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Michele Heisler, MD, MPA

Faculty

Michele Heisler, MD, MPA, is Professor of Internal Medicine at the University of Michigan Medical School, Professor, School of Public Health, and Research Scientist at the Ann Arbor VA's Center for Clinical Research Management. Dr. Heisler's clinical interest is chronic disease, with a focus on diabetes. Her research centers on patient self-management of chronic illnesses, patient-doctor relations and disparities in processes and outcomes in chronic illnesses.

Last Name: 
Heisler

CBSSM Seminar: Lisa Lehmann, MD, PhD, MSc

Fri, June 09, 2017, 3:00pm
Location: 
NCRC, Building 10, G065

Lisa Lehmann, MD, PhD, MSc
Executive Director, National Center for Ethics in Health Care
U.S. Department of Veterans Affairs

"Moral Distress in Health Care: The Role of Courage and Culture"

Supporting information for: 2017 CBSSM Research Colloquium and Bishop Lecture (Norman Daniels, PhD)


"Setting priorities for Medicaid: The views of minority and underserved communities"
Presenter: Susan Goold, MD, MHSA, MA


Co-authors: Lisa Szymecko, JD, PhD; H. Myra Kim, ScD; Cengiz Salman, MA; A. Mark Fendrick, MD; Edith Kieffer, MPH, PhD; Marion Danis, MD, Zachary Rowe, BBA


Setting priorities for state Medicaid programs challenges policy makers. Engaging beneficiaries affected by tradeoffs could make allocations more just and more sensitive to their needs. 

Academic-community partnerships adapted the simulation exercise CHAT (CHoosing All Together) to engage community members in deliberations about Medicaid spending priorities.  After an informational video about Medicaid, individuals and deliberating groups choose from a menu of spending options constrained by limited resources. We randomly assigned participants from low-income communities throughout Michigan to participate in CHAT with (n=209) or without group deliberations (n=181) in English, Spanish or Arabic. Data collection included pre- and post-CHAT individual priorities and group priorities.

Low-income participants ranged from 18 to 81 years old (Mean 48.3); 61.6% were women. Over half (56.7%) self-identified as white, 30.8% African-American, 17.3% Hispanic, 9.2% Native American, and 12.1% Arab, Arab-American or Chaldean. Most (65.9%) had a chronic condition and 30.3% reported poor or fair health.

Before CHAT, most participants prioritized eligibility consistent with Medicaid expansion. They also prioritized coverage for a broad range of services. Most accepted daily copays for elective hospitalization (71.6% deliberators, 67.9% controls) and restricted access to specialists (60.2% deliberators, 57.4% controls). Deliberators were more likely than controls to increase, after deliberations, what they allocated to mental health care (between arm difference in allocation=0.22, p=.03) and eligibility (between arm difference in allocation=0.18, p=.04). Deliberating groups also prioritized eligibility; only 3 of 22 chose pre-expansion eligibility criteria, and 9 of 22 chose to expand eligibility further.

Members of underserved communities in Michigan put a high priority on Medicaid expansion and broad coverage. When given the opportunity to deliberate about priorities,  participants increased the priority given to expanded eligibility and coverage for mental health services.


"How Acceptable Is Paternalism? A Survey-Based Study of Clinician and Non-clinician Opinions on Decision Making After Life Threatening Stroke"
Presenter: Kunal Bailoor, MD Candidate


Co-authors: Chithra Perumalswami, MD, MSc; Andrew Shuman, MD; Raymond De Vries, PhD; Darin Zahuranec, MD, MS


Complex medical scenarios may benefit from a more paternalistic model of decision making. Yet, clinicians are taught to value patient autonomy, especially at the end-of-life. Little empirical data exist exploring opinions on paternalism.

Methods: A vignette-based survey exploring surrogate decision making after hemorrhagic stroke was administered to clinicians (faculty, residents, and nurses) at an academic health center, and non-clinicians recruited through a university research volunteer website. The cases involved an urgent decision about brain surgery, and a non-urgent decision about continuation of life support one week after stroke. Respondents rated the acceptability of paternalistic decision making, including clinicians not offering or making an explicit recommendation against the treatment, on a 4 point Likert scale.

