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Nonmaleficence: do no harm or minimize harm

WV is highest in the nation for opioid overdose
SB 437
o Governors Substance Abuse Bill
o Defines chronic pain
o Mandatory best prescribing practices training
o Mandatory use of Controlled Substance Monitoring
Program (CSMP)
o People getting drugs from multiple providers dropped
WV Board of Medicine Policy for the Use of Controlled
o The Board expects that physicians incorporate safeguards into
their practices to minimize the potential for the abuse and
diversion of controlled substances
we have obligation to ensure medication are used for medical purposes
Patient autonomy may conflict with professional integrity
Recent CDC guidelines & Chronic Pain
o Excludes cancer and palliative treatment
o When considering long term opiates, focus on functional goals:
Set realistic expectations, plan to stop if not helping
Use tools evaluating pain, enjoyment of life, general
If not improving by 30%, opioid risks likely outweighing the
o The guidelines we have adopted advocate the use of non-
pharmacologic therapies (such as exercise and cognitive
behavioral therapy) and non-opioid pharmacologic
therapies (NSAIDs) for chronic pain.
o However, When opioids are appropriate, prescribers will follow a
start low and go slow principle, measuring effectiveness by
functional goals rather than pain severity
Universal Precautions for Prescribing Opioids
o Take substance abuse histories
o Should at least ask about hx of alcohol or drug abuse
o should screen everyone without profiling
o use of a single pharmacy
o Require consent to discuss status with patients family
o urine toxicology screening
Are you ethically obligated to prescribe pain medications? you try to
help in any way you can

Physician Assisted Suicide

o Physicians indirectly help patients die, providing a fatal Rx dose
taken by the patient
o Whats behind the question when we are asked if we can
end it all?
o What should you ask?
Tell me more
o Top reasons
loss of autonomy
loss of activities enjoyed
loss of dignity
loss of bodily functions
burden for family, friend, caregivers
o How should the physician respond?
Clarify the request
Determine the root causes
Affirm your commitment to caring for patient
Address the root causes
Affirm patients control over trx decisions and legal
alternatives for control of comfort
Seek counsel from colleagues
o Time is an essential component in adaptation
o good palliative care decreases requests for PAS
o The ACP does not support legalization of PAS
o patients that may be vulnerable
poor, disabled, unable to speak for themselves or minority
groups who have experienced discrimination
o AAHPM takes a position of studied neutrality on the
subject of PAD

o An act in which a physician directly assists a patient in dying,
usually via lethal injection

The double effect

o Providing a medical treatment for the purpose of relieving pain
and/ or suffering even though a foreseeable, unintended
consequence of the treatment is hastening death
o It is morally permissible to do an act which has both good and
bad effects as long as all four of the following are present:
The act must be inherently good, or morally neutral
The good effect must not be obtained by means of the bad
The bad effect must not be intended, only permitted
There must be a proportionately grave reason for
permitting the bad effect

Palliative Sedation
o Combination of double effect and withdrawal of treatment
o Proportionate palliative sedation
More common, generally accepted
Intent is to preserve alertness as much as possible
o Palliative Sedation to unconsciousness
More controversial (esp. if hastening death), should be
rare, may be needed for extreme suffering
o Uses benzos or barbiturates for sedation with opioids for pain
o Patient usually dies from dehydration
o Should require 2nd opinions (palliative care, ethics)
o Recognizes there are limits to palliative care
o Should rarely be used
o Quantitative futility (statistical definition)-the requested
treatment is unlikely to benefit
o Physiological futility-requested treatment is not working or is
known not to work
o Qualitative futility-the goal is not worth achieving-whats the
o Who decides on what is futile?
Medically ineffective treatment-means that, to a
reasonable degree of medical certainty, a medical
procedure will not:
Prevent or reduce the deterioration of the health of
an individual; or
Prevent the impending death of an individual
o How to decide what is medically ineffective?
case-by-case evaluations using a fair process approach
is likely the best option
When can a life-sustaining treatment be withheld or withdrawn
from adults?
o Patient or proxy in agreement
The care is something that the patient would not want
Doesnt have to be medically ineffective; may work
physiologically but wont change course of events (ex. Abx
when dying from cancer)
o Patient or proxy not agreeing
Consensus on poor medical prognosis
Is medically ineffective, or burden of continued care
exceeds expected benefits
Comparative worth is not a factor in the decision
Advance Care Planning

