Task: Patient’s Spiritual Needs: Case Analysis

Case Study: Healing and Autonomy Mike and Joanne are the parents of James and Samuel, identical twins born 8 years ago. James is currently suffering from acute glomerulonephritis, kidney failure. James was originally brought into the hospital for complications associated with a strep throat infection. The spread of the A streptococcus infection led to the subsequent kidney failure. James’s condition was acute enough to warrant immediate treatment. Usually cases of acute glomerulonephritis caused by strep infection tend to improve on their own or with an antibiotic. However, James also had elevated blood pressure and enough fluid buildup that required temporary dialysis to relieve. The attending physician suggested immediate dialysis. After some time of discussion with Joanne, Mike informs the physician that they are going to forego the dialysis and place their faith in God. Mike and Joanne had been moved by a sermon their pastor had given a week ago, and also had witnessed a close friend regain mobility when she was prayed over at a healing service after a serious stroke. They thought it more prudent to take James immediately to a faith healing service instead of putting James through multiple rounds of dialysis. Yet, Mike and Joanne agreed to return to the hospital after the faith healing services later in the week, and in hopes that James would be healed by then. Two days later the family returned and was forced to place James on dialysis, as his condition had deteriorated. Mike felt perplexed and tormented by his decision to not treat James earlier. Had he not enough faith? Was God punishing him or James? To make matters worse, James’s kidneys had deteriorated such that his dialysis was now not a temporary matter and was in need of a kidney transplant. Crushed and desperate, Mike and Joanne immediately offered to donate one of their own kidneys to James, but they were not compatible donors. Over the next few weeks, amidst daily rounds of dialysis, some of their close friends and church members also offered to donate a kidney to James. Task: Patient’s Spiritual Needs: Case Analysis
However, none of them were tissue matches. James’s nephrologist called to schedule a private appointment with Mike and Joanne. James was stable, given the regular dialysis, but would require a kidney transplant within the year. Given the desperate situation, the nephrologist informed Mike and Joanne of a donor that was an ideal tissue match, but as of yet had not been considered—James’s brother Samuel. Mike vacillates and struggles to decide whether he should have his other son Samuel lose a kidney or perhaps wait for God to do a miracle this time around. Perhaps this is where the real testing of his faith will come in? Mike reasons, “This time around it is a matter of life and death. What could require greater faith than that?” © 2019. Grand Canyon University. All Rights Reserved. PHI-413V Topic 5 Overview Intervention and Ethical Decision-Making Different models of ethical decision-making suggest different steps and priorities, but the important thing to note is that all models are attempting to organize all of the relevant information in a case so that nothing is left out of consideration. Still, the way in which all of the relevant details in a case are considered will always take place within the context of a worldview. As such, the most important determinant of a bioethical decision is not a methodology but the worldview context in which the methodology is functioning. Consider, then, how the Christian biblical narrative determines the values that are deemed relevant or important in a case and how different worldviews would impact the decision-making in different cases. In addition, the clinical encounter with patients will require one to at least be familiar with what a patient would need in terms of spiritual care. It is not always expected that health care providers be experts in regards to spiritual care. However, it is important that they at least be facilitators capable of recognizing a patient’s worldview, as well as the persons and resources that would meet a patient’s spiritual needs. Examine carefully the methods and goals of a spiritual needs assessment in helping to determine a patient’s spiritual needs. As has been clearly seen in previous topic overviews, the Christian worldview revolves around Jesus Christ and one’s relationship with God through him. The spiritual needs of Christians will be met by the persons and resources that enable one to see oneself as a child of God, and which bring hope, peace, and joy in the midst of suffering and uncertainty. © 2019. Grand Canyon University. All Rights Reserved. 1 Aligning Ethics with Medical Decision-Making: The Quest for Informed Patient Choice Benjamin Moulton and Jaime S. King M edical practice should evolve alongside medical ethics. As our understanding of the ethical implications of physician-patient interactions becomes more nuanced, physicians should integrate those lessons into practice. As early as the 1930s, epidemiological studies began to identify that the rates of medical procedures varied significantly along geographic and socioeconomic lines.1 Dr. J. Alison Glover recognized that tonsillectomy rates in school children in certain school districts in England and Wales were in some cases eight times the rates of children in other districts, with the only significant predictive fact ors being the current chief medical officer in the area and the socioeconomic well-being of the child’s parents. Task: Patient’s Spiritual Needs: Case Analysis

