September 2012 by SMCMA

September 2012 | Volume I /No. 7

A Publication of the San Mateo County Medical Association

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Editor’s Introduction

Bioethics By russ granich, MD

What is bioethics? It is the offspring of our technology, the study of the ethics brought about by advances in medicine. It also involves the exploration of values and culture in all of our practices. This month we have a themed issue on bioethics. We are fortunate to be allowed to publish some excellent articles on bioethics from the San Diego County Medical Society. An article by Dr. Pettus talks about the concept of “total pain” that goes beyond the ability of opioids to treat. Ms. Carrasca talks about integrating the three main goals of care: cure, relief and comfort in modern, technology driven medical practice. Nancy L. Vaughan, Esq. wrote about patient autonomy and informed consent, hitting the highlights of what we are all obligated to do and why. Ms. Mitchell discusses a disturbing case that denied a patient’s autonomy and how that changed the way we practice. Dr. Cederquist describes an all too common situation where a family member changes what a patient previously expressed about goals of care. It is a good example for what lead to SMCMA’s recent policy statement on treating “unbefriended patients”. To get a copy of this “unbefriended patients” policy, contact SMCMA at smcma@smcma.org or (650) 312-1663. We hope to stimulate your mind and stir your soul with thought provoking articles.

San Mateo County Physician September 2012 Vol. I / No. 7

Table of Contents President’s Message...........................5 Executive Report.................................7 The Surrogate Who Demands ‘Everything Be Done’...........................8 A Test of Autonomy..............................9 Informed Consent and Patient Autonomy........................10 Integration Model Trifecta................................................11 Global Health Ethics..........................13 Membership Update and Classified Ads..................................18

About the Cover: The photo was taken by Poppy Richie. Poppy is the wife of SMCMA’s Controller, Jim Richie. This was taken along the SF Bay Trail in San Mateo County near a nesting site for these white pelicans.

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Patient Protection and Affordable Care Act (ACA) By gregory Lukaszewicz, MD While the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (ACA) may have brought an end to the constitutional questions regarding the law, the work of actually implementing the ACA needs now to actually take place. In upholding the law’s constitutionality, specifically the provisions related to the individual mandate, the Supreme Court has hopefully ensured that a greater number of our citizens across the country will have access to both insurance coverage and medical care. While there is ongoing opposition to the ACA , the state of California has been taking a different tact even before the final ruling of the Supreme Court such as working to establish a Health Insurance Exchange However, we all recognize that we have only just started down the path of health care reform. We should view this historic legislation and ruling as a starting point from which we can continue to craft a system that benefits everyone. Implementation of the law will be an ongoing process, and physicians should continue to play a major role

in California’s new health care delivery system as it takes shape. . The California Medical Association has long supported certain health care reforms contained within the ACA such as a ban on refusing to cover patients with pre-existing conditions and limits designed to prevent excessive profits or administrative costs at the expense of patients. I suspect that most physicians support the goals of the ACA of controlling medical cost inflation, providing adequate primary and preventative care, and increasing patient access to more affordable care. Unfortunately, many of the reforms present in the act build upon the broken foundation of Medicare and Medicaid without addressing the problems of inadequate funding for these existing programs. Physicians understand that health care costs are continuing to rise and will be an ongoing problem for our economy and nation. Physicians are very much interested in being part of the solution to this problem and in developing new ways to control health care costs without cutting care or services. However, unless

our political leaders recognize that if we do not address the issue of funding these historical health care reforms (which the ACA has not done), then the law may only exacerbate already existing problems such as patient access to health services or place an increased burden on physicians already struggling to maintain their practices. The San Mateo County Medical Association, along with the California Medical Association (CMA), will continue on behalf of both patients and physicians to search for solutions to the problems facing our health care system, recognizing that the ACA itself and the recent Supreme Court ruling are but one step along the very long road of health care reform. As individual physicians we will continue to deliver outstanding care to our patients. Through our professional organizations such as the SMCMA, CMA and AMA, we will work to ensure that health care reform, as laudable a goal as it is, is not simply carried out at our expense.

