Ethics in Hospice and Palliative Care

Ethics in Hospice and Palliative Care

Ethics & Advocacy for the Mental Health Population Anita J. Tarzian, PhD, RN [email protected] (410) 706-1126 Anita J. Tarzian, UMB SON 021317 What do we mean by ethics? The discipline that considers what is right or

what should be done in the face of uncertainty or conflict about values. Involves making reflective judgments about the optimal decision or action among ethically justifiable options. www.ethics.va.gov/ETHICS Anita J. Tarzian, UMB SON 021317 Ethics vs. law You cant legislate morality. Areas of overlap LAW &

REGULATION S PERSONAL MORALITY ETHICS Anita J. Tarzian, UMB SON 021317 Anita J. Tarzian, UMB SON 021317 Anita J. Tarzian, UMB SON 021317 McShane Bell Foundry

Baltimore, MD April 13, 1956 Anita J. Tarzian, UMB SON 021317 John Nash & schizophrenia https:// www.youtube.com/watch?v=Yqj1DhUKJco Anita J. Tarzian, UMB SON 021317 DISABILITY OR DIFFERENCE?

https:// www.youtube.com/watch?v=EuzE6lMQQmo Anita J. Tarzian, UMB SON 021317 Ethical reasoning Rights-based Natural Legal

Consequentialism Utilitarianism Duty-based Prima facie principles Deontology Anita J. Tarzian, UMB SON 021317 Virtue ethics

Aristotle 394-322 B.C.E. The goal of human life is to seek happiness, an excellent activity of the soul, & to cultivate practical wisdom Anita J. Tarzian, UMB SON 021317 Rests 4 Dimensions of Moral Life Sensitivity: Can you recognize issues? Reasoning: Can you work through issues and make reasoned judgments? Motivation: Do you identify with professional commitments and responsibilities? Action: Can you enact your judgments and

commitments? Rest JR. Moral Development: Advances in Research and Theory. New York: Praeger Press, 1986. Anita J. Tarzian, UMB SON 021317 RIGHTS Infer obligations Natural v. legal rights Negative v. positive rights Anita J. Tarzian, UMB SON 021317

Universal Declaration of Human Rights http://www.un.org/en/documents/udhr/ Article 1 All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. Article 3

Everyone has the right to life, liberty and security of person. Article 4 No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms. Article 30 Anita J. Tarzian, UMB SON 021317 Tarasoff v. Regents of the University of California

Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976), Anita J. Tarzian, UMB SON 021317 Laws, Regulations & Guidelines on Involuntary Treatment Right to refuse treatment Presumption of Competency; Declaration of Incompetency; Informed Consent; Standard: Serious Risk of Physical Harm to Themselves or Others in the Near Future; Least Restrictive Alternative (Mental

Health America: http://www.mentalhealthamerica.net/go/position-statements/22 AHAs Patients Bill of Rights COMAR (Code of Maryland Regulations) for Nursing Homes Anita J. Tarzian, UMB SON 021317 Medications may be administered to a patient against his/her expressed will only under one of the following conditions: 1. An emergency exists wherein an individual presents a danger to the life or safety of the individual or

others. 2. With the approval of a guardian or personal representative who has the legal authority to make health care decisions for the patient. 3. Through substituted consent for non-psychiatric treatments. 4. Under the authority of a duly authorized and executed Clinical Review Panel (psychiatric medications only). 5. Under the authority of a court of law. Emergency Medication Administration to the Objecting Patient. Revised and Approved by Statewide Pharmacy and Therapeutics and Statewide Clinical Director s 5-18-07

Anita J. Tarzian, UMB SON 021317 Duty-based Kants Categorical Imperative Act only on that maxim which you can at the same time will to be a universal law. Emphasis on self-determination Anita J. Tarzian, UMB SON 021317 1724 - 1804

PARADIGM LEGAL CASES Buck v. Bell. (1927) forced sterilization Anita J. Tarzian, UMB SON 021317 Justice Holmes, 1927 We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be

strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concerned, in order to prevent our being swamped with incompetence. It is better for all the world if, instead of waiting to execute degenerate offspring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11. Three generations of imbeciles are enough. Anita J. Tarzian, UMB SON 021317 Ethical Principles as duties

W.D. Ross Fidelity Reparation Gratitude

Justice Beneficence Self-Improvement Non-maleficence Beauchamp & Childress Kant Respect for Persons Anita J. Tarzian, UMB SON 021317 Respect for Persons

To promote individual self-determination Individual autonomy the right to make ones own health care choices To protect persons who are not rational agents by promoting their well-being and preventing them from being harmed. Treat others, particularly vulnerable persons unable to reason on their own, as an end withal and never as a means merely. (Kant) Anita J. Tarzian, UMB SON 021317

Simple vs. Complex Autonomy Simple autonomy decisions based solely on the patients choice irrespective of other factors Complex autonomy the individual and his/her choices cannot be separated from a greater social context Includes the thick, interpersonal detail that defines the lives we lead and influences the decisions that we as individuals may make Kaufert & Koch (2003), Theoretical Medicine, 24, 259-469 Geertz (1973), The Interpretation of Cultures, NY: Basic Books

Anita J. Tarzian, UMB SON 021317 Individual, Family, Community Anita J. Tarzian, UMB SON 021317 Beneficence & Nonmaleficence Obligation to do good, not harm, to other people. Promote well-being:

Patient/Family support during crisis Advocating to allow elderly patient to stay in home Protecting vulnerable child from abusive parent Do no harm: Not breaching privacy/confidentiality Not coercing client to comply with treatment hes refused Not allowing prejudice to bias treatment Anita J. Tarzian, UMB SON 021317 Justice Fair and equitable determination of what is owed to a person including distribution of

resources and fair treatment for individuals and society Distributive justice equal share merit need outcomes Anita J. Tarzian, UMB SON 021317 Problems with principles Over-emphasis on autonomy Under-emphasis on justice

