domingo, 29 de noviembre de 2009

Emergency medicine

Emergency Medicine Curriculum in Bioethics
Joel Yaphe MD FRCPC MHSc Staff Physician Department of Emergency Medicine University Health Network Assistant Professor Department of Medicine University of Toronto
MHSc in Bioethics, University of Toronto
Joint Centre for Bioethics
Class of 2002
• To provide bioethics teaching for residents in Emergency Medicine
Course Objectives:
• To create an awareness of bioethics issues as they apply to Emergency Medicine
• To provide a mechanism for obtaining knowledge on relevant bioethical issues
• To stimulate development of skills relevant to bioethical issues in clinical practice
• To stimulate learners to develop frameworks for approaching bioethical issues as they arise in clinical practice
• To prepare residents for materials which may appear on RCPSC examinations in Emergency Medicine
• Develop a pilot curriculum to be implemented over the first 6 months of 2002
• Develop a method for feedback and evaluation of the curriculum
• Review the curriculum in May of 2002 (Resident and Faculty input)
• Rework the curriculum for academic year 2002-2003
Course Development Phase: (September – December 2001)
• Time allotment arranged with Program Director
o 2 hour sessions on academic “half-day”
o 3rd Tuesday of each month, Jan-June (1300-1500)
o PGY 3-5 have protected time and will be the target group for 2002
• Informal polling of faculty and residents for needs assessement
• Review of existing materials and creation of preliminary curriculum
• Development of evaluation tool
• Contact individual faculty members re: interest in development and participation
• Obtain feedback from faculty on curriculum –modify as necessary
• Publicity phase:
o Precirculation of schedule
o Contact individual participants about upcoming session(s)
Implementation Phase: January to June 2002
Iterative Phase: May – Sept 2002:
• Evaluate course and implement change based on:
o Session evaluations
o Final evaluation
o Focus groups (residents and faculty)
This phase will consider ways of broadening the target group (to include PGY1-2) and will deal with the issue of providing ongoing exposure.
Emergency Medicine Bioethics Curriculum Resources
SAEM Ethics Curriculum for Emergency Medicine Residencies
Available on-line at
Moskop JC, Mitchell JM, Ray VG. An Ethics Curricdulum for Teaching Emergency MedicineResidents. Ann Emerg Med 1990; 19(2):187-192
Bioethics Curriculum for Canadian Emergency Medicine Residents
Developed by:
Dr. M Ackerman
Associate Clinical Professor
Division of Emergency Medicine
McMaster University
Hamilton, Ontario, Canada
Available from author
RCPSC Bioethics Education Project
Available on-line at
Royal College Emergency Medicine Program
Biomedical Ethics Objectives
Available on-line at
McKneally MF, Singer PA. Bioethics for Clinicians: 25. Teaching bioethics in the clinical setting. CMAJ 2001; 164(8):1163-7
Iserson KV, Sanders AB. Ethics in Emergency Medicine. Tucson AZ, Galen Press 1995.
Session 1a: Introduction(1h)
Key Issues
Pretest (30 min)
Introduction (30 min-45min)
• Why Teach Ethics
• What do the learners know
• Introduce course objectives
• Review course outline and timetable
• Short review of available reference material
• Discussion of ethical problems particular to emergency medicine
Course Evaluation Tool
Paradigm Cases
Pedagogic Method
Combination of didactic (powerpoint presentation) and group discussion
Handouts of objectives and reading list/resources
Session 1b and Session 2: Autonomy Issues (3h total)
Key Issues
Autonomy Issues:
• Informed Consent and Refusal
• Capacity
• Substitute Decision-making
• Advance Directives
• Treatment of Children and Adolescents
Curricular Objectives
• To gain knowledge and understanding of the ethical basis and implications of informed consent and the related concepts
• To be aware of the relevant (Ontario)law on informed consent
• To develop an awareness of the special issues related to treatment of Children and Adolescents
• To introduce two frameworks for ethical decision-making
• To introduce the “4 principles”
Paradigm Case(s)
Mallette vs Shulman
The suicidal patient – A man presents with a Tylenol overdose and refuses treatment
Ill-looking 2 y.o. child with possible meningitis – parents refusing recommended investigation and treatment
Unaccompanied 12 y.o. presents for treatment of a laceration
Ill 12 y.o. with pancytopenia, refusing investigation and treatment
Pedagogic Method
• Role Play
• Group Discussion
• Powerpoint slides as supplements
Session 1b
Case will be introduced with faculty-resident role play
Assign preparation for session 2: Key readings
Session 2
Participants will be asked to work out an approach to suicide and pediatrics cases