Results: Of 924 eligible individuals, 818 (649 non-clinicians, 169 clinicians) completed the survey (completion rate 89%).  A minority of respondents (15.3%) found it acceptable not to offer surgery. Most believed it was acceptable to make an explicit recommendation that would likely result in death (73% for avoiding surgery, 69% for stopping the ventilator). Clinicians were more likely than non-clinicians to consider not offering surgery acceptable (30% vs 11%, p<0.0001). Clinicians were more likely to consider recommendations against surgery acceptable (82% vs 71%, p=0.003) and to consider recommendations to discontinue the ventilator acceptable (77% vs 67%, p=0.02). There were no differences between the nurse and physician acceptability ratings (p=0.92).

Conclusions: Clinicians and the lay public differ on the acceptability of paternalistic decision making. Understanding these differences are vital to improving communication between clinicians, patients, and families.


"Ethical Challenges Faced by Providers in Pediatric Death: A Qualitative Thematic Analysis"
Presenter: Stephanie Kukora, MD


Co-authors: Janice Firn, PhD, MSW; Patricia Keefer, MD; Naomi Laventhal, MD, MA
 

Background: Care providers of critically ill patients encounter ethically complex and morally distressing situations in practice. Though ethics committees guide ethical decision-making when conflicts arise in challenging cases, they rarely address routine needs of individual providers. Without ethics education, providers may lack skills necessary to resolve these conflicts or insight to recognize these dilemmas.

Objective: We sought to identify whether providers remark on ethical dilemmas/moral distress without being specifically prompted, when asked to comment on a recent in-hospital pediatric death. We also sought to characterize the nature of dilemmas or distress if found.

Methods: Providers involved in a deceased child’s care in the 24 hours prior to death were electronically surveyed. Questions included demographic information and free-text response. Free-text responses were thematically analyzed in Dedoose.

Results: There were 307 (35%) free-text responses in 879 completed surveys (33% total response rate), regarding the deaths of 138 patients (81% of in-hospital pediatric deaths) from November 2014 to May 2016. Multidisciplinary care team members from diverse hospital units were represented. 52 respondents described ethical challenges and/or moral distress. Disagreement/regret was a major theme, with subthemes of futility, suffering, and “wrong” medical choice made. Failure of shared decision-making was also a major theme, with subthemes of autonomy and best interest, false hope, denial, and misunderstanding/disagreement between the family and medical team. Some providers revealed personal ethical struggles pertaining to their role, including medication provision for pain at the end of life, struggling to be “truthful” while not divulging information inappropriate for their role, and determining when providing comfort care is ethically permissible.

Discussion/Conclusion: Providers experience ethical conflicts with pediatric end-of-life care but may be unwilling or unable to share them candidly. Education assisting staff in identifying and resolving these dilemmas may be helpful. Further support for providers to debrief safely, without criticism or repercussions, may be warranted.


"Capacity for Preferences:  An overlooked criterion for resolving ethical dilemmas with incapacitated patients"
Presenters: Jason Adam Wasserman, PhD; Mark Navin, PhD
 

Clinical bioethics traditionally recognizes a hierarchy of procedural standards for determining a patient’s best plan of care. In broad terms, priority is given first to autonomous patients themselves and then to surrogates who utilize substituted judgments to choose as they believe the patient would have chosen. In the absence of good information about what the patient would have wanted, clinical ethicists typically retreat to the “best interest” standard, which represents a relatively objective assessment designed to maximize benefits and/or minimize harms.  In this paper, we argue that “capacity for preferences” is a conceptually distinct and morally salient procedural standard for determining a patient’s best plan of care.  We build our argument on the grounds that 1) that many patients who lack decisional capacity can nevertheless reliably express preferences (an empirical claim); 2) these preferences are distinct from best interest and not reducible to best interest considerations; 3) that capacity for preferences, at a minimum, has moral valence for situations in which best interest is undetermined (and we argue this happens more frequently than commonly recognized); and, finally, 4) that capacity for preferences in incapacitated patients lacking reliable or valid surrogates might even subvert a best interest course of action in some cases.  Some precedent for our analysis can be found in the concept of pediatric assent. However, the idea that patient preferences matter morally has broad application for adult patients, including for those with advanced dementia and other mental illnesses that preclude capacity for decision-making.

