Tag: decision making

Blog Posts (6)

February 12, 2016

Pain Relief is an Ethical Issue

When patients lack capacity, physicians look to family and friends to step in and provide consent for treatment on behalf of the patient.  These surrogates, whether they were appointed by the patient as their health care agent or become health care surrogates by default under state law based on their relationship to the patient, have the right to receive information related to the care and treatment of the patient and have the corresponding responsibility to make health care decisions for the patient based on either the patient’s previously expressed wishes or her best interests.  What they don’t have, however, is the right to control and direct every minute aspect of the patient’s care in the hospital.  It would take several blog posts to discuss the conflicts that occur between surrogates and health care providers because of this (such as DNR orders, barriers to discharge, and demands for certain medications, to name a few), but perhaps the most concerning example of surrogate over-reach is the issue of inadequate pain management.

The use of pain medication can be difficult for both patients and providers, especially with the rate of opioid abuse in this country.  Patients and their families are often afraid of the possibility of addiction, while physicians are reticent to prescribe narcotics for fear of misuse.  Whether or not a patient is a “drug-seeker” is a common question that arises when physicians are deciding what to prescribe.  However, in the context of terminal illnesses – particularly at the very end of the illness – the shift in focus from curative to palliative care highlights the need for sufficient pain control in the face of nearly intractable pain.  It is in this context that denial of pain medication, or poor pain management, is most clearly an ethical issue.

I have often heard complaints from health care providers about how surrogates have refused to consent to pain medications, or insist that physicians give lower doses than medically appropriate.  When I ask how the provider responded to such requests, all too often the answer is, “I followed their direction.”  We are so used to turning to surrogates for consent for every treatment and procedure, but is it really within the surrogate’s authority to consent to or refuse pain medication?   Assuming there is no advance directive from the patient opposing adequate pain medication, do surrogates have the right to refuse it?  More importantly, is it ethical for physicians to withhold adequate pain medication at the direction of a surrogate despite obvious signs of pain in the patient?

While respect for autonomy is a bedrock principle in our society, and we would certainly honor the informed refusal of pain medication by a patient with capacity, this respect for autonomy does not mean we necessarily honor the directives of the patient’s surrogate to the same extent as we would the patient herself when it comes to pain control.  Without explicit direction from the patient, certain basic assumptions are made about what the patient would want: namely, relief of pain and suffering.  While questions of withdrawal of life-sustaining treatment or palliative surgery may properly be left to the surrogate, the provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence.  We have an obligation to do no harm to patients, and to the extent possible, to relieve suffering.  While the side effects of opioids should certainly be considered and discussed with the patient’s family, particularly as it may affect the patient’s awareness or respiration, if other palliative approaches are not sufficient to address the patient’s pain, these side effects should not preclude the use of pain medication.  Interventions aimed at pain relief should be given in the overall best interests of the patient, considering the risks and benefits.  Especially at the end of life, providing comfort to the patient should be of utmost importance, even if the surrogate objects.  When pain relief is an ethical issue, it is not an issue for the surrogate alone to decide.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

June 8, 2015

Actions vs. Words: What counts most in understanding patient preferences?

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Clinicians striving to help patients achieve healthcare goals often encounter the perplexing dichotomy of the patient’s stated goals and preferences and actions to the contrary. Some of these challenges can be overcome with education and close follow up to help reinforce adherence to medical recommendations, but other times, these barriers are more enigmatic.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Take for example, a patient who requires hemodialysis to sustain life. She sometimes shows up for her outpatient dialysis, but more often does not show up and is admitted to the hospital for emergent dialysis several months in a row. In consultation with her providers she is adamant that she does not want to die, and knows that she needs the dialysis to remain alive. She is discharged, and the pattern continues. Liberal scheduling with the outpatient service, transportation, reminders are all offered. Psychological tests and support are provided, and yet, her action pattern of not adhering to the treatment plan continues. Again, she is advised it is acceptable to halt and she will be offered palliative care. She refuses, and says she wants to live and will sit for dialysis. What is her genuine preference? Should we honor these statements, or accept her actions as the more authentic expression of her wishes? Though this hypothetical example is quite familiar to renal care providers, the dynamic spans many scenarios leaving many practitioners with a dilemma about the practical limits of honoring verbalized wishes that are not supported by congruent actions.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
March 10, 2015

