Core Competencies

4.05 Healthcare Systems: Ethics

Introduction

Medicine is a profession; it is not merely a composite of simple commercial transactions but is an inherently moral enterprise. Hospitalized patients are particularly vulnerable due to the impact of their illnesses and their dependence on healthcare providers who have specialized knowledge and control over its use. Physicians have fiduciary obligations to their patients and are expected to prioritize patients’ interests over their own. Physicians should make decisions that promote patients’ own interpretations of what are good or beneficial outcomes. Pediatric patients are even more vulnerable because their parents/guardians interpret what is good and make decisions on their behalf. Ethical dilemmas are increasingly encountered due to medical advances, patient complexity, questioning of science, and conflicts between cultures and societies. Pediatric hospitalists should have the knowledge, skills, and attitudes required to identify, analyze, and assist with resolving ethical issues, and to act ethically.

Knowledge

Pediatric hospitalists should be able to:

  • Compare and contrast “business ethics” (the accountability of organizations to use policies and procedures to justify and take responsibility for their activities) with “professional ethics” (application of defined expertise [knowledge and skill] to the practical benefit of others).
  • Describe the principles of respect for autonomy, beneficence, nonmaleficence, and justice.
  • Distinguish between the concepts of privacy and confidentiality and describe an example of an ethically justifiable violation of a patient’s confidentiality.
  • Discuss the differences between advance care planning, advance directives (such as durable powers of attorney for healthcare and living wills), Physician Orders for Life-Sustaining Treatment (POLST), and do not attempt resuscitation (DNAR) orders.
  • Describe the elements of medical decision-making capacity and informed consent.
  • Compare and contrast between informed consent and assent.
  • Compare and contrast between the best interest and substituted judgment standards.
  • Describe when it is ethically acceptable to withhold or withdraw life-sustaining treatment, including medically provided nutrition and hydration.
  • Cite examples of differing types of futility, including physiologic (proposed intervention cannot achieve the desired effect), quantitative (proposed intervention is highly unlikely to achieve the desired effect or benefit the patient) and qualitative (the quality of benefit of the proposed intervention will produce is exceedingly poor), and review the response to requests for “potentially inappropriate treatments” as recommended by the American Thoracic Society and other professional organizations.
  • Describe scenarios when ethics consultation may be of value, attending to conflicts around potentially life-changing decisions between any of the following: patient, family/caregivers, healthcare team members, and others.
  • Articulate the criteria for justifiably overriding a parent’s or guardian’s refusal of recommended treatment, such as in cases of medical neglect.
  • Review the process for requesting an ethics consult within the local context.
  • Summarize the goals of and steps involved in an ethics consultation.
  • Cite common reasons for consulting risk management and/or legal representatives.
  • Discuss the different roles played by ethics consultants, risk managers, and lawyers.
  • Compare and contrast the ethical obligations of clinicians versus researchers.
  • Review the potential adverse effects of actual or perceived conflicts of interest in the various roles pediatric hospitalists perform, including clinical care, research, and administration, and discuss the strategies used to manage these conflicts.

Skills

Pediatric hospitalists should be able to:

  • Provide competent care while fulfilling ethical duties to patients and the family/caregivers.
  • Communicate honestly and compassionately, maintaining patient privacy and confidentiality.
  • Demonstrate professionalism, completing all professional responsibilities in an ethical manner.
  • Demonstrate skills in initiating an ethics consult and in collaborating with an ethics consulting team.
  • Demonstrate basic skills in resolving ethical conflicts with patients and the family/caregivers, in collaboration with ethics consultants as appropriate.
  • Demonstrate the ability to identify in oneself and among care team members any moral distress or conscientious objection and develop a plan for reasonable accommodation.
  • Evaluate medical decision-making capacity and identify appropriate proxies as needed.
  • Demonstrate skills in communicating indications, benefits, risks, and alternatives for various interventions consistent with the decision makers’ health literacy.
  • Elicit goals of care and recommend treatments consistent with these goals and against treatments that conflict with them as appropriate.
  • Identify patients for whom advance care planning is appropriate and collaborate in and/or refer for advance care planning.
  • Complete and implement POLST forms, advance directives, and DNAR orders.
  • Identify and manage potential conflicts of interests.
  • Identify and avoid boundary violations.
  • Identify personal biases and avoid unjust discrimination.
  • Report impaired healthcare providers and those with unethical behavior to appropriate entities using pertinent procedures.
  • Consistently adhere to appropriate documentation and coding practices.

Attitudes

Pediatric hospitalists should be able to:

  • Respect patients and their family/caregivers and value their participation in shared decision-making.
  • Recognize the importance of a patient’s own experiences on their quality of life.
  • Reflect on and provide support for family/caregivers as they express their values and the goals they have for their children.
  • Realize the need to include an ethical perspective in the approach toward healthcare decision-making, regardless of role in clinical care, administration, research, or education.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Collaborate with hospital administration to develop and maintain ethically sound institutional practices, policies, and culture.
  • Advocate for healthcare policy that improves the quality of and access to pediatric healthcare services.

References

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