"What Sarah Said"

And it came to me then that every plan
is a tiny prayer to Father Time
As I stared at my shoes in the ICU
that reeked of piss and 409
And I rationed my breaths as I said to myself
that I'd already taken too much today
As each descending peak on the LCD
took you a little farther away from me
Away from me

Amongst the vending machines and year-old magazines
in a place where we only say goodbye
It stung like a violent wind that our memories depend
on a faulty camera in our minds
But I knew that you were a truth I would rather lose
than to have never lain beside at all
And I looked around at all the eyes on the ground
as the TV entertained itself

'Cause there's no comfort in the waiting room
Just nervous pacers bracing for bad news
And then the nurse comes ‘round and everyone will lift their heads
But I'm thinking of what Sarah said,
that "Love is watching someone die"

So who's going to watch you die?...

--Death Cab for Cutie

Listen to the complete song from the album Plans here.

Week Four Online Challenge

Last week we talked mostly about the difference between withdrawing and withholding life-sustaining treatments, and touched a bit on surrogate decision makers, the challenge of interacting with families and what to do when it becomes clear that some medical approaches are futile. These are each topics that could consume an entire class, if not a whole quarter. It's reasonable that you feel like there are some loose ends!

This week's challenge offers a chance for each of you to do a little teaching about some of these difficult issues.

How do you break bad news? Write about one strategy you use (or could use) to talk with patients or families about death or a terminal diagnosis.

Update Jan 27, 2009: If this is an issue you are particularly interested in, there's a good article available about grief in the ER available on eMedicine. You may need to register for a free login with MedScape to read it.

WA On-Line access to Living will...

Like a hand-full of other states, WA has gone on-line with documents to help verify health care wishes for residents of Washington.

This site includes AA, DPOA, POLST and Mental health directives. Patients and physicians are asked to fax or mail in copies of these forms to the department of health. Then an account is set up for the patient to access their own information on-line.

If a health care provider wants to gain access to the information they must apply for an account through DOH and must have a valid license.

A Few More Resources

These are all from the UW Ethics in Medicine site. Click on the Bioethics Topics button to see the long list. Relevant to this week are:

Advance Directives
Do Not Resuscitate Orders
DNR During Anesthesia and Urgent Procedures
End-of-Life Issues
Physician-Assisted Suicide
Termination of Life-Sustaining Treatment

These pages provide excellent information about both medical and ethical issues related to DNR and end-of-life situations.

Why Do Doctors Ignore Living Wills?

In the reading for today, the author cites a survey which concluded that 65% of physicians "would not follow a living will if the instructions conflicted with the doctor's own view of the prognosis or expected quality of life." (Colby p. 142) My first reaction to this statement is: Who do those doctors think they are, substituting their judgement for my wishes!!!

But then I begin to wonder how this situation arises. The living will seemingly can only "respond" to specific scenarios. Who is defining that scenario that the living will is responding to? Who beyond the physician is outlining the prognosis or expected quality of life? Who is the doctor disagreeing with? Is this statistic saying that physicians substitute their judgement if they think the patient didn't really mean what they said in their living will or that they would feel differently about their life (say as a quadraplegic) if only they had a chance to live that life?

Other thoughts about what this statistic is really indicating?

Week Three Online Challenge

This week, we will discuss the topic of withholding medical treatment at the end of life. The readings identify issues related to living wills, while a previous blog post here introduces "Death with Dignity." This week's online challenge focuses on a topic closer to home: the cost of life sustaining treatment.

Many ethicists (especially those familiar with emergency medicine) argue there is no difference between withholding and withdrawing treatment. The point being that taking someone off the ventilator is the same as not intubating the patient in the first place. (Recall last week's challenge though: intubating in the ED may be the option that buys us time to make a decision...) Frequently, within the conversation about whether or not to withhold treatment is a cost/benefit analysis. This brings us to this week's question:

What are the costs involved in starting life-sustaining treatment in the ER?

Think both of who incurs the costs and what specific costs are involved. If you're stumped or if someone already posted your idea, refer to the four box framework for inspiration.

Laws About Death

This week we will be talking about issues related to death and resuscitation. There are two legal and political issues that are important in this discussion: DNR orders and I-1000. Hopefully you have already taken a look at the Physicians Orders for Life Sustaining Treatment (POLST) form linked at the course readings webpage and have had a chance to read the chapter from Bill Colby's book about living wills. I'd encourage everyone to post some thoughts on the blog about DNR and living wills by clicking "New Post" in the upper right corner of the page. (You need to be signed in first.)

There is one other topic that you should be aware of if you think you will practice medicine in Washington or Oregon. The Washington Death with Dignity Act passed by initiative in November 2008. Sometimes it's an interesting challenge to read the original text, but its always helpful to have a digest. I've pasted in information about safeguards of the law from the pro-I-1000 website, below.

