Description Refusals take place across the spectrum of healthcare – from the clinician who refuses to offer treatment believed to be futile, non-beneficial or inappropriate; the patient who spurns a proposed discharge plan; the family who declines to discuss changes in goals of care; the hospital system that decides not to carry certain drugs on its formulary; or the healthcare system that refrains from providing coverage to certain regions or categories of patients. These are some of the many dimensions of “no” that will be explored in this highly interactive program combining case studies, lecture and participant engagement in both plenary and small break out sessions. objectives

Upon completion of this program, the participants should be able to:

Explore common ethical dilemmas occurring at the bedside when health professionals refuse to provide medical treatment to specific patients or categories of patients Examine the moral dimensions underlying refusals of treatment by patients or their surrogates Discuss ethical considerations that arise when healthcare systems limit treatment options or deny care to defined patient populations Introduce resources for statewide networking and dialogue around contemporary issues in clinical ethics

AuDiencePhysicians, nurses, hospital ethics committee members, social workers, chaplains, psychologists, counselors, other health care providers, attorneys, philosophers, clinical ethicists, and students and community members with an interest in clinical ethics

Friday, September 18, 2015Registration 7:30 –8:30 AM Program 8:30–5:00 PM

Early Registration Fee through September 11th:$129 per person

$103 per person for CENNC Professional Member Level, Benefactor Level and Founder Level

$109 per person for CENNC Individual Member Level, and Sponsoring Institution Level

$65 per person for full-time students (proof of student status required at check-in)

Location:MAHEC Mary C. Nesbitt Biltmore Campus121 Hendersonville Rd. Asheville, NC

Friday, September 18, 2015

Saying No: Exploring the Ethical Dimensions of Refusals in Healthcare

Jointly provided by:

AgenDA & objectives

7:30 AM Registration/Check-in with Continental Breakfast (provided)

8:30 AM Welcome/Conference Overview

When Professionals, Patients, or surrogates say “no”: the CliniCal Context

8:45 AM Keynote Address: Medicine Cannot Cure Death: Saying ‘No’ to Requests for Life-Prolonging Treatment Lawrence Schneiderman, MD; Philip Rosoff, MD • Discusspursuingtreatmentsdemandedbythefamilythathavelittlelikelihoodofachievingthegoalsofmedicine • Reviewthegoalsofmedicine • Discusshowtoagreewhenmedicaltreatmentfailstoachievesuchgoals • Determinewhatthephysicianshoulddoandnotdoundersuchcircumstances • Determinetheroleothersshouldhaveinmakingthesedecisions

9:45 Panel Discussion Lawrence Schneiderman, MD; Philip Rosoff, MD; John Moskop, PhD; Christine Coughlin, JD Moderator: J. Clint Parker, MD, PhD

10:30 Break

10:45 Break Out Sessions 1

1A. By Word or By Action: Patients and No | Arlene Davis, JD • Describetheaspectsoftheclinician-patientrelationshipthatarechallengedwhenrecommendationsarenotfollowed • Discusshowthelanguageofnon-complianceandnon-adherence,ortheintroductionofpatientcontracts,candisrupt the relationship • Examinetheidealofsharedgoalsundermoralapproachesthatstemfromvirtue,duty,andfromconsequences • Evaluateoptionstoreframephysician-patientconversations,usingcaseexamples

1B. When Surrogate Decision-makers Say, “No”, How Should Clinicians Respond?|John Moskop, PhD • Reviewthemoralrationaleforrelyingonsurrogatedecisionmakers • DescribetheNorthCarolinastatutoryhierarchyofauthorizedsurrogatedecisionmakers • Identifythreestandardsusedtoguideandevaluatesurrogates’choices • Evaluateoptionsforrespondingtosurrogates’refusalsoftreatment,usingcaseexamples

1C. When Clinicians Say, ‘No’: Conscientious Refusals in Medicine |J. Clint Parker, MD, PhD • Discussdifferentunderstandingsofwhatconscienceis • Presentandevaluateargumentsforcurtailingconscientiousrefusals • Presentandevaluateargumentsforprotectingconscientiousrefusals

Noon Lunch (provided)

When institutions, systems, or soCiety says “no”: the PoliCy Context

12:45 The Promise and Limits of the Affordable Care Act | Jonathan Oberlander, PhD • DescribetheimpactoftheAffordableCareAct(ACA)ontheUShealthcaresystem • ExplainthevariouswaysinwhichtheACAattemptstolimitaccesstoanduseofmedicalcare • AnalyzetheconsequencesoftheACA’slimitsandhowtheywillshapehealthcarereformincomingyears

