PHHE 435 PC Ethical Issues Discussion
PHHE 435 PC Ethical Issues Discussion
Description
Although there are a number of techniques and technologies supporting medical nutrition and hydration, the ultimate goal is to sustain life for those patients who are unable to take in sustenance. The point is not just which technology is most appropriate/effective, but rather the decision to begin ‘extraordinary means of treatment’ for patients who are terminally, fatally, hopelessly ill with no chance of recovery. Describe a brief scenario that details the primary issues that should be considered when patient, provider, and possibly the patient’s family members are deliberating the use of medical nutrition and hydration.
PHHE 435/535 Ethical Decision Making for Health Professionals Module 9A Medical Nutrition and Hydration Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Objectives • Identify a number of the types of feeding and hydration technologies and procedures • Pinpoint the critical issues in conceptualizing the emotionally charged area of medical nutrition and hydration • Describe a number of seminal cases that have led to important changes of institutional policies Question of Continuing Nutrition • Important part of good patient care • Is it always a good thing? • May not be morally reasonable • Burdens and benefits 1 Relevant Technologies • Peripheral IV Lines Photo Credit: James MacDonald Two Types of Feeding Tubes • Feeding Tubes – Tubes provide access of nutrients into gastrointestinal systems (surgical) Enteral Two Types of Feeding Tubes • Gastrostomy tube (G-tube) Photo Credit: KidsHealth – Inserted under local anesthesia through abdominal wall 2 Two Types of Feeding Tubes • Nasogastric tube (NG-tube) Photo Credit: 3D4Medicalcom Two Types of Feeding Tubes • Nasogastric tube (NG-tube) – Inserted through nose, esophagus to stomach Photo Credit: D4Medicalcom 3 Two Types of Feeding Tubes • Nasogastric tube (NG-tube) – Inserted through nose, esophagus to stomach • Problems – irritation, nausea, could aspirate, tie hands of patients Two Types of Feeding Tubes • Both types use gravity to control flow of nutrients • Can use for indefinite period Total Parenteral Nutrition Photo Credit: SlidePlayer Photo Credit: http://www.sapreemies.za.org/image/neonatal_equipdetail_pic2.jpg 4 Lines • Insert line into large central chest vein • Specially formulated (total) nutritional fluid, indefinite periods • Alternative to feeding tubes Photo Credit: Still Miles to Go Lines • See these in hospitals, nursing homes, homes (with appropriate care) Photo Credit: Sima Dimitric Lines • New technique: Partial Parenteral Nutrition (through arm) • Can provide more nutritional support than peripheral IV 5 Conceptualizing Medical Nutrition & Hydration • Could be considered in two categories Conceptualizing Medical Nutrition & Hydration • Could be considered in two categories – Feeding Photo Credit: Ann Conceptualizing Medical Nutrition & Hydration • Could be considered in two categories – Feeding – Providing medical treatment Photo Credit: Ashley Van Haeften • Requires insertion and monitoring 6 Differences • Involuntary feeding • Not provide medication • Symbolism of providing nutrition Photo Credit: Daneshjal Differences Photo Credit: Erich Ferdinand Is it reasonable to force the concept ‘nutrition’ into one or the other category – the shoehorn effect How We Classify Photo Credit: Clive Varley • Moral judgment influenced/determined by how procedures for providing nutrition are classified Immoral Moral 7 Different Positions of Bishops New Jersey Rhode Island • Describe nutritional support of PVS patient as distinct from medical treatment • Describe as artificially invasive medical treatment • Withdrawal would be moral • Starving to death Photo Credit: Jim the Photographer • Withdrawal of feeding tube immoral Categorization • Really should be a new category • Medical Nutrition and Hydration Case of Clarence Herbert • 1981 • Harbor City, California • 55 years old • Intestinal/kidney problems http://pix.epodunk.com/locatorMaps/ca/CA_10249.gif 8 Case of Clarence Herbert • During surgery, suffered arrest • CPR attempted, suffered brain damage • Comatose, on respirator Case of Clarence Herbert • Wife told of no hope for recovery • Gave consent to withdraw life-support Photo Credit: Peter Stevens Case of Clarence Herbert • ICU nurse refused • Neurologist asked for additional tests • Physician cancelled order to remove http://www.uchs.org/images/icu.JPG 9 Case of Clarence Herbert • Tests confirmed brain death • Physician prepared family for withdrawing life support • However, patient continue to breathe on his own Case of Clarence Herbert • Consult with family