Question

At 80, R.L. lives with his wife in a retirement community. He has always valued his independence, but recently he has been having trouble caring for himself. He is having difficulty walking and managing his medications for diabetes, heart disease, and kidney problems.

His doctor diagnoses depression after noting that R.L. has lost interest in the things he used to enjoy. Lethargic and sleepless, R.L. has difficulty maintaining his weight and talks about killing himself with a loaded handgun. He agrees to try medication for the mood disorder.

Two weeks later, before the effect of the medicine can be seen, R.L. is hospitalized for a heart attack. The heart is damaged so severely it can't pump enough blood to keep the kidneys working.

Renal dialysis is necessary to keep R.L. alive, at least until it's clear whether the heart and kidneys will recover. This involves moving him three times a week to the dialysis unit, where needles are inserted into a large artery and a vein to connect him to a machine for three to four hours.

After the second treatment, R.L. demands that dialysis be stopped and asks to be allowed to die.

You are R.L.'s physician. What should you do?

R.L.'s was an actual case that presented his physicians with a common dilemma in treating patients with serious illnesses: Had depression rendered him incapable of making a legitimate life-and-death decision?

When patients agree to undergo or refuse medical treatment, they are supposed to reach the decision by a process called informed consent. The doctor discloses information about the medical condition, treatment options, possible complications, and expected outcomes with or without treatment.

To give informed consent or refusal, the patient must be acting voluntarily and must have the capacity to make the decision. That means the patient must be able to understand the information, appreciate its personal implications, weigh the options based on personal values and life goals, and communicate a decision. From an ethical point of view, informed consent is based on the philosophical principles of autonomy and beneficence. In R.L.'s case, these two principles are in conflict. First, R.L.'s prognosis is unclear, and the physician does not know if the benefits of dialysis will outweigh the burdens. Under normal circumstances, this decision would be made by R.L., but the physician suspects the patient's capacity for autonomous decision making is impaired by depression.

Depression is a mood disorder that can profoundly affect a person's ability to think positively, experience pleasure, or imagine a brighter future. Depressed people frequently have little energy, poor appetites, and disturbed sleep. They may have difficulty concentrating, or they may be troubled by feelings of guilt and hopelessness. Preoccupation with death is common and, in some cases, may include contemplating suicide.

Because R.L. was suicidal before his heart attack, no one was sure whether his refusal of dialysis represented an authentic exercise of his right to stop life-saving treatment or a convenient means to passively end his life. On the other hand, if the doctor continued dialysis, he would be denying R.L. the same right to refuse treatment that another patient who was not depressed would have.

When patients ask to have life-sustaining treatment withheld, doctors have been taught to consider whether depression is driving the request, because the condition lifts in two-thirds of those who are treated with anti-depressant medications. The presumption is that once the problem has cleared, the patient will look at treatment decisions differently.

Recent research has challenged that presumption by showing depressed patients don't necessarily choose to hasten death in the first place and they often make the same decisions after they recover from depression.

Thus, depressed patients may be able to give informed consent, but doctors and loved ones must consider whether the decision to refuse medical treatment is logical, internally consistent, and conforms with past life choices and values.

In R.L.'s case, the doctor, in consultation with a psychiatrist, decided to continue the course of anti depressant medication to see if, when it began to take effect, R.L. would change his mind about treatment. In the meantime, his dialysis was continued.

After five weeks, R.L. showed no improvement, and he began to refuse medications and food. His wife was asked to give consent for a feeding tube.

On conferring with the rest of the family, R.L.'s wife denied the doctor's request. Her husband's repeated refusal of dialysis had convinced the family R.L. really did want to die. In addition, R.L.'s unchanged physical condition indicated that, if he survived to discharge, he would probably need nursing home care, a fate he had resisted even before his depression.

Ultimately, the physician shared the family's assessment that R.L.'s consistent refusals indicated an authentic wish to halt treatment. He was taken off dialysis and put on comfort measures. Six days later, he died.

Instructions

• Write a 1,000-1,200 word essay using APA style that applies the relevant aspects of the ACHE Code of Ethics to an assigned case study.

Question:

What are the ethical questions involved when depression impairs seriously ill patients' ability to make decisions?

Answer 1

ANSWER

What are the ethical questions involved when depression impairs seriously ill patients' ability to make decisions?

Depression affects your decision making in several ways. When we say depression leads to poorer decision, it means that the decisions lead to outcomes that have less positive impact on your life over the long run.

The first way depression leads to poor decisions is that depressed people tend to be more indecisive

Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder.

Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions.

Certain questions in this context are:

• · Depression impair performance on tests of decision-making capacity?
• · Does depression affect the insight of an individual?
• · Do patients with depression regain DMC-Decision making capacity after the treatment?

In this case study following interpretations are made.

1. The patient does not wish to receive treatment; however, he clearly meets clinical criteria for a major depressive episode and continues to express self-harm intent.

