Ethicssummary.docx.docx

1. What should have been done POINT ONE: Informed consent Legal: Mental capacity enough to consent (fulfilled) (ANSEL) Ethical: Doing everything to enable the patient to make the decision in the best way possible JAYASHRI ● How holistic must our assessment be? Scope of doctor’s duty? ● Ensuring the patient is able to handle all other aspects, eg. Caregiver, finances ● Empathy/ considering patient factors (eg. Frame of mind) Professional: (HUILING) ● ● ● ●

Clear communication Documentation Why was the patient information sheet not useful in avoiding this problem? Tenets of professionalism

POINT TWO: Involvement of caregiver in decision-making. Family conferences (SHERRY) Another issue identified is the Role of Family in Medical Decision-making, in this case, whether the sister had a legal and ethical right to be informed of the details of the procedure just like that patient and if the doctors had a duty to involve her in the consent-taking

So CDM is increasingly an area of interest precisely because, legal considerations such as patient autonomy to self-determination have raised ethical challenges for patient-directed practices of clinical decision-making.

Avowedly, there’s been much debate about the meaning of this principle of a patient’s autonomy when exceptions to the principle may be justified. General guidelines of which have been outlined previously by my co-presenter.

Corollary of the strong focus on autonomy is the rejection of the idea of patients as passive recipients of care and consequently, any paternalistic influence anyone may have on the decision-making process is routinely frowned upon. Many worry that involvement of family members’ who may have divergent values and priorities from those of the patients, could compromise patients' autonomy. For Eg, In this case, the sister’s unwillingness to care for her brother’s cholestomy bag for extended period of time, might make her more keen in letting him choose other options, preventing him from accepting this treatment which might very well be medically the most indicated intervention. Therefore, those who are heavily involved in competent patients' decision-making, many times their caregivers, are often met with suspicion. And this is often a reason why patients are urged to make decisions independent of their family’s desires.

Medicine and the family – overlapping responsibilities for care: How far should the interests of patient’s significant others and carers influence medical decision-making?

one must recognise that influences exist in many forms and on different levels, along a continuum from noncontrolling to controlling. It is important to not automatically assume involuntariness whenever family is involved. Certainly, it is expected that the patient’s family may have distinctive or even incommensurable interests. However, it does not preclude the possibility of engaging in meaningful compromises that meet various needs of all members, which too might put the patient at ease with his own responsibilities. One might argue that such decision-making is then not individualistic and not clinically based; nonetheless, it respects the patient’s overall agency, might allow him to plan in advance before the procedure with his mother and sister present and better perform his role as a caregiver of his mother.

Furthermore, in this case, where the sister, primary caregiver, is under tremendous pressure to care for her children and meet her financial needs, consideration of the impact healthcare decisions may have on intimates not only promotes patients’ overall agency, but also the caregiver’s psychological well-being and health status.

Given our relational identity and intertwined interests and responsibilities, respect for patients’ autonomous agency cannot be just about presenting them the opportunity to independently choose off a therapeutic menu. As Donchin (40: 246) points out, any account of autonomy that preserves even minimally Kantian features will recognize that ‘what we want for ourselves may not enhance our autonomy if it can be attained only by dodging responsibilities towards others who depend on us’. As long as all family members are committed to long-term reciprocity and a collaborative arrangement that balances power relations equitably, apparently diverging interests do not necessarily imply irresolvable conflicts or undue pressure. Efforts to ‘protect’ patients from their family or to override their decisions to involve their family not only violate patients’ autonomous agency and relational identity, but also neglect the well-being of carers.

Although legally, doctors are simply bound by informed consent and patient autonomy, it is impractical for medicine especially in an asian context, to not take families seriously, because increasingly, the patient-family relationship is being seen as special and important as illness has implications for a patient’s position and interests within the family.

These facts, in turn, have ethical significance for medicine, where physicians aim to restore persons to living, and functioning, as well and fully as possible. In view of the importance of family relationships to the patient, healthcare professionals are hence expected to observe a number of practices that express professional respect for familial interest in a patient’s welfare.

Recognition of family and significant others: Doctors should acknowledge that a patient’s interests and well-being are unlikely to be independent of persons closely related to the patient (typically family members) Attention to complex needs, roles and responsibilities: Doctors should attend to mutual interests and responsibilities for patient care that are shared by close relatives and healthcare professionals Honest communication and respect for relationship norms: Conversations with patients and their families about their range of interests and goals in seeking medical help should be open, honest, and respectful of cultural norms; they should be started early, followed up, and revisited if circumstances change Understanding familial conceptions of risk and just action: Doctors should seek to know how the patient and family understand and evaluate risks of alternative treatment interventions and choices, including what counts as a just distribution of care and support within the family. Also suggests possible ways of overcoming potential problems that they foresee in a professional capacity.

Rethinking good medical practice: Accepting responsibility for moderating complex sets of interests beyond that of doctor and patient is now indispensable to good medical practice

In this case, the medical team did fail the ethical expectations to actively involve both the mother, who is the a dependent of the patient as well as the sister, his caregiver into the care and decisionmaking platform. In doing so, the miscommunication between the patient and his family could have been avoided, allowing a complete discussion on post-op care plans. The medical team can also better understand how the patient and family understand and evaluate risks of alternative interventions and choices, including what counts as a just distribution of care and support within the family.

Challenges of taking families seriously in medical decision-making

Taking families seriously is considerably more complex a matter than simply addressing everyone in the same sitting. While respect for patients demands that they be adequately informed and consent

taken for what happens to their bodies, the involvement of caregivers - in the informed consent process requires consideration of a full range of ethical requirements including respect for personal voice and self-determination, acknowledgement of responsible persons, protection of vulnerable parties, preservation of justice, and the integrity of persons implicated in caring relationships.

In cases like this though, this may mean that doctors may have to break patient confidentiality, currently an ethical and legal requirement in many jurisdictions. … (add patient confidentiality). However, a number of strategies have been proposed by healthcare professionals and bioethicists for maintaining honesty, trust and informed consent to treatment or breaches of confidentiality in such situations. For example, the use of softer (avoiding definitive words like “cancer”) or ambiguous language (saying “a growth” rather than “a malignant tumour”) has been suggested as a means of offering patients greater control over how much information they desire to share with their family. Hence, the sophisticated challenges surrounding this matter should not however, be cited as a reason for non-disclosure to families during family conferences.

POINT THREE: Role of the medical student (KAVEN)

1. Damage control (script of family conference) (DINIE) First clarify the situation. Ask the family what they understand of the situation. Cover our ass, without further angering pt. Calmly explain what was told to the patient, and show that there was a misunderstanding Explain that we did not involve the sister because we weren’t aware at that point that the sister would be involved in the care of the colostomy bag. If we had known about her involvement, would have informed her directly. Show that we are willing to arrange further care by referring to MSW, etc