Chapter Three Indications for medical

intervention

The principles of Beneficence and Nonmaleficence

What is the patient’s medical problem? Is the problem acute? chronic? critical?

emergent? reversible? What are the goals of treatment? What are the probabilities of success? What are the plans in case of therapeutic failure? In sum, how can this patient be benefited by

medical and nursing care, and how can harm be avoided?

Definition of medical indications

Medical indications are the facts, opinions, and interpretations about the patient’s physical and/or psychological condition that provide a reasonable justification for diagnostic and therapeutic interventions.

The goals and benefits of medicine

Cure sometimes, support frequently, comfort always.

The essential point of clinical ethics is to know when cure is possible, how long support should be continued, and when comfort should become the primary mode of care.

To understand the ethical issues in a case, it is necessary to consider the clinical situation of the patient, that is, the nature of the disease, the treatment proposed, and the goals of intervention.

The disease

A disease may be acute (rapid onset and short course) or chronic (persistent and progressive). It can be emergent (causing immediate disability unless treated) or nonemergent (slowly progressive). Finally, a disease can be curable( the primary cause is known and treatable by definitive therapy) or incurable.

These clinical distinctions are relevant in the ethical analysis of any case.

The treatment

Patients’ decisions about treatment will vary based on their goals, desires, and values.

A medical intervention may cause serious adverse effects.

Both patients and physicians should consider it when agreeing on a treatment plan.

The goals of medicine

Promotion of health and prevention of disease

Maintenance or improvement quality of life through relief of symptom, pain, and suffering

Cure of disease Prevention of untimely death

Improvement of functional status or maintenance of compromised status

Education and counseling of patients regarding their condition and prognosis

Avoidance of harm to the patient in the course of care

Assisting in a peaceful death

The goals of medicine

Clinical judgment and clinical uncertainty

“What are we accomplishing?” “Is the expected outcome worth the e

ffort?” “Do the benefit justify the risks?” “A science of uncertainty and an art

of probability.”

clinical judgment.

The process by which a clinician attempts to make consistently good decisions in the face of uncertainty is called clinical judgment.

clinical uncertainty

Clinical medicine was described as “A science of uncertainty and an art of probability.”

Although evidence-based medicine and practice guidelines aim to reduce the “uncertainty” and the “probability” of which Osler spoke, some degree of uncertainty always remains.

The shared decision making that constitutes an appropriate professional relationship.

Shared decision making

Paternalistic

The doctor made a diagnosis, prescribed treatment, and gave “orders”, providing minimal information to the patient.

Patient autonomy

The patient was seen as the authoritative decision maker.

Shared decision making

a collaboration in which the physician shares with the patient medical knowledge and opinion, and the patient shares with the physician values and preferences.

The best medical decision for an individual patient will depend on how the patient evaluates different risks and benefits.

Even when the physician’s

recommendation is based on sound

evidence, the patient should be the final

decision maker, because only patients can

assess the risks, benefits, goals, and costs

of treatment in their own lives.

Medical error

A 1999 Institute of Medicine (IOM) report on medical error estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors, as many as those who die of vehicular accidents, breast cancer, or AIDS.

Medical error

Medical error was defined as the failure of a planned action to be completed as intended, or as the use of a wrong plan to achieve an aim.

Some errors resulted from incompetence or mistake judgment by competent physicians.

Other errors were caused by system failure that often went unrecognized and uncorrected.

When medical error occurs as a result of incompetence or negligence, it constitutes a serious breach of the physician’s professional responsibility.

Indicated and Nonindicated Interventions

Innumerable interventions are available to modern medicine, from advice to drugs to surgery.

Interventions are indicated, then, when the patient’s physical or mental condition may be benefited by them.

Interventions may be nonindicated for a variety of reasons.

Case

Mrs. Care, a 48-year-old married woman ;was diagnosed with MS 15 years ago ;is confined to a wheelchair ;is blind in one eye ;she has become profoundly depressed, is

uncommunicative even with close family, and refuses to leave her bed.

The moribund patient

“Moribund” means “about to die”, that is, the patient’s death is inevitable and will soon take place.

The patient’s organ systems are disintegrating rapidly and irreversibly.

Death can be expected within hours.

The terminal patient The prognosis of any patient with a lethal

disease.

“Terminal” is defined as having 6months or less to live.

The benefits of accurate prognostication include informing patients and families about the situation, allowing them to plan their remaining time and arrange appropriate forms of care.

Medical futility

The Oxford English Dictionary defines it as “incapable of producing any result, failing utterly of the desired and through intrinsic defect.”

Many commentators prefer to use “medically ineffective or non-beneficial treatment” rather than “futility”.

What level of statistical or experiential evidence is required to support a judgment of futility?

Who decides whether an intervention is futile, physicians or patients?

What process should be used to resolve disagreements between patients (or their surrogates) and the medical team about whether a particular treatment is futile?

Is probabilistic futility a substantive or procedural norm for clinical judgment?

Orders not to resuscitate (DNR)

3.3 Legal implications of forgoing treatment

Determination of death

cardiorespiratory criterion ----irreversible cessation of circulation and respiration

Brain Death

Brain Death

In 1968, this concept was clarified in the Harvard Report on Brain Death.

Unreceptivity and unresponsivity to external stimuli,

no movements or breathing, no relaxes, and no discernible electrical activity in the

cerebral cortex as shown by EEG.

The physician has the authority to declare the patient dead .

Certain philosophical problems about the adequacy of the definition of death by brain criteria remain open to debate.

Working in groups of 3 or 4, describe values you feel are important in directing professional behavior

Good Behaviors

HonestyAltruismExcellenceEmpathyCompassionResponsibility

AccountabilityIntegrityRespectSelf-RegulationConfidentialityApply Principles

Excellence

Be the best physician possibleCommitment to continued learning

throughout your careerGive all patients best care possible

Altruism

Act for the good of othersAct for the good of your communityDo NOT act for your own personal gain

Respect

Recognize the feelings and rights of Patients Families Other physicians All members of the health care team

Self-regulation

Know the limits of your knowledge and skill

Seek help from colleagues when needed Refer patients to a capable colleague

Confidentiality

Keep patient and other information confidential

Be careful when, where, and with whom you talk about patients

Get permission before sharing confidential information with others

Integrity

Defend what is the best practice Expect your self to meet the highest

standardsAct fairly with othersAcknowledge the work of others

Relationships With Patients

Respect beliefs and cultural differencesInclude patients and families in making

decisions Identify alternatives for treatment Help patients understand, make choices

Relationships With Colleagues

Respect and courtesyLearn how to work well with other

members of the health care team

Acting for the Good of society

Adopt these good behaviors in all aspects of your life

Recognize physician’s responsibilities in society

Dealing With Dying Patients

Continue to care for a patient even when cure is not possible

Provide care to reduce pain and suffering of the dying patient

Do NOT abandon or “give up” on a patient

Empathy

Ability understand the experience or viewpoints of others What are the concerns of an adult who parent is

dying? What are the feelings of a patient who is

dealing with a diagnosis of cancer?

Compassion

Act with concern for others’ feelingsAct to improve others’ well being Act to end suffering

ResponsibilityDo what you are expected to do

Get to clinic on time Complete tasks assigned

Keep promises to individual patients and their care

Keep promises to colleagues and other health care professionals

Accountability

Take responsibility for your own actions Admit to errors or bad decisions you have made Accept the consequences of your behavior

Do not make unnecessary excuses