There are multiple safeguards in Washington’s death with dignity law. These safeguards include independently witnessed oral and written requests, two waiting periods, mental competency and prognosis confirmed by two physicians, and self-administration of the medication. Only the patient – and no one else – may administer the medication.

Washington’s Death with Dignity safeguards:

1. The patient must be at least 18 years old
2. The patient must be a resident of the state of Washington
3. The patient must be terminally ill - not disabled, but diagnosed as terminally ill
4. The terminally ill patient must have 6 months or less to live, as verified by two physicians
5. Three requests for Death with Dignity must be made (two verbal and one written)
6. Two physicians must verify the mental competence of the terminally ill patient
7. The request must be made voluntarily, without coercion, as verified by two physicians
8. The terminally ill patient must be informed of all other options, including palliative care, pain management and hospice care
9. There is a 15 day waiting period between the first oral request and the written request
10. There is a 48 hour waiting period between the written request and the writing of the prescription
11. The terminally ill patient's written request must be independently witnessed, by two people, at least one of whom is not related to the patient or employed by the health care facility
12. The terminally ill patient is encouraged to discuss their decision with family (not required because of confidentiality laws)
13. Only the terminally ill patient may self-administer the medication
14. The patient may change their mind at any time

The safeguards in Washington's Death with Dignity Act ensure that terminally ill patients are making a voluntary and informed decision. These same safeguards have worked in Oregon for over 10 years. Patients must be terminally ill, must have less than 6 months to live, the patient must make two independently witnessed requests, and every step of the process must be approved by two doctors.

Because this is a political issue (it passed with 58% of the vote), it's important to include the position of the sizable minority. A comprehensive opinion of the opposition is available at noassistedsuicide.com. Specifically, there are lengthy arguments centered on the:

• text of the initiative
• claims of the initiative's supporters and
• a critique of Oregon's law
  

I take the position that when health care issues come up in elections, it's my social obligation as a care provider to become informed about the issue. For one reason or another, there are very few physicians in politics, and only slightly more who advise policy makers. The least we can do as future docs is to be able to provide facts about the issues to patients and our opinions to friends.

Case Analysis Examples (for the final paper)

As we mentioned in class, there are a number of legitimate ways that cases are analyzed in written form. You are welcome to use an approach based on previously posted recommendations (available here and here), but if you want a different perspective, consider visiting the case log for the ethics journal, Virtual Mentor. There you will find cases on a wide range of topics. One case that pits patient autonomy against the duty to treat is especially relevant to our discussion last week. Read it here. What do you think of the response to the case?

And remember our discussion about leaving AMA versus elopement? For my personal take on the word elope, check out this humor piece.

I-1000

In a week and a half, the Bioethics and Humanities Department (the department sponsoring Ethics in the ER) is presenting a brown bag lecture about a topic that will be important to our discussions the next few weeks:

I-1000: The Washington Death
with Dignity Act

Patricia Kuszler, MD, JD
Charles I. Stone Professor of Law
UW School of Law

Steve Milam, JD
Affiliate Assistant Professor
Bioethics and Humanities

Wednesday, January 28th, 2009
11:30-12:30 p.m.
Plaza Cafe Conference Rooms A & B

Brown bag means 'bring your own' lunch. I've heard Dr. Kuszler speak before. This will be worth your time if you can make it. For more information, view this flier.

Prisoners and Consent

This week in class we talked about whether prisoners/inmates had a right to refuse (or decline) medical treatment or if they could be forced to undergo treatment. Several people felt that such individuals could be forced to recevie therapy, while I was under the impression that this was not true. I decided to look into this and here is what I found:

In, "Fundamentals of Emergency Care" by Beebe & Funk (Florence, KY: Cengage Learning, 2001), the authors state, "Although an individual who is imprisoned does not lose the right to make decisions regarding medical treatment, many states have enacted laws regarding medical treatment of incarcerated individuals." They continue, "If however, the prisoner refuses treatment, further care may not be provided unless another individual is authorized to consent on the prisoner's behalf."

I was able to find the official Washington State Department of Corrections policy on "Offender Consent for Healthcare". Overall, it states that inmates should be provided the same information as any other patient regarding the risks and benefits of care, but that at certain times, this decision can be over-ridden in the interest of public safety. I think applicable passages are: "VI. Refusal of Health Care Services. A. Offenders capable of providing consent have the right to refuse examinations, treatments, and procedures, whether invasive or non-invasive, after having been provided with the information listed in the General Requirements section of this policy." As well as: "E. The right to refuse treatment does not apply when the treatment is allowed or required by statute, case law, policy, court order, or when the condition requiring treatment is self-induced and failure to intervene poses a risk of significant harm. [4-4397]"

For more information and some interesting discussion of the care of prisoners in the ER, you can also check out Moskop JC. "Informed consent and refusal of treatment: challenges for emergency physicians." Emerg Med Clin North Am. 2006 Aug;24(3):605-18. This article reviews a lot of the issues we discussed in class and finishes with a discussion of some recent legal cases regarding medical care of inmates as well as some case examples that an ER provider might face.