2. In this case, the physician’s duty of beneficence, which prioritizes treatment of depression, conflicts with the patient’s initial autonomous desire to end his life.

The psychiatrist should explore this tension by providing appropriate education to the patient of his diagnosis and clinical options and exploring if the patient would accept voluntary hospitalization.

3. The psychiatrist has a duty to “first do no harm.” This encompasses the imperative to ensure that medical issues are not left untreated and that any treatment plan (e.g., pharmacotherapy) will take the patient’s medical issues into consideration and will not increase the risk of clinical harm.

4. The psychiatrist is respecting the duty of confidentiality toward the patient and seeks his permission prior to speaking with his wife. In some emergency situations, there may be legal protections for gathering clinical information without the patient’s direct consent. However, if the patient is conscious and cooperative, it would be prudent for the physician to ask the patient for permission to speak with his wife first.

RELEVANT ASPECTS OF THE ACHE CODE OF ETHICS TO THIS ASSIGNED CASE STUDY.

ACHE CODE OF ETHICS

The purpose of the Code of Ethics of the American College of Healthcare Executives is to serve as a standard of conduct for members. It contains standards of ethical behavior for healthcare executives in their professional relationships. These relationships include colleagues, patients or others served; members of the healthcare executive's organization and other organizations; the community; and society as a whole.

The Code of Ethics also incorporates standards of ethical behavior governing individual behavior, particularly when that conduct directly relates to the role and identity of the healthcare executive.

The fundamental objectives of the healthcare management profession are

• · to maintain or enhance the overall quality of life, dignity and well-being of every individual needing healthcare service and
• · to create an equitable, accessible, effective and efficient healthcare system.
• · Healthcare executives have an obligation to act in ways that will merit the trust, confidence and respect of healthcare professionals and the general public. Therefore, healthcare executives should lead lives that embody an exemplary system of values and ethics.

In fulfilling their commitments and obligations to patients or others served, healthcare executives function as moral advocates and models.

• · Since every management decision affects the health and well-being of both individuals and communities, healthcare executives must carefully evaluate the possible outcomes of their decisions. In organizations that deliver healthcare services, they must work to safeguard and foster the rights, interests and prerogatives of patients or others served.
• The role of moral advocate requires that healthcare executives take actions necessary to promote such rights, interests and prerogatives.

As per code of ethics The Healthcare Executive's Responsibilities to Patients or Others Served
The healthcare executive shall, within the scope of his or her authority:

• · Work to ensure the existence of a process to evaluate the quality of care or service rendered;
• · Avoid practicing or facilitating discrimination and institute safeguards to prevent discriminatory organizational practices;
• · Work to ensure the existence of a process that will advise patients or others served of the rights, opportunities, responsibilities and risks regarding available healthcare services;
• · Work to ensure that there is a process in place to facilitate the resolution of conflicts that may arise when values of patients and their families differ from those of employees and physicians;
• · Demonstrate zero tolerance for any abuse of power that compromises patients or others served;
• · Work to provide a process that ensures the autonomy and self-determination of patients or others served;
• · Work to ensure the existence of procedures that will safeguard the confidentiality and privacy of patients or others served; and
• · Work to ensure the existence of an ongoing process and procedures to review, develop and consistently implement evidence-based clinical practices throughout the organization.

· Statement of the Issue

End-of-life decision making and care are important aspects of the delivery of patient-centered healthcare.

Medical interventions have shaped the dying process, giving us options that can impact when, where and how we die. Intervening during the dying process with medical care can sustain lives, even when there is little or no hope for recovery or a meaningful existence. However, such actions may be inconsistent with patient preferences and foster unwarranted variations in end-of-life practice patterns.

In response, patients or next of kin should exercise control over decisions regarding use of medical interventions that may prolong existence rather than allow the natural progression of the dying process. The traditional value to preserve life by all possible means is now being weighed against patient-centered, quality-of-life considerations based on evidence-based care and a shared decision-making process.

Policy Position

The American College of Healthcare Executives (ACHE) expects healthcare executives to be committed to the compassionate and competent care of dying patients, including addressing the ethical dilemmas surrounding death and dying. Additionally, executives should promote public dialogue that will lead to an awareness and understanding of end-of-life issues and policies

In this case study

when a dilemma arose between the patient`s demand and physician`s role , considering the mental capacity of patient, wife was given the right to arrive at a decision. But later when patient responded to treatment, patients decision were also respected to arrive at a conclusion

ACHE encourages all healthcare executives to play a significant role in addressing this issue by:
Ensuring Ethical End-of-Life Decision Making

• · Healthcare executives and their organizations should ensure the patient’s (or, when lacking decision-making capacity, the authorized surrogate’s) self-determination regarding end-of-life decision making. Generally, informed adult patients or their surrogate have the ethical and legal right to accept or refuse any recommended treatments based on the ethical principle of autonomy. Such decision making should include an open, truthful discussion regarding the patient’s situation and evidence-driven healthcare options.
• · The healthcare executive should ensure patient or surrogate decisions are appropriately documented and respected.
• · When there is a disagreement or uncertainty regarding treatments for patients, healthcare providers should respond with empathy and thoughtful exploration of all possibilities, including palliative care with the appropriate decision maker. Healthcare executives should ensure there are clear guidelines, including a process to address care-management disagreements (such as, situations when the patient or surrogate is desiring non-beneficial treatments), as well as provide support to healthcare professionals, patients and/or surrogates responsible for making treatment choices.

