Abstract
Introduction
Ethical dilemmas arise related to tension between one or more values held by stake-holders. Identifying which ethical principles (i.e., autonomy, beneficence, non-maleficence, and justice) are in tension represents one way to categorize ethical dilemmas that arise in clinical cases. The purpose of this review is to describe the population of patients for whom Medical Ethicists (ME) were consulted and identify the primary ethical principles in tension for these cases.
Methods
A retrospective chart review of patients admitted from 2/2014–8/2019 (n=3701) capturing ME notes. Each note was independently rated by burn team RNs and medical ethicists to identify which two of the four common ethical principles were perceived to be in tension. Reviewers also noted if surrogate decision-making and/or goals of care were prominent themes in the case. Additional data points include circumstances of injury, total body surface area (TBSA) involved, age, mortality, length of stay (LOS), Hospital Day (HD) of ethics consult (EC), +/- psychology/psychiatry note, +/-chaplaincy, +/-palliative care, initiator of and stated reason for the EC.
Results
Of the 3701 patients admitted, 26 had formal EC’s (0.7%). Twelve died. Average age was 55.6 (7–85). Two patients had Calciphylaxis and four self-immolated. One EC concerned interests of fetus vs the pregnant patient. TBSA for the burned group averaged 39.7% (2–100). Average LOS was 55.6 days. Average HD of ethics consults was 20.5. For mortalities, EC was 10.8 HDs prior to death. LOS for survivors was 55.6 vs 42.33 days for non-survivors. TBSA for survivors was less than those who died (29% vs 50%). Chaplaincy was involved in 19/26 (73%), palliative care 3/26 (12%), Psychology/ psychiatry 15/26 (58%) of EC’s. The burn RNs most often characterized the ethical dilemmas as tension between beneficence and nonmaleficence while the ethicist found autonomy vs. nonmaleficence. All raters found only 1 or 2 cases involved justice. The team identified GOC tension in 20/26 cases, the ethicist, fewer than half. The burn team requested ethics consultation in all cases of self-immolation. Initiators of ethics consults were 14 burn team, 7 burn MD, 1 burn nursing, 2 chaplaincy and 2 not stated.
Conclusions
Circumstances of injury, the nature of wound and intensive care management and the association of significant injury with end of life care present challenges to the burn team. Many may be framed and addressed as ethical dilemmas. This pilot exploration of clinical utilization of medical ethics suggests patterns and questions that warrant further discussion and study. Value-driven tensions between the professional duties to do good, the duty to do no harm, and the duty to respect autonomous decisions by patients and by extension, surrogate decision makers, account for most triggers for ECs initiated by the burn team.
Applicability of Research to Practice
Directly Applicable.
Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice
