Sildeset from case-based Grand Rounds workshop on ethics in the Emergency Department. Cases are posted separately. Presented February 17th, 2016 at LIJ Medical Center. Complementary post and supplemental materials at: http://theempulse.org/ethics-grand-rounds-2-17-2016

1. Refusals, AMA’s and Withdrawals of Care in the ED -
Can You Do the Right Thing?
David A. Marcus
@EMIMDoc - EMIMDoc.org
Attending Physician, Dept of Emergency Medicine
Attending Physician, Division of Medical Ethics

2. Sam Packer, MD
Director, Division of Medical Ethics
Fred Smith, MD
Division of Medical Ethics
Donna Field, M. Div., BSn, PCCN
Division of Medical Ethics
Lauren Sparber, MD
Fellow, Division of Medical Ethics
Guest Faculty

3. ●Autonomy/Self-Determination
●Beneficence
●Non-Maleficence
●Distributive Justice
Value Based Clinical Ethics

4. Case #2: What a Pain!

5. C - Communication
U - Understanding
A - Appreciation of Consequences & Acceptance
of Medical Facts
R - Rational (does not necessarily = Reasonable)
Decisional Capacity - C.U.A.R.

6. Strong Paternalism may be justified if:
●The risk to the patient is great
●The risk of the medical intervention is
minor
●The resulting limitation in autonomy is
minimal
Also:
●If there is a threat to self or others
Duty to Detain - A Moral Question

7. Duty to Detain - A Legal Problem

8. So, Who Needs Psych Anyway?

9. Case #1: Say What?!

10. ●Parental consent = Parental access
oEXCEPT if leads to harm/distress
oand minor > 12 yrs old
●Minor consent = No parental access
●In NYS all minors may consent for:
oRepro/contraception services
oDrug/EtOH counseling
oMental Health services
oHIV testing
oSexual assault treatment
●Married, pregnant, parents, emancipated
Parental vs Adolescent Consent

11. Case #3: Hot Shot

12. Case #4: To Everything
There is a Season

13. For patients lacking decisional capacity
#1: Legal Surrogate/Proxy
#2: Non-Separated Spouse or Domestic Partner
#3: Child, age > 18 years
#4: Parent
#5: Sibling, age > 18 years
#6: Close Friend
Full text at: http://bit.ly/14FjixT
NYS Family Health Care Decisions Act

14. Restrictions on surrogacy:
●Physician, staff member, administrator at
facility from which patient was transferred
cannot serve as surrogate UNLESS they
belong to categories 2-6.
●If a physician is surrogate, he or she
cannot serve as the patient’s attending.
NYS Family Health Care Decisions Act

15. “Nothing in this article shall obligate health care
providers to seek the consent of a surrogate if an adult
patient has already made a decision about the
proposed health care, expressed orally or in writing or,
with respect to a decision to withdraw or withhold life-
sustaining treatment expressed either orally during
hospitalization in the presence of two witnesses
eighteen years of age or older…”
NYS Family Health Care Decisions Act

16. Prognostication in the ED

17. Case #5:
Stop. Just Stop.

18. ●Value based ethical analysis augments
clinical decision making in the ED
●C-U-A-R to determine capacity
●Psych for capacity only if complex, active
psych condition or suicidal
●FHCDA defines surrogates in NYS
oOnly when patient lacks capacity
ohttp://www.nysba.org/FHCDA/
Summary

19. Slides and supplemental readings will be
posted at
www.theEMpulse.org
and
www.EMIMDoc.org
THANK YOU!