One other thing to toss out there: occasionally suspects are brought in by police officers for medical care. It used to be that they would be left there a long with a card to contact the police officer when the patient was okay to be released. However, due to confidentiality of patient records, at least at Harborview, we now have to obtain consent from the patient to call the arresting officer. If the suspect does not consent, we either can't call when the patient is released from medical care, or the officer has to remain at the patient's bedside for the duration of care.

What's with the lights?

This is might seem a little bit off topic, but I thought that I would get other people's perspectives (including those of you who have worked in pre-hospital EMS), and I will bring it back to an ethical issue.

Why do AMR rigs drive with lights and sirens on?

At least in Seattle, Medic One provides first responder care to patients. The premise of using lights and sirens is that rapid arrival on scene of an incident will help to decrease mortality in emergent situations (although even this premise is debated). Since telephone triage is not 100% effective, unless it is absolutely clear that there is not a life threatening situation, Seattle Fire responds with lights and sirens going. And when it is clear that a life hangs in the balance, Medic One comes along with similar displays to encourage the motorist (as well as pedestrian and bicyclist) to move out of the way. Once on scene it is determined that the patient does not need ACLS certified transportation to the hospital, AMR (a private company providing ambulance transport in Seattle) is summoned. At this point someone (a paramedic or firefighter, occasionally via telephone conversation with a physician) had determined that a life threatening emergency does not exist and that the patient does not need to be transported post-haste to the nearest emergency room. Yet, AMR will arrive on scene with lights and sirens going.

For anyone that has witnessed the number of near miss accidents of been in an emergency vehicle rushing through a busy city, it is apparent how dangerous it is for the operators of the emergency response vehicle, let alone the citizenry. Despite this, someone has decided that it's okay for AMR to drive as fast as possible to a non-emergent scene. How does one balance the ethics of this response with the danger it exposes everyone too?

Just as a clarification: this is not to say that certain AMR rigs do not transport critically ill patients. Indeed, AMR in Seattle has pediatric critical care and adult critical care vehicles that provide inter-hospital transport (and occasionally from the helipad at Harborview to another hospital). Usually this is done without use of lights and sirens, as even though the patient is sick, they are already receiving appropriate care.

I have some ideas behind this, but wanted others to weigh in first.

Week Two Online Challenge

Here's an online challenge on a topic we will come back to later in the course. Last week we talked about the 4 box method as a way to work through complicated ethical dilemmas. How long did it take to do one case at our first class? An hour! Will we have that kind of time in the emergency department? Of course not. But our approach right now is important to help with learning the basics. So what's next?

Kenneth Iserson is an emergency physician and bioethicist who has been writing about ethics in the ER for several decades. He has outlined a rubric for making decisions that consists of two questions:

1. Is this dilemma a type of ethical problem for which you have already worked out a rule, or is it at least similar enough that the rule could be reasonably extended to cover the situation? (Yes? --> USE THE RULE! / No? --> Ask question #2)
2. Is there an option which will buy you time for deliberation without excessive risk to the patient? (Yes? --> TAKE THAT OPTION! / No? --> Use a reliable reasoning technique.)

If you haven't already guessed, a primary goal of this class is to start building a set of rules that will allow you to answer "Yes!" to question 1 more often. One thing I think we should all think about, however, is:

What kind of delay tactics might be appropriate in question #2?

Psychiatric Holds

In the next class, we will be talking about issues in autonomy and consent. One really big issue within these topics is how to approach dilemmas that involve patients with mental illness. You may know that the Harborview ER has its own psych ward and psychiatrist (plus a resident) in house 24 hours a day. Not every emergency department will have such a resource. In fact, few do. Emergency providers must be familiar with the law, or at least with hospital procedures relevant to detaining a person.

Dr. Cooper will be giving a lecture on Wednesday about what is needed to establish consent. Needless to say, the mentally ill fall short on several accounts. (Can you name which?) The interesting thing is that each state defines autonomy differently. "5150" for example, refers to California's involuntary detainment statutes. We live in a state that is among the most protective of individual autonomy. It is very difficult to detain someone in Washington.

There are three ways to learn about Washington's system.