2 Unfortunately, Dr. Glover’s work revealed that the increase in tonsillectomies did not improve the health of adolescent patients and appeared to be performed “as a routine prophylactic ritual for no particular reason and with no particular result.”3 These prophylactic surgeries often had severe consequences, as the President of the Royal Society of Medicine noted: “It was sad to reflect that many of the anesthetic deaths mentioned by Dr. Glover were due to the children’s having undergone an unnecessary operation.”4 Since the 1970s, research by Jack Wennberg and colleagues has also revealed similar geographic variations in procedure rates for a wide range of medical conditions in the United States.5 In accordance with Glover’s findings, Wennberg concluded Benjamin Moulton, J.D., M.P.H., is a Lecturer in Health Law at Harvard School of Public Health and a Senior Legal Advisor at the Foundation for Informed Medical Decision Making. From 1994 to 2008 he served as the Executive Director of the American Society of Law, Medicine & Ethics. Jaime S. King, J.D., Ph.D., is an Associate Professor of Law at the University of California, Hastings College of the Law. that physician recommendations and communication to the patient were major driving forces of these variations, rather than clinical need or patient preference.6 As a result, over the last three decades, medical ethicists have shifted from guiding physicians to focus on beneficence and improving patient health as emphasized in the Hippocratic oath7 toward a more subjective and “patient-centered” practice, which also prioritizes patient autonomy in medical decision-making.8 While this shift toward autonomy is well represented in the literature and ethical guidelines, health services research demonstrates that in clinical practice many physicians have yet to strike the ideal balance between absolute patient autonomy and beneficence. Recent studies have found that most physicians still undervalue disclosure and underestimate the variability in patient preferences.9 Alternatively, in an effort to promote a more “patient-centered” model of decisionmaking, we have received anecdotal reports that other physicians have altered their disclosure practices to provide patients with information on the risks and benefits of the treatment options, but then require the patient to make the treatment decision without the benefit of the physician’s medical opinion.10 In these infrequent instances, the pendulum has swung too far. The unmitigated rise of autonomy can result in the decline of beneficence.11 In today’s medical practice, patients frequently receive either too little medical information to make an informed treatment decision or too little physician opinion to feel confident in their choice. Task: Patient’s Spiritual Needs: Case Analysis

To satisfy their ethical obligations to patients, health care providers should implement a system of medical decision-making that balances the importance of both ethical principles. Shared medical decision-making can accomplish this goal by promoting patient autonomy, while also the effects of health information technology on the physician-patient relationship • spring 2010 85 IND EPEND ENT leaving room for physician beneficence. In this article, Section I reviews the evolution in the medical literature regarding the relative importance of autonomy and beneficence and argues that a shared decision-making approach can best achieve the desired balance. Section II suggests integrating shared decision-making into medical practice through use of the following: (1) successful practice models; (2) state policy incentives; and (3) national health care legislation. I. The Ethical Principles of Medical Decision-Making Respect for autonomy and beneficence are two of the fundamental principles that govern medical ethics.12 While beneficence obligates physicians to act for the benefit of their patients,13 respect for autonomy requires singular goal of improved health.17 However, medical care does not occur in a vacuum. The beneficence-focused, decision-making model compelled patients to adopt not only their physician’s treatment choices, but also their physician’s values, levels of risk aversion, and personal preferences.18 Often treatment decisions impact significantly more than the patient’s health, such as their ability to work, care for their children, or participate in their favorite activities. Beneficence unbounded by concerns for patient autonomy quickly turns into paternalism.19 In the name of promoting patient health, physicians often independently selected a treatment regiment without providing information to patients regarding available alternatives or the risks associated with a particular treatment. Over time, it became clear that In this article, Section I reviews the evolution in the medical literature regarding the relative importance of autonomy and beneficence and argues that a shared decision-making approach can best achieve the desired balance. Section II suggests integrating shared decision-making into medical practice through use of the following: (1) successful practice models; (2) state policy incentives; and (3) national health care legislation. them to ensure that patients have enough information to make a reasoned and autonomous medical decision.14 Although these principles can complement one another, they also regularly conflict, requiring their relative priority to be established. Medical ethicists, physicians and patients have repeatedly redefined the relationship of these principles in order to enhance the medical decision-making process. Unfortunately, such revisions have not gained general adherence in practice thereby leaving the balance between the two principles in day-to-day medical care suboptimal at best. A. Beneficence The American College of Physicians requires physicians “to promote good and act in the best interest of the patient and the health of society.”15 Historically, this duty has been thought of in terms of the patient’s medical benefit, rather than promoting her best interests on a broader level.16 As a result of their superior training and knowledge of medicine, physicians bore the responsibility of acting as agents for their patients, determining the best treatment options to fulfill the 86 patients often had other goals, preferences, and values that competed with their physician’s goal of improved health or their physician’s opinion of what they ought to do. Task: Patient’s Spiritual Needs: Case Analysis

