00:01
When we're thinking about
life sustaining treatments,
there may be times when
the clinician judges,
the treatment may
be too burdensome,
or even not worth offering
to a patient or family.
00:13
We call these,
potentially inappropriate
and futile treatments.
00:17
There's distinction
between the two
that I'm going to
walk you through.
00:21
So potentially
inappropriate treatment is,
there's some chance that it
will accomplish the effect
sought by the patient or their
authorized decision makers.
00:30
So there's some rationale for
considering the treatment.
00:34
It's not a treatment
that's forbidden by law,
so it's permissible
for the clinician to offer it.
00:41
But the clinician feels that
there are ethical justifications
for refusing to provide
the requested treatment.
00:48
For instance, they feel that
it's not going to
offer the benefit that
is hoped for or,
the benefit relative
to the burdens
imposed by the treatment
are not worth trying to achieve.
01:01
That could be that there's
less than desirable outcomes,
could be that there are
quality of life considerations
that the person's quality
of life is going to be worse
if you instituted the treatment
than if you decided not to
offer it in the first place.
01:18
So there could be a couple
of examples of this of,
take a patient for instance,
that's in the
intensive care unit,
they have multi-organ
system failure.
01:27
Now their kidneys
are also failing.
01:30
There is an option
for consideration
of offering hemodialysis,
that would be the next step
for managing renal failure.
01:39
But the clinician judges,
this is potentially
inappropriate,
because the really the chances
that it's going to be successful
are pretty minimal.
01:48
And it's going to be burdensome
to offer the hemodialysis
when they already have
multi-organ system failure.
01:54
So it might be presented
by the clinician of,
this is something maybe
we don't want to offer
to the family or to the patient.
02:02
There may be another example,
but patient with cancer.
02:07
They're judged to have a
cancer that's inoperable
and its current state
but maybe if they underwent
a course of chemotherapy,
it would shrink the tumor
enough to make it operable.
02:18
There could be the
option of offering
the chemotherapy to the patient.
02:23
But there's concerns that the
chemotherapy that would be involved
would have a lot
of side effects,
potential complications,
might be too burdensome to
get through the chemotherapy,
in order to get to
that milestone of
being able to have the
surgery down the road.
02:41
So the clinician
might present this as
this might be potentially
inappropriate to offer you
because I'm concerned,
it's going to be more
burdensome than beneficial.
02:49
There may be, surgeons
that would say,
You know, I'm not going to offer this
operation, knew it's clear,
the patient needs surgery,
if they're going to try to,
keep the person alive
but I'm concerned that the
patient is going to die
on the operating table.
03:05
And I think it would
be inappropriate for me
to bring them to
the operating room,
knowing that their chances of
success are close to nothing.
03:13
In there, again,
I may not want to
offer this treatment
to the patient or to the family.
03:21
So you present this to the
family or to the patient.
03:24
And, if you explain
the rationale
for why you would
not recommend it,
why you might choose a
different course of action,
different treatment plan,
may be based on something that's
going to be more attentive
to the patient's comfort
than trying to, you
know, keep them alive.
03:42
Maybe they're, presented
with that information,
they're going to accept your
conclusion and your recommendation.
03:48
But there may be times
where they disagree
with that assessment
and so because they know that
this is a potentially
available treatment,
you've offered it as an option,
they may wish to pursue it,
even if you think it's
potentially inappropriate.
04:04
So now you've got a conflict
and you have need to figure out
a way to resolve this difficulty,
resolve this conflict.
04:12
There are going
to be various ways
when we think about clinical
ethics in resolving conflicts.
04:17
One is avoidance,
, so just avoiding the
conflict in the first place.
04:21
Just, not even considering
that there is a conflict.
04:26
The other is accommodation,
just going with what
the other person says
and going along
with their wishes.
04:33
There could be competition
of just saying,
Nope, I'm going to
put up a fight and,
argue for my position
against your position.
04:40
There could be a compromise,
so trying to see if
you could negotiate
and figure out a way that,
, some of your interests
could be met as the clinician,
some of the patient or
family's interests could be met
and you reach some sort
of compromise agreement
or there could be an
opportunity for collaboration.
04:57
So trying to work
together with them
to figure out what's going to
be the best course of action
that everyone can
sort of get behind.
05:06
When you think about
conflict resolution,
the things that are going
to be most important
in achieving desirable outcomes
are, first of all,
this idea of emotional
safety and relationships.
05:17
So if you've established
a therapeutic relationship
with the patient or
therapeutic relationship
with their surrogate
decision makers,
knowing that they
feel safe in having,
, really difficult
conversations with you,
it's going to be the first step
in achieving a desirable outcome.
05:33
There has to be a recognition that
there's a fair process underway,
it's not, a unilateral decision.
05:40
But there is an
opportunity for discussion,
debate, reflection,
figuring out a course of
action that everyone could,
could agree to.
05:48
And then the last
thing that generally
needs to happen for there
to be a desirable outcome is
the outcome itself.
05:55
So after a plan is instituted,
what actually happens
with the patient.
06:01
If it's an outcome that
people can get behind,
then, it's going to be
successful conflict resolution,
take an example of,
you know, everyone is
convinced on the medical team,
that CPR would not be
appropriate for a patient,
they're concerned
that it either work,
or that, if the
resuscitation works,
that the patient is
going to be worse off
in whatever
condition they're in,
post resuscitation.
06:29
And they're convinced that
they don't want to offer
CPR to the patient.
06:35
But the family member
comes to them and says,
you know, my loved one said,
he always wanted to be
there for his children,
he always wanted to
fight to the end,
and demonstrate to them
that he never wanted
to give up on them.
06:49
And, going through with the CPR,
even if we don't think it's
going to be successful,
is going to be a demonstration,
that he's done
everything possible,
to stay alive for his children.
07:01
If the healthcare
team hears that,
maybe they would change
their perspective,
and get behind this
idea of trying to,
continue with full code
and attempting CPR,
even if it has limited
chances of success.
07:15
So it's always in
the discussion,
and this fair process of
trying to resolve the conflict.
07:21
That's where the
clinical ethics,
stands of making sure everyone's
interests are respected here,
you're hearing them and
figuring out a path forward.
07:35
So how do you do that?
Well, you need to
have a family meeting,
we have a separate lecture
about how to conduct
a family meeting.
07:42
This is an opportunity to
really clarify goals of care
sort of, again, understand
the patient's perspective,
we need to decide
which interventions are going
to need to have discussion.
07:55
Maybe, you know, while
there's the conflict underway,
there's the disagreement,
you're going to continue the
interventions that are in place,
or you're going to offer the
life sustaining interventions
that are in question,
in case, they are
needed in the future.
08:13
Sometimes you need to
bring in a third party.
08:16
So there might be an
opportunity for bringing in
an ethics committee or
an ethics consultant,
to facilitate a discussion,
to try to reach some resolution
in this disagreement,
get some recommendations
about how they would
think about the issues.
08:30
Again, knowing
what the patient's
preferences, values
and goals are,
and what the medical
condition is.
08:38
And then really,
if the clinician
feels that it would be
against their conscience to
institute this treatment,
there is the possibility
of considering transfer.
08:50
If the disagreement persists,
you can reach any resolution,
you might offer, the
patient and the family
the opportunity to
transfer their care
to another institution
to another provider,
that might be able
to offer the care
that you don't think
is appropriate,
or the treatment that you
don't think it's appropriate.