1:45 Break

2:00 Break Out Sessions 2

2A. When the State Says “No”: Toward Local Solutions in Caring for Undocumented Immigrants | Nancy Berlinger, PhD; Jacob Perrin, MA • Describerestrictionsontheuseoffederalfundswhenapatientisuninsuredandnot“legallypresent”;choicesthatstateshave made concerning the use of public funds to support health care for the uninsured; and the ethical and practical consequences of these policy choices • Exploretheobligationsoflocalhealthcareprofessionalsandorganizationstoremaininguninsuredpopulationsinthecontextof these policy choices, with reference to local solutions in North Carolina and elsewhere in the US • Applylessonsfromexistingapproachestotheanalysisofpracticalproblemsintheirownorganizationsandcommunities

2B. Exploring the Legal Consequences of Saying No | Christine Coughlin, JD • Explorelegalissuesandtheoriesthatmayarisewhenaproviderdeterminesthatapatientorsurrogatedecision-maker’srequest for medical care or services is futile, medically inappropriate, or non-beneficial • Evaluate the various legal sanctions and consequences that may be applied when a provider refuses to offer the medical care or services requested by the patient or surrogate decision-maker; and • Discuss the various sources of applicable law (such as statutes, regulations, judicial decisions) that may be relevant when a provider is considering drafting policies concerning futility or other refusal of medical care or services

2C. Categorically No: “Upstream” Decisions on Screening, Testing, and Treatment | Nancy M.P. King, JD • Reviewtheroleofempiricaldataandpolicyguidancelimitinguseofscreening,testing,andtreatmentregardedasunsafe, non-beneficial, and excessively cost-inefficient • Appreciateanddiscusssocietalinfluencesonaccesstoscreening,testing,andtreatment • Applyethicalandpolicyreasoningtodecisionmakingaboutcategoricaldeterminationsbyinstitutions,providers,andinsurers

3:15 Break

3:30 Panel Discussion: The ‘R’ Word: Rationing Healthcare in America Today Lawrence Schneiderman, MD; Philip Rosoff, MD; Nancy Berlinger, PhD; Nancy M.P. King, JD; William Hathaway, MD Moderator: John Moskop, PhD

4:45 Closing Remarks/Wrap Up

5:00 Adjourn

speAker profiles

Nancy Berlinger, PhD, is a Research Scholar at The Hastings Center. Her research focuses on ethical challenges in health care work,inclusiveofclinicalethics,healthcareorganizationalethics,and related areas of public health and human rights. Her current projects and other research activities address decision-making and care concerning people with life-threatening or chronic illness; access to health care for undocumented immigrants and other low-income migrant workers, ethical challenges in safety-net health care systems; and the ethics of workarounds and other improvised practices for managing problems of safety and harm in health care systems.

Christine Nero Coughlin is a law professor at Wake Forest University School of Law. Her teaching and scholarship are concentrated in the areas of Bioethics, Health Care Law and Legal Analysis and Writing. She is a recipient of the Wake Forest University Teaching and LearningCenter’sTeachingInnovationAward,theJosephBranchAward for Excellence in Teaching, and a multi-recipient of the Graham Award for Excellence in Teaching Legal Research and Writing. She is the Director of the Legal Analysis, Writing and Research Program at the Law School, has an appointment in the Wake Forest University Graduate School of Arts and Sciences, and is a core faculty member for the Center for Bioethics, Health & Society at Wake Forest University School of Medicine.

Arlene M Davis, JD, is Associate Professor of Social Medicine and core faculty in the Center for Bioethics at UNC-Chapel Hill. Her work focuses on clinical and research ethics and draws upon her prior experience in private practice and in pediatric and public health nursing. Davis co-chairs the Hospital Ethics Committee at UNC Health Care and directs its clinical ethics service. In addition to her work in clinical ethics, she is an investigator in the Center for Genomics and Society and a member of the research ethics consultation service at UNC.

Nancy M.P. King, JD, is a professor of Social Sciences & Health Policy at Wake Forest Institute for Regenerative Medicine. She is also the Co-Director for the Center for Bioethics, Health & Society at Wake Forest School of Medicine.