In a liberal society, the beneficence-focused model impinges patients’ rights on both a theoretical and an empirical level. Theoretically, it frustrates patients’ abilities to establish their own conception of the good and to make autonomous choices about how to best obtain those goals.20 This frustration would have been less damning if physicians proved to be good agents for their patients’ long-term goals. Unfortunately, empirical research demonstrates that physicians are highly inaccurate at predicting the goals and preferences of their patients.21 As a result, paternalism, and in many ways beneficence, have fallen out of favor in medical ethics with the rise of the patients’ rights movement and the legal doctrine of informed consent. In the late 20th century, respect for autonomy began to supercede beneficence and paternalism as the leading medical decision-making paradigm due to strong arguments from lawyers, judges, and medical ethicists that patients should determine what happened journal of law, medicine & ethics Moulton and King to their bodies, as they ultimately had to experience the consequences of the chosen treatment decision.22 B. Autonomy Respect for autonomy has become the dominant and controlling principle in both informed consent law and medical ethics. The American Medical Association’s Code acknowledges that “[t]he patient’s right of self-decision can be effectively exercised only if the patient possesses enough information to enable an informed choice” and that “the patient should make his or her own determination about treatment.”23 The AMA requires physicians to disclose “all relevant medical information to patients” to enable them to make medical decisions based upon their personal beliefs, values, and life goals. Under this standard, physicians must respect patients’ decisions even when those decisions do not promote their physical well-being or conform with the physician’s medical judgment.24 At the extreme, courts have upheld a competent patient’s right to decline medical treatment even when that treatment would be life saving.25 The importance of this shift has gained both national and international recognition. In 2002, after several years of collaboration, the American Board of Internal Medicine in conjunction with the American College of Physicians and the European Federation of Internal Medicine published a charter on medical professionalism for the new millennium that urged all physicians to follow three fundamental ethical principles and ten attendant professional responsibilities. In pertinent part, the charter notes that “[p]hysicians must be honest with their patients and empower them to make informed decisions about their treatment…. and ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. Task: Patient’s Spiritual Needs: Case Analysis

”26 In 2006, a group of large national employers, reached out to the American College of Physicians and the Academy of Family Physicians to create the Patient-Centered Primary Care Collaborative (PCPCC), dedicated to improving physician-patient relations and health care delivery. Now with the support of its ever increasing membership that includes over 300 large national employers, most of the major primary care physicians associations, health care benefits companies, academic medical centers, and health care quality improvement organizations, the PCPCC established joint principles of ethical patient care that require “patients [to] regularly participate in decision-making” and physicians to seek feedback “to ensure that the patients’ expectations are being met.”27 In 2008, the National Quality Forum, a not-for-profit organization created to address national health care quality measurement and reporting, convened the National Priorities Partnership (NPP) to focus on six of the U.S. health care system’s top priorities. First on the NPP’s list is Patient and Family Engagement, which entails ensuring that (1) physicians ask patients for feedback on their care; (2) patients receive the tools necessary to manage and navigate their care; and (3) patients have access to the information and assistance necessary to make informed treatment choices.28 The existence of these national and international bodies demonstrates the growing momentum behind a shift away from the historical roles of the paternalistic physician and the compliant patient to a new model of an autonomous, informed, and participatory patient.29 While the medical community has espoused the value of autonomy in principle, much more work must be done to promote patient autonomy in practice. Health services research conducted in the last 15 years reveals a consistent pattern of inadequate information disclosure and low patient comprehension and retention. In a multi-national study conducted in 2004, the Commonwealth Fund found that 31 percent of sicker patients30 in the United States left their physician’s office without having important questions answered, which was the highest percentage among the five countries studied (Australia, Canada, New Zealand, and the United Kingdom).31 Likewise, 47 percent of sicker patients reported that the physician did not ask their ideas and opinions about treatment and care.32 This startling data suggests not only a consistent failure to meet the disclosure requirements necessary to obtain a legal consent, but also a breach of fundamental medical ethics on a systemic level. Variation between the United States and the four other nations studied may have occurred for a number of reasons. Some variation may result from financial incentives within the U.S. health care system, as physicians are generally reimbursed based on the volume of procedures they perform, not time spent discussing the procedures with patients.33 Other inadequacies may result from physicians’ lack of understanding of patients’ informational needs. Task: Patient’s Spiritual Needs: Case Analysis

In a study comparing physicians’ and patients’ opinions on the importance of different aspects of outpatient care, patients prioritized the factors related to the provision of information second only to clinical skill, while physicians prioritized it sixth out of the nine domains of outpatient practice.34 In a study of physician and patient encounters in outpatient care, Braddock et al. found that while physicians disclosed the nature of the patient’s condition 83% of the time, they only discussed the risks of the procedure with the patient in 9% of all cases and in 22% of more serious cases, such as an invasive in-office procedure or change in medi- the effects of health information technology on the physician-patient relationship • spring 2010 87 IND EPEND ENT cation.35 Alternatives to the physician’s recommended treatment were discussed even less frequently. In addition to the underprovision of information, Calkins et al. found that physicians tend to overestimate patient comprehension of their discharge instructions.36 A study conducted at the Mayo clinic found that patients failed to report 54% of the “most important health problems” discussed by physicians with respect to their medical care when asked to recount the health problems discussed during the encounter.37 Despite ethical mandates requiring disclosure of all relevant medical information and legal standards obligating physicians to obtain an informed consent based on those disclosures, clinical evaluation research studies suggest that patients are routinely asked to make decisions about treatment choices in the face of what can only be described as avoidable ignorance. Decisions made under a shroud of ignorance have negative consequences for both individuals and the U.S. health care system as a whole, in the form of unnecessary procedures. In the absence of complete information, individuals frequently opt for procedures they would not otherwise choose. Mounting clinical … Task: Patient’s Spiritual Needs: Case Analysis