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EXECUTIVE REPORT

Physician Employment Continues on its Rise By sue u. malone The recruiting and consulting firm, Merritt Hawkins’ 19th Annual Survey of Salaries, report that within two years, more than 75 percent of newly hired physician will be hospital employees. In the 2011-12 year, 63 percent of the company’s search assignments featured hospital employment of the physician, up from 56 percent the previous year and only 11 percent eight years ago. Phillip Miller, Vice President of Communications for Merritt Hawkins expressed the view that the whole medical profession is shifting away from private practice to employment. Fewer doctors want to go into independent private practice, which has been a major trend over the past few years. The demand for primary care physicians remains strong. For the seventh consecutive year, family physicians and general internists were the firm’s two most requested physician search assignments. Demand for pediatricians has also increased; now the ninth most requested assignment. By contrast, the specialty was not in the top 20 in

2005-06. Other specialties in demand are for psychiatrists, hospital medicine, and general surgery. On the other hand, demand for radiologists and anesthesiologists has decreased. Radiology, which was Merritt Hawkins’ most requested specialty in 2003, ranked only 18th in its 2011-12 annual survey. Also, for the first time since the firm began compiling data, anesthesiology was not among its 20 most requested search assignments. Anesthesiology is one of the few areas in medicine where allied health professionals are replacing physicians. Changing practice styles are a major factor in the primary care shortage as many physicians are embracing part-time practice or are seeking structured hours as part of a “controllable lifestyle.” Further, according to the Health Resources and Services Administration (HRSA), female primary care physicians work 18 percent fewer hours than male doctors.

accounted for just 1 percent of the firm’s searchers last year. While part of a long-term trend, it is startling that only 1 percent of this company’s searches were for solo practitioners. SMCMA Family Barbeque September 15 - Coyote Point Don’t miss an opportunity to join with your colleague and their families at SMCMA’s Family Barbeque Sunday, September 16 at Coyote Point Park from Noon to Four. This free event, which we expect to make an annual outing, will bring members and their families together for a funfilled day with great food, entertaining games for the kids, and excellent company. What a great opportunity for members to meet each other in a relaxed environment while the kids play on bounce castles in the park. Our picnic site at the Eucalyptus 1 Site, Coyote Point, 1701 Coyote Point Drive, San Mateo.

The recruitment of physicians into solo practice settings has almost entirely abated. Solo physicians

SAN MATEO COUNTY PHYSICIAN | page 7

The Surrogate Who Demands ‘Everything Be Done’ Counter to the Patient’s Wishes By Lynette C. Cederquist, MD A 63-year-old man with a history of multiple medical problems, including early dementia, seizure disorder, hypothyroidism, and alcoholism, is admitted to the hospital with acute respiratory failure requiring intubation in the field by paramedics. He has now been in the ICU on the ventilator for eight days with the diagnosis of MRSA pneumonia. On previous hospital admissions, he had been deemed DNAR/DNI per his stated wishes. The patient’s baseline mental status is that he is alert to self and conversant. Upon this admission, the admitting team was informed that the patient’s sister, who is acting as his surrogate, had “made him” a “full code/full care” once he returned to the SNF. There was no completed advance directive designating her as DPOA for healthcare, but she is his only remaining family member. The social worker at the SNF reported that she, the social worker, did not feel the patient had sufficient decisional capacity to complete a POLST (Physician’s Orders for Life Sustaining Treatment) form. She also reported that the patient’s sister never visited him at the SNF. One of the treating physicians who had cared for the patient during his previous admission reported that he had informed her (the physician) that he wished to be DNAR because he hated being in hospitals and did not wish to have his life extended if his heart stopped. Upon this admission, the admitting physician had contacted the patient’s sister by phone, at which time the sister again insisted that the patient continue to be “full code full treatment.” Subsequently, the treating team had tried repeatedly to contact the patient’s sister, but she did not page 8| San Mateo county physician

