Working in a Healthcare Team

Definition

Components of an Effective Healthcare Team

• Structured handovers (SBAR - Situation, Background, Assessment, Recommendation)
• Regular team meetings and case discussions
• Active listening and non-hierarchical exchange of information

• Respect for autonomy - All team members support patient's right to make informed decisions
• Non-maleficence - Teams serve as a safety net; another professional may catch an error the primary physician misses
• Accountability - Each member is responsible for their actions and should speak up if standards are compromised
• Confidentiality - Information shared within the team must remain within professional boundaries

Challenges in Teamwork

• Hierarchical barriers and professional rivalries
• Poor communication leading to medical errors
• Role ambiguity
• Burnout affecting team dynamics

Importance

• Medication errors by up to 50%
• Hospital readmissions
• Patient mortality in ICU settings

Conclusion

Bioethics: Case Studies and Decision Making

Definition

The Four Pillars of Bioethics (Beauchamp & Childress)

Ethical Decision-Making Framework

1. Identify the ethical problem - What conflict exists? (e.g., patient refusal vs. physician duty)
2. Gather facts - Medical, social, legal, and contextual information
3. Identify stakeholders - Patient, family, healthcare team, institution, society
4. Apply ethical principles - Which principles are in conflict?
5. Consider options - What are the possible courses of action?
6. Make a decision - Justified, transparent, and defensible
7. Evaluate outcome - Reflect on what was learned

Illustrative Case Studies

• Conflict: Beneficence (doctor's duty to treat) vs. Autonomy (patient's right to refuse)
• Decision: If the patient is competent, mentally sound, and fully informed of consequences, their refusal must be respected
• AETCOM Lesson: Respect for autonomy overrides paternalism. The doctor's role is to inform, counsel, and support - not override

• Conflict: Confidentiality (patient's right) vs. Non-maleficence/Justice (protecting a third party)
• Decision: Counsel the patient strongly; if continued refusal persists and the spouse faces serious harm, limited disclosure may be ethically justified - but legal guidance should be sought
• AETCOM Lesson: Confidentiality is not absolute; it can be overridden when there is clear, serious, and imminent harm to an identifiable third party

• Conflict: Justice - who deserves priority access to a scarce resource?
• Decision: Criteria such as clinical urgency, prognosis, and likelihood of benefit are used - NOT age, gender, social status, or ability to pay
• AETCOM Lesson: Allocation must be transparent, evidence-based, and free of discrimination

• Conflict: Veracity (truth-telling) vs. Family wishes and cultural norms
• Decision: The patient has the right to know their diagnosis. However, truth must be delivered with empathy, compassion, and at the patient's own pace. Culturally sensitive communication is key
• AETCOM Lesson: Truth-telling is an ethical duty, but how truth is communicated matters as much as what is said

Role of Ethics Committees

• Multi-disciplinary review
• Policy guidance
• Support to clinicians in morally distressing situations
• Mediation between patient, family, and team

Key Takeaways for AETCOM

• Bioethics is not about finding a "perfect" answer - it is about making the most justifiable decision given the circumstances
• Ethical reasoning requires empathy, knowledge of law, communication skills, and moral courage
• Case-based learning in bioethics trains medical students to recognize dilemmas early and respond thoughtfully
• The goal is always the patient's wellbeing - physical, emotional, social, and dignified

Bioethics Case Study: Autonomy and Decision Making

What is Autonomy?

Prerequisites for Valid Autonomous Decision-Making

Case Study 1: Refusal of Life-Saving Treatment

• Autonomy - Patient's right to refuse treatment
• Beneficence - Doctor's duty to save life
• Non-maleficence - Harm from inaction

• Ramesh is a competent adult - he understands the consequences
• His refusal is voluntary and informed
• The physician's role is to:
  • Provide clear, non-coercive information about risks of refusal
  • Explore fears, address misconceptions
  • Involve a counselor or chaplain if needed
  • Document the refusal with witness signatures

"A competent patient's informed refusal, even of life-saving treatment, must be respected. Autonomy overrides paternalism."

Case Study 2: Patient with Diminished Capacity

• Autonomy vs. Competence - Can Sunita make a valid decision?
• Family pressure vs. patient welfare
• Role of surrogate decision-making

• Sunita's capacity is fluctuating - she is not fully competent
• The son cannot simply override her; his role is to be a surrogate (substitute decision-maker), not a guardian with absolute authority
• Surrogate decisions must follow the substituted judgment standard - "What would Sunita have wanted?" - not what the son prefers
• If no prior wishes are known, the best interest standard applies

• Assess capacity formally (psychiatry/neurology referral if needed)
• Involve the ethics committee if conflict persists
• Surgery may proceed if deemed in her best interest, with surrogate consent - but Sunita's expressed wishes must not be dismissed

"When capacity is diminished, surrogate decision-making must reflect the patient's prior values and best interests - not the family's convenience."

Case Study 3: Adolescent Autonomy

• Autonomy of a minor vs. Parental authority
• Confidentiality vs. legal age of consent
• Duty of care

• In India, age of majority is 18; however the concept of "Gillick competence" (UK origin, increasingly applied globally) holds that a mature minor who understands the implications of a decision can consent to certain medical treatments
• The doctor must assess her maturity and understanding
• Providing contraception protects her from unwanted pregnancy and STIs - aligns with beneficence

"Adolescent autonomy must be respected in proportion to their maturity and understanding - rigid age cutoffs alone do not determine capacity to consent."

Stepwise Model for Autonomy-Based Decisions

1. Is the patient competent?
        ↓ YES                     ↓ NO
Respect their decision     Identify surrogate decision-maker
Ensure it is informed      Apply substituted judgment / best interest standard
Document thoroughly        Involve ethics committee if conflict arises

Limits of Autonomy

• The patient lacks competence (psychosis, delirium, intoxication)
• Decision harms a third party (e.g., refusing isolation in infectious disease)
• Emergency situations where consent cannot be obtained
• Minors in certain jurisdictions, unless Gillick-competent

Key Takeaways

• Autonomy is the cornerstone of modern medical ethics - it replaced centuries of medical paternalism
• It requires competence + information + voluntariness
• Doctors must act as facilitators, not gatekeepers, of patient decisions
• Even disagreeable decisions must be respected if autonomously made
• Documentation of informed consent or refusal is both an ethical and legal safeguard