Introduction
Phronesis
Core element 1 | Pursuit of worthwhile ends (goals) derived from a concept of human flourishing |
Core element 2 | Accurate perception of concrete circumstances detailing the specific practical situation at hand |
Core element 3 | Commitment to moral principles and virtues that provide a general normative framework |
Core element 4 | Deliberation that integrates ends (goals), concrete circumstances, and moral principles and virtues |
Core element 5 | Motivation to act in order to achieve the conclusions reached by such deliberation |
Methodology
Methods
Ethics
Data Collection
Analysis
Code | Goals/outcomes (1) | Concrete circumstances/context (2) | Virtues/principles/normative framework(3) | Integrating 1, 2 and 3 | Motivation to initiate the process and implement the decision reached |
---|---|---|---|---|---|
BX01 | + | + | + | + | + |
BX02 | + | + | + | ||
BX03 | + | + | + | ||
BX04 | + | + | + | + | + |
BX05 | + | + | + | + | + |
BX06 | + | + | + | ||
BX07 | + | + | + | + | + |
BX08 | + | + | + | ||
BX09 | + | + | + | ||
BX10 | + | + | + | ||
BX11 | + | + | + | ||
BX12 | + | + | + | + | + |
BX13 | + | + | + | + | + |
NX01 | + | + | + | + | |
NX02 | + | + | + | + | + |
NX03 | + | + | + | + | + |
NX04 | + | + | |||
NX05 | + | + | |||
NX06 | + | + | |||
NX07 | + | + | |||
NX08 | + | + | + | + | + |
WX01 | + | ||||
WX02 | + | ||||
WX03 | + | ||||
WX04 | + | + | + | + | + |
WX05 | + | + | + | + | + |
WX06 | + | + | + | + | + |
WX07 | + | ||||
WX09 | + | ||||
WX10 | + | + | + | + | + |
WX11 | + |
Code | Goals/outcomes (1) | Concrete circumstances/context (2) | Virtues/principles/normative framework (3) | Integrating 1, 2 and 3 | Motivation to initiate the process and implement the decision reached |
---|---|---|---|---|---|
W101 | + | + | + | + | + |
W101-FP | + | + | + | + | + |
W102 | + | + | + | ||
W103 | + | + | + | ||
W104 | + | + | + | ||
W104 -FP | + | + | + | ||
W105 | + | + | + | ||
W106 | + | + | + | ||
W107 | + | + | + | ||
W107 -FP | + | + | + | ||
W108 | + | + | + | ||
W108-FP | + | + | + | + | + |
WFY2-01 | + | + | + | ||
WFY2-02 | + | + | + | ||
WFY2-03 | + | + | + | ||
WFY2-04 | + | + | + | ||
WFY2-05 | + | + | + | + | |
WFY2-06 | + | + | + | + | + |
N101 | + | + | + | + | |
N102 | + | + | + | + | + |
N103 | + | + | + | + | |
N104 | + | + | + | + | |
N105 | + | + | + | ||
N106 | + | + | + | + | |
N107 | + | + | + | + | |
N108 | + | + | + | + | |
B101 | + | + | + | + | |
B102 | + | + | + | ||
B103 | + | + | + | ||
B104 | + | ||||
B104-FP | + | + | + | + | + |
B105 | + | + | + | ||
B105-FP | + | + | + | ||
B106 | + | + | + | + | + |
B107 | + | + | + | + | |
B108 | + | + | + | + | |
B108-FP | + | + | + | ||
B109 | + | + | |||
B109-FP | + | + | |||
B110 | + | + | + | + | |
B110-FP | + | + | + | + | + |
B111 | + | + | + | + | + |
B111-FP | + | + | + | + | + |
B112 | + | + | + | + | + |
N101-F | + | + | + | + | + |
N105-F | + | + | + | + | + |
N107-F | + | + | + | + | + |
NFY2-01 (2) | + | + | + | + | + |
Findings
Goals of Care to Pursue
[T]hat he (patient) was not willing to have the feeding and he was willing to stop his feeding – he didn’t want the PEG reinserted again (WX04).
Keeping the patient’s brain perfused so that he is able to function; although it may shorten life there is some quality of life” and for that it was necessary to discontinue “all the medication that might knock him off centrally, making him drowsy. I’ve got to do everything I can both medically and, from the therapy perspective, to optimise his function because that will tell us how far he can rehabilitate and where he’s going to go to after hospital (BX05).
[I]t was inappropriate to keep putting her (patient) through tests that [made] her uncomfortable…. what are we really achieving, and so, I went out and I spoke to the Registrar. He was like, “Yeah, I don’t think we should do anything for her.” Like, with the discussion with the daughter, and the grandson. I think that was the right thing to do [not to intervene] (W101-FP).
Recently a patient was offered an operation by a surgeon that was clinically the right operation to be offered, but the way it was communicated to the patient, they have refused to have the operation. They think it’s completely not the right thing for them… (NX03).