return calls, and she never visited him in the hospital. The treating team felt they were treating him overaggressively, going against his previously stated wishes. An ethics consultation was requested. This Case Involved Several Ethically Challenging Components 1. If the patient now lacks decisionmaking capacity but previously refused aggressive life-sustaining treatment, on what basis would the physicians now proceed with life-sustaining treatment? If the patient previously had decisionmaking capacity and had consistently refused treatment, then, as long as the circumstances are not significantly different, the patient’s prior wishes should still be honored. 2. What if the patient now lacks decision-making capacity but is refusing treatment? Ethical and legal guidelines are generally lacking. When treating such a patient, one must weigh risk of treatment vs. the risks of not treating. In general, if a treatment is a one-time event (such as surgical repair of a fracture), and risks are low, with a high probability of benefit, one could ethically justify proceeding with treatment despite the patient’s refusal. Treatment that is ongoing and requires patient cooperation (such as a prolonged course of chemotherapy, radiation treatments, or dialysis), while still perhaps ethically defensible, is often not feasible if such treatment requires physically restraining a patient. This potentially exposes the patient and the treating staff to risk of harm, and starts to look more like battery. In these cases, it is important to involve the ethics consult service and perhaps risk management. 3. If the sister does not make herself

available for discussions regarding the patient’s treatment, does she still qualify to act as his surrogate, or is he now an unrepresented patient? Physicians often feel trapped when a family member initially insists that “everything be done,” then disappears or avoids any further discussions with the physicians. Ethically and legally, part of the definition of acting as DPOA or surrogate includes the stipulation that the person must be willing and reasonably available to provide substituted judgment. In this case, since the patient’s sister did not make herself available to meet with the doctors, she should no longer have been considered to be his surrogate. This patient would then be considered an unrepresented or “unbefriended” patient. Treatment of the unrepresented patient is not addressed in California healthcare law. The California Hospital Association has a model policy after which many hospitals model their own policies (2). This policy designates the treating team, in conjunction with the ethics consultant, to act as surrogate decision maker for nonemergent treatment. Treatment decisions should be made according to the best interest standards — any treatment that would be deemed to be in the best interest of the patient and in accordance with the patient’s wishes and values, to the extent that they are known. In this particular case, the patient’s previously stated wishes and values were known. 4. On what basis is the sister in this case making decisions regarding that patient’s treatment, and is she representing his best wishes and continued on page 15

A Test of Autonomy marilyn mitchell, rn, bsn, Mas In 1973, Donald Cowart was a 26-yearold Air Force pilot in the Reserves visiting his father in Texas. They were surveying some property his father was considering purchasing. Unknown to them, there was a gas leak on the property at the time. As they were leaving, they turned the ignition to their car, which sparked an explosion, engulfing them both in flames. Instinctually, they both screamed in pain. A neighbor came running to their aid. When he arrived, Donald asked the neighbor for a gun so he could shoot himself. He’s been quoted as saying, “Can’t you see I’m a dead man?” The neighbor replied that he was unable to do that and instead got them help. Donald’s father died on the way to the hospital, and Donald survived, despite being burned on 65% of his body. Treatment for burn victims was very different in the 1970s, and much of what Donald experienced would be considered torture by today’s standards. Just as treatment wasn’t ideal, pain control was dominated by a fear of creating drug addiction. The combination of treatments that caused excruciating pain along with inadequate medication for pain was too much for Donald to endure. He repeatedly requested that he be allowed to die a natural death. Plus he had been a very active young man and did not want to live as a blind and physically damaged person. The medical team refused to heed his requests for discontinuing treatment. He was evaluated by two different psychologists and found to be mentally competent, yet his continued requests were ignored. After more than a year of treatment, he was discharged and began a new life. He changed his first name from Donald to Dax. He completed a law degree from Texas Tech University in 1986 and successfully sued the oil company responsible for the gas leak that led to his condition. He also continues to speak out publicly for the rights of individuals to accept or refuse medical treatment.