and physician, decide to remove peripheral IV lines • Died six days later • Cause of death – Dehydration – Brain damage – Pneumonia Case of Clarence Herbert • Disagreement between physicians and nurse – Complained about failure to order misting device Photo Credit: Adam Sporka 10 Case of Clarence Herbert • Filed complaint with LACDHS • Passed along to DA • Both physicians charged with murder, 1982 http://archimedes.galilei.com/stlcofcc/blogimages/king‐drew.jpg Case of Clarence Herbert • Magistrate reviewed case and ordered complaint to be dismissed • L.A. Superior Court reinstated charges Ethical Analysis – Situational Awareness: Facts of the Case Photo Credit: Ankarino 11 Ethical Analysis – Situational Awareness: Facts of the Case • Unconscious, breathing (w/o respirator) • Court diagnosis PVS may have been premature, perhaps should have waited longer to determine if permanent • However, unlikely to recover Ethical Analysis – Situational Awareness: Facts of the Case • Not altogether clear what patient’s wishes were • Knew feeling about respirator, but unclear sentiments about feeding Ethical Analysis – Situational Awareness: Facts of the Case • Proxy and family signed document releasing physician from liability 12 Ethical Analysis – Situational Awareness: Facts of the Case • Providers not appear to suffer from distress at withdrawing respirator and IV lines Ethical Analysis – Situational Awareness: Facts of the Case • Physicians acted with high degree of professional autonomy, ignoring memo to get legal consultation before withdrawing Good/Bad Features • If patient not have awareness, not experience benefits/burdens • Death is bad, but not for this patient • If would survive, preserved life good, but not for him 13 Good/Bad Features • Family believes response to withdraw is the most reasonable action • Will suffer if their recommended action not taken Good/Bad Features • ICU Nurse was very distressed at the course of events Good/Bad Features • ICU Nurse was very distressed at the course of events – No existing guidelines 14 Good/Bad Features • ICU Nurse was very distressed at the course of events – No existing guidelines – Autopsy Good/Bad Features • ICU Nurse was very distressed at the course of events – No existing guidelines – Autopsy – Respiratory withdrawal w/o confirmatory test Good/Bad Features • ICU Nurse was very distressed at the course of events – – – – No existing guidelines Autopsy Respiratory withdrawal w/o confirmatory test Hydration stopped after short time in coma 15 Prudential Reasoning • Patient’s Perspective – • No longer has decision-making capacity, but may have refused feeding tubes to keep him alive • Appears to be a reasonable position Photo Credit: Peter Stevens Prudential Reasoning • Proxy’s Perspective – • If spouse is following through on patient’s expressed wishes, acting in a reasonable manner, and action is justified Photo Credit: Horia Valan • Difficult to diagnose permanent unconsciousness early on Prudential Reasoning • Provider’s Perspective – • Acting in a morally responsible way if following through on the wishes of permanently unconscious patient – Withdrawal of medical nutrition and hydration Photo Credit: Minnesota National Guard 16 Court Decision • California Court of Appeals ordered murder charges dropped Photo Credit: Ed Bierman Court Decision • Saw the procedure as a medical treatment • Allowed physicians to determine whether it was appropriate to withhold Photo Credit: Ed Bierman Court Decision • Saw the procedure as being withheld (not withdrawn) • What is the difference? • Influences the way one views ‘murder attempt’ Photo Credit: Ed Bierman 17 Court Decision • None of the physician’s actions could have killed patient • Behavior of omission Photo Credit: Ed Bierman Court Decision • Actually, would have a stronger case to say withdrawn rather than withheld • Can better decide how to proceed Photo Credit: Ed Bierman Court Decision • Sought to distinguish between terms proportionate and disproportionate Benefits VS Burdens 18 Court Decision • Allowed proxy to use ‘Substituted Judgment’ because… Photo Credit: Ed Bierman Court Decision • Allowed proxy to use ‘Substituted Judgment’ because – She was aware of his wishes Photo Credit: Ed Bierman Court Decision • Allowed proxy to use ‘Substituted Judgment’ because – She was aware of his wishes – Could not use best interest standard Photo Credit: Ed Bierman 19 Court Decision • Legal setting is not the proper place to make decisions about medical treatment • Seeking legal intervention in this case was unnecessary Photo Credit: Ed Bierman Court Decision • Despite what some believe, court is not a real threat to providers who withdraw feeding