Thank you to Robert Fullbright, our Sutter staff bioethicist, who gave a great Grand Rounds this week titled Ethical Principles in Practice, introducing us to the the ethics framework at SSRRH and walking us through some tricky ethical situations that we encounter in our work.
A recording of his presentation is available HERE.
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my notes:
We are so lucky to have a team of bioethicists on-call for us to consult on ethical issues in caring for hospitalized patients! Anyone in the hospital -- nurses, pharmacists, residents, attendings, family members, patients themselves-- can initiate an ethics consult. Whenever possible, the person who made the consult can remain anonymous, if they so desire. The most common ethical issues that arise in the hospital setting include: autonomy and consent, beneficence and non-maleficence, patient rights and provider obligations.
When to consult ethics?
- surrogate decision-making
- unrepresented patients
- conflict with family and medical team
- unaligned goals of care
- refusal of treatment
- challenging patient situations
- non-beneficial treatment
- issues protecting patient rights
Capacity describes a person's ability make a decision. In medicine, capacity refers to the ability to utilize information about an illness and proposed treatment options to make a choice that is congruent with one's own values and preferences.
Decision-making capacity can change from day to day, hour to hour. It can also be intact for some simpler decisions, but not present for more complex decisions. The question we need to ask ourselves as the medical team is "does the patient have capacity with regards to making _____________(this particular decision)?"
The four components of capacity:
- the ability to communicate a choice
- the ability to understand relevant information
- appreciate a situation and its consequences
- reason about treatment options
Surrogate Decision Maker
If a patient lacks capacity, we are responsible for using a surrogate decision-maker--that is EITHER 1) a person that the patient indicates is who they want to be making decisions for them OR 2) a person that we appoint on behalf of the patient (if the patient is unable to do so themselves).
In California, there is no legal hierarchy (i.e. a good friend and a brother have equal standing), except when it comes to decisions about organ-donation. The "best surrogate" is one indicated by a patient. If none has been indicated, the "best" surrogate in the person who knows the person's preference and appears to make decisions in the patient's best interest.
Of note, Also in California, verbal appointing of a surrogate decision-maker during a hospitalization supersedes a written DPOA for the duration of the hospitalization.
If there are multiple people working together to make decisions for a patient, the medical team should appoint one person as the main "point of contact". This does not mean we don't take others' opinions into account in decision-making.
Non-beneficial Treatment Policy
CA Probate Code 4735 states that physicians/hospitals have no obligation to perform treatment that is medically ineffective or contrary to generally accepted standard of care. "Medically ineffective" is defined as treatment that won't offer significant benefit (e.g. trach/PEG in a patient with advanced dementia). In order to activate the policy, physicians must provide notice and reasonable assistance with transfer to another physician or institution, if family desires. The Ethics Subcommittee usually is involved in this process.
Speaking of policies, remember that all SSRRH policies can be located on the INTRANET at the following website: https://sh-smcsr.policystat.com. This includes the unrepresented patient and non-beneficial treatment policies.
