Advance Directives and Patient Ethics
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Questions and Answers

What is the primary concern regarding the patient's prognosis?

  • The patient will fully recover.
  • The patient will need extensive rehabilitation.
  • The likelihood of infection increases significantly.
  • The prognosis is very poor and may result in handicaps. (correct)
  • Which concept affirms that each person has moral value and dignity?

  • Nonmaleficence
  • Beneficence
  • Justice
  • Respect for Autonomy (correct)
  • What does an Advance Directive allow a person to do?

  • Override the wishes of family members.
  • Force healthcare professionals to act against their judgment.
  • Mandate life support in all circumstances.
  • Decide on healthcare options when not competent. (correct)
  • How many witnesses are typically required for an Advance Directive, and what is one mandatory stipulation regarding their qualifications?

    <p>Two witnesses, one of whom must be a medical practitioner (D)</p> Signup and view all the answers

    Who is legally capable of making an Advance Directive?

    <p>Any adult with necessary mental capacity. (A)</p> Signup and view all the answers

    What is a crucial criterion for a person to be deemed competent in the context of making an Advance Directive?

    <p>Understanding a therapeutic or research procedure (B)</p> Signup and view all the answers

    Why is it a concern to keep the patient on life support?

    <p>Other patients may require critical care resources more urgently. (C)</p> Signup and view all the answers

    Which of the following situations allows a person to specify decisions in an Advance Directive?

    <p>Being terminally ill (C)</p> Signup and view all the answers

    What should healthcare professionals NOT ignore when making decisions?

    <p>The preferences of the patients. (B)</p> Signup and view all the answers

    What is the distinction between an Advance Directive and euthanasia?

    <p>Advance Directives clarify health care wishes; euthanasia involves ending life. (B)</p> Signup and view all the answers

    What is one benefit of having an Advance Directive for patients?

    <p>Protecting against their defined harmful outcomes (C)</p> Signup and view all the answers

    What is one ethical dilemma presented in the patient's case?

    <p>If the patient would have wanted to be resuscitated after a head injury. (C)</p> Signup and view all the answers

    Which of the following conditions qualifies as mentally incompetent regarding making an Advance Directive?

    <p>Suffering from dementia or a psychiatric condition (A)</p> Signup and view all the answers

    What kind of decisions do Advance Directives often specify in terms of treatment?

    <p>Not receiving life-sustaining treatment or specific basic care (C)</p> Signup and view all the answers

    What is required for a medical practitioner before they can sign as a witness on an Advance Directive form?

    <p>Confirmation of the patient's ability to understand the directive's nature and effect (D)</p> Signup and view all the answers

    How does an Advance Directive aid healthcare professionals?

    <p>It helps in making difficult decisions regarding patient care (A)</p> Signup and view all the answers

    What is the primary ethical principle potentially violated if a nurse chooses to keep a patient's suicide plan secret?

    <p>Beneficence (B)</p> Signup and view all the answers

    Why might a patient in outpatient care decline standard treatment like chemotherapy?

    <p>All of the above (D)</p> Signup and view all the answers

    Which guiding principle emphasizes the importance of respecting a patient's right to make their own decisions?

    <p>Autonomy (C)</p> Signup and view all the answers

    In a situation where a patient expresses a wish to commit suicide, what should be considered regarding confidentiality?

    <p>It can be breached if it protects the patient from harm (B)</p> Signup and view all the answers

    What is a key role of healthcare providers in the informed consent process?

    <p>To understand patient concerns and discuss treatment options (A)</p> Signup and view all the answers

    Which factor is NOT typically included in the informed consent discussion?

    <p>Personal preferences of the healthcare team (B)</p> Signup and view all the answers

    In the case of Mr. Green, what ethical principle is most at stake concerning the decision to share his suicidal thoughts?

    <p>Nonmaleficence (C)</p> Signup and view all the answers

    Which consideration might influence a patient's decision to seek alternative treatment over standard medical procedures?

    <p>Distrust in healthcare providers (B)</p> Signup and view all the answers

    What is one of the main ethical principles that prioritizes patient decision-making in healthcare?

    <p>Autonomy (C)</p> Signup and view all the answers

    Which guiding principle of medical ethics is concerned with the idea of providing benefit to the patient?

