











9/24/2014 4:03:00 PM

9/24/2014 4:03:00 PM