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ELOM12 Ethical, Legal, and Organizational Medicine Ethical and Legal Issues in Canadian Medicine Toronto Notes 2019
Open Disclosure of AEs: Transparency and Safety in Health Care
Surg Clin North Am 2012;92(1):163-177
Health care providers have a fiduciary duty to disclose AEs to their patients. Professional societies codify medical providers’ ethical requirement to disclose AEs to patients in accordance with the four principles of biomedical ethics. Transparency and honesty in relationships with patients create opportunities for learning that lead to systems improvements in health care organizations. Disclosure invariably becomes a component of broad systems improvement and is closely linked to improving patient safety.
Truth-Telling in Discussing Prognosis in Advanced Life-Limiting Illnesses
Palliat Med 2007;21(6):507-517
Purpose: To examine truth telling in discussing prognosis in patients with progressive advanced life-limiting illnesses and their caregivers. Methods: Systematic review of studies of any design evaluating communication of prognostic information that included adult patients with advanced, life-limiting illnesses, their caregivers and qualified health care professionals (HCPs).
Results: 46 eligible studies were identified. While most HCPs believed that patients and caregivers should be told the truth about prognosis, many avoid the topic or withhold information, possibly due to perceived lack of training, stress, no time
to attend to emotional needs, fear of negatively impacting the patient, uncertainty about prognostication, requests from family members, and a feeling of inadequacy or hopelessness regarding unavailability of curative treatments.
Conclusion: Truth-telling regarding prognosis in advanced life-limiting illnesses is poor by HCPs, likely related to multiple personal limitations, professional demands and perceptions regarding impact on the patient and caregivers.
• disclosureallowstheinjuredpatienttoseekappropriatecorrectivetreatmentpromptly
• physiciansshouldavoidsimpleattributionsastocauseandsoleresponsibilityofothersoroneself
• physiciansshouldofferapologiesorempathicexpressionsofregret(e.g.“Iwishthingshadturnedout
differently”) as these build trust and are not admissions of guilt or liability
• ApologyActsacrossCanadaprotectapologies,bothasexpressionsofregretandadmissionsof
responsibility, from being used as evidence of liability and negligence
Breaking Bad News
• ‘badnews’maybeanyinformationthatrevealsconditionsorillnessesthreateningthepatient’ssenseof well-being
• poorly done disclosure may be as harmful as non-disclosure
■ caution patients in advance of serious tests and disclose possible bad findings
■ give time for patient to reflect prior to receiving such news
■ give warnings of impending bad news by reviewing prior discussions
■ provide time for the patient and questions
■ adequate supports and strategies should always be provided following disclosure of difficult news
• SPIKESprotocolwasdevelopedtofacilitate“breakingbadnews” ■ SETTINGandLISTENINGSKILL
■ Patient PERCEPTIONS of condition and seriousness
■ INVITATIONfrompatienttoreceiveinformation
■ BNOWLEDGE - provide medical facts ■ ExploreEMOTIONSandEMPATHIZE ■ STRATEGYandSUMMARY
Arguments Against Truth-Telling
• may go against certain cultural norms and expectations
• mayleadtopatientharm,butonlyinextreme,raresituations
• medicaluncertaintymayresultinthedisclosureofuncertainorinaccurateinformation
Exceptions to Truth-Telling
• a patient may waive his/her right to know the truth about their situation (i.e. decline information that would normally be disclosed) when:
■ the patient clearly declines to be informed
■ a strong cultural component exists that should be respected and acknowledged
■ the patient may wish others to be informed and make the medical decisions for them
• the more weight for the consequences for the patient from non-disclosure, the more carefully one must consider the right to ignorance
• ‘emergencies’:anurgentneedtotreatmaylegitimatelydelayfulldisclosure;thepresumptionisthat most people would want such treatment and the appropriate SDM cannot be found
• ‘therapeutic privilege’
■ withholding of information by the clinician in the belief that disclosure of the information would
itself lead to severe anxiety, psychological distress, or physical harm to the patient
■ clinicians should avoid invoking therapeutic privilege due to its paternalistic overtones and is a
defence of non-disclosure that is rarely accepted anymore
■ it is often not the truth that is unpalatable; it is how it is conveyed that can harm the patient
Ethical Issues in Health Care
Managing Controversial and Ethical Issues in Practice
MCC-CLEO Objectives 1998
• discussinanon-judgmentalmanner
• ensurepatientshavefullaccesstorelevantandnecessaryinformation
• identifyifcertainoptionslieoutsidethephysician'smoralboundariesandrefertoanotherphysicianif
appropriate
• consultwithappropriateethicscommitteesorboards
• protectfreedomofmoralchoiceforstudentsortrainees
Reproductive Technologies
Overview of the Maternal-Fetal Relationship
• ingeneral,maternalandfetalinterestsalign
• insomesituations,aconflictbetweenmaternalautonomyandthebestinterestsofthefetusmayarise
Ethical Issues and Arguments
• principleofreproductivefreedom:womenhavetherighttomaketheirownreproductivechoices
• coercion of a woman to accept efforts to promote fetal well-being is an unacceptable infringement of
her personal autonomy
The fetus does not have legal rights until it is born alive and with complete delivery from the body of the woman