In his own words, “No one has the right to force other kinds of medical treatment upon you without your consent. There is no legitimate law, there is no legitimate authority, there is no legitimate power anywhere on the face of this earth that can take the right away from a mentally competent human being and give it to a state, to a federal government, or to any other person.” Fundamental to his case is the concept of autonomy and each person’s right to make his or her own decision. His case illustrates the challenge the medical community may have in allowing a patient to make a decision they do not agree with or the patient’s right to make a decision that could be considered mistaken. It’s tempting to believe that if someone does not agree with standard medical treatment, they must be wrong. You may consider cases you have encountered where a person requested not to be treated and later changed their mind after undergoing treatment. They may even express gratitude that their requests were ignored. Those experiences make this kind of case extremely difficult for the medical team. In general, there are instances where the medical team would be right to ignore a competent patient’s requests. Those instances include when a patient requests assisted suicide (except in Oregon, Washington, and Montana), if a patient requests willful self-injury (such as an unnecessary amputation of a healthy limb), if a patient requests medically unnecessary treatment, if a patient requests a medication or treatment that is prohibited by law, or if a patient requests to be included in a medical experiment since there is no right to participate in research and often research protocols are very specific. On the other hand, though, everyone does have a right to refuse treatment, and it has been well established through numerous cases. In the case of Bovia v. Superior Court in 1986 in

California, it was ruled that a competent adult could refuse tube feeding, even if the person did not have a terminal illness. The right to accept or refuse treatment is intertwined with the process of informed consent. The reason I call it “the process of informed consent” is that there is more to it than asking a patient to sign a document. Patients can and do file malpractice claims if they believe they did not receive adequate informed consent. Patients need to be informed, in language that they understand, of the risks, benefits, and alternatives to treatments, and to be given an opportunity to confirm their understanding prior to the treatment. The process needs to be done honestly, with no effort to coerce them, for it to be valid. Perhaps Dax would have consented to treatment if there had been an agreement to manage his pain more adequately. Dax has gone on to lead a life that by his own admission is happy. He is married and financially secure. Yet he continues to speak on the topic of patient’s rights. When asked if he would still want the freedom to die back during those days after his accident, even though he has gone on to lead a happy life, he always says yes. He has said, “Another individual may well make a different decision. That’s the beauty of freedom.” Ms. Mitchell has been an RN for nearly 32 years and received her master of advanced studies in health law degree from UCSD/California Western School of Law in 2009. She works for Kaiser Permanente in the Department of Service Quality. This article has been reprinted with permission from the San Diego County Medical Society. References: •

Link to a video where he speaks about his case: http://www.youtube.com/ watch?v=lSsu6HkguV8

•

Problems in Health Care Law, R.D. Miller, Jones & Bartlett Publishers, 2006

•

Intervention and Reflection: Basic Issues in Medical Ethics, Thomson Wadsworth, 2004

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Informed Consent and Patient Autonomy By nancy l. vaughan, esq. In 1847, the American Medical Association’s (AMA) Canons of Ethics warned that physicians should not deliver bad news to patients. It was believed that telling a patient about a bad prognosis might appear to magnify the doctor’s role in caring for the patient. A physician was the “minister of hope and comfort to the sick,” and his role was to “smooth the bed of death, revive expiring life, and counteract the depressing influences of those maladies …” (1). Today the AMA’s Canons of Ethics instruct that physicians “shall” respect the rights of patients, “safeguard their confidences and privacy,”… and make relevant information available to patients. This reflects the change in attitude by Western society toward patient autonomy from a traditionally paternalistic practice of medicine (2). One of the earliest legal decisions to set forth the principle of patient autonomy was written in 1914 by Justice Benjamin Cardozo, in Schloendorff v. Society of New York Hospital. Justice Cardozo wrote, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body…” (3). This principle of patient autonomy was not widely respected, however, because of an ongoing belief (now referred to as benevolent deception) that patients would make decisions contrary to their own best interest if they were informed of possible outcomes and complications associated with a particular treatment. This philosophy is reflected in the 1957 case of Salgo v. Leland Stanford Jr. University Board of Trustees, in which the phrase “informed consent” was first used. This California Court of Appeals decision found that a physician

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could be held liable for failing to provide facts sufficient to allow a patient to make an informed decision about proposed treatment. The court suggested, however, that in order to protect a patient’s well-being, the physician must exercise discretion when deciding what risks to disclose, to keep from alarming an already apprehensive patient who may as a result refuse to undergo surgery (4).

consider important in deciding to have the proposed treatment or procedure, and any other information skilled practitioners would disclose to the patient under the same or similar circumstances. The patient must always be told about the risk of death, serious injury, or significant potential complications that may occur if the procedure is performed” (6). There are only a few exceptions to these rules.