Developing and Implementing End-of-Life Organizational Guidelines

• · Healthcare executives should ensure appropriate end-of-life care and decision-making policies and procedures are developed and implemented, including do-not-resuscitate orders, withholding and withdrawing life-sustaining treatment, medical futility issues and organ donation. Such guidelines should be regularly reviewed.
• · When developing and implementing guidelines, healthcare executives should encourage cooperation and understanding among the clinical staff, members of the governing body and executive management. Executives should ensure appropriate methods for raising awareness and staff education are provided regarding end-of-life ethical dilemmas, including how to access organizational ethics resources.
• · If organizational policies limit specific end-of-life options for patients and families or surrogates, healthcare executives have a responsibility to ensure that procedures are in place to provide full disclosure of such limitations.

Ensuring Available End-of-Life Care Support for Patients, Families and Staff Members

• · In the care of patients at the end of life, executives should support the development and availability of effective resources such as palliative care and hospice programs for patients and families to preserve psychological, social and spiritual well-being.
• · Executives should ensure effective support programs, such as ethics committees and employee assistance, are available to staff members to address ethical conflicts and moral distress that frequently surround end-of-life decision making and patient care.

Promoting Community End-of-Life Discussion

• · Executives should heighten awareness of ethical issues, including the patient or surrogate’s right to choose treatment, through facility and community information forums that promote open discussion among patients and their families, attorneys, clergy, journalists, physicians, other healthcare professionals and the public. By raising and openly discussing ethics issues, healthcare executives will aid the staff and the public in understanding the importance of thinking about end-of-life issues and the organization’s interest in ensuring patient-centered care.
• · Healthcare executives should foster reasoned, compassionate, patient-centered decision making that considers the rights, preferences and values of patients and staff members. While interpretation of these principles will vary by local custom and law, healthcare executives have a responsibility to ensure their organization operates with respect for the inherent worth, rights and human dignity of every individual.
• ACHE expects healthcare executives will promote ethical end-of-life decision making with the use of advance planning documents and end-of-life organizational guidelines.
• Executives should ensure end-of-life care support resources are available for patients, families and staff members. Lastly, healthcare executives should serve as a community resource in end-of-life discussions.

Autonomous Decision Making

• Persons have a right to put forward their end-of-life treatment preferences. The Federal Patient Self-Determination Act (PSDA)
• The person’s right to autonomously voice their end-of-life treatment choices has to be respected ethically considering the use of advance treatments and their prognosis. This right of autonomy has some limitations, and hence faces an ethical dilemma. The healthcare professional should respect the patient’s autonomy while considering its limitation and carry out their duties to benefit the patient without doing harm.

IN THIS CASE STUDY:

Patients autonomous decision making is considered and hence patient was withdrawn from life saving treatment.

Ethical Theories Involved in End-of-Life Care

Depressed patients lack appreciation

• Several of the articles highlighted appreciation as the component of capacity lacking in depressed individuals.
• In simple terms, the transition from simply understanding the medical facts, to actual application of those facts by an individual to their own situation, can be impaired in the depressed individual.
• When depression was seen to impair a patient’s ‘ability to comprehend the consequences of a choice’, again indicating that appreciative ability is at stake in depressive illness.

Accountability

• Elliot (1997) addressed the capacity of depressed individuals from a different perspective, drawing moral responsibility into the picture.
• Whilst accepting DMC could be influenced by both cognitive and emotional factors, he pinpointed two criteria required for accountability that are potentially compromised in depressed patients; namely, decisional authenticity and a minimal level of concern regarding one’s own welfare.
• Lack of ‘decisional authenticity’ refers to the fact that depressed individuals may not make decisions that reflect their ‘true’ autonomous self. Equally, they may not possess a minimal level of concern for their own welfare, without which any claim of DMC is jeopardized.

Emotion, cognition and capacity

• All the clinical ethical literature recognizes interplay between cognition, emotion and DMC. The widespread view is that capacity assessment must take into account both cognitive and emotional factors.
• ‘Depressive helplessness produces an underestimation of one’s possible effectiveness in the face of serious illness. Guilt and worthlessness may make one believe that suffering and death are deserved.
• Anhedonia may make it impossible to imagine that life will offer any pleasures for which it is worth enduring … illness. Depressive hopelessness can make it impossible to imagine that life will ever offer a better balance of pleasure and pain that it does at present.’

Impression: This case study outlines how the patients autonomy is respected even when decision making ability was altered, keeping in view the principle of beneficience and non-malificience.

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