Invited faculty:
HSC ethicist for second hour
Assign preparation for session 3: Key Readings
Session 3: End-of-Life Care (2h)
Key Issues
End-of-Life Care:
Decsion-making with respect to life-sustaining treatments
Symptom control
Support of Patients and Families
Advance Directives
Euthanasia/Assisted Suicide
Palliative Care
Conflict in EOL Care
2 cases will be assigned to residents for presentation in the next session
Relevant readings will be recommended
Curricular Objectives
• To introduce a framework with which to approach end-of-life decision making
• To gain an appreciation of the issues involved in provision of life-sustaining treatments, particularly as they apply to emergency medicine
• To gain an appreciation of the role of advance directives and substitute decision-makers in EOL care
• To discuss the concept of “futility”
• To gain knowledge of methods for provision of comfort in end of life care, specifically:
o Techniques for pain control
o Control of respiratory distress
o Provision of support for family and friends
• To develop an appreciation of the ways in which conflict can develop in EOL decision-making
• To develop an appreciation of the ethical and legal issues surrounding Euthanasia/assisted suicide and palliative care
Paradigm Cases
A 90 year old is brought into the ED by ambulance. She is hypotensive and has laboured respirations.
A 65 year old previously healthy man is brought into the ED after sudden collapse. He has been intubated by paramedics. He is found to have a large intracerebral haemorrhage,
Pedagogical Method
Cases presented by faculty. Participants will work through cases and generate discussion.
Key points will be emphasized with powerpoint slides
Case1: (50min)
Severe illness, requiring aggressive medical intervntion - exact etiology unknown (?cardiogenic shock, ?aspiration)
Treatment preferences: Assess patient capacity; Check for AD’s, SDM’s
Ultimate decision not to intubate
Provision of appropriate comfort care
Case 2: (50 min)
Investigation: CT shows large ICH
Prognosis: Neurosurgeons feel that there is no possibility for recovery
Treatment: Consultants recommend extubation
Problems: Family does not want patient extubated, consultants do not want to admit patient to ICU
Session 4: The Physician –Patient Relationship (2h)
Key Issues
Truth Telling
Communication Issues/Skills
A study will be given to the group for discussion in the next session
Curricular Objectives
To recognize the ethical, legal, and professional basis of maintaining patient confidentiality
To recognize situations under which patient confidentiality may be breached
To develop an approach to dealing with difficult confidentiality issues
To develop an appreciation of difficult issues around “truth-telling” and an approach to dealing with them
Paradigm Cases
Case 1: A patient presents to the ED with a first seizure. Relevant information:
• Alcohol withdrawal seizure
• Patient works as a truck driver
Case 2: An injured patient is being treated in the ED and asks the doctor to hurry up so that he can “go out and get the guy who did this to me”.
Case 3: A 15 year old female presents to the ED with nausea and abdominal pain. She is accompanied by her mother.
Case 4: A family brings in an elderly man who is clearly ill. One of the family members takes you aside and tells you that he has cancer, but that you should not tell him.
Pedagogic Method
First Hour:
2 Cases will be presented by faculty member.
Participants will work through the cases in a small group discussion format.
Important points will be summarized or expanded upon with powerpoint slides.
Second Hour:
2 cases will be presented by residents, who will guide the discussion
Faculty member will participate as a resource person
Session 5: Ethical Issues in Teaching and Research (2h)
Key Issues
ED physician roles in research with human subjects:
-developing a study
-becoming a co-investigator
-enrolling subjects
Teaching in the ED
Curricular Objectives
To develop a framework for determining the ethicality of research with human subjects
To develop an understanding of the concept of equipoise
To develop an appreciation of this issues involved in the use of placebo
To develop an approach to ED participation (enrollment of patients) in human subject research
To develop an appreciation of issues involved with teaching in the ED
Paradigm Cases
A prehospital care RCT study looking at the treatment of status epilepticus. (NEJM Aug 2001. ) Three treatment arms were used – diazepam, lorazepam, placebo
Part 2: Cases
A fourth year medical student is seeing a man with a laceration to his face
A man comes in with a cardiac arrest and the first year resident wants to intubate him
……Intubation fails, and staff intubates the patient.