Weighing of principles depends on context Combine principles with narrative or casuistic (case-based) approach Anita J. Tarzian, UMB SON 021317 Consequentialism Jeremy Bentham (1748-1832) Actions are to be

judged strictly on the basis of how their outcomes affect general utility (happiness). John Stuart Mill (1806 1873) We ought to aim at maximizing the welfare of all sentient creatures, and that

welfare consists of their happiness. Anita J. Tarzian, UMB SON 021317 British J of Psych (2017), 210, 157164. Anita J. Tarzian, UMB SON 021317 Obligatory dangerousness criteria RIGHT

Protects rights of individuals with mental illness Voluntary measures are more effective than forced commitment WRONG Fails to protect

individuals with mental illness who need help Harms to society if mentally unstable individuals not treated Anita J. Tarzian, UMB SON 021317 Methods of ethical justification Deontology Rule based

Duty to protect liberty rights High bar for involuntary treatment Consequentialism Outcomes based Maximize benefits, minimize harms May consider lower bar for involuntary treatment if

supported by outcomes Anita J. Tarzian, UMB SON 021317 Manson, H.M. (2012). The development of the CoRE-Values framework as an aid to ethical decision-making. Medical Teacher, 34: e258e268, at e262. Anita J. Tarzian, UMB SON 021317 Manson, H.M. (2012). The development of the CoRE-Values framework as an aid to ethical decision-making. Medical Teacher, 34: e258e268, at e263. Anita J. Tarzian, UMB SON 021317 CASE STUDY

A 17 year old female is admitted to the medical ward of a community hospital for malnutrition and weight loss due to anorexia nervosa. The nurse is told by the patient's physician and nursing supervisor to interact minimally with the patient to avoid being "manipulated" by her, and to use restraints as necessary to ensure that the patient receives the ordered tube feedings via nasogastric tube. The nurse believes that it is her duty to try to establish a therapeutic bond with the patient, and that actively force feeding the patientincluding with the use of hand restraintswill do more harm than good. Anita J. Tarzian, UMB SON 021317

Case commentary Mid-Atlantic Ethics Committee Newsletter http ://digitalcommons.law.umaryland.edu/maecnewsl etter/38/ Anita J. Tarzian, UMB SON 021317 Moral Distress Knowing the ethically right thing to do, but being unable to act upon it. Acting in a manner contrary to your

personal & professional values, which undermines your integrity and authenticity. Jameton, A. (1993). Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs, 4(4), 542-551, as cited in assigned reading for class. Anita J. Tarzian, UMB SON 021317 Values-based practice Woodbridge-Dodd K. (2012). Values-based practice in mental health and psychiatry. Curr Opin Psychiatry. 25(6), 508-12.

Be aware of values Be clear where values are in reasoning process Improve knowledge of values Use communication to resolve value conflicts

Start with the clients values Dont resolve values conflicts by a preprescribed rule but by balancing different values perspectives Make decisions with clients in partnership VBP works in partnership with EBP Anita J. Tarzian, UMB SON 021317 Mrs. W Mrs. W is a 72 year old woman with Alzheimers dementia who resides in a chronic care facility. She is physically functional, but has become increasingly agitated and paranoid. She insists on leaving the facility. Despite staff attempts

to calm and distract her, she becomes increasingly agitated. She refuses all medications. A physician orders that she be given a psychotropic medication. The nurse questions whether it is appropriate to hold her down to give her the medication by injection, since she is refusing. Anita J. Tarzian, UMB SON 021317 Ethical question/concern Is it ethically justifiable to make Mrs. W. take medication by force or deception against her will?

Anita J. Tarzian, UMB SON 021317 Relevant information Gut reaction Codes of Professional Conduct Laws/Regulations Ethical Principles Values Plan of action How will you justify the decision? Manson, H.M. (2012). The development of the CoRE-Values framework as an aid to ethical decision-making. Medical Anita J. Tarzian, UMB SON 021317

Teacher, 34: e258e268, at e263. Giving Alzheimers Patients Their Way, Even Chocolate (NYT, 12-31-2010) http://www.nytimes.com/2011/01/01/health/01care.html Anita J. Tarzian, UMB SON 021317 Beatitudes Nursing Home A Journey to Becoming Restraint-Free & Staying There http://www.youtube.com/watch?v=BmVpuO

3rcqY (7 min) Anita J. Tarzian, UMB SON 021317 Using improv in persons with dementia https:// www.youtube.com/watch?v=3ETna2mX49M Anita J. Tarzian, UMB SON 021317 RESOURCES

American Nurses Association http://www.nursingworld.org AMAs Virtual Mentor http://virtualmentor.ama-assn.org American Psychological Association http://www.apa.org Maryland Healthcare Ethics Committee Network http://www.law.umaryland.edu/mhecn

Anita J. Tarzian, UMB SON 021317 Relevant information Gut reaction Codes of Professional Conduct Laws/Regulations Ethical Principles Values Plan of action How will you justify the decision?

d EBP & VBP here! How has this changed? http://www.nursingworld.org/codeofethics Is patient harm to self or others? What is least restrictive means? Respect for persons (autonomous choice or vulnerable person needing protection?); Beneficence/nonmaleficence; Fairness to

others? What are values of patient, family, staff, fellow NH residents? Others? What next steps should you take? Would an ethics consult help? Use ethical reasoning here Manson, H.M. (2012). The development of the CoRE-Values framework as an aid to ethical decision-making. Medical Anita J. Tarzian, UMB SON 021317 Teacher, 34: e258e268, at e263.

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