In 1972, the California Supreme Court rendered a decision in Cobbs V. Grant, perhaps the most important case in California regarding the right of a person to make an informed decision to consent to or refuse proposed medical treatment. In this case, the patient was told about the general nature of an operation he was about to undergo, but was not told of any of the risks associated with the procedure. Following surgery, the patient suffered serious complications, requiring multiple hospitalizations and several major surgeries. Dr. Grant was sued by the patient; his own testimony at trial established that he had not disclosed any of the inherent risks of the surgery and that this was consistent with the community standard. The court held that a physician has “a duty of reasonable disclosure of the available choices with respect to proposed therapy and of the dangers inherently and potentially involved in each” (5).

Physician practices vary widely on how compliance with this responsibility is documented. Some don’t document it at all. Some simply give the patient the information verbally and make a chart note that reads “R.B.A. given.” While this may technically document that the physician has given informed consent, it may later make it very difficult for a juror to understand what the discussion included. Thus it is always better to write a detailed chart note about the discussion, and better still to ask the patient to read a document outlining the risks (after a thorough discussion with the physician), initial various paragraphs acknowledging understanding, and sign the document in front of a witness.

As a result of Cobbs V. Grant, California law requires a practitioner to explain “the likelihood of success and the risks of agreeing to a medical procedure in language that the patient can understand.” He must give the patient as much information as is needed to make an informed decision, including any risk that a reasonable person would

Occasionally, a patient’s mental capacity to make a decision is not clear. Patients are under an unusual amount of stress during illness, and many experience anxiety, fear, and depression. This stress should not necessarily preclude one from making an informed decision however, and an assessment should be made of the patient’s ability to understand his or her situation, the risks associated with the decision at hand, and to communicate a decision based on that understanding. When capacity is not clear, a further continued on page 15

Integration Model Trifecta By london carrasca, mph, rn

In this article, I wish to explore the underlying concepts that the above epigraph addresses and how it is (or isn’t not) incorporated into our current healthcare paradigm. I hope to provide ideas for bioethics education and dialogue that we as healthcare providers can implement to foster change in our healthcare culture and community. We seem to have become a society of technologists and at times have lost sight of the goals of medicine and the lost art of healing. The role of the humanistic healthcare professional (with all the responsibilities that include difficult and time-consuming conversations that encompass a wide range of topics, from antibiotic prescribing to end-of-life discussions) has been replaced by the role of the technologist (expensive utilization of high technology and aggressive treatments, but not always better quality of life and functional capacity outcomes, and with harm attached to them). As noted above, the bioethical duty of the healthcare professional is to cure sometimes, to relieve often, and to comfort always, while addressing the goals of medical treatment, benefit vs. harm (burden), and benefit vs. effect of potential medical treatment options. Factors to be considered are the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of life sustained (Jonsen et al, 2002). The obligation to alleviate pain, suffering, and disability is as serious as an obligation to save an endangered life (Jonsen et al, 2002). Throughout this process, respect for

and dignity of the patient should be held in high regard, and informed consent should be provided to the patient and/or legally recognized surrogate decision maker(s). One important qualification is that physicians are not obligated to offer nonbeneficial medical treatment (supported by the American Medical Association, California Probate Code, California Medical Association, and SDCMS Bioethics Commission). Indeed, the Patient Self-determination Act gives the patient the right to refuse, but not demand, treatment. The goals of medicine (curative vs. palliative or concurrent focus) should be addressed in a thoughtful manner [including considerations regarding realistic and attainable goals; timelimited trials; shared decision-making with the patient and/or surrogate decision maker(s) and exploration of influencing worldviews; prognostication; framing conversations and collaborative approach of the treating healthcare team]. The physician also has a “systems ethics” responsibility to the healthcare team (not lone decision maker in the process, and has a duty to recognize the impact on other physicians, healthcare providers, and healthcare system). There should be collaboration and coordination with other stakeholders who are involved in the patient’s medical treatment, and they should be included in the decisionmaking process. To help address these difficult and challenging bioethical issues and dilemmas, healthcare bioethics committees and community bioethics

