Pain Contracts as Policy: A Good Idea?

On April 27 the Center for Practical Bioethics convened a broad spectrum of pain management professionals to consider the utility and the ethics of pain contracts or agreements. The meeting focused on professional, patient and policy issues around physician use of contracts to prescribe opioids and other pain medications.

The Center will produce a policy brief from comments delivered during this gathering and the November issue of the American Journal of Bioethics will be devoted to the concept of pain contracts.

In a three part series starting April 30 The Bioethics Channel will feature interviews with participants in this program. In this edition, Drs. Scott Fishman and Richard Payne discuss the professional impact of pain contracts.

Pain Contracts: Great Good or Great Harm?, Scott Fishman, MD, University of California-Davis, April 30, 7 minutes 10 seconds

Pain Contracts: Unintended Consequences, Richard Payne, MD, Duke Institute on Care at the End of Life, April 30, 6 minutes 24 seconds

Electronic Aids Enhance Informed Consent?

Rosemary Flanigan

April 30, 2010

A few years ago a Health Affairs article authored by Annette M. O’Connor, et al. (“Toward the ‘Tipping Point’: Decisions Aids and Informed Patient Choice.” 2007.Health Affairs 26(3)716-725) noted that "preference-sensitive treatment decisions involve making value trade-offs between benefits and harms that should depend on informed patient choice. There is strong evidence that patient decision aids not only improve decision quality but also prevent the overuse of options that informed patients do not value. . . .”

I have long been interested in real informed consent determination, and if “decision aids when used as adjuncts to counseling improve decision quality and reduce the overuse of surgical treatments by 25%,” then I guess they can’t be all bad.

These “decision aids” are growing like rabbits, and the article states that “An important element of these practice models is the key supportive role played by specially designed IT systems. For example, [one breast care program] is attempting to improve clinical care quality by incorporating IT to screen patients, inform physicians, cue the decision aid, assess naïve and informed preference, flat emotional distress and monitor decision quality”

WOW!! And all of this to help the patient decide risks/harms.

But wait, we’re not finished: The article goes on to say that the practice models for these “decision aids” can be used as examples for developing national standards (for health professionals and for health care organizations) AND certification is not far behind.

TELL ME, TELL ME, are we so bad with our present system of gaining informed consent that we might be attracted to these (computer-generated) aids??? (Or is my anti-electronic bias showing??? Might it not be just as well to suggest some people I could talk to if I can’t decide on a treatment modality?) HELP!

Conflict = Ethics Consult

Rosemary Flanigan

April 29, 2010

I’ve told countless ethics committees: “When will you have a consult? When there’s a conflict.”

But maybe there is more to see here: Maybe the moral distress felt by families who are having too much information thrown to them, are being asked questions to which they have no answers, are being deluged by concerns over which they have no control, need to have the services of an ethics committee made available to them.

Perhaps they don’t even see what they are facing as conflictual; but the sensitive physician who offers to participate in such a consult might provide great benefit to the family and perhaps even to him/herself!

What do you think?

Roaming for Ethics Consults

Rosemary Flanigan

April 28, 2010

Some hospitals have people who "roam" about the hospital looking for ethical issues and/or pain sufferers.

Last week when I was talking to a group of nurses and one complained that she often has to do inhumane treatment on a child without being able to talk to the physicians who were ordering it, I reached back into my life as an academic and wondered if hospitals couldn’t profit from a DEAN!!

We always had recourse to a dean who could whip recalcitrant faculty into some sort of order. I think well-functioning ethics committees could serve this purpose, IF issues are brought to them.

What do you think?

Deadly Medicine: Creating the Master Race

Susan Bachrach

Jean Zeldin

April 23, 2010

Looking back, we can’t imagine how it happened. But it did … and Deadly Medicine—Creating the Master Race, examines now Nazi Germany nearly annihilated European Jewry.

In this edition of The Bioethics Channel, host Lorell LaBoube visits with Susan Bachrach, the curator of the Deadly Medicine exhibit on loan from the United States Holocaust Memorial Museum and on display through June 10 at the National Archives in Kansas City.

Also on the program is Jean Zeldin, executive director of the Midwest Center for Holocaust Education.

