Catholic Health Care: Maintaining Identity & Integrity in ...
Ethics at the End of Life: Understanding Conflict & Seeking Resolution Rachelle Barina, MTS, PhD(c) Gateway Alliance Conference August 6, 2015 9a.m. - 12:30p.m. 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 issues Outline 1. Intro to Ethics 2. Reflection on your own thought patterns & comparison to moral theories 3. US culture, death, and dying 4. 5 Cases 1. 2. 3. 4. 5. 6. 7.
Advance directives & end of life conversations Treatment after a suicide attempt Relationship of law and ethics Communication strategies Futility impasses Scope of clinicians responsibilities in helping patients live & die well Policy and physician assisted suicide or physician aid-indying What is ethics?? Ethics DOING (ACTION) How we ought to act in relation to others 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 others RIGHT GOODS BEING (CHARACTER) Who we ought to become as persons THE ULTIMATE GOOD The purpose and end of our lives: Flourishing
5 Ethics Lived Ethics 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 dont (or shouldnt) check your conscience at the door. Health Care Ethics: Define boundaries & advocate options that 6 Ethics & Feelings of Moral Distress
Personal effects Quantifiable decrease in well-being, withdrawal from social interactions, resentment & sadness Professional effects Quantifiable impact on clinical care, communication Organizational effects Significant job turnover You need intellectual tools and social support as you address difficult questions. 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 OToole, first published as Four Ways People Approach Ethics, in Health Progress. Theories & Approaches to Ethics BEING (CHARACTER) DOING (ACTION) Principles Virtue Utilitarian Consequentiali sm 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. 9 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 sources The 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? Utilitarian Consequentialism Begin not with principles but with consequences and usefulness. What are the valued ends? What will happen if you pursue each option? Calculation Greatest good for the greatest number. Comparison of costs/burdens and gains/benefits The ends justify the means
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. 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. emember: Text your questions to 661-523-2995 Discuss with one partner 1. 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? 2. 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? emember: Text your questions to 661-523-2995 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 Text your questions to 661-523-2995 Break! Profession Your al Guidelines personal, Why ethics at the end of Cost of
values, Providing experienc Treatment Family es and Dynamics ideas Religious life?? Commitments Ethics & End ofMedical Life Laws & Fear of lawsuits
Technologic al interventio n Organizational Values & Policies culture and the default to treat Physician & care team dynamics Regulation and Policy
Miscommunicatio n and Misconceptions Times Past and Present Pre-Modern Medicine Modern Medicine Little 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 couldnt 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 disease People thought about morality, even if not naming it as such More people experience end of life in institutions. Bioethics Slide credit: Mike Panico Most people have numerous end of life options. Are we dying in the ways we want? Are we thriving as health
declines? 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. What percentage of people in the US die in a hospital? In an ICU?
50% die in a hospital 70-80% 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 ICU Are we dying in the ways we want? Why does end of life continue to pose challenges? Personal Interpersonal
Medical Structural Accepting our Differences Medicine US culture mortality is are brought to almost always tends to deny REALLY HARD. light. has another and avoid the Death and Long standing option to try. realities of dying and conflicts and The culture of
finitude and often raise grudges come medicine death. questions up. leads to a Systematic about the Spirituality or tendency to challenges meaning of faith can be try it. from our life, death, important and Technological
health care and divisive. interventions system. flourishing. are difficult to Preconceived forego or ideas about withdraw. hospice. Problems of our HC System Shape End of Life Current System Care 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 $$ Event & hospitalizati on Diagnosti cs ICU ED, Admission
Nursing Home Primary Care Nursing Home More Diagnostic s, Terminal diagnosis Specialist(s ) The Patie nt
Home Primary Care Specialist(s) Slide credit: Mike Panicola To Make the Situation Worse 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 nations Approximately 92% of older adults have at least one chronic disease that leads to significant health decline prior to death. Slide credit: Mike
Panicola member: Text your questions to 661-523-2995 Dying in the US Today Terminal Illness Function Sudden Death Time Organ Failure From Let's talk about dying - Peter Saul Frailty
How are we going to fix the conflictridden, expensive, and dissatisfying ways we die? Advance Directives First proposed by a lawyer in 1967 Surrogate DMs and treatment directives Advance 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) We frequently overestimate how much treatment-based directives will advance patient autonomy and self-determination. Concerns about Treatment Directives Accurate prediction of situational preferences Misunderstanding & lack of perspective Tremendous cognitive bias in making treatment decisions in advance. (Recent experience, way of asking questions, the AD form itself)
Stability of preferences Advance directives must be acknowledged and interpreted. They often fail to resolve difficult clinical situations. What Can Advance Directives do? Designate a surrogate decision maker. Treatment directives may help us know about a persons 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. End of Life Conversations
Our conversations are poor because: We usually dont 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. 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. Better Questions to Start with
Theconversationproject.org Advance 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? End of Life Conversations & Culture Shift emember: Text your questions to 661-523-2995 Better EOL conversations are not enough Structural: Reimbursement, institutional practices, physician expectations, realistic advertising messages, access
to and easier/earlier transitions to hospice, etc. Cultural Personal: shiftsabout end of life, Reflection and acceptance Realistic expectations of medicine, Conversations with family & surrogate decision makers emember: Text your questions to 661-523-2995 2 minute discussion Personally or professionally, how might you be able to promote more substantive conversations about living toward the end of life? This talk included case
presentations that are not available for distribution. Questions? you! Thank
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