tubes when asked by proxy/family Ethical Reflections • Morally justified, given the right circumstances • Major problem in this case: Communication Breakdown Photo Credit: Nguyen Hung Vu 20 Ethical Reflections • Physicians • Nurses – Decision made too quickly • Proxies – Claim did not fully understand patient’s condition Photo Credit: Jacob Haddon Failure of Communication Good Ethics Good Communication Continue Photo Credit: Tracy Sorensen 21 PHHE 435/535 Ethical Decision Making for Health Professionals Module 9B Medical Nutrition and Hydration Master of Public Health Program – Copyright © 2017. Board of Trustees of Northern Illinois University. All Rights Reserved. Case of Elizabeth Bouvia • The Bouvia Case Revisited Case of Elizabeth Bouvia • 1986 • Lancaster, California • 28 years old • Born with CP, quadriplegia • Minimal movement head, face, fingers 1 Case of Elizabeth Bouvia • Required pain medication • Fairly intelligent, clear thinking Case of Elizabeth Bouvia • Suffered from nausea from eating solid food • Physician thought appropriate to put on liquid diet (nasogastric tube) Case of Elizabeth Bouvia • Requested not to insert tube • Advanced Directive 2 Case of Elizabeth Bouvia • Physicians did not honor request • Were familiar with previous attempt to starve herself with medical assistance Case of Elizabeth Bouvia • Court supported providers to force feeding tube • Patient changed her mind Case of Elizabeth Bouvia • Patient’s lawyer filed injunction to remove feeding tube • Court refused, reasoning only appropriate if patient unconscious and terminal • Not the case with Ms. Bouvia 3 Case of Elizabeth Bouvia • Higher Court reversed lower court • Tube was removed • Patient fed orally, and survived Case of Elizabeth Bouvia • Argued that two criteria (unconscious and terminal) should not apply • Patient has a right to refuse life-sustaining treatment • No civil/criminal liability for provider following through Ethical Analysis • Appropriate for 4 Ethical Analysis • Appropriate for – Still have decision-making capacity Ethical Analysis • Appropriate for – Still have decision-making capacity – Experiencing pain Ethical Analysis • Appropriate for – Still have decision-making capacity – Experiencing pain – Little hope of recovery/improvement 5 Ethical Analysis – Situational Awareness: Facts of the Case Photo Credit: Ankarino Ethical Analysis – Situational Awareness: Facts of the Case • Experiencing excruciating pain • Very ill • Prognosis not promising • Having difficulty with orally ingested foods Ethical Analysis – Situational Awareness: Facts of the Case • Tube inserted over her objections • Could not remove it herself • Not gave informed consent for more comfortable G-tube 6 Ethical Analysis – Situational Awareness: Facts of the Case • Both physicians and initial judge viewed her wishes as a suicide attempt, not a refusal for treatment Good/Bad Features • Needed tube to provide adequate nourishment • Preserve life, good • Removal result in her death, bad Good/Bad Features • Both oral nourishment and tube caused distress • Providers felt this was a suicide attempt by a patient that was not terminal, caused distress 7 Prudential Reasoning • Patient’s Perspective • Consider her physical condition • Actually, distress caused by oral nourishment, NG tube, refusing medical nutrition Prudential Reasoning • Patient’s Perspective • Was her choice unreasonable? • Refusal to prolong a painful life • Given all the circumstances, decision morally justified Prudential Reasoning • Proxy’s Perspective • No proxy • Patient maintained competence 8 Prudential Reasoning • Provider’s Perspective • Did not acknowledge patient’s situation, or honor her request Photo Credit: Seattle Municipal Archives • Created situation where providers were forcing treatment on competent patient helpless to resist Prudential Reasoning • Provider’s Perspective • This caused great distress to patient • Demonstrated a lack of respect Photo Credit: Seattle Municipal Archives • Paternalism Ethical Reflection • Only option for patient is to choose the less worse Photo Credit: Jacob Haddon • Burdens of treatment greater than benefits 9 Ethical Reflection Photo Credit: Jacob Haddon • In some cases, providers should allow flexibility for suffering patients to decide their own fate Ethical Reflection • Previous history may have influenced the providers • Patient appears to have changed her mind Photo Credit: Jacob Haddon • Need to ensure that decision is not only a temporary ideation Ethical Reflection • Depression may have influenced her initial suicidal thoughts Photo Credit: Jacob Haddon • May be difficult to verify desire is genuine and permanent 10 Conclusion 11
