Trustworthiness and Relational Autonomy

(1) Review these key ethics concepts:

  1. Autonomy and Relational Autonomy
  2. Virtue
  3. Trust and Trustworthiness

**Keep in mind that this session will focus on cases that are meant to draw out population level biases and ethical concerns in particular clinical interactions. We will be addressing more societal, systematic, and broader justice issues in other sessions (see Justice in Healthcare). Likewise, we will come back to system level methods of advocacy (including advocacy for clinicians with underrepresented minority identities) in other sessions. Here, our intention is to start thinking creatively about how to be in relationship with particular patients in complex contexts.**

(2) Then READ:

Stonington SD. Whose Autonomy? JAMA. 2014;312(11):1099-1100. 

As you read CONSIDER…

  • How do the concepts of autonomy and trust come into play when the patient/family/physician may have different perspectives about the best course of action?
  • How do you think building trustworthiness relates to respecting patient autonomy?

(3) APPLY what you have learned so as you READ and REFLECT on CASE 1 (you should remember this case from your IPE Session Teamwork and Values)

As you read CONSIDER…

  • What are Doris’ goals and those of the care team? How do they align and how they conflict?
  • How does trustworthiness factor into this case? Might it guide clinicians in some particular way? How so?
  • What does it mean to “first, do no harm” in this case?

CASE 1 – DORIS

Doris at hospital admission  

Doris Carlson is a 72-year-old woman who was brought to the ED by medics shortly after collapsing at home with shortness of breath and leg weakness.  She was in her usual state of health, able to walk a couple of blocks and care for herself, until a week prior to admission, when she noticed that she was even more short of breath than usual and her legs were swelling.  She thought maybe it was the heat, but four days ago she couldn’t lay flat to sleep.  Finally her legs were so weak that she fell in her hallway this morning.  She was able to crawl to the phone to call the medics, who had a tough time getting her out of her apartment because the rooms were stacked with books and periodicals.

Doris lives alone and says she likes it that way.   When she retired 4 years ago from her job as a librarian, she moved into a second floor apartment with an elevator.  Doris is obese and was diagnosed with type 2 diabetes and hypertension almost 15 years ago, but hasn’t actually seen a doctor in years and takes no prescription medications.  She does take Vitamin D because she read about the low levels among Seattleites. At baseline, she can walk a couple of blocks before feeling out of breath, and is able to get to the grocery store and other key places on foot.  In the week before collapsing though, she hadn’t been able to get to the store, and had no one she could call on for help.

Doris at Hospital Day 19 

Doris refused most recommendations and therapies, yet she loved to have long conversations with everyone on the team.  The Cardiology team spent hours teaching about her cardiac disease, and trying to negotiate a mutually acceptable plan.  The pharmacy team spent hours providing drug education.  The team eventually resorted to only sending one person into the room during morning rounds to avoid delaying their rounds.  The dietitian had prolonged conversations about better diet choices for diabetes, as well as a low sodium diet (and also tried to help out with the avocado situation). Hospital dentistry evaluated Doris given her lack of dental care, diabetes, and left lower jaw tenderness while in the hospital, but she refused to go down to the clinic for a full exam or x-rays.  The team social worker spent hours first trying to identify community supports, and then skilled nursing facility placement, only to have Doris refuse all options.  Doris even refused to be discharged home by cabulance insisting she would take a taxi.

While most patients on the medical floor have a primary nurse, no one would volunteer to take Doris.  Eventually, a plan was developed for rotating care of Doris daily among the nursing team to diminish frustration. Doris would often complain that she didn’t like someone on her care team, often trying to engage the person currently with her to “help” with some problem.  The physical therapist and occupational therapist also spent hours with Doris but had a different experience. While Doris was fairly passive receiving OT and PT therapy, she was appreciative of their attention and efforts.

Because of her unwillingness to take most oral medications, Doris remained quite hypoxic on room air, and was thus not ready for discharge.  She declined home oxygen, though she wore it in the hospital.  Doris’ hospitalization dragged on for weeks during a time when the hospital was full and other patients were being diverted.

The Cardiology team requested a Psychiatry consult to assess Doris’ decision-making capacity.  Doris refused to talk to Psychiatry but after discussing with other team members, the psychiatrist (and cardiologists) felt Doris was indeed able to make decisions for herself.

By hospital day 19, the Cardiology team decided to discharge Doris with or without home oxygen, medications, dental follow-up, assistive equipment or any other social services.  They had offered ample recommendations but she was unwilling to accept any.  Other team members were uncomfortable with this plan, given that her room air oxygen saturation remained in the low 80s.  Her nurse asked if she was supposed to just remove the oxygen at the curb and wish her “good luck” as she got in the cab?

One team member eventually was so uncomfortable, discharge was delayed and an ethics consultation was requested.

 

SHIFTING GEARS A LITTLE… we’re going to look at the intersection of the values of autonomy and trustworthiness in the more complicated context of IV drug use and addiction. 

(4) WATCH this short clip from Dr. Gabor Maté… 

And this TED Talk by Johann Hari…

As you watch these talks, reflect on what you’ve learned so far about the social determinants of health and health equity. Keep these social structures and the relevant isms in mind as you consider the ethical obligations of clinicians as they treat patients who are suffering from the harmful effects of IV drug use.

(5) READ this publication by Dr. Kirkpatrick (Cardiologist and Ethics Consultant at UWMC): 

“Infective Endocarditis in the Intravenous Drug User” in AMA Journal of Ethics. 2010;12(10):778-781.

Dr. Kirkpatrick uses a case and casuistic comparisons to critically reflect on the meaning of the term ‘futility’ in contexts where a patient’s addiction to IV drugs might be taken as a reason against pursuing a particular medical intervention.

As you read HIGHLIGHT the central ethics obligations that Dr. Kirkpatrick applies in his discussion.

(6) Finally, in light of what you’ve learned above, READ and REFLECT on Case 2:

CASE 2: MOIRA

Moira is a 28yr old woman with two children (7 and 9yrs old). She has a history of endocarditis and has been admitted for volume overload. She has been admitted several times over the past 6 years and has already received multiple surgical interventions (including two valve replacements). Her endocarditis is exacerbated by ongoing IV drug use. While she is consistently open about her drug use and desire to stop, she continues to use. Each time, staff have been surprised by her ability to recover from surgery, but also frustrated by each new admission. She is currently being considered for a third valve replacement.

Moira alternates between passive acceptance of her care and anger at staff. She will sometimes knock food off her tray, throw her bedpan, or verbally lash out at medical staff (e.g. “just leave me alone!” or “don’t pretend you care!”). Because of this, staff members have warned each other to take caution when entering her room. Moira has a “behavior contract” and often behaves more passively when her father (Rick) is in the room. So, the medical team typically waits until the father is present to conference with the patient. Moira is often alone in her room as her father is very busy with his job and taking care of Moira’s two children.

The medical team disagrees about whether or not to offer the valve to Moira. While one of her nurses doesn’t understand why it has not yet been offered, another feels burnt out from caring for Moira over several admissions and is frustrated by Moira’s lack of participation in her care. Similarly, while the attending is reluctant to do another valve replacement knowing it will not fix Moira’s underlying disease (her addiction), the resident believes that she is a sufficiently good candidate medically and it will likely allow her more time (months to years) with her family.

Moira and her family have been consistently homeless or houseless. She had been staying in a shelter with her children prior to the current admission. While the children’s father is not present, Moira’s father Rick is very involved in her care and is in the process of adopting the two children.

Should Moira be offered a third valve replacement?

 


For further investigation on addiction, see Dr. Maté’s website: https://drgabormate.com/.