Non-maleficence is considered to be the overriding principle for

anyone who accepts the responsibility of caring for a patient

Advanced Care Planning

A process of shared decision-making in communication among the
patient, family, friends, and the health care team
Determine patients values, preferences, MPOA, and goals for current
and future medical care
Sometimes includes completion of written Advance Directive, DNR,
and/or POST form
Updated periodically, as needed, and
Respected when the patient no longer has the capacity to participate
in medical decision-making
Shared Decision-Making
o Process of communication between patient and clinician based
on patients overall condition
o addresses the ethical need to fully inform patients about risks/
benefits of treatments
there becomes a point when we cant have both (remaining
independent & staying alive)
o Physician may have to make this apparent in a shared decision
making discussion
give patients an estimate of their prognosis specific to their overall
o People (and doctors) tends to have an optimistic bias
o Facilitates informed decisions about treatment choices
o Helps with perspective
Perspective Matters
o young people aspire to achieve, to get, to have (focus on
o older people focus on intimacy, deeper relationships (focus on
o When people feel death may be close, their priorities shift
Focus should not be on there is nothing more we can do, but What
can we do to have the highest quality of life in the remaining days?
o less medicine doesnt always mean less life early palliative
care has shown to increase end of life in cancer patients
Palliative Care
Care for people with serious illnesses and progressive chronic illness.
Focuses on providing patients with relief from symptoms, pain,
and stress
earlier discussions leads to better quality of life

Advance Directives & Medical Orders That Help Respect Patient

If someone lacks capacity, the first thing we should do is see if
there is an Advance Directive
Medical Power of Attorney
Living Will *unlike an advance directive
Do Not Resuscitate order* because they require a
physicians order and can be
Physician Order for Scope of Treatment (POST)*
completed by a health care
proxy (someone designated to
make decisions)
What is a Medical Power of Attorney?
An Advance Directive
Allows you to name a person to make decisions for you when you are
unable to make them for yourself (lack capacity)
Allows you to make specific instructions for care you would like to
receive to guide the MPOA
Do not need to be terminally ill for an MPOA
Other names: health care proxy, durable power of attorney for health

What is a Living Will?

An Advance Directive
A document that says how you want to be treated ONLY if you are
terminally ill or in a persistent vegetative state, when you lack
In WV law, it supersedes all other Advance Directives, even a POST

Stages of Advance Care Planning

1st create MPOA
2nd Revisit advance directives and determine what goals of
treatment should be followed if complications result in bad
3rd Establish a specific plan of care expressed in medical orders
using the POST form

Post-forms vs. Advance Directives

Problems with Advance Directives and DNR cards, POST

Often synonymous with Advance Care Planning, which is not about
the form, it is about the plan
o A plan that positively impacts health care
ADs are part of a medical culture that is not readily accepted by all
cultures, not necessarily valued by our communities

Cultural Humility & Advance Directives

Advance Directives are not necessarily the way we need to get all
decisions made for:
o the most appropriate care, and
o the outcomes the way they should be
o depending on a persons beliefs and goals
It is possible for Advance Care Planning and high quality conversations
to accomplish the above without Advance Directives

Ask-Tell-Ask approach to Conversations with Seriously Ill Patients

o Build trust by learning what matters to the patient
o Assess understanding of patients medical condition/ prognosis,
and what they want to know
o Determine goals for treatment
o What is the course of action that best serves this understanding
oExplain overall condition
oDiscuss likely future complications (what they want to know as
some dont want details)
o Assist with informed decision about advance care planning
o What questions do you have?
o Tell me what you understand from what I told you. How would
you explain it to your family

Feeding Tubes
Conditions where feeding tubes are likely helpful (these can also be
possibly helpful depending on the patients physical state, mental
state, goals of patients, what patient considers to be a good quality of
o Short bowel syndrome
o Short-term critical care stay
o Brain Injury
o Radiation therapy/ chemo in proximal GI tract / Head and Neck
o Abdominal cancers (stomach) with proximal GI obstruction
Conditions where feeding tubes are likely not helpful
o Advanced Dementia
o Advanced Parkinsons disease
o Advanced cancer with cachexia
Avoiding tube feeding does not mean taking away food
Careful hand feeding provides human contact and can help maintain
weight and intake
Feeding tubes can cause pain and distress for people with advanced
When dementia reaches end-stage, feeding efforts can focus on
comfort and human interaction more than nutritional goals
Equals should be treated equally and unequals unequally