1. Read the law. Start here and here, and focus on this section and the laws referenced. Make sure you are caffeinated.
   
2. Look at a description not written in legalese. (This description of Washington's Involuntary Treatment Act is published by Snohomish County)
   
3. Have someone explain it to you. We can go over it in class.

One or two of our cases on Wednesday may deal with this issue, so if you have a chance to read about it, you'll be one step ahead.

Class Resources

Hi there everyone,

The reading assignments have been posted and are available in .pdf format at the course website, as is a copy of Dr. Cooper's case discussion outline and her example of a three page case writeup. If you have not signed up for the blog yet, please do so before Wednesday. If you have questions, read this intro to the blog.

ALSO, We'll be posting the lecture outlines and supplemental material at an Ethics in the ER Catalyst Workspace. Up now are two handouts Dr. Fryer-Edwards made about the four box method and ethics frameworks. They will be good resources for you when you prepare your discussions and write your final assignment.

Have a great weekend.

Welcome to the Ethics in the ER Blog

Welcome to the course blog for MHE 597E: Ethics in the ER. We are requiring course participants to make one entry or comment a week. This may seem daunting for folks not used to blogs or blogging, but I think you will find it pretty easy. This post is meant to provide you with some basic instructions about making entries on this blog. (It will stay at the top of the queue for a week.)

Is This Blog Private?

You may have concerns about blogs as a public repository of ideas. Statements made on blogs, in social networking sites, or on personal websites have lives of their own. They persist, even after the site is deleted. As such, it is important to us that this be an environment where your comments are safe and freely offered. Using the Blogger program, you may select an an anonymous user name or may use your name (like I do). There are benefits to both options - the main one for me using my real name is that I want the credit and accountability for what I write. It's a good habit to get into thinking that what you post will be visable to all, but if you are on the fence at all, I recommend you choose an anonymous name. (Be sure to email me your name so that you get credit for your posts!) This blog will be publicly accessible, but only class participants will be able to post new entries.

Getting Started:

Blogger is owned by (surprise!) Google. This means that you will need a Google account to use the blog. If you already have a Gmail address, you can use that one, but be aware that your email may be linked to your user name. If you want to be fully anonymous, consider making a second Google account with a separate email address. (You can even use your u.washington.edu address. Your username can still be a pseudonym.) Set up your user name by following this link, or just follow the directions in the invitation email you received on 1/3. When you make your blogger profile, the name you use to post and your first and last name fields are each different. If you want to be anonymous, you do not have to use your real name.

Once you have an account, check out your dashboard. You have received an invitation to join the Ethics in the ER blog, and should see it here. If there is any step that doesn't work out, this will be the one. Email Thomas if you cannot get to this step, or we can sort it out on Wednesday after class. Every time you log in, you can use the dashboard to view the blog or make a new post.

Post Content:

You can reply to a comment by clicking on the "X Comments" link at the end of the post or make a new post by clicking "New Post" at the top of the screen.

So now that you have an account, what exactly do you post? For guidance, we make the following suggestion (from the syllabus):

Each week, instructors will post a vignette or news story relevant to emergency medicine or medical ethics. Students are asked to type one response to this topic or to the assigned reading. Entries may take many forms. We expect to receive entries similar to what is found on other blogs: reviews of the reading, ‘ah-ha’ moments, questions you are left with, rants about politics, an account of a relevant patient encounter, a poem, or links to other stories or internet resources. When possible, entries should include concepts learned from class.

One final note is that HIPPA compliance does not stop with blogging. It is important that you maintain confidentiality if you ever refer to anything associated with a patient encounter. For tips on how to do that, you can consult the Healthcare Blogger Code of Ethics. I (Thomas) will be your point person for questions about blogging or the blog, so feel free to send me an email at any time, or post a comment below.

Happy blogging!

Jan 7 Helpful Links

A couple of resources that will be very helpful to you through the class are available at the UW Ethics in Medicine page that is maintained by the Department of Bioethics and Humanities. I've linked the general resource page in the upper right of this blog, but you may want to bookmark it yourself.

In specific, check out the four links under the Clinical Ethics bullet. There is a link to the four box method and one example of how to write a simple case discussion. We will provide you with another in the near future.

See you in a few hours!

Week One Online Challenge

Each week, I'll be posting an online challenge a few days before class to help us all prepare for the two hours we spend together in class. Responding with comments will be a regular way for you to participate in online discussions, but is neither required, nor is it the only way you contribute. You are also encouraged to make your own posts. We'll talk more about this in class on Wednesday. So on to this week's challenge:

You've signed up for a class titled, "Ethics in the ER."

The first part of the challenge is to think of 3 words or phrases relevant to medical ethics. It's okay to repeat a previous poster's words, but push yourself to think of new contributions.

The second part of the challenge is to think of one way that medical ethics might be different in the emergency room.

You can answer one or both parts here. We'll be discussing what you come up with in class.