Doing the Right Thing: Ethics and Wound Care

  As clinicians, we are in the business of solving problems. We make diagnoses, weigh the risks and benefits of various options, and initiate treatments. We take charge, and the whole concept of ‘evidence based medicine’ is predicated on the idea that given enough data, a ‘right’ answer can be found. However, unlike scientific questions, ethical questions rarely have well-defined “right” answers. Every day, we are faced with situations that would challenge a modern Solomon, and often we can only hope for ‘best answers.’ That is the purpose of medical ethics, to provide a structured approach to finding the best answers to increasingly common ethical dilemmas.

What Is “Ethics?”

  In philosophy, ethical behavior is that which is “good” or “right.” But how can we know what is “right” in a given situation or for a given patient? Accepted behavior may change somewhat as society changes. There was a time when having a “paternalistic” attitude towards a patient was considered acceptable, that is, allowing the healthcare provider to play the role of the parent. This might even have included concealing information from a patient. A colleague told me (with regret) how his family conspired with a physician to conceal the terminal illness of a grandparent in the 1950’s. Such an attitude is considered completely unacceptable today but was not considered unethical a few generations ago. However, there are some behaviors which have never been acceptable, even though history records that they have occurred. Many books have been written about the appalling actions of the Nazi doctors, or the shocking ethical breaches in the Tuskegee syphilis trial. We ask ourselves exactly how these things happen. The complex answer begins with the dehumanizing of people and abusing positions of authority.

  Patients are vulnerable because they are ill, and the education and knowledge of the healthcare professional places him or her in a position of power in relation to the patient. A brief article can not do justice to the field of medical ethics, but there are 3 basic principles which govern ethical behavior for all healthcare professionals. The first duty of the healthcare professional is often considered that of ‘nonmaleficence’—in other words, “first do no harm.” Preventing harm is more important philosophically, morally, and legally than ‘doing good.’ The next goal of this relationship is beneficence. Beneficence is always acting in the patient’s best interest. A friend of mine needed a particularly difficult surgery and I got a specialist recommendation from a colleague. I reported to my friend that the specialist is the one my colleague would chose for his own wife. After a pause, she asked, “But does he like his wife?” Beneficence is choosing what is best for the patient. This is required because patients often cannot act on their own, whether out of ignorance, fear, illness, or vulnerability.

  The third principle is that of autonomy, that is, that patients are allowed to make their own decisions after being provided with as much information as possible. That is why we have the process of “informed consent.” Not all cultures have the same understanding of autonomy and consent. When I was a resident in the 1980’s, some Afghani ‘Freedom Fighters’ who had been severely disfigured fighting the Soviets were sent to the U.S. for facial reconstructive surgery. I was attempting through a translator to help a plastic surgeon obtain consent for a complex surgical procedure when a tough Afghani soldier began to cry saying, “Allah has appointed you as my doctor. You do whatever you think is best and don’t explain it to me.” In contrast, our culture highly values ‘self-rule’ as the underpinning of a democratic society. That is the moral basis for our concept of self governance, and is also the basis for self determination in medical decision making.

  The doctor-patient relationship is also fiduciary, meaning it is based upon trust and reliance. This means that it depends on the attribute of altruism on the part of the physician. Altruism is the deliberate pursuit of the interests or welfare of others.

Ethics in Wound Care

  In the last century, there has been an exponential growth in medical technology. The results have been life-saving for patients, but not without some tradeoffs. Patients can have allergic and idiosyncratic reactions to even the most carefully tested medications, and there are risks to all invasive interventions. Furthermore, technology does not come cheap; someone must pay for it. So, how do we decide when to use these technologies? A dilemma of modern medicine is that its reimbursement has become procedurally based. Clinicians are paid for what they do for patients, not for what they refrain from doing. Thus the system, by its very nature, encourages intervention. When added to the modern patient’s high expectations, the availability of technology, the economic pressures to generate revenue for economic survival, and the litigious nature of society that apportions blame if investigation and treatment are not undertaken, the result is a higher probability of medical interventions. Is that so bad? After all, wound centers are under pressure to increase their revenue if they are to remain economically viable operations. And we are here to help people.

Where is the Balance Between “Doing Well” and “Doing Good?”

  As an example in the wound-healing arena, it might be tempting for financial managers to mandate wound debridement at specific intervals. Debridement has been scientifically documented to be of benefit in wound healing. However, mandating that patients undergo an invasive procedure at specific intervals, perhaps with less regard to wound status than to generated revenue, is a policy which cannot be condoned from an ethical standpoint. Such policies have led to an investigation by the Office of the Inspector General (OIG). Their report stated that 47% of miscoded services were not actually surgical debridement, and that some of the debridement services might have been part of an “inappropriate pattern.” For example, one patient had 43 debridements purported to involve muscle within a 9-month period. If these debridements actually were performed, it is hard to imagine that they met the criteria of nonmaleficence, and if they were documented but not done, then the clinician was not being altruistic (at least, not being truthful). The findings of the OIG report led to the setting of limits on per patient debridement number by some Medicare contractors.