Distributive Justice: the fair and appropriate distribution of benefits and


Belmont Report
Ethical Principles and Guidelines for the Protection of Human Subjects
of Research (respect for persons, beneficence, justice)

Justice in Research
Vulnerable populations lack the capacity to make informed and free
decisions about participation in research
They should not be overrepresented
They should not be underrepresented
They should have equitable access to benefits of research

Vulnerable Populations
Economically Disadvantaged
Cognitively Impaired
Terminally Ill (?)
Prisoners, Students, Military
Ethnic and Minority Populations
Pregnant Women (?)
Developing World Nations

Each according to need whoever needs it the most, gets it first
Greatest good greatest number we take the resource & do as
much with it
Generational Reciprocity I have already taken my share, so I
have to leave resources for other people
First come first serve

Fair Inning

Public Health Issues

Focus on population outcomes rather than individual outcomes
Autonomy vs. Public Health
Changes in physician role
ex: natural disasters, man-made disasters, immunization, seat belt.

herd effect
if we can keep enough people vaccinated, we prevent public health

Organ Transplantation
we try to avoid moral judgements when distributing sources
Blood type and other medical factors weigh into the allocation of every
donated organ, but, other factors are unique to each organ-type
you have to be sick to quality for also be able to benefit from it

Brain Death & the Dead Donor Rule

Brain death in the United States is defined as irreversible loss of
functioning in the entire brain, both the cortex and the brainstem. This
is also called whole-brain death
there are inconsistent brain death protocols throughout hospitals

Donation After Circulatory Determination of Death

Donation after cardiac death (DCD) is organ donation by a patient
who is deceased by means of cardiac arrest, rather than being
determined to be brain dead.
A DCD donor is a patient who is on a ventilator and has minimal brain
function, is not expected to survive, and the family wants to
discontinue mechanical support. The family, physicians and OPO staff
determine the time and place of ventilator withdrawal. This usually
occurs in an operating room so that the organ procurement process
can take place soon after cardiac death is declared

Live Donation
Ethical Issues:
o Consent from Donors
Family Members, Minors
McFall v. Shimp, 10 Pa. D. & C. 3d 90 (July 26, 1978)
Harm to Donor
o How much is too much?
Confidentiality of Recipient
Motives of Donor
o Money, Fame, Beneficence
o Payment to Donors
o Reimbursement for Donors

Sarah Murnaghan

Additional Ethical Considerations

Voluntary (Opt in vs. Opt out)
o in the USA Opt in
The role of media
Creating a Market for organs
Socially Directed Donations
Age.. (at what age should we not give organs?)

Media Sensationalism

Death as a Contested Concept

Definitions of death have shifted and changed over the years
How dead is dead?

Religious Objections

Healthcare professionals are less likely to donate

Pandemic Planning
forces us to think what we would do in these situations
a pandemic is a global disease outbreak
how do you distribute things if everyone is affected at once?
o Which groups to prioritize for vaccine or antiviral medications?
(medical providers, military, police, vaccine manufacturersbut
then go gets it after that?) => greatest good greatest
o How to ration medicines, healthcare services, equipment, and
basic supplies?
o Limitations on personal freedoms: social distancing, closing
schools, bans on social gatherings (even religious), quarantine,
bans on travel..
The duty to care issue could be challenged. Staff and
physicians will struggle with the issue of personal safety and well
being as they deal with the threat of exposing themselves and their
families to contagion

Roe v. Wade made abortion legal in the US
o the states were forbidden from outlawing or regulating any
aspect of abortion performed during the first trimester of
o could only enact abortion regulations reasonably related to
maternal health in the second and third trimesters
o and could enact abortion laws protecting the life of the
fetus only in the third trimester. Even then, an exception
had to be made to protect the life of the mother
Planned Parenthood vs. Casey
o the state may ban abortion after fetal viability as long as
exceptions were made to protect the womans health or life.
o Allows for state to require parental notification if a minor seeks
an abortionbut there must be a judicial process in place for
adolescents to seek approval through the courts rather than
their parents (except if married, graduated from HS or
emancipated in WV)
Conscientious Objection
the refusal to perform a legal role or responsibility because of personal
alert colleagues & patients
you cant abandon the patient (you have to find someone else)