The exhibit is sponsored by the Midwest Center for Holocaust Education, in partnership with the National Archives at Kansas City and in cooperation with the Center for Practical Bioethics.

Physician and Ethics Consults and Questioning Character

Rosemary Flanigan

April 23, 2010

I am going to push once more on this issue of physicians and ethics consults (or the lack therof)—and hopefully not risk losing some good friends—to ask:

Is it ennui, intimidation, or just plain lack of interest what others think of your decisions that lead physicians, for the most part, to shun ethics consults?

I even gave you an “out”—I suggested that if being a physician equals being who you are, then to question your judgment (or to lay that judgment out for others to consider) might be questioning your very character.

I talked with a group of nurses last week only to hear several of the experienced ones say that they were not considered “part of the team”, weren’t “consulted” on a case by the physicians, and I wondered, “Then why am I worrying about doctors’ not bringing cases to a multidisciplinary group if they don’t talk them over with the attending nurses?”

Cast a little light here—docs or non-docs -- Why?

Couldn't attend Annual Dinner? No problem.

Annual Dinner audio now available

Some 700 people attended the Center's Annual Dinner on April 13, 2010. They witnessed award presentations and an announcement that the Center, with this event, raised more than $360,000.

(Link: 2010 Leadership Sponsors)

Eleanor Clift of Newsweek magazine and The McLaughlin Group on PBS presented the keynote address. Ms. Clift also spoke the next day at the annual Bioethics Symposium, along with Perry Fine, MD, of the University of Utah.

Dr. Fine's presentation was entitled "The Missing Element in Healthcare Reform: Medicare Cost- Curve at the End of Life - OR - The Economics of Healthcare for Older Americans: From Virtue to Voodoo and Back Again."

Audio from the event and presentations can be found below.

Links:

Annual Dinner opening program and Vision to Action Awards, 49 minutes 39 seconds
Annual Dinner: Eleanor Clift keynote, 34 minutes 40 seconds
Symposium: Eleanor Clift, 1 hour 20 minutes
Symposium: Perry Fine, MD, 1 hour
Symposium: Perry Fine, MD PowerPoint

Could There EVER Be An Okay Way to Pay for Body Parts?

Summer Johnson, PhD
April 21, 2010

Would payment for funeral expenses be okay to increase the rate of cadaveric organ donation?

What about upping the ante for getting men to spill their seed or to be able to pay women to undergo hormone injections to donate those precious ova?

Summer Johnson comments in this post on bioethics.net.

Physicians and Ethics Consults -- Why so Few?

Rosemary Flanigan

April 20, 2010

Why, in my 17-year experience with ethics committees, do so few physicians call for consults?

I am surmising that when faced with a “problem,” they consult one another. Most of them, I think, see the “problem” not just as a professional quandary but as a moral one, and they are eager to do “the right thing.”

So let us say two of them are standing in a doorway discussing a “problem” (and I’m sure their talk is laced with numbers) and let’s say they reach different conclusions of “the right thing to do.”

OK, I would imagine (having never been party to such a consult), they disagree and the attending goes into the room and takes care of the patient as he/she had just argued. The other physician walks down the hall to take care of other business.

What is at stake beneath these differing care plans? Ultimately, I allege, it’s virtue ethic: what it means to be a good physician!!! And doctor to doctor can be argued because they are both part of the “fraternity.”

But to argue interpretations of “the right thing to do” with non-physicians might, for some of them, be questioning their very essence as a “good” doctor.

YES, that can be true of NP’s, too. But my non-evidence-based judgment is that nurses might be more open to discussion of their “virtus,” their good habits, than are physicians.

Do blow me out of the water if you disagree!!!!

Ethics Committee Workshop April 30

Friday, April 30
8:00 to Noon

Kansas City University of Medicine and Biosciences
1750 Independence Ave
Kansas City, MO

Target Audience: New ethics committee members, and for those who need a refresher on the basics!

Upon completion of the workshop, the learner will be able to:

*Describe how we make ethical decisions
*Describe the evolution of healthcare ethics in the U.S.
*Identify key ethical issues in selected landmark cases
*Explain the components of a typical case for consultation

For more information and to register click here.