John C. Moskop, PhD, is Professor of Internal Medicine and Wallace and Mona Wu Chair of Biomedical Ethics at the Wake Forest School of Medicine. He chairs the Clinical Ethics Committee at Wake Forest Baptist Medical Center and is a core faculty member in the Wake Forest Masters Degree Program in Bioethics. From 1979 through 2009, he was a faculty member in the Department of Medical Humanities of The Brody School of Medicine at East Carolina University. He is author of more than one hundred articles and book chapters on ethical issues in emergency medicine, death and dying, organ transplantation, the allocation of health care, and other topics in bioethics. Dr. Moskop serves on the Ethics Committee of the American College of Emergency Medicine and is a consultant to the Ethical and Judicial Affairs Committee of the North Carolina Medical Society. In 2013, he was elected Treasurer of the Academy for Professionalism in Health Care.

Jonathan Oberlander, PhD, is Professor and Chair of Social Medicine, Professor of Health Policy & Management, and Adjunct Professor of Political Science at the University of North Carolina-Chapel Hill, where he teaches in the School of Medicine and Gillings School of Global Public Health.

J. Clint Parker, MD, PhD, received his BSE from Duke University, his PhD in philosophy from Rice University, and his MD from the Brody School of Medicine at East Carolina University. He completed his training in internal medicine and nephrology through the Brody School of Medicine. He currently teaches medical ethics at the Brody School of Medicine and practices nephrology at Eastern Nephrology Associates in Greenville, NC. His research interests include moral philosophy and clinical ethics. He currently serves as the chair of the medical ethics committee at Vidant Medical Center in Greenville, NC.

Jacob Perrin, MA, is a second-year medical student at the University of North Carolina-Chapel Hill School of Medicine. He recently completed a joint internship with the Clinical Ethics Network of North Carolina and The Hasting Center on health care access for undocumented immigrants, the topic of his thesis research for his MA in bioethics from Wake Forest University.

Philip M. Rosoff, MD, MA, is Professor of Pediatrics and Medicine at Duke University Medical Center and the Duke School of Medicine. HeistheChairofDukeHospital’sEthicsCommittee,amemberof the Trent Center for Bioethics, Humanities & History of Medicine and a core faculty member of the Duke Science & Society Initiative.His work concentrates on the intersections between clinical medical ethics and healthcare policy. His first book, Rationing is Not a Four Letter Word: Setting Limits on Healthcare was published by MIT Press in 2014. His next book, Drawing the Line: Healthcare Rationing and the Cutoff Problem will be published in late 2016 by Oxford University Press.

Lawrence J. Schneiderman, MD, Professor Emeritus in the Departments of Family Medicine and Public Health, and Medicine at the University of California, San Diego, (UCSD) has had a distinguished career in medicine and ethics. Founding co-chair of the UCSD Medical Center Bioethics Committee, he has been an invited visiting scholar and visiting professor at institutions in the United States and abroad, and is a recipient of the Pellegrino Medal in medical ethics. Schneiderman has written more than 190 medical and scientific articles, chapters, and books, including The Practice of Preventive Health Care (Addison Wesley), Wrong Medicine: Doctors, Patients, and Futile Treatment (with Nancy S. Jecker, Ph.D.) (Johns Hopkins), and, Embracing Our Mortality: Hard Choices in an Age of Medical Miracles (Oxford). He has also written a novel, Sea Nymphs by the Hour (Bobbs Merrill), short stories (Pushcart Nomination) and plays (DramaLogue Award, Beverly Hills Theatre Guild/Julie Harris Award). Dr. Schneiderman is a member of the American College of Physicians (Fellow), American Medical Association, Physicians for Social Responsibility, American Society for Bioethics and the Humanities, American Society of Law and Medicine, Authors Guild, The Dramatists Guild of America, and is Chair of the Editorial AdvisoryBoardofThePhysician’sIndexforEthicsinMedicine.Heconducts empirical research on end-of-life care, and provides ethics consultations and invited talks for a variety of audiences, including academics and practitioners in medicine, law and philosophy, as well as the lay public.

Continuing Medical Education (CME) Credit:

AccreditationThis activity has been planned and implemented in accordance with the accreditation requirements and policies of the North Carolina Medical Society (NCMS) through the joint providership of the Mountain Area Health Education Center, Mission Hospitals and Clinical Ethics Network of North Carolina (CENNC). The Mountain Area Health Education Center (MAHEC) is accredited by the NCMS to provide continuing medical education for physicians.

CreditMAHEC designates this live activity for a maximum of 6.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DisclosureThe Mountain Area Health Education Center adheres to the ACCME Standards regarding industry support to continuing medical education. Disclosure of faculty and commercial support relationships, if any, will be made known at the activity.

CNE:6.75 CNE Contact HoursTheMountainAreaHealthEducationCenter’sDepartmentofNursingEducation is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver bytheAmericanNursesCredentialingCenter’sCommissiononAccreditation.

Participants must attend entire day to receive credit for that day. No partial credit is given for this activity. MAHEC adheres to the ANCC/ACCME Standards regarding industry support to continuing nursing education. Disclosure of presenters, planners, and commercial support relationships, if any, will be made known at the time of the activity. Total credit earned will be determined based on the concurrents you attend.

Continuing Education Units (CEU):The Mountain Area Health Education Center designates this entire continuing education activity as meeting the criteria for 0.7 CEUs as established by the National Task Force on the Continuing Education Unit. This program provides 6.75 contact hours.

creDit

NAADAC:MAHEC is a Provider approved by NAADAC Approved Education Provider Program. Provider #647. Full attendance is required to receive credit from NAADAC. 6.75 hours

NBCC:Mountain Area Health Education Center (MAHEC) has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 5514. Programs that do not qualify for NBCC credit are clearly identified. MAHEC is solely responsible for all aspects of the programs.6.75 hours

Psychologists:MAHECisrecognizedbytheNorthCarolinaPsychologyBoardasan approved provider of Category A Continuing Education for North Carolina Licensed Psychologists. Full attendance at each part is required to receive credit from the NC Psychology Board. 6.75 hours

plAnning committee

Elaine Alexander, MSN, RNC-OB Nurse CE Planner Mountain Area Health Education Center Asheville, NC

Mary Caldwell, MDiv, MA Clinical Ethicist Mission Health Asheville, NC

Arlene M. Davis, JD Associate Professor of Social Medicine Center for Bioethics UNC Chapel Hill Chapel Hill, NC

Dina Gillespie Continuing Medical Education Planner Mountain Area Health Education Center Asheville, NC M. Lisa Hammon, RN, BS, MA Executive DirectorClinical Ethics Network of North Carolina Deb Love, JD, MBA, MA Director of Bioethics, Corporate Novant HealthWinston-Salem, NC

John Moskop, PhD Professor of Internal Medicine Wallace and Mona Wu Chair of Biomedical Ethics Wake Forest School of Medicine Winston-Salem, NC J. Clint Parker, MD, PhD Teaching Assistant Professor, Medical Ethics East Carolina University Greenville, NC Philip M. Rosoff, MD, MA Professor of Pediatrics and Medicine Trent Center for Bioethics, Humanities & History of Medicine Duke University

meDicAl course Director John Watford, MD Mission Hospitals Asheville, NC

Elaine Alexander, MSN, RNC-OB Nurse CE Planner Mountain Area Health Education Center Asheville, NC

Mary Caldwell, MDiv, MA Clinical Ethicist Mission Health Asheville, NC

Arlene M. Davis, JD Associate Professor of Social Medicine Center for Bioethics UNC Chapel Hill Chapel Hill, NC

Dina Gillespie Continuing Medical Education Planner Mountain Area Health Education Center Asheville, NC M. Lisa Hammon, RN, BS, MA Executive DirectorClinical Ethics Network of North Carolina Deb Love, JD, MBA, MA Director of Bioethics, Corporate Novant HealthWinston-Salem, NC

John Moskop, PhD Professor of Internal Medicine Wallace and Mona Wu Chair of Biomedical Ethics Wake Forest School of Medicine Winston-Salem, NC J. Clint Parker, MD, PhD Teaching Assistant Professor, Medical Ethics East Carolina University Greenville, NC Philip M. Rosoff, MD, MA Professor of Pediatrics and Medicine Trent Center for Bioethics, Humanities & History of Medicine Duke University

$129 per person

$103 per person for CENNC Professional Member Level, Benefactor Level and Founder Level

$109 per person for CENNC Individual Member Level, and Sponsoring Institution Level

$65 per person for full-time students (proof of student status required at check-in)

registrAtion

After the early registration deadline, the total cost will be the registration fee + $15.00.

Registration fee includes light breakfast and lunch.

Cancellations received at least two weeks in advance of