Perception of Concrete Circumstances
He was – sometimes just saying ‘no’ with the head and things, so we came to the point that through our conversation, I realised that the patient has capacity, perfect capacity when you take the time to allow him to express and I acknowledged… he did not want the tube reinserted (WX04).
So, within the WHO ICF classification there’s a very clear definition of disability- so the pathology, impairment, activity limitation, participation limitation and then contextual factors- physical structures around the person, like their caregivers etc. and the legal, contextual factors… (BX05).
Commitment to Moral Virtues and Principles
Respecting Patient’s Values
A huge part in my decision making is influenced by I think the patient’s values and beliefs, and the family’s values and beliefs as well (BX01).
So, I discussed with him and I really get to that information; it took me obviously more than ten minutes… [and because] that was his (patient’s) decision, with capacity, after talking to him…. I got to what the patient really wanted to happen; I respect that, and I help him in the best way possible (WX04).
Interpersonal Communication
…. the way it was communicated to the patient, they have refused to have the operation. That made me think well, this doctor could be fantastic in terms of his clinical acumen but if his communication is not there, well, that’s not going to give a favourable outcome (NX03).
Holistic Approach
[W]e have a holistic view of the whole person, so they’re not just a heart that’s been damaged with the rest of the body attached to it; we’ve got to look at the whole picture… that really is another way of saying the holistic biopsychosocial model (BX05).
Recognizing Limits of Treatment
For me, it's about the cost of suffering, prolonging a life where… And we get questioned a lot …..Well, we can see the situation's futile, why don't we withdraw sooner? (BX12).
So, [the] consultant will go on a ward round say, ‘I think we should do X, but if when we do X this happens, do Y, and if that doesn’t work then we’ll do Z.’ And I feel like they are wise and thought out decisions. So, I think maybe they can see the outcome of the decision that they make in the future, and how that relates to everything else (BX01).
Seeking Guidance
He [registrar] reviewed the patient, and we got the Medical Registrar as well, who came in and saw her, and he was, kind of, the most senior medical person there at that point, ‘cause it was during the night, and he made the decision. He was like, “Yeah, I don’t think we should do anything for her.” I think that was the right thing to do (W101-FP).
Courage
So, for a good ethical decision, that emergency medicine Consultant absolutely challenged how I viewed that patient and I would like to think it’s probably changed how I view other patients in the future (WX09).
Deliberation to Integrate Concrete Circumstances, Moral Principle/Virtues to Achieve the ‘Good End’
So what I need to do is try and optimise his [patient’s] health in general to enable his brain to function as well as it possibly can… Then look at modifying the factors around him, so looking at whether it’s too noisy, whether he gets communication in the right way, all those sorts of things. But the essential thing is getting him as fit as possible (BX05).
If you have already in your mind motivated to do a particular thing, then the conversation probably becomes biased, so sometimes you just go with the open mind, and then with the conversation with the patient, you think what would be the next step (BX04).
[T]o make him [Registrar] see that side of it, and he (Registrar) agreed. He (Registrar) reviewed the patient… [The decision made should have] “been made as soon as they came in to hospital; of not to do any more, and to make them comfortable. And then as soon as that decision was made, everything just became a lot calmer, and the family were happier, the patient was happier. It was just a shame that it took, kind of, the whole day for that to happen (W101FP).
Was it a good ethical decision or was it just good medicine?… is a bit of a challenge but it probably became good medicine because it was a good ethical decision (WX09).
Motivation (to Initiate the Process and to Act to Achieve the Conclusions Reached by the Process of Deliberation)
So, as a decision-maker we are pushed [in] different ways … our organisations pulling from us, the patient, the family, we have our own knowledge…. they are pulling in different directions. Sometimes they are all in the same direction which is good and that makes it easy in these cases, but sometimes they are pulling in different directions…I go for what was best for the patient and [in] agreement with the patient (WX04).
Lots of factors that come into play. It’s what the situation is, what is the state of the patient, where if I don’t make a decision, what will happen to the patient, basically? What will be the consequence of the decision that I will be making? If I don’t make a decision, then if I delay the situation, what would happen to the patient? (BX04).
You have to be motivated in the first place to try to get to the right decision…. then motivation comes in recurrently [throughout] the process, because what you think is the best decision in the circumstances, that may not be what the organisational best decision might be- so all they really care about is hitting a target, they kind of don’t care how you get there. So, there are pressures on staff to perform and to make certain decisions, which are not necessarily congruent with good patient care” (Int3-02). Furthermore: “It is essential to do what is in the best interest of the patient and for this it helps to be able to understand your values, so you are motivated to do the right thing for the patients (Int3-02).
So they’re not just a heart that’s been damaged with the rest of the body attached to it; we’ve got to look at the whole picture and the cardiologists I’ve had debates with have always been very happy to take on board that holistic perspective and see the limitations of their treatment. And have not had a problem in going off protocol when there’s clearly a best interest’s issue (BX05).