Ethics Consultation Process

Maggie Procunier RN BSN

Bioethics & Patient Rights
South Miami Hospital
 Morals

An individual’s own code for acceptable

behavior
They arise from an individual’s conscience
They act as a guide for individual behavior
They are Learned
 Ethics
Ethics deals with the
“rightness” or
“wrongness” of human
behavior
Concerned with the
motivation behind the
behavior
Bioethics is the application
of these principles to life-
and-death issues
Ethical Principles
Autonomy
Nonmaleficence
Beneficence
Justice
Fidelity
Confidentiality
Veracity
Accountability
 Autonomy
The freedom to make decisions about oneself
The right to self-determination
Healthcare providers need to respect patient’s
rights to make choices about healthcare, even if the
healthcare providers do not agree with the patient’s
decision.
 Nonmaleficence

Requires that no harm be caused to an

individual, either unintentionally or
deliberately
This principle requires nurses to protect
individuals who are unable to protect
themselves
 Beneficence
This principle means
“doing good” for others
Nurses need to assist
clients in meeting all
their needs
◦ Biological
◦ Psychological
◦ Social
 Justice
Every individual must be treated
equally
This requires nurses to be
nonjudgmental
 Fidelity
Loyalty
The promise to fulfill all
commitments
The basis of accountability
Includes the professionals
faithfulness or loyalty to
agreements & responsibilities
accepted as part of the
practice of the profession
 Confidentiality
Anything stated to nurses or health-
care providers by patients must
remain confidential
The only times this principle may
be violated are:
◦ If patients may indicate harm to
themselves or others
◦ If the patient gives permission for the
information to be shared
 Veracity
This principle implies
“truthfulness”
Nurses need to be truthful
to their clients
Veracity is an important
component of building
trusting relationships
 Accountability
Individuals need to be
responsible for their own
actions
Nurses are accountable
to themselves and to
their colleagues
 Ethical Dilemmas

Occur when a problem

exists between ethical
principles
Deciding in favor of one
principle usually violates
another
Both sides have
“goodness” and “badness”
associated with them
 Why call an Ethics Consult?
Ethics Consult can help:
◦ Discover and understand the issues
◦ Serves as a forum for sharing of concerns and
questions
◦ Identifies possible treatment alternatives
◦ Provides guidance to the staff, patient, and
family members
◦ Resolves conflicts
 Using the Nursing Process

Assessment
Planning
Implementation
Evaluation
 Approach to Ethical Dilemma
A p p roach

A ssessm en t P la n n in g I m p le m e n ta tio n E v a lu a tio n

A m I in v o lv ed D e te r m in e g o a ls W o rk to w a rd s D e te r m in e
o f trea tm en t a m u t u a l ly w h e th e r d e s ir e d
a c c e p ta b le d e c is io n o u tco m es h a v e b een
reach ed

C o lle c t I d e n tify U se of R e -e v a lu a te a s n e c e s s a r y
th e fa c ts D e c is io n -M a k e r s d is c u s s io n a n d
n e g o tia tio n

W h a t V a lu e s a r e in c o n flict L is t a n d
R a n k th e o p tio n s
Ethical Decision Making Process
Describe the problem
Gather the facts
Clarify values
Note reactions
Identify ethical Principles
Clarify legal rules
Explore options and alternatives
Decide on a recommendation
Develop an action plan
Evaluate the plan
 Case #1
Patient is an 89 year old male admitted with
Hyperkalemia, ESRD, HTN, and Bladder Cancer.
Patient’s past medical history includes recurrent
bladder carcinoma, CVA, hernia repair and
hemodyalisis. Patient was admitted due to weakness
and 2 weeks of diarrhea for which he had refused to
be dialyzed for 7 days.
Patient lives at home with wife and daughter who
are both his healthcare surrogates. Based on
patient’s poor prognosis, oncologist had
recommended on previous admissions that patient
be made Hospice Care with comfort measures.
 Case #1 Cont.
Daughter and wife have refused Hospice care and
want patient to be dialyzed and continue
aggressive treatment to include full resuscitation
if cardiopulmonary arrest. Daughter and wife
have requested all physicians to refrain from
speaking to patient about his prognosis.
At this time all physicians have followed daughter
and wife’s request not let patient know that his
cancer has returned, except for the “new”
attending physician.
 Is there an Ethical dilemma?