Kathryn L. Moseley, MD, MPH, will present "African American and White Disparities in Pediatric Kidney Transplantation: Unfortunate or Unjust?"on Thursday, March 18, 2010, 3:30-4:45 pm, room 7C-09 North Ingalls Bldg, University of Michigan, Ann Arbor campus. Dr. Moseley is an Assistant Professor in the Department of Pediatrics and Communicable Diseases and the Bioethics Program.  All are welcome!
 

Bioethics Grand Rounds -Scott Grant MD, MBE

Wed, May 24, 2017, 12:00pm
Location: 
UH Ford Auditorium

Scott Grant, MD, MBE, University of Chicago: "Dealing with complications and poor outcomes and surgical futility"

Scott Grant, MD, MBE, University of Chicago

Abstract: Surgical complications are ubiquitous and effect all surgeons. This talk will review how surgical ethics is distinct from traditional medical ethics in that surgeons have a greater and more direct responsibility for the outcomes of their patients than medical doctors. It will review how surgery harms before healing and the importance of weighing risks and benefits in decision making. Ways of assessing perioperative risk and preventing complications will be reviewed. Strategies for coping with complications will be described. Human error theory and the "Swiss cheese" model of human error will briefly be discussed. The SPIKES protocol for breaking bad news will be reviewed. Different definitions of futility will be described. Various procedural approaches to futility disputes will be analyzed. The best tool in approaching challenging "futility" situations will be described - open and honest communication between the patient or surrogate and the physician.

Reshma Jagsi was recently elected to the Board of Directors for the American Society of Clinical Oncology (ASCO). Congratulations!

Research Topics: 
Tue, January 03, 2017

Jeremy Sussman was quoted in a recent New York Times article, "You're 'prediabetic'? Join the club."

Research Topics: 

Raymond De Vries, PhD

Associate Director

Raymond De Vries PhD is Associate Director at the Center for Bioethics and Social Sciences in Medicine at the University of Michigan and is a Professor in the Department of Learning Health Sciences and the Department of Obstetrics and Gynecology. He is also visiting professor at CAPHRI School for Public Health and Primary Care, University of Maastricht, the Netherlands.

Last Name: 
De Vries

CBSSM is co-sponsoring the MICHR Research Education Symposium: Life at the Interface of Genomics and Clinical Care. This event will be held March 15th, 8-1 pm. Keynote speaker is Dr. Ellen Wright Clayton, JD, MD, Rosalind E. Franklin Professor of Genetics and Health Policy; Craig-Weaver Professor of Pediatrics; Professor of Law; and Director, Center for Biomedical Ethics and Society, at Vanderbilt University. Dr. Wright Clayton’s topic will be “Addressing Biomedical Ethics.”

Ladies and Gentlemen of the Jury (Jun-09)

How should the US judicial system determine compensation for "pain and suffering"  Take a look at a complicated case. 

Ladies and Gentlemen of the Jury

Let's suppose that you're a member of a jury for a court case involving an industrial accident. A 29-year-old employee, Charlie, has suffered brain damage in this accident.

Charlie was once a skilled worker who operated complex machinery. Since the accident, he has functioned cognitively at the level of a three-year-old child, and there is no chance for improvement of his state. Charlie has no visible scars on his body and is not experiencing physical pain from the accident.
 
Furthermore, as a result of the brain damage, Charlie is emotionally happier than he was before the injury. Several witnesses have testified that Charlie was somewhat volatile before the accident—he got angry easily and had bouts of sadness. The witnesses noted that since the accident Charlie is always happy, despite his cognitive impairment.
 
