bioethics cme lecture

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The Case of the Depressed Patient Josephus Ceasar S. Clauor, M.D., PTRP

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this is a case of a depressed patient who wishes to terminate all his life saving procedures.

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Page 1: Bioethics CME lecture

The Case of the Depressed

PatientJosephus Ceasar S. Clauor, M.D., PTRP

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• R.L. • 80 yrs.old • Male, married• Lives with his wife in a retirement community

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• always valued his independence

• having difficulty walking and managing his medications

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• Lethargic and sleepless

• Diagnosed “DEPRESSION”

• Difficulty maintaining weight

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• Talks about killing himself with a loaded handgun

• Agrees to try medication for mood disorder

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• 2 weeks later, he was hospitalized for a heart attack

• Heart is severely damaged affecting the kidneys

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• Renal dialysis is necessary

• Involves moving him 3x a week to the dialysis unit

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After the second treatment

• R.L. demands that dialysis be stopped and asks to be allowed to die

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What should you do?

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Had depression rendered him incapable of making a legitimate life-and-death decision?

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Informed consent– medical condition– treatment options– possible complications– expected outcomes

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• To give informed consent or refusal, the patient must be acting voluntarily and must have the capacity to make the decision

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• From an ethical point of view, informed consent is

based on the philosophical principles of

autonomy and

beneficence

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What are major Bioethical Principles?

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Bioethical Principles

• Autonomy/Freedom• Veracity• Privacy/Confidentiality• Beneficence/Nonmaleficence• Fidelity• Justice

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Autonomy

• The right to participate in and decide on a course of action without undue influence

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Autonomy

• Self-Determination:--- which is the freedom to act independently. Individual actions are directed toward goals that are exclusively one’s own

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Veracity

• The duty to tell the truth.

Truth-telling, honesty

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Privacy/Confidentiality

• Respecting privileged knowledge.

• Respecting the “self” of others.

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Beneficence/Nonmaleficence

• The principle and obligation of doing good and avoiding harm.

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Beneficence/Nonmaleficence

• This principle counsels a provider to relate to clients in a way that will always be in the best interest of the client, rather than the provider.

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Fidelity

• Strict observance of promises or duties.

• Should be honored by both provider and client.

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Justice

• Deals with fairness• Equity and equality • Provides for an individual to claim that to which they are entitled.

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Depression

• a mood disorder • difficulty concentrating• frequently have little energy

• poor appetites• disturbed sleep

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Depression

• they may be troubled by feelings of guilt and hopelessness

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Depression

• preoccupation with death is common

• in some cases, may include contemplating suicide

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• suicidal before his heart attack

• an authentic exercise of his right to stop life-saving treatment

• or a convenient means to passively end his life

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• 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.

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Depression is driving the request?

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• the presumption is that once the problem has

cleared, the patient will look at treatment

decisions differently

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Recent research has challenged that

presumption

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Thus, depressed patients may

be able to give informed consent

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But doctors and loved ones must consider whether the decision to refuse medical treatment is:

• logical• internally consistent• conforms with past life choices and values

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• In R.L.'s case, the doctor, in consultation with a psychiatrist, decided to continue the course of anti depressant medication

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R.L’s dialysis was continued

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• After five weeks, R.L. showed no improvement

• began to refuse medications and food

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• 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

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• Her husband's repeated refusal of dialysis had

convinced the family R.L. really did want to die

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• 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

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• Ultimately, the physician shared the family's assessment that R.L.'s consistent refusals indicated an authentic wish to halt treatment .

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• He was taken off dialysis and put on comfort

measures.

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Six days later…..

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……he died

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Viva Pit Senyor !!!