Actions or Words? What counts when patients give inconsistent signals?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">One of the challenges clinicians must learn to manage is the patient who does not adhere to medical recommendations while expressing the desire to be well. It is widely accepted that patients with the capacity to make informed decisions retain the right to make choices that are good for them and choices that are not, there are instances where capacity to make a choice becomes less relevant than the practical considerations related to achieving the patient’s goals. When patients state they wish to recover from illness but refused to comply with the necessary treatments this disconnect poses a different kind of dilemma. Morally, it is simpler to digest that that some patients will refuse treatment, and there is robust support for respecting refusals. But what do we do when a patient asks for one thing but does another? Such cases pose intractable impasses for providers who arrange care plans based on the patient’s stated goals of recovery, yet encounter what seem to be enigmatic refusals to adhere to recommendations and interventions. There is a clear obligation to attempt to understand the patient’s perspective and thoroughly as possible. What may appear to be inconsistencies in preference may very well have a logical explanation. Once efforts to unpack dissonant expressions have been exhausted, a different approach may be needed to figure out what may be possible for such a patient. The first question is often about capacity – does a patient who asks for one thing but does another possess the ability to make an informed decision? In some cases, the resolution ends here if the patient is found to be unable to make an informed decision – or does it? If the objection is strong, and the intervention requires a high degree of cooperation from the patient, capacity may be moot because there is no practical way to proceed without cooperation. For example, a patient who insists she does not want to die, but simultaneously resists life sustaining dialysis leaves providers with very few options. A patient receiving a temporary intervention to buy time for recovery may in fact, not achieve the desired healing – how long must a bridge therapy continue? In such cases, capacity may be part of the picture, but I would argue it sometimes becomes a red herring we chase instead of taking a hard look at the medical facts and practical considerations in such cases. </span></p> <div style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></div>
October 29, 2014

Quarantine: The politics are as real as the science

<p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Implementation of medical quarantines in America brings into conflict various legitimate arguments regarding who, if anyone, should have the authority to restrict movements of citizens.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">Quarantines are not new, but they exist now in a world with new dangers and new opportunities for abuse.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">In teaching medical students in recent years, it became apparent that many students found the concept of a home quarantine to be abhorrent.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">Many were aghast at the concept that a patient could be restricted from daily activities, and found it an egregious violation of civil liberties and ethical conduct.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">Interestingly, these views were often </span><span style="line-height: 19.0400009155273px; text-decoration: underline;">not</span><span style="line-height: 19.0400009155273px;"> mitigated substantially when students were informed that, in former days, quarantines were fairly common in this country and elsewhere.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">In a world before the Internet in which home confinement was really quite restrictive, medical quarantines for diseases such as small pox, tuberculosis, or even measles were not uncommon.</span><span style="line-height: 19.0400009155273px;"> </span><span style="line-height: 19.0400009155273px;">Such quarantines were usually imposed by a local health official.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">In addition, many families self-quarantined, or at least avoided exposure to potential sources of disease.</span><span style="line-height: 19.0400009155273px;"> </span><span style="line-height: 19.0400009155273px;">For example, some people used to avoid many summer activities for fear of contracting polio.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">Due largely to the development of vaccination, many of the diseases that would have invoked a quarantine in earlier years are no longer of concern, and the concept of quarantine has become a bit anachronistic, even in a world that offers many portals that would seemingly make confinement less onerous.</span><span style="line-height: 19.0400009155273px;">  </span><span style="line-height: 19.0400009155273px;">But the topic of quarantine requires renewed consideration in the world of today.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><strong style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
December 10, 2012

Political opinions: fast herd or slow ideology?

Sometimes politicians make claims that may seem at odds with the ideological background they represent. Would you agree with your party if they presented a statement that went against their ideological foundation? Put this way, you would probably not, right? But in fact, you’d very likely do so. It’s been known for a while that in […]
March 9, 2012

DIY mobile EEG – real-time tracking in the store

OK here goes. A brief time ago we recorded real-time EEG while a person walked and shopped in a grocery store. An abbreviated version of the movie can be seen here. As you can see, besides the large frame showing what the person is oriented towards (although there is no eye-tracking) the smaller right hand […]

Published Articles (12)

American Journal of Bioethics: Volume 12 Issue 2 - Feb 2012

Seeking Better Health Care Outcomes: The Ethics of Using the "Nudge" J.S. Blumenthal-Barby

American Journal of Bioethics: Volume 12 Issue 2 - Feb 2012

Nudge, Nudge or Shove, Shove—The Right Way for Nudges to Increase the Supply of Donated Cadaver Organs Kyle Powys Whyte, Ph.D.

American Journal of Bioethics: Volume 11 Issue 8 - Aug 2011

Response to Open Peer Commentaries on ?The Concept of Voluntary Consent"

American Journal of Bioethics: Volume 11 Issue 2 - Feb 2011

Science and Behavior

American Journal of Bioethics: Volume 11 Issue 2 - Feb 2011

Behavioral Equipoise: A Way to Resolve Ethical Stalemates in Clinical Research

American Journal of Bioethics: Volume 10 Issue 4 - Apr 2010

Doing What We Can With Advance Care Planning

American Journal of Bioethics: Volume 10 Issue 4 - Apr 2010

Too Soon to Give Up: Re-examining the Value of Advance Directives

American Journal of Bioethics: Volume 9 Issue 4 - Apr 2009

Screening in the Dark: Ethical Considerations of Providing Screening Tests to Individuals When Evidence is Insufficient to Support Screening Populations

American Journal of Bioethics: Volume 9 Issue 2 - Feb 2009

Response to Commentaries on ?Patient Autonomy for the Management of Chronic Conditions: A Two-Component Re-Conceptualization?

American Journal of Bioethics: Volume 9 Issue 4 - Apr 2009

Response to Open Peer Commentaries for ?Ethical Considerations of Providing Screening Tests to Individuals When Evidence is Insufficient to Support Screening Populations?

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