You are now in the jury room. You and your fellow jury members have decided that the factory where Charlie worked had inadequate safety precautions. The jury will return a verdict for the plaintiff, Charlie. The jury has already agreed on a sum to compensate Charlie for his medical expenses, his ongoing medical care, and lost wages for the rest of his life.
 
Charlie's attorney has asked for an additional monetary award for pain and suffering. Which statement below most closely describes your thoughts, as a juror trying to decide on an award for pain and suffering?
 
  • Charlie should get a very large award for pain and suffering, since his life overall has been so adversely affected by the accident.
  • Charlie should get a moderate award for pain and suffering, since he has suffered cognitive impairment, but he does not have ongoing physical pain.
  • Charlie should get a very small award for pain and suffering, since he is actually happier now than he was before the accident.
  • I don't think that the US judicial system should allow awards for pain and suffering at all.
  • I'm not sure what pain and suffering means in a legal sense, and I don't know what to award to Charlie.

How do your answers compare?

In a recent article, CBDSM's Peter A. Ubel and Carnegie Mellon University's George Loewenstein challenge the conventional view that awards for pain and suffering should be made literally as compensation for feelings of pain and of suffering. Ubel and Loewenstein argue from their expertise in the psychology of judgment, decision making, adaptation, and valuation of health states.

They cite many studies showing that people adapt well to very serious disabilities, such as paraplegia and blindness, returning fairly quickly to near-normal levels of happiness after a period of adjustment. Thus, if juries make pain-and-suffering awards literally on the basis of misery, such awards would be unacceptably small.

But Ubel and Loewenstein delve further. Even though people with serious disabilities have normal levels of happiness, they would still prefer not to have the disabilities. "We believe that the reason for this discrepancy between hedonic measures and stated preferences . . . is that people care about many things that are not purely hedonic, such as meaning, capabilities, and range of feeling and experience."

In enlarging the definition of pain and suffering, Ubel and Loewenstein do not propose to merely add to the factors that a jury must take into consideration in the current judicial system. Indeed, the authors find several problems with the current system, including inequities in compensation and the evaluation of injuries in isolation. They include in their article a three-part proposal for a radical change in judicial procedure.

First, they would recruit a random panel of citizens to compile and categorize injuries. Groups of injuries would be ranked on the basis of the appropriate level of compensation for those injuries. This panel would call on experts to inform their decisions. "Decisions about an injury's proper category would take into account not only the emotional consequences of the injury but also the person's ability to function across important life domains—social functioning, work functioning, sexual functioning, sleep, and the like."

This list of grouped and ranked injuries would have some similarities to the list of health conditions that the State of Oregon created in the 1990s to help allocate Medicaid funds. Another existing model for this list would be lists used to make decisions about workers' compensation claims—for example, benefits for loss of a thumb are twice as great as benefits for loss of a second finger.

Second, Ubel and Loewenstein propose a mechanism for determining monetary damages. Using the list produced by the citizen group described above, federal or state legislators could determine a maximum award for pain and suffering. Based on this damage cap, a range of awards would be set for each category of injuries.

Third, the juries would enter in, using the guidelines set up in the steps described above and then tailoring awards to the individual circumstances of each case. Under this plan, juries would do what people tend to do best: compare and rank things. Ubel and Loewenstein note that "juries could help determine if the victim has extenuating circumstances that should drive the award to either the lower or upper end of acceptable compensation for that group of injuries. . . Our proposal does not do away with jury trials but instead enables juries to involve themselves in the kind of judgments they are best suited to make."

Ubel and Loewenstein conclude, "The determination of pain-and-suffering awards should be revised to take account of recent advances in understanding human judgment and decision making."

Read the article:

Ubel PA, Loewenstein G.Pain & suffering awards: It shouldn't be (just) about pain & suffering. Journal of Legal Studies 2008;37(2):S195-216.

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