forums may be utilized to promote bioethics education and dialogue regarding these important issues and health policy debates. A healthcare bioethics committee is an advisory group that provides a forum for structured interdisciplinary review and discussion of medical, bioethical, spiritual, and legal considerations for patients, families, and healthcare providers. Community bioethics forums may provide bioethics education to community members via collaboration with healthcare institution bioethics committee members; members of the bioethics community at large; members of the educational community; healthcare students/residents and members of the nonhealthcare community public. It involves a great deal of time, effort, and resources to build a foundation for this bioethics education and to form networking to expand the reach and breadth of the bioethics community to be able to continue on this educational journey of sharing knowledge and learning from others. Many communities lack the resources to provide any type of comprehensive bioethics education. I believe it is time to look at healthcare organization and community culture, policies, and practices to identify, assess, and solve systems issues that lead to complex bioethical issues and dilemmas. This would enable us to address current issues and future directions of bioethics education from not only a physician perspective but with mixed disciplines, healthcare organization, and community focus to broaden the worldview; as well as continued on page 15

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Global Health Ethics -

A Response to ‘Total Pain’ By katherine irene pettus, phd Question: How are the following three sets of facts related? •

•

Americans account for 4.6% of the world’s population but consume approximately 80% of the world’s opioid supply, 99% of the world’s supply of hydrocodone, and roughly two-thirds of the world’s illegal drugs. The mainstream media and the medical journals proclaim an “epidemic” of prescription drug abuse, death from overdoses, and painkiller addiction. Yet, the Institute of Medicine’s 2011 report on pain in America estimates that 116 million Americans suffer from chronic, untreated pain that persists for weeks to years, with total financial costs of $560–$635 billion per year in direct medical costs and lost wages, at an annual price tag of $100 billion to state and federal budgets. The IOM calls this a “public health crisis.” Furthermore, the World Health Organization (WHO) estimates that 5 billion people live in countries with little or no access to controlled medicines, and have no or insufficient access to treatment for moderate to severe pain. This includes people with late-stage cancer and AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease, and so on — it issues no estimates but believes that millions go untreated.

The three sets of facts are related in that, together, they represent a global scenario of “total pain.” Global health ethics can frame an appropriate

response to this scenario. In what follows, I will briefly define both concepts. Modern hospice and palliative care pioneer Dr. Cicely Saunders was trained as a social worker, nurse, and physician. She was also a person of deep faith. Dr. Saunders’ concept of total pain […] saw pain as a key to unlocking other problems and as something requiring multiple interventions for its resolution. Thus was formulated the idea of total pain as incorporating physical, psychological, social, emotional, and spiritual elements. Crucially, total pain was tied to a sense of narrative and biography, emphasizing the importance of listening to the patient’s story and of understanding the experience of suffering in a multifaceted way. (1) Understanding global suffering in a multifaceted way requires listening to the voices of those in pain, rather than marginalizing them or repressing them. Such an approach is beneficent and amplifies autonomy. While access to opioid analgesics is essential to good medical practice, and opioids are the only remedy for some kinds of severe physical pain, Dr. Saunders acknowledged that the multifaceted sense of “total pain” could not be relieved solely through analgesics. Addiction to painkillers, for example, and the widespread fear of opioid addiction among medical practitioners and patients, paradoxically generates its own dimensions of lethal pain. Certainly, the greatest happiness is not correlated with the greatest consumption of painkillers: Americans may be “awash in opioids,” according to one analyst, but the United States

