PSY 802 Chapter Notes - Chapter 6: Shared Decision-Making In Medicine, Terri Schiavo Case, Life Extension

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Published on 27 Apr 2016
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Chapter 6: End of Life Decisions
End of life decisions made by team of caregivers, family members, and individuals themselves
Some decisions made long before crisis/illness is encountered (e.g. making a will or establishing life
insurance)
Other decisions arrive near-death (e.g. decision to withhold treatment)
Still, other decisions begun earlier in life, and completed after death (e.g. settling of estate)
Of daily deaths, two-thirds will involve decision made by family
End-of-life (EOL) decision making: aspects of life-threatening/terminal illness that involve choices about actions
to be taken for individuals, families, and professional caregivers
Decisions pertain to EOL in general, not just those that pertain to period of EOL care whilst actively dying
Usually placed low on list of priorities in life
Should be considered early in life and periodically reviewed and revised to help decrease burdens on
survivors
Ethics (good vs bad): investigation of good versus bad, as these concepts relate to moral obligations and duties
(ethical investigation results in collection of moral principles or values that guide behaviour); more subtle and
challenging questions
Not necessarily considered to adopt particular set of views/rules, but to allow us to practice reflection and
produce options that enable us to think for ourselves and enact personal preferences
Morals (right vs wrong): involve conforming to established codes or acceptances of right and wrong
Autonomy: individual’s right to self-government (self-direction, freedom, and moral independence)
Limited by rights of others and society at large (choices may be overridden if they do not consider effect
on “family commons”)
Autonomy is offset by respect for values of others with whom one has a significant relationship (“respect
for others”)
Autonomy may be limited by impact of decisions on welfare of individual, interests of others (e.g.
society), and allocation of scarce resources
Cultural and religious beliefs influence how individual’s exercise autonomy
Surrogate: substitute decision-maker
Beneficence: involves doing good or granting benefits that enhance personal/social well-being
Non-maleficence (counterpart of beneficence): injunction to “do no harm”
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Includes not abandoning patient who has made ill-advised decisions
Justice: qualities of impartiality and fairness, and right/proper action
Going beyond one’s feelings, prejudices, and desires to find balance among conflicting issues
Informed Consent: (shared decision making; physician and patient seeking common goal of optimal, appropriate
care)
Informed consent (achieved legal definition in 1957): right to being informed about diagnosis and treatment
options (risks and benefits); shared decision-making and mutual respect; based on:
Must be a flexible process; some more interested in being informed than involvement in decision-making
Especially important when there are teams of specialists working with patient (patient may be confused as
to who to talk to/ask for advice); also important if treatment is experimental or elective
Inquiring about desire to receive medical treatment to cure condition
Terminal cases, becomes less about “informed consent” and more about “truth-telling” about EOL
Based on:
Competency to consent
Freely-given consent
Adequate understanding-based consent
Tied to quality of communication between practitioner and patient
Informed Consent/Healthcare Consent Act of Ontario
Patient legally competent to consent
Patient must be informed by practitioner
Must follow specific procedure
Must include question and answer period
Consent must be voluntary
SUPPORT Study of Communication Quality (Study to Understand Prognoses and Preferences for Outcomes
and Risks of Treatment):
41% of patients talked to doctors about prognosis or CPR preferences
80% of cases physicians misunderstood CPR preferences
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When against CPR, do-not-resuscitate order never written 50% of time
50% of patients had moderate to severe pain in final three days
SUPPORT Phase 2:
Special nurse advocates assigned to make patients’ wishes known
Still, no improvement in physician-patient communication
Terms to signify decision to forgo CPR (“medical heroic”) tactics:
DNR: Do Not Resuscitate (1974); type of advance directive
May not specify which treatments should be withheld vs initiated (there are life-saving interventions other
than CPR)
Who decides which interventions are heroic vs ordinary? (especially difficult if attending physician not on
scene)
Some say it should be replaced with AND (Allow Natural Death)
No Code
CMO: Comfort Measures Only
History of Informed-consent Study
1961 (12%): tendency for doctors to withhold information (none reported a policy for this)
12% would inform patient of incurable cancer
Replaced harsh/unpleasant descriptions with indirect ones; cancer described as
unaggressive/gentle
Allowed for a general description of diagnosis, while eliciting patient’s cooperation in treatment
1977 (97%;reversal of attitudes; truth-telling): 97% would inform patient of diagnosis truthfully
Still had shortcomings: willing to engage in some deception in complicated/ethically sensitive situations
Justified decisions in terms of consequences/maintaining patients’ confidences
Also, hard to determine prognosis with absolute certainty
Prognosis: expected course of disease (can be difficult to predict); some doctors prefer to offer hope by describing
others’ recoveries, failing to mention that most die
CPR (cardio-pulmonary resuscitation): efforts to restart heart and breathing; ranging from external chest
compression to electric shock; viewed differently from other medical procedures (should decision not to offer CPR
be disclosed?)
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