    <p>Beneficence (C)</p> Signup and view all the answers

    In the context of an ethical dilemma, what might be a significant concern regarding a patient with a poor prognosis but without the funds for critical care?

    <p>Excessive spending of taxpayer money (D)</p> Signup and view all the answers

    What does 'nonmaleficence' emphasize in medical ethics?

    <p>Avoiding harm to patients (C)</p> Signup and view all the answers

    Considering the provided case of a 35-year-old male with severe brain injury and slim chances of recovery, which ethical principle may be challenged?

    <p>Nonmaleficence (C)</p> Signup and view all the answers

    According to the ethical framework discussed, which principle is primarily concerned with fairness irrespective of various demographics?

    <p>Justice (B)</p> Signup and view all the answers

    If a healthcare professional encounters a scenario where an elderly patient with a terminal disease requests aggressive treatment, which principle should be foremost in consideration?

    <p>Autonomy (B)</p> Signup and view all the answers

    In the ethical dilemma of funding critical care for a patient with a poor prognosis, which response reflects an extreme ethical stance?

    <p>Cost should not be a consideration as every life matters (D)</p> Signup and view all the answers

    What does nonmaleficence primarily emphasize in healthcare?

    <p>Avoiding harm to patients (A)</p> Signup and view all the answers

    What is the primary focus of beneficence in nursing practice?

    <p>Doing good for patients (B)</p> Signup and view all the answers

    In the event of a conflict between beneficence and nonmaleficence, which principle is considered more stringent?

    <p>Nonmaleficence (C)</p> Signup and view all the answers

    Which of the following best describes the benefit-risk ratio in healthcare?

    <p>An assessment of potential risks against expected outcomes (B)</p> Signup and view all the answers

    What principle addresses fairness and equity in healthcare distribution?

    <p>Justice (A)</p> Signup and view all the answers

    When considering organ allocation, which factor is least likely to be considered?

    <p>Patient's preference (D)</p> Signup and view all the answers

    Which of the following represents a potential benefit of surgical procedures?

    <p>Symptom relief (B)</p> Signup and view all the answers

    What is a primary concern when recommending treatment to a patient?

    <p>Patient’s values and insights (C)</p> Signup and view all the answers

    What is the first step to resolve an ethical dilemma?

    <p>Identify ethical issues (C)</p> Signup and view all the answers

    Which approach promotes shared decision-making in healthcare?

    <p>Patient education and open communication (D)</p> Signup and view all the answers

    What can help resolve ethical dilemmas according to the provided content?

    <p>Reading and discussing ethical issues (A)</p> Signup and view all the answers

    What should be considered about the patient when addressing ethical dilemmas?

    <p>The patient's values and preferences (D)</p> Signup and view all the answers

    Which of the following is NOT part of preparing for resolving ethical dilemmas?

    <p>Consulting only legal counsel (D)</p> Signup and view all the answers

    Why is it important to engage in discussions with colleagues regarding ethical issues?

    <p>To generate diverse perspectives and insights (A)</p> Signup and view all the answers

    Which statement about ethical consensus is true?

    <p>There are areas of both consensus and controversy in ethics. (A)</p> Signup and view all the answers

    What is a vital aspect of planning for open communication with patients?

    <p>Establishing a clear dialogue about treatment options (A)</p> Signup and view all the answers

    Flashcards

    Autonomy in medical ethics

    Respecting a patient's right to make their own healthcare decisions, as long as they have the capacity to do so.

    Nonmaleficence in medical ethics

    The duty to avoid causing harm to patients.

    Beneficence in medical ethics

    The duty to act in the best interest of the patient.

    Justice in medical ethics

    Fair and equitable distribution of healthcare resources.

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    Ethical dilemma in healthcare

    A situation where there is no clearly correct course of action.

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    Capacity for decision making

    A patient's ability to understand their condition, treatment options, and make a reasoned decision in their best interest.

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    Critical care costs

    The financial implications of providing medical care, particularly in intensive situations.

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    Poor prognosis

    A prediction that a patient's recovery is unlikely to be successful, or that the outcome will be severe.

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    Advance Directive

    A written statement where a competent adult details their desired healthcare in the future when they lose that competence.

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    Respect for Autonomy

    The ethical principle that acknowledges each person's right to make their own healthcare decisions.

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    Competence (for Advance Directive)

    The mental capacity to understand and make healthcare decisions.