Too Soon to Give Up on Advance Directives

Michael Green, MD
Benjamin Levi, MD

April 16, 2010
15 minutes 7 seconds

Advance directives are in the news with a recent study in the New England Journal of Medicine and the fifth anniversary of the death of Terri Schiavo. So where do advance directives stand these days and how might we make better use of them?

Michael Green, MD and Benjamin Levi, MD of the Penn State College of Medicine offer a computer-based based approach to advance directives in the April 2010 issue of the American Journal of Bioethics. Lorell LaBoube visits with both in this edition of The Bioethics Channel.

Link: Podcast, Too Soon to Give Up on Advance Directives

Are you having "The Talk?"

Today is National Healthcare Decisions Day, a day to make your medical wishes known during a serious illness or at the end of life, including the designation of someone to speak for you when you can no longer speak for yourself.

Studies show that 85% of us will be unable to express our wishes when the inevitable comes. It’s a burden that too often is assumed by family or loved ones during an extraordinarily difficult time.

So have “The Talk” today. Below you will find links to help.

Links:

NEW Caring Conversations

Caring Conversations for Young Adults

Caring Conversations, Spanish

Courageous Conversations (for veterans)

Have "The Talk" this Friday, April 16

April 16 is National Healthcare Decisions Day, a day to help individuals and families make practical preparations for end-of-life decisions, including the designation of someone to speak for you when you can no longer speak for yourself.

The Center for Practical Bioethics offers a tool to promote those discussions, a revised and updated version of Caring Conversations.

“April 16 is intended to be a social prompt,” says Myra Christopher, president and CEO of the Center for Practical Bioethics, “to give people a reason to have conversations that are too often delayed or postponed.”

For your copy of the new,updated Caring Conversations click here.

Embracing Bioethics

Barbara Bollier, MD

April 9, 2010

A mother, a physician, a volunteer, a state legislator.

And on April 13, 2010, a recipient of the Vision to Action Award by the Center for Practical Bioethics.

Her name is Dr. Barbara Bollier and she talks about the bioethics center in this edition of the Bioethics Channel.

Link: Embracing Bioethics, The Bioethics Channel, April 9, 13 minutes 38 seconds

Top 10 Podcasts: First Quarter 2010

The Center’s weekly podcast, The Bioethics Channel, is reaching a larger audience by the week and month. Since starting in February 2009, the podcast has been downloaded almost 18,000 times.

Here are the top ten podcasts by downloads for the first quarter of 2010 … and thanks for listening!

L2

1. Ashley X Revisited, Norman Fost, MD and John Lantos, MD

2. Terri Schiavo Lives On, John Carney

3. Is it ethical to want to live forever?, Glenn McGee, PhD

4. Making or Having a Baby: The Ethics of Genetic Testing, Glenn McGee, PhD

5. Futile CPR. Always Wrong?, Rosemary Flanigan

6. Rethinking Vegetative States, Glenn McGee, PhD

7. Gay Men & Donating Blood, Art Caplan, PhD

8. Drugs, Ethics and the Quality of Life, Bruce White, MD

9. Mobility and Transportation for our Aging Population, Scott Helm, PhD

10. Genetics, Jewish Diseases and Personalized Medicine, John Lantos, MD

Moving Beyond NO DOZE

Rosemary Flanigan
April 9, 2010

Maybe because I am elderly I have more time to think about these matters, but I worry about a society that wants more and more—and if it means remembering better, operating on less sleep, overcoming inhibitions, heightening desires, etc., would anyone doubt that the lines at the drug stores will be out the doors?

I remember once buying NO DOZE around exam time in college—and that was 63 years ago! Big Pharma is way beyond No Doze now!!

Back in the March/April 2005 issue of the American Journal of Bioethics Alan Leshner opined in an issue devoted to neuroethics, “”I argue that the simple fact that the brain is the origin of the mind and therefore in many ways the seat of our very humanity, confers very special status on it as an organ. It therefore requires that we devote special attention to it, even if in concept many of the issues are not so dissimilar from the issues surrounding other biomedical phenomena.”

Lots of work ahead of us.

Life at All Costs Decisions

Rosemary Flanigan

April 7, 2010

Back in October, we had an interesting exchange about “Saturday Morning Postmortem” which appeared in the Hastings Center Report last Sept/Oct. and I used it in my two ethics brown bag sessions.