  Clinic visit frequency is another highly debated area across many primary care specialties. Just how closely do patients need to be followed once a treatment plan has been established? If the patient or caregiver can be trained to perform the dressing changes at home, the advanced practitioner does not need to see the patient for these routine dressing changes. Multiple repeat visits to a wound care center for ‘patient convenience dressing changes’ is not considered a good expenditure of money by most payers. However, there might be good reasons for frequent visits, such as highly exudating wounds that need a multi-layer compression wrap changed 2 times per week. If this need is clearly documented by the physician, frequent clinic visits are justified. Do patients always need to be seen by the advanced practitioner? Patients whose treatment plan requires their frequent attendance in a clinic, for example, to change a negative-pressure wound dressing, may not require a physician evaluation with similar frequency in the absence of a change in their status. Yet, when a physician tries to minimize the frequency of follow-up visits, he or she might be constrained by the policies of the hospital or clinic. These competing pressures make it difficult for the clinician to keep what is ‘best for the patient’ foremost when deciding on the frequency of follow-up visits.

  Hyperbaric oxygen therapy (HBOT) is an intervention that can be life-and-limb saving. It also generates revenue for the hospital, as well as the physician. The cost-benefit of HBOT is increased when patients who were going to get well anyway or whose limbs would be lost despite HBOT, are a priori excluded from treatment. However, careful selection of HBOT patients reduces revenue for the hospital and physician, since it likely means that fewer patients will be treated; although it might preserve Medicare reimbursement for this technology for future generations since the Centers for Medicare and Medicaid Services (CMS) continues to evaluate the cost-benefit of all the technology it covers. Policies which mandate that a certain percentage of wound center patients undergo hyperbaric treatment (not based on medical necessity) will not withstand ethical or legal scrutiny.

The 3-Cs of Decision Making

  The problem is that sometimes we know what we need to do and then don’t do it. “Currently, physicians in our hospital wash their hands approximately 50% of the time that they conduct a patient encounter.” That statement, in a memo from the Chief Medical Officer of my hospital, was echoed in a recent fascinating presentation by Swiss physician Didier Pittet who heads the World Health Organization’s campaign on hand washing. He works in the same hospital in Vienna as Ignaz Semmelweis who, in 1847, decreased puerperal fever from 10% to 1% by getting doctors to wash their hands in chlorinated water before touching patients. More than 160 years later, we are still trying to get doctors to wash their hands before seeing patients. Why is that so hard?

  There are three factors which control ethical decision making. They are usually referred to as the ‘3-C’s’ of Decision making: Compliance, Conscience and Conduct. You have to know the rules and be willing to follow them (compliance), then you must decide that you are committed to follow the rules (conscience), and then you must take action to do so (conduct). If you are ignorant of what is right (Semmelweis began his hand washing campaign before the germ theory was discovered), if you have not committed to change your behavior, or if there are obstacles which prevent your behavior, a change will still not occur. For example, compliance with hand washing is correlated with how convenient hand-sanitizing stations are. Ethical behavior in wound care is much more complex to map than hand-washing.

  I worked at a hospital in which I discovered that there was fraudulent billing of the hyperbaric services. When I discovered the problem, I went to the CEO of the hospital and informed him of what it would take to bring the hospital into compliance. He gave lip service to correcting the problem, and I initiated the corrective actions, but the hospital failed to implement the necessary changes because it would mean angering a powerful physician. So, I resigned my privileges after writing a memo to the administration explaining why I was leaving. Although I did not report the hospital or physician to Medicare, eventually a ‘whistleblower’ did, with painful financial consequences for the hospital and the physician. In considering the ‘3-C’s’ of decision making, both the hospital administrator and the doctor involved knew the laws, but were not committed to follow them (problems with both conscience and conduct).

What is Right vs. What is Legal

  Of course, almost every day I find myself caught between what is ‘right’ and what is ‘legal.’ A patient needs something (stockings, or a medical device), and I might be able to get it donated to them. The letter of the law says that certain ‘gifts’ could be considered by Medicare as an ‘inducement to treat.’ However, in my own mind, it is the ‘right’ thing to do from the perspective of “universal justice.” Or perhaps the deeply flawed ‘ICD-9’ coding system offers me two, more or less equally inaccurate ways of identifying a diagnosis. One of them is likely to get more therapies covered for the patient, and thus be more likely to lead to healing. Shall I call this a diabetic foot ulcer or a pressure ulcer? Is that an ethical question or am I simply making a pragmatic medical decision?

  There are no easy answers to these questions, and nowadays the road is even harder because most people lack any sort of reference point. What made the Hippocratic Oath an important advance forward was that prior to that time, patients did not know whether the ‘physician’ they were seeing might be paid by one of their enemies to give them poison instead of medicine. In taking the oath, physicians appealed to the ‘higher powers’ in which they placed their faith (the gods of healing) that they would act in the best interest of the patient. “I swear by Apollo Physician and Asclepius and Hygieia and Panaceia ... that I will fulfill according to my ability and judgment this oath and this covenant.” Since fewer individuals now believe in absolute truth, it is no wonder that ethical standards are harder to teach, much less follow.

Who Are You When No One is Watching?

  Dr. Edmund Pellegrino, Founder of The Center for Clinical Bioethics at Georgetown University said, “Ethics requires that the physician be a person who can be expected to habitually act in the patient’s interests when no one is watching.” While another ‘self-check’ is to ask yourself, “How would I feel if my actions were discussed in the newspapers?,” the fact is, we need to hold ourselves to the highest possible standard even if we are the only one who will ever know. So, the real question is, “Who are you when no one is watching?”