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    Advance Directive and Euthanasia

    Different concepts. Advance directives are about expressing future healthcare wishes, while euthanasia is about ending a life.

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    Patient's Healthcare Decisions

    The patient's preferences, regarding their treatment and care, must be considered in healthcare decisions.

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    Prognosis (for a patient)

    The predicted outcome or course of a medical condition.

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    Who can make advance directives?

    Any adult with the mental capacity to make healthcare decisions.

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    Continuity of Care

    Ensuring the consistent delivery of patient care during treatment and transition of needs.

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    Informed Consent

    The process of obtaining a patient's voluntary agreement for a medical procedure or treatment after providing them with clear and understandable information about the risks, benefits, and alternatives.

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    Elements of Informed Consent

    The essential components of informed consent include: purpose of treatment, nature of treatment, benefits of treatment, complications of treatment, cost of treatment, role of the patient, role of the healthcare provider, and alternative treatments.

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    Open Communication

    Active and transparent dialogue between a healthcare provider and a patient, ensuring that the patient's perspectives and concerns are addressed and understood.

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    Ethical Dilemma

    A situation in healthcare where there is no clearly correct course of action and different ethical principles may conflict.

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    Autonomy

    Respecting a patient's right to make their own healthcare decisions, as long as they have the capacity to do so.

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    Nonmaleficence

    The duty to avoid causing harm to patients.

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    Beneficence

    The duty to act in the best interest of the patient.

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    Justice in Healthcare

    Fair and equitable distribution of healthcare resources.

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    Advance Directive (AD)

    A legal document where a person outlines their wishes regarding medical care, especially during terminal illness, coma, or other end-stage conditions.

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    Who needs witnesses for an AD?

    Usually, two witnesses are required, one of whom must be a medical practitioner. The witnesses must not have any vested interest in the person's estate.

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    What is mental competence for an AD?

    The ability to understand the AD, its consequences, and to make informed decisions regarding medical procedures and risks.

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    When does an AD take effect?

    An AD comes into effect when the person is terminally ill, in a permanent coma or vegetative state, or has other severe life-limiting conditions that are irreversible.

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    What does an AD usually specify?

    Generally, an AD outlines the person's preference for withholding life-sustaining treatments or refusing certain medical interventions under specific conditions.

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    Benefits of an Advance Directive

    It safeguards the patient's wishes, reduces family stress over decisions, and helps medical professionals make informed choices in complex situations.

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    Is an AD legally binding?

    In common law jurisdictions, Advance Directives are legally binding.

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    Who can benefit from an AD?

    Anyone, regardless of age or health status, can benefit from creating an Advance Directive to ensure their healthcare wishes are respected.

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    Patient's view on harm

    The potential negative consequences a patient perceives from a treatment, which may differ from a healthcare professional's perspective.

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    Nurse's view on harm

    The potential risks or negative outcomes a healthcare professional anticipates based on their medical knowledge and experience.

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    Benefit-Risk Ratio

    The assessment of the potential benefits of a medical intervention compared to its potential risks.

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    Limited Resources Allocation

    Difficult decisions about distributing scarce medical resources, such as organs, when demand exceeds supply.

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    Ethical Consensus

    Agreement among people about what is right or wrong in a particular situation.

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    Ethical Controversy

    Disagreement about what is right or wrong in a particular situation.

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    Shared Decision-Making

    The process where both a healthcare professional and a patient work together to decide on the best course of action.

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    Patient Values and Preferences

    What matters most to a patient about their health, including their beliefs, goals, and wishes.

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    Open Communication in Healthcare

    Honest and clear dialogue between a healthcare professional and patient about their health.

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    Gather Information

    Collecting all relevant information before making a decision, including medical facts and patient preferences.

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    Resolving Ethical Dilemmas

    The process of finding a solution to a situation where there is no easy right or wrong answer, considering all relevant factors.