……Resuscitation fails, patient is pronounce dead. Staff asks resident if he wants to try the intubation again.
Pedagogic Method
Part 1: (1h)
Residents will be given the study proposal in advance and will come prepared to assess it as if they were members of an REB
Faculty will be available as a resource person, and will provide visual aids (eg: powerpoint slides) to illustrate appropriate points.
Faculty will provide a framework for ethical analysis of research with human subjects (to be presented at the end)
Part 2: (1h)
Participants will work through a clinical scenarios illustrative of ethical issues in teaching in the ED
Faculty will help to clarify issues and will provide appropriate visual aids
Session 6: Physician Relations with the Pharmaceutical Industry (2h)
Key Issues
Pharmaceutical industry financial support for education
Pharmaceutical financial support for research
Pharmaceutical industry as a source of medical information
Material contributions from the pharmaceutical industry:
o “Gifts” to physicians
o Samples for patients
Curricular Objectives
To develop an appreciation of the ways in which physician prescribing practices can be affected by pharmaceutical promotional material
To become aware of suggested guidelines for ethical interactions with the pharmaceutical industry, and the differences between them
Paradigm Cases
You are invited to attend an educational session on the management of …….
The session will be held at one of the top restaurants in the city.
The pharmaceutical representative from DRUGCO offers complimentary textbooks to the residents.
Your academic department of emergency medicine plans to set up a research institute in collaboration with a pharmaceutical company
Pedagogic Method
Cases will be discussed in a small group session. Invited guests will include:
Emergency physician with expertise on relationships with the pharmaceutical industry
Representative from the pharmaceutical industry
Pharmacist from a teaching hospital who specializes in emergency department pharmacotherapy
Really Good Easily Accessible Reading Materials:
CMAJ Bioethics for Clinicians series
SAEM ethics curriculum
RCPSC Bioethics Education Project
Ian Anderson Project on EOL Care
University of Washingtom
Ethics in Medicine
Bioethics Pretest
This pretest consists of 3 cases, with short answer questions for each.
Total time allowed is 30 minutes.
Questions may be answered in point form.
This test is being administered solely for the purpose of course evaluation, and will not be used to evaluate individuals. However, it will be helpful to compare individuals’ pretest scores with those of a post-test to be administered in June. To this end, you have been assigned a personal numeric code which should be entered on your test papers.
ID Number_______
A 19 year old male presents to the Emergency Department after ingesting a large amount of acetaminophen tablets. He is being assessed by the medical student, who comes to you and tells you that the patient wants to leave. The medical student wonders if the patient can be further assessed or treated without his consent.
What is the basis for the concept of “consent to treatment”
What are the elements of informed consent:
What are the exceptions to the requirement to obtain informed consent?
How would you approach this situation?
ID Number _______
An 89 year old woman presents to an Emergency Department in downtown Toronto with respiratory distress. The junior resident who is assessing the patient comes to you for some advice. She is not sure that aggressive life-sustaining measures are appropriate for this patient, and has ascertained that the patient does not have the capacity to make the necessary treatment decisions.
Who should make treatment decisions for incapable patients?
What factors should be considered in making treatment decisions for incapable persons?
The decision is made not to intubate the woman, nor to perform any other life-sustaining measures, but she becomes increasingly uncomfortable. The resident is concerned about giving medications that may precipitate death.
Define the following terms and indicate the way that they are currently viewed in Ontario:
Physician-assisted suicide
How would you approach this patient? Justify your actions
ID Number ______
A 37 year old man presents to the Emergency Department with a stab wound to the arm. He recognizes another patient who is leaving the department, and in the course treatment, tells you that when he leaves the ED, he is going to “get that guy”.
Why is doctor-patient confidentiality important?
Under what circumstances might doctor-patient confidentiality be breached?
How would you approach this issue?
Emergency Medicine Bioethics
Evaluation Form
Strongly Disagree
Strongly agree
Clear objectives were provided
The content was relevant and was presented at an appropriate level
This session contributed to my knowledge and understanding
The format was appropriate
Strongly Disagree
Strongly Agree
The presenter(s) were enthusiastic
The presenter(s) demonstrated appropriate knowledge and expertise
The presenter(s) used an effective style/method of presentation
The presenter(s) stimulated interest and participation
Suggestions for improvement:

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