If you recall, it was a case of a seventy-one-year-old woman who had been in the surgical ICU for eleven days following treatment for a small bowel obstruction. She had often told her husband (her surrogate) and countless care providers during her stay that she’d rather “die than have a colostomy.” The expedited ethics consult consisted of a junior faculty member and a graduate student/ethics fellow, members on call of the ethics committee of a large teaching hospital.

Remember that the husband had consented to surgery which would result in her having a colostomy because he understood that she would live with “the bag” only a few days. But their investigation revealed that the husband had misunderstood; they clarified the wife’s prognosis with her husband who then called the daughter and stopped the order for an operation. The woman died two days later.

In the current issue of Hastings Center Report, three well-known names sent letters to the editor: Felicia Cohn, UCIrvine, Mark Aulisio, Case Western, and Kansas City’s own John Lantos.

All three delivered a blistering review of the consult, but it is John’s question I wish to explore here: If the husband’s rescinding his consent to surgery was based on a misperception of reality (his wife’s reason for never permitting a colostomy—because it stank), can it truly be autonomous?

Many consults attempt to clarify the “life at all costs” decisions made by surrogates, says John; ought now the husband/wife’s misunderstanding of ostomy care have been equally explored?

The authors admit in a “reply” that “[W]e wonder to this day whether a truly autonomous decision is ever possible. . . .”

Studies: Advance Care Planning Helps

John Carney

April 6, 2010

The first study appearing March 23, 2010 in the online version of BMJ entitled, “The impact of advance care planning on end of life care in elderly patients: randomized controlled trial” concluded that advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.

This study was conducted as a randomized clinical trial in Melbourne Australia on patients 80 years or older. About half of the 300 patients were in either the experimental or control group.

The second study appeared about a week later in the New England Journal of Medicine on April 1, 2010. This retrospective study entitled “Advance Directives and Outcomes of Surrogate Decision Making before Death,” involved nearly 3,800 seniors who died between 2000 to 2006 in the US, and for whom a patient representative was able to answer a series of questions about the decision making prior to the death.

The study concluded “both a living will and a durable power of attorney for health care appear to have a significant effect on the outcomes of decision making. Thus, advance directives are important tools for providing care in keeping with patients’ wishes. For more patients to avail themselves of these valuable instruments, the health care system should ensure that providers have the time, space, and reimbursement to conduct the time consuming discussions necessary to plan appropriately for the end of life. Data suggest that most elderly patients would welcome these discussions.”

What’s good about both of these studies is that they come at a time of growing awareness among consumers that redirecting goals of care may actually improve the outcome and satisfaction for patients who are dealing with advanced disease, increasing debility and frailty and a growing skepticism that more is better in US healthcare.

They also underscore the fact that advance care planning helps – despite recent claims otherwise.

Terri Schiavo -- Five Years Later

Glenn McGee, PhD

April 2, 2010

Five years ago you could not avoid hearing about Terri Schiavo. Her story turned into a national shouting match over life and death and who decides. But has much changed since Terri died on March 31st, 2005?

In this edition of The Bioethics Channel, host Lorell LaBoube explores the meaning of Terri Schiavo on the fifth anniversary of her death with Glenn McGee, PhD, the John B. Francis Chair at the Center for Practical Bioethics.

Link: Podcast, 20 minutes 21 seconds

Informed consent and decisional capacity

Rosemary Flanigan
April 2, 2010

I’ve was thinking of the implication of enhancing one’s decisional capacity AND the validity of one’s informed consent.

Now, because I have been blessed with good genes and am lucky, I am not well informed first-hand about the informed consent process in hospitals, but I have heard that healthcare professionals are less liable to argue with a patient who readily signs the form than with the patient who hems and haws.

We all know that the signed form represents little in the way of evidence of real informed consent. I know how increased information, illustrations and stories can enhance decisional capacity for the patient who is decisionally problematic. But what about brain enhancement that minimizes risk, safety, self-preservation?

Are we careful enough in the informed consent process to address both sides of the issue: the cognitive/affective underbelly and the cognitive/affective over-stimulated?