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    Study Notes

    Course Information

    • Course Title: Health Ethics 1: Introduction to Ethical Approaches and Decision Making Framework
    • Course Code: MEDF 1021
    • Term: Term 1 2024-25
    • Instructor: Yin Ting Cheung, Ph.D., Associate Professor, School of Pharmacy, The Chinese University of Hong Kong
    • Email: [email protected]

    Outline

    • Background and Definitions
    • Scenarios (poll)
    • 4 Guiding Principles of Medical Ethics
      • Autonomy
      • Nonmaleficence
      • Beneficence
      • Justice
    • Take-home Message

    Learning Objectives

    • Understand the basic bio-ethical approaches, including theories and principles
    • Appreciate the uniqueness of different ethical viewpoints
    • Learn about the principle of respecting patients' autonomy

    What is Ethics?

    • Moral principles that govern a person's behavior or the conducting of an activity

    Why Health Ethics?

    • A set of moral principles that guide medical decision-making
    • Ethical issues are embedded in every clinical encounter
    • People may have diverse beliefs, attitudes, feelings, and opinions
    • Patient goals may conflict with healthcare professional goals

    Ethical Dilemma 1

    • When should abortion be legal?
      • A. At any time the woman decides
      • B. Before 6 weeks of age of fetus
      • C. Before 12 weeks of age of fetus
      • D. Only under specific situations (e.g., sexual harassment)
      • E. Never should be legal

    Ethical Dilemma 2

    • When should medical euthanasia be permitted?
      • A. Anytime a patient decides
      • B. When certain criteria are met (e.g., age > 65, terminal disease)
      • C. Never, it goes against the Hippocratic oath ("First, do no harm")

    Ethical Dilemma 3

    • A patient with poor prognosis who lacks funds for critical care. How much should be spent by the public hospital on prolonging life, as per the family's wishes?
      • A. 250,000 HKD
      • B. 500,000 HKD
      • C. 1,000,000 HKD
      • D. 5,000,000 HKD
      • E. Cost should not be a consideration as every life matters

    Case 1

    • A 35-year-old male with congenital Moyamoya disease in intensive care with severe intracranial bleed and possible extensive paralysis.
    • Patient's girlfriend states he does not want resuscitation.
    • Patient's parents want life-sustaining care.
    • Medical prognosis is very poor.

    Case 1: Sorting Facts

    • Prognosis = very poor.
    • If he ever wakes up, he will be handicapped
    • Is it in his best interest to keep him alive with machines?
    • Who will take care of him after he leaves the hospital?
    • Is it fair to keep this patient in the ICU when there are other patients who need the service more?
    • Legally, who can make a life and death decision for the patient?
    • Ethically, is it right for doctors to withdraw care?

    Respect for Autonomy

    • Respect for persons affirms every person's inherent moral value and dignity.
    • Healthcare professionals should not ignore or override patient preferences.
    • Respect patient's capacity to make decisions and their right.

    Advance Directive

    • A written statement allowing a competent individual to specify healthcare wishes for the future when they are no longer competent.
    • Important for providing clarity regarding patient preferences and wishes for family and healthcare professionals

    Who Can Make an Advance Directive?

    • Any adult with the necessary mental capacity to make their own healthcare decisions
    • Requires two witnesses, one of whom must be a medical practitioner
    • Witnesses must not have any interest in the person's estate

    Standards of Competence

    • Ability to comprehend and process information
    • Ability to reason about consequences
    • Ability to understand and deliberate on risks and benefits
    • Ability to make a decision based on this deliberation

    How Does an Advance Directive Operate?

    • Specifying decisions during terminal illness, irreversible coma/persistent vegetative state, or other irreversible life-limiting conditions.
    • Usually involves decisions about life-sustaining treatment and basic care.
    • Advance directives are legally binding.

    Benefits of Advance Directives

    • Protection against harmful outcomes
    • Reduced stress for families
    • Aids healthcare professionals in difficult choices

    Drawbacks of Advance Directives

    • Lack of explicit instructions
    • Individual preferences can change
    • Difficulty in determining whether prior decisions are still in the best medical interest
    • Potential for conflict between medical needs and patient wishes

    Ethical Dilemma 2

    • Case about a 54-year-old teacher diagnosed with ischemic heart disease and prescribed aspirin. The patient expresses concerns about taking a blood thinner.

    Ethical Dilemma 2: Case Information

    • Patient diagnosed with ischemic heart disease
    • Doctor plans to prescribe aspirin
    • Possible benefit to reduce myocardial infarction but increased risk of bleeding
    • Patient expresses discomfort taking blood thinner
    • Patient's late husband died from complications of heart valve replacement

    Case 2: Discussion Points

    • Patient still does not want to take aspirin
    • Patient is competent
    • What should the healthcare provider do?
      • Should listen to patient decision and respect patient autonomy?
      • Should they continue to persuade patient of benefits?
      • How should "bad" decisions be handled in a clinical encounter?

