AETCOM module: Bioethics for Undergraduate Medical Students
- 1. Case Studies On Patient Autonomy & Decision Making Dr. Lavanya SH Department of Pharmacology BGSGIMS Attitude Ethics & Communication Module AETCOM - Bioethics
- 2. Bioethics – Origin & Significance Bioethics is a philosophical disciplineencompassing social, legal, cultural, epidemiological, and ethicalissues arisingdue to advance in healthcare and life science research Dates back to the Nuremberg Doctor’s Trial – Nazi Regimen
- 3. What is Medical Ethics? Medical ethics – Moral principles for registered medical practitioners in their dealings with each other, their patients and state
- 4. Foundation of Medical Ethics http://medinterestblog.blogspot.com/2015/10/4-principles-of-medical-ethics.html
- 7. Case study – AETCOM Booklet 2.5 You evaluate Mrs. Lakshmi Srinivasan who is a 48 year old woman presenting with lymphadenopathy. She had been complaining of mild fever and weight loss for the past 4 -5 months. Examination of the neck shows large rubbery lymph nodes that are present also in the axilla and the groin. There is a palpable spleen. She is accompanied by her caring husband. https://www.nmc.org.in/wp- content/uploads/2020/01/AETCOM_book.pdf
- 8. Case study contd...... Lakshmi undergoes a lymph node biopsy and the pathologist calls you and tells you that she has a lymphoma. That evening Mr. Srinivasan comes in first into your office and leaves the report on your table. As you read the description you realise that the final diagnosis has been altered to Tuberculosis by whitening out the pathologist’s report. When you look up he tells you –“Sir, I googled lymphoma - it is almost like a cancer. My wife can’t handle that diagnosis. She has always been a worried frightened person. I want you to tell my wife that she had TB. She is waiting outside, doctor. I thought I will call her in after I had a chat about this with you”.
- 9. Discussion Q1 Does the patient have a right to know their diagnosis? Yes, every patient has the rightto know their diagnosis Truthfuland open communicationbetween physician and patient is essential for trust in the relationship and for respect for autonomy Withholdingpertinentmedicalinformationfrom patientsin the belief that disclosure is medically contraindicated createsa conflict between the physician’sobligationsto promote patient welfare and to respect patient autonomy
- 10. Discussion Q2 What should the patient be told about their diagnosis, therapy and prognosis? Paternalismversus Autonomy https://aneskey.com/the-ethics-of-withholding-and-withdrawing-mechanical-ventilation/
- 11. Moving from Paternalism to Shared Decision Making Paternalism - The physician alone makes the decision https://org/2019/11/21/shared-decision-making-protecting-patient-autonomy-and-informed- consent/
- 12. Discussion Q3 How much should be told to a patient about their illness? The obligation to communicate truthfully does not mean that the physician must communicate information to the patient immediately or all at once. Information may be conveyed over time in keeping with the patient’s preferences and ability to comprehend the information. Physicians should always communicate sensitively and respectfully with patients.
- 13. Discussion Q4 Are there exceptions to full disclosure? Can family members request withholding of information from patient? Although the principle of respect for autonomyis the most importantaspect, the principlesof beneficence and non-maleficence have a place in evaluating truth-telling and nondisclosure, as in this case study Timing of full, truthfuldisclosure can be influenced by: Age & emotional state of patient Family’s desire for such disclosure
- 14. Practical aspects of Disclosure Develop an understandingof the family’s point of view Understand the patient’s true preferences for receiving information Convey information over time considering patient’s preferences & comprehension Offerfull disclosure when the patient is able to decide whetherto receive the information.
- 15. Case study 2 You are taking care of 78-year-oldMrs. Mythili who was living all alone in an apartment withonly a live-in caretaker, 3 streets away from your clinic. She is a widow and her only son emigrated to the US 32 years ago. He visits her once a year. One year ago, she had a fall with a hip fracture that healed badly. She has hypertensionwhichis reasonably controlledon medications. She continuesto come to your clinic once a month. Four monthsago, she spent some time talking about her sister who recentlydiedfollowing metastatic breast cancer. “My sister suffereda lot, Doctor - they put a tube down her throat to breathe.Even when her heart stoppedthey kept thumpingher chest - it was awful. If I ever fall sick I don't want to go through all this. Promise me, doctor, that you won’t do all of this to me. I have lived all alone since my husband died but I have lived independently- now I don't want to dependon a machine to live”
- 16. Case contd.... One day you get a call from the Emergency Room of the local hospital stating that Mrs. Mythili has been admitted by the caretaker. She had developed fever and shortness of breath. She was brought hypoxic to the emergency room and they had intubated her. Chest X ray revealed a large pneumonicpatch. Laboratory testing revealed hyponatremia. When you visited her she is somewhat drowsy, intubated and restrained. The nurse tells you that she is sometimes lucid; at other times not even able to recognise her son who was there since this morning. She points out at the endotracheal tube and makes a pleading gesture to remove it. https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf
- 17. Her son accosts you in the hallway. He tells you that he got a call while he was traveling in Singapore and took the first flight out to be with his mom. He was very distressed at his mother’shealth and that he wants “everything”possible done for her. You ask him if she had ever indicated what she wanted to be done if she were to require hospitalizationand intubation - he says that he used to speak to her every month on the phone and she was always cheerfuland enquiring abouther grandchildrenbut did not talk about her health.
- 18. Ethical Concepts in this CASE Patient Autonomy Decision Making Capacity Surrogacy in Decision Making Autonomy vs Beneficience vs Non-maleficience
- 19. Supporting Mrs. Mythili’s decision which honors her own beliefs and wishes recognizes the role of …. Autonomy (Self- Determination) The moral and legal right of a person with decisional capacity to determine what will be done with their own person. This respects the right of each person to make decisions regarding their own body and course of life. However.................
- 20. Is she competent to make decisions? What determines decision making capacity & competency? “Testing” decision making capacity Ability to communicate Ability to understand treatment options Ability to grasp consequences of accepting or declining therapy Ability to reason In this case, the patient is incapacitated: Unable to understand the benefits, risks, alternatives to treatment
- 21. Who can decide?? Surrogate Decision Makers: Individual with authority to consent to medical treatment for an incapacitated patient Who can be legal surrogate-decision-makers? • Spouse • Adult child with Power of Attorney or majority of adult children • Parents (In case of minors) • In Parents Absence – (Grandparent, Adult sibling, Adult aunt/uncle Educational institution with written authorization, Court with jurisdiction • Nearest living relative • Patient’s clergy
- 22. What if the Surrogate decision maker opts for ‘Do not Resuscitate’? The Conflicts: Autonomy vs Beneficience vs Non- maleficience Initiation of life-saving measures may be indicated (beneficence) if there is uncertainty about the outcomes of therapy and how much benefit there will be for the patient Withdrawalof life-sustaining therapies (non-maleficence) may be appropriate whenthey are no longer beneficialor desirable for the patient and produce negative outcomes
- 23. Rule of Thumb Rightness or wrongness of an action depends on the merits of the justification underlying the action, not the action itself. Every situation needs to be evaluated in its own context, so that patients, families and caregivers can achieve comfort and trust in the final decisions.