ranks only 14th in the Gallup World Happiness Poll (2). As Dr. Saunders said, “Mental distress may be perhaps the most intractable pain of all.” What can the “narrative and biography” of the American people reveal about the so-called “epidemic” of painkiller abuse? How is that narrative connected to the fact that opioids are unavailable for medical use throughout most of the world? To discern the answer to this complex question, Saunders directs us to listen to the patient’s (our) (his)story. Physicians have the model at hand: Listening in order to clarify goals of care is the cornerstone of ethical medical practice. Such listening (rather than simply talking) is also a core practice of democratic citizenship. “The branches of your intelligence grow new leaves in the wind of this listening.” — Rumi The concepts of total pain and global health ethics both have sufficient scope to frame the three sets of facts cited at the beginning of the article. They can unlock the (global) problems of untreated suffering that require multiple interventions. According to Solomon Benatar, emeritus professor of medicine and founding director of the University of Cape Town Bioethics Centre, “The domain of global health ethics provides a context within which the many relevant disciplines that have valuable insights to offer can usefully engage, and through that engagement promote, better understanding of the extensive changes that are needed” (3). Global health ethics is more than the continued on page 17

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Surrogate

Informed Consent

Integration Model

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values? Family members or surrogates are not supposed to make decisions based on what they want; they are supposed to act in substituted judgment representing what the patient would want done. We often don’t know with certainty the basis for family members’ requests for overly aggressive treatment, even when the physician believes continued treatment is nonbeneficial or futile. In many cases, the family member is acting out of feelings of guilt or grief. Occasionally, there can be secondary gains, such as the patient’s pension or other financial gain. In this case, the sister never relayed having any conversations with her brother that led her to believe he would want aggressive treatment, and she did not appear to have a very close relationship with him, so her motives for demanding such treatment were unknown.

analysis of the appropriate next step (an interpreter, a psychiatric consultation, or workup by other specialist) can be helpful. Keep in mind that a patient’s refusal of treatment does not mean the patient lacks capacity. Patients have the right to refuse treatment, even those treatments that may be lifesaving. Informed consent is about patient autonomy, with the goal of giving the patient the opportunity to be an informed participant in healthcare decisions, regardless of what that decision is.

encourage dialogue on these issues and promote compassionate and quality patient care. No discipline exists in isolation, so it is important to address issues across the spectrum. There must be coordination and collaboration among disciplines to address these complex bioethical issues with open and transparent processes.

Physicians frequently make the mistake of asking a surrogate, “What do you want us to do?” Alternatively, they should be asking, “If your loved one could talk to us now, what do you believe he/she would tell us?” This can often result in a different response. Reframing the conversation in this way can also reduce the amount of guilt such decisions can provoke, as nobody wants to feel like they were the one to say they wanted to limit or stop treatment. In this case, the ethics consultant also tried unsuccessfully to contact the sister. The treating physicians were advised that they should proceed with treating this patient as an unrepresented patient. They subsequently did change his code status to “DNAR” based on his previously documented statements. Fortunately, the patient was successfully extubated and transferred back to his skilled nursing facility.

Ms. Vaughan is an attorney who has specialized in healthcare law. She is currently teaching bioethics at California Western School of Law and at Thomas Jefferson School of Law. References: 1.

Original Code of Medical Ethics of the American Medical Association, adopted at the adjourned meeting of the National Medical Convention in Philadelphia. May 1847

Principles of Medical Ethics, American Medical Association, adopted June 1957; revised June 1980; revised June 2001.

Schloendorff v. Society of New York Hospital, 211 N.Y. 215, [1914]

Salgo v. Leland Stanford Jr. University Board of Trustees, 154 Cal.App.2d 560 (1957)

Cobbs V. Grant, 8 Cal. 3d. 229 (1972)

California Civil Jury Instructions (CACI) #532

In addition, there should be healthcare organization and community support to bring in recognized leaders in the bioethics field for lectures, clinical education, and discussions regarding these important bioethical issues and dilemmas. Some pearls to address complex bioethical issues are communication, collaboration, respect for all members of the healthcare team, transparency of inquiry, education, and lessons learned for change in culture, practice, and policies. Mr. Carrasca is co-chair of Rady Children’s HospitalSan Diego (RCHSD) Bioethics Committee; RCHSD bioethics consultant; community bioethics committee member at two San Diego-area hospitals, and a member of the SDCMS Bioethics Commission.