• Autonomy?
• Nonmaleficence?
• Beneficence?
• Justice?
• Fidelity?
• Confidentiality?
• Veracity?
• Accountability?
 What would you do?
Tell “new” physician to get on board with
the rest of the healthcare providers in
following the wife and daughter’s request…
Tell the patient that his wife and daughter
are keeping information from him…
Do nothing…
Call for an ethics consult?
Ethical Decision Making Process
Describe the problem
Gather the facts
Clarify values
Note reactions
Identify ethical Principles
Clarify legal rules
Explore options and alternatives
Decide on a recommendation
Develop an action plan
Evaluate the plan
 Resolution
Ethics spoke with Attending physician and plan was to
speak first with daughter and wife regarding their role as
health care surrogates.
Attending physician, healthcare team, and ethics would
then meet with patient and inquire if he wanted
information regarding his prognosis and/or medical care.
After speaking with daughter, wife, and patient
individually and obtaining a clearer understanding of the
patient’s wishes, and the clarification of the healthcare
surrogates role, a family conference would be scheduled
with health care team and family to summarize the
findings…
 Resolution
Things never go as you plan them…
Daughter refused to have wife speak with
the team
Daughter wanted to be part of the
conversation when attending spoke to her
father to inquire if he wanted information or
not…
Attending agreed to let daughter be present
during the conversation (mistake)
 Case # 2
88 year old male with extensive medical history including end
stage Parkinson's disease. He was admitted due to pneumonia
and was intubated and now is in Intensive care unit. Patient’s
wife was identified as proxy since patient had never completed
an Advance Directive or had a Living Will.
2 weeks have passed and patient has been unable to be weaned
from ventilator.
Wife continues to indicate she wants to take patient home on the
ventilator…
Attending physician did not feel that wife’s request to take patient
home were realistic nor did he feel patient would have “a good
quality of life.”
His recommendations were Comfort Measure/Withdraw of life
support.
 Case # 2 Continued
Palliative Care is involved and many family
conferences have been held. Wife refuses to make
patient a Do Not Resuscitate, or sign any type of
withdrawal papers. She wants “full care”
She continues to verbalize she wants to take patient
home.
Wife had full time 24 hour care team at home taking
care of patient and she wants to take him home.
Ethics consult is called by attending physician….
 What would you do?
Try to convince wife that a DNR would be
the best for the patient in his condition…
Speak to physician to find out what he
plans to do next…
Call for an ethics consult
 Ethical Decision Making Process
Describe the problem
Gather the facts
Clarify values
Note reactions
Identify ethical Principles
Clarify legal rules
Explore options and alternatives
Decide on a recommendation
Develop an action plan
Evaluate the plan
 Resolution
Palliative Care and ethics consultant met with wife and she
understood that if he went home, he would have to have a
tracheotomy. Recommendations from team was to arrange
Respiratory department to show caregivers and wife how
to take care of patient once he was at home with
tracheotomy.
Wife agrees to tracheotomy and a consult is requested.
Wife was also informed of him having to go to a skilled
nursing facility first and then after he was stronger would
be able to go home.
Patient was trached and discharge to skilled nursing facility
for rehab.
 Case #3
54 year old male - history of previous subdural hematoma, HTN, and
atrial fibrillation. Patient aspirated and coded. He is in intensive
care unit on ventilator and Dopamine for hemodynamic stability.
Attempts at weaning have been unsuccessful…wife (healthcare
surrogate) signed consent for tracheotomy in order for patient to
be weaned off ventilator as recommended by pulmonologist…
On the same day wife signed consent for tracheotomy, Primary Care
Physicians during rounds feels that his prognosis is poor, and his
recommendation for plan of care is to have patient made CMO and
eventually withdrawal of life support should be initiated, he did
not agree with pulmonologist recommendations…
Pulmonologist does not agree with current plan to make patient
CMO and withdrawal and wants to continue therapy…”he can
improve, give him time”.
 Case #3 Cont.
Pulmonologist contacts wife regarding the scheduling of the
tracheotomy, and is surprised to find out that she has signed
papers for Comfort Measures Only & withdrawal of
ventilator…
Family is now confused with conflicting goals of care…wife
has agreed to CMO and withdrawal of vent after speaking
with attending but is still not sure she is doing the right
thing…she would like to give time but “how long?”
Staff is torn between wife’s decision and her verbalization of
“confusion” and physician’s recommendations and conflicting
opinions by pulmonologist and attending physician…
Pulmonologists calls for ethics consult…patient is not
withdrawn awaiting ethics recommendations…
 What would you do?
Tell wife attending is right and she should sign the
CMO papers…
Tell wife she should get a pulmonologists second
opinion…
Call Risk Management because of the conflict
between the attending and pulmonary doctor…
Call attending and tell him wife is confused…
Do NOTHING!

** Ethics Consult was requested by pulmonologist…

 Ethical Decision Making Process
Describe the problem
Gather the facts
Clarify values
Note reactions
Identify ethical Principles
Clarify legal rules
Explore options and alternatives
Decide on a recommendation
Develop an action plan
Evaluate the plan
 Resolution
Social Work and ethics chair spoke individually to attending
and pulmonologist to clarify goals of care and prognosis.
Social Work and ethics consultant spoke with patient's wife
and she verbalized her confusion but had agreed to sign
CMO and Withdrawal of life support at the time because she
didn’t really understand what that meant…
Wife wanted to give her husband a chance to be weaned off
ventilator and she rescinded the CMO and Withdrawal of
Life Support forms
Patient had the scheduled trache done the following day
Patient was transferred to vent floor and was transferred to
long term care facility for rehab…