ethics and end of life decisions jeffrey j. kaufhold, m.d. grandview hospital
TRANSCRIPT
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Ethics and End of Life Decisions
Jeffrey J. Kaufhold, M.D.Grandview Hospital
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Grandview Hospital and Medical Center “Treat the patient, not just
the symptoms” 452 bed facility Inpatient and outpatient 3 Behavioral Health floors Over 100 Residents,
Interns, and Medical Students
Affiliated with Ohio University College of Osteopathic Medicine
Faith-based organization – part of KMCN
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Southview Hospital and Family Health Center Offers surgical,
inpatient, and outpatient services
Growing Women's Health Center
Sycamore Women’s Center feeds patients into SVH maternity center.
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Bioethics Advisory Committee
Provides consultations Reviews policies Education Mentoring
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Legal, Financial and Quality Issues
Legal – protection Financial – regulatory agency
requirements Quality – quality indicators
Pain management Organ donation and reporting Patient and family satisfaction
surveys
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Key Factors
Communication Goals of palliative, comfort care Evidence based approach Competency of patient to decide
Pain Depression Drug or disease induced delirium
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Communication
Common problems Communication triangle – patient,
doctor, and family What are the goals?
Understanding the illness Outcome of treatment
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Relationship Building
Nursing staff Medical staff support Patient/family wishes
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Goals of Care
Palliative and comfort care DNR does not mean do not treat What does comfort care involve?
What treatments/medicines are stopped?
What treatments/medicines are started?
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Principles in Ethical Decision Making
Paternalism Autonomy Utilitarianism Non Malfeasance Futility Outcomes Analysis Levels of Care
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Definitions
Ethics Advance Directives Brain Death Cardiac Arrest Comfort Care Decisional Capacity DNR
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Definitions
DNR Comfort Care DNR Comfort Care Arrest Futile Care Health Care Power of Attorney Level of Care Orders Living Will Respiratory Arrest Resuscitation
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Cultural Issues
Cultural perspectives on end of life issues
Ethnicity Religious beliefs Poverty and illiteracy
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Resuscitation of Residents with DNR orders in LTCFs
Measured the frequency of EMS calls to ECFs for patients with DNR orders
Calls 392 DNR 139 (35%) Resus. Attempted 29 (21%) Becker Yeargen et al. Prehospiital
Emergency Care 2003: 7: 303-6.
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The Ohio Law on DNR-CC
Creates a portable DNR Form ID bracelet wallet card
Description of Components of CPR Stipulates what will NOT be done if
pt is DNR Provides protection from liability
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Ohio Law on DNR-CC Living will applies to persistent
vegetative state. New version (1999) has provision for
establishing DNR arrest or DNR Comfort Care only.
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Definitions
DNR Old terminology, means Do not
Resuscitate. DNR-CC-Arrest
New Terminology, means do not resuscitate: Provide comfort care when the end comes, continue all other treatment until then.
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Definitions
DNR – CC Means Comfort Care measures only
are to be given. Discuss with pt/family as to whether certain measures could be STOPPED, such as dialysis, Vent support, Lab draws, pressors, antibiotics, etc.
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Level of Care Orders Procedure for placing limits on
resuscitative efforts Progress note Orders Copy of Ohio DNR – CC form End of each daily PN should state
“Pt is DNR “
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Order of Principles
Who Decides? Patient’s wishes
Patient’s spokesperson Caregiver
Physicians on case may invoke futility
Ethics committee or consultant
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Who to Contact
Each hospital has an Ethics Committee
Nursing supervisor, risk manager Program Chairperson Write an order Discuss with attending if appropriate Attend a committee meeting to learn
more!