Resources: •

Dunn, H. Hard Choices for Loving People. Available: www.hardchoices.com

•

Emanuel, EJ, & Emanuel, L. (1992). “Four Models of the Physician-Patient Relationship.” JAMA, April 22/29, 267(16): 221-226.

•

Emanuel, L, & Librach, SL. (2007). Palliative Care: Core Skills and Clinical Competencies. Saunders Elsevier.

•

Himelstein, BP, et al. (2004). “Pediatric Palliative Care.” NEJM, 350(17): 1752-1762.

•

Jonsen, AR, et al. (2002, 2010). Clinical Ethics. McGraw Hill.

•

Lown, B. (1999). The Lost Art of Healing. Ballantine Books.

•

Lynn, J, et al. (2008). Improving Care for the End of Life. Oxford University Press.

•

McPhee, SJ, et al. (2011). JAMA Evidence: Care at the Close of Life. McGraw Hill.

•

Rushton, CH. (2006). “Defining and Addressing Moral Distress.” AACN Advanced Critical Care.

Dr. Cederquist, SDCMS-CMA member since 2005, has been a full-time faculty member at UCSD Internal Medicine since 1994, with a focus in chronic pain management and palliative care. She is also chair of UCSD’s Ethics Committee and director of the ethics consult service. References: 1.

CA Probate Code 4711-4717

California Hospital Association Model Policy for Acute Care Hospitals. Health Care Decisions for Unrepresented Patients.

SAN MATEO COUNTY PHYSICIAN | page 15

Global Ethics continued from page 13

sum of its individual national parts: Its discourse acknowledges and calls out the local deficits of autonomy, beneficence, and justice that allow suffering to metastasize on a global scale. The inverse of those deficits is embodied in those collaborative educational and public health responses oriented toward distributive justice conceived as the equitable distribution of pain relief. Moving from the abstract to the concrete: A new series of documentary films at www.treatthepain.com (the Global Access to Pain Relief Initiative) provides an accessible and compelling entry point into the larger conversation. Other resources include organizations such as the International Association for Hospice and Palliative Care (www. hospicecare.org) and the Pain Policy Studies Group (www.painpolicy.wisc. edu), a WHO collaborative at the University of Wisconsin. PPSG conducts and distributes careful, evidence-based studies, provides trainings and fellowships for practitioners, and even publishes a regular blog on pain issues. Dr. Pettus (political theory, Columbia University) is a new member of the SDCMS Bioethics Commission and is writing a book on palliative care and public policy for SUNY Press (forthcoming 2013). She can be reached at kpettus@ucsd.edu or (858) 775-0429. References: 1.

Clark, David PhD (2000) “Total Pain: The Work of Cicely Saunders and the Hospice Movement” APS Bulletin • Volume 10, No. 4.

http://www.forbes.com/2010/07/14/ world-happiest-countries-lifestyle-realestategallup-table.html

Benatar, Solomon and Gillian Brock (2011) Global Health and Global Health Ethics Cambridge University Press

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Russ Granich, M.D., Chair Edward G. Morhauser, M.D Michael Stevens, M.D

Sharon Clark, M.D. Gurpreet K. Padam, M.D.

Sue U. Malone.............................................Executive Director Reina O’Beck..................................................Managing Editor

2011-2012 Officers & Board of Directors Gregory C. Lukaszewicz, M.D...................................President Amita Saxena, M.D..........................................President-Elect Vincent Mason, M.D.................................Secretary-Treasurer John D. Hoff, M.D...........................Immediate Past President Raymond Gaeta, M.D. Russ Granich, M.D. Edward Koo, M.D. C.J. Kunnappilly, M.D. Michael Norris, M.D.

Michael O’Holleran, M.D. Irwin Shelub, M.D. Kristen Willison, M.D. Chris Threatt, M.D.

David Goldschmid, M.D. ......................................CMA Trustee Scott A. Morrow..............Health Officer, County of San Mateo Dirk Baumann, M.D. .............................AMA Alternate Delegate

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