Below you will find our collection of posters and tools presented at professional conferences. These files are made available for the benefit of those involved in health care; they are protected by copyright.
Many patients, especially the elderly and those with mental illness, have diminished or no capacity to participate in decision-making. Consider, for example, the patient who influenced by her paranoid schizophrenia refuses to allow her aortic stenosis to be managed by catheritization with valvuloplasty even though her prognosis is excellent if she does so and poor if she does not. Another example is the patient without any next of kin who has dementia, diabetes, and osteomyelitis with gangrene who needs an amputation of his foot and rehabilitation but who refuses. A last example is the medically fragile young adult with severe developmental delay who simply cannot understand the importance of dental extraction of a mesioangular impacted wisdom tooth.
In these and similar cases, patients often can still express, sometimes very forcefully, their will – through words or deeds: the patient who wants to leave the hospital; the patient who makes threatening physical gestures when staff approach; or the patient pulls out a nasogastric tube or, worse, a PEG tube.
Moreover, a surrogate may agree to an intervention or care plan justified by the patient’s “best interests” however that plan may be contrary to the patient’s “expressed” will. Is it fair to the patient to simply follow the surrogate or, in the absence of a surrogate, to simply move ahead based on a presumption that the patient must be protected from his or her lack of capacity? In other words, is the consent of a surrogate or the benefit of a clinical plan sufficient to ethically justify moving ahead regardless of the patient’s expressed will? This paper will address the ethical significance of the incapacitated will of a patient and offer a methodology for caregivers to use to address the ethical issues of these types of patients who need, but do not want, beneficial care. It will do so by exploring the ethical rationale for keeping the decision as close to the patient as possible and will offer a decision aid used in our ethics consultations to guide decisions and care planning for patients with diminished capacity.
Related Publications / Conferences:
2014, ASBH – San Diego
2014, ICCEC – Paris
2009, J. Tuohey & J. Young, J. Hosp. Ethics (PDF)
2008, ICCEC – Rijeka
|Poster / Tool
||Title & Authors
||Rounding as an Ethicist: Challenges and Recommendations
Nicholas J. Kockler, John F. Tuohey
Poster – Full Size (46.5x57.5) (PDF)
Bibliography Select Bibliography (PDF)
Ethics, Rounding, Proactive, Clinical Teaching, Coaching
Clinical rounding is instrumental to the delivery of quality care. Rounding with a dimension of ethics is not a new idea and may be a mechanism to bridge clinical medicine and ethics.
Three aspects of rounds with ethics relate to challenges ethicists face while participating. First, an ethicist has a dual role of teacher and consultant. As participants in rounds may be unfamiliar with ethics, rounding with an ethicist can be a learning forum. Yet, rounding can be a form of ethics consultation. Thus, this learning forum shifts ethics from didactic settings to patient care. Some challenges exist because of this dual role: for example, physicians may ask questions that are too theoretical as answers to them may not apply in a particular case. Next, rounding with an ethicist reflects proactive ethics consultation. In general, a majority of ethics consultations occur in response to a specific request. Moreover, ethicists may review cases; these consults are retrospective. In contrast, proactive ethics consultation seeks to address ethical issues prior to the emergence of crisis, conflict, or an obvious concern or question. Having an ethicist present for rounds creates the venue for engaging in this proactive discussion: it avoids two weaknesses of typical consultation procedures – conflict-centeredness and retrospective ‘after-the-fact’ analysis. Despite this, certain challenges also exist. For example, patient care is riddled with contingencies, and depending on how frequently the ethicist rounds, those contingencies may be missed or difficult to anticipate. Lastly, we have previously presented (ICCEC 2012) that ethics consultation is a form of coaching wherein the ethicist cultivates practical wisdom, integrity, and moral freedom in the clinician. As ethicists we find ourselves coaching while rounding. However, this may set up challenges to what clinicians expect (advisement) versus what ethicists provide (coaching). Plus, without adequate training or experience, it may be difficult for an ethicist to identify and share ethically relevant clinical insights in real-time during rounds.
In this session, we will give attention to the ethicist’s role in clinical rounding and how an ethicist effectively participates by attending to contexts, his/her purpose, teaching tactics, and assessment about the issues in a case. In addition, we will highlight the challenges faced whilst rounding as ethicists and propose solutions to address them.
Related Publications / Conferences:
2013, ICCEC – Munich