    Patient's Rights (HK Medical Association)

    • Right to information (reasonable and balanced understanding of sickness, prognosis, treatment)
    • Right to operation
    • Right to charges for medical services and treatment
    • Right to drug use, dosage, common side effects
    • Right of refusal
    • Right of confidentiality
    • Right to medical reports
    • Right to launch a complaint

    What is a "Bad" Decision?

    • A "bad" decision is one that does not lead to optimal health outcomes for the patient.
    • It can be subjective and vary based on clinical outcome, patient's autonomy and values.

    "Bad" vs. Uninformed Decisions

    • Unlike bad decisions, uninformed decisions do not involve value judgments.
    • In cases when the patient lacks full understanding of information, decision-making is not fully autonomous.
    • Consent for medical interventions necessitates patients being informed and giving their voluntary consent.
    • Patients need to agree with healthcare professionals' recommendations, considering risks.
    • The plan of care requires discussing medical / treatment options to reach a mutual decision with the patient.
    • Respect patient autonomy
    • Understand patient values on intensity of medical care and risk levels
    • Enhance patient well-being, judging based on patient goals
    • Meet legal requirements
    • Promote patient best interests, clarifying misunderstandings
    • Patients may not understand medical information
    • Example: A patient with Stage 2 breast cancer declines standard treatment (chemotherapy, radiation), preferring TCM
    • How would oncologists advise the patient?
    • How would TCM practitioners advise the patient?

    Communication Skills

    • Establish open communication with patients to discuss options.
    • Understand patient perspectives and concerns, addressing family issues.
    • Discuss with colleagues or social workers.

    Case 3

    • Mr. Green, a 57-year-old with aggressive prostate cancer, facing imminent death, confides in a nurse that he intends to commit suicide.
    • What should the nurse do?

    Sorting Facts (Case 3)

    • Patient is on palliative care
    • Nurse keeping the secret respects patient autonomy and confidentiality.
    • But… Should the nurse act on beneficence and nonmaleficence and tell other health staff?
    • How does the patient's perspective of harm differ from the nurse's?

    Nonmaleficence & Beneficence

    • Nonmaleficence: Do no harm to patients
    • Beneficence: Do good for patients
    • Understanding the concept and conflict when they arise.

    Benefit-Risk Ratio

    • Healthcare professionals must evaluate procedures based on a benefit-risk ratio.
    • Consideration of potential benefits (relief) versus potential risks (harm).
    • Crucial to discuss risk/benefit with patients, allowing them to weigh options.

    Justice

    • Treating every person with fairness and equity, distributing health care benefits and burdens fairly in society.
    • Decision of distributing limited kidneys (example) based on different criteria, including age, projected organ survival, ability to pay, medical benefit, comorbidities, and compliance

    Organ Allocation

    • Examples of allocation criteria in organ transplantation (e.g., kidney, heart, liver, cornea)
    • Detailed explanation and examples of a candidate scoring system for organ allocation

    Genetic Testing

    • Discussion on whether genetic testing should be equally and universally provided, and whether restrictions on its availability are justified.

    Equitable Distribution of Genetic Services

    • Equitable distribution of genetic services, including prenatal diagnosis, should prioritize those with the greatest medical needs, regardless of ability to pay.

    Conclusions

    • Patient welfare and best interests should be prioritized
    • Healthcare teams should provide information to patients and families
    • Patient welfare is more important than financial considerations
    • Advocates for public health, treating citizens equally under the law

    Conclusion (Resolving Ethical Dilemmas)

    • Identifying ethical issues, understanding ethical consensus and controversy
    • Reading on ethical dilemmas and discussing with colleagues
    • Gathering information on medical situations and patient values & preferences
    • Planning for open communication and patient education, leading to shared decision-making

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    Description

    This quiz explores critical aspects of Advance Directives, including patient prognosis, moral value, and legal competence. It addresses ethical dilemmas and the importance of respecting patient choices in healthcare decisions. Test your knowledge on the implications of Advance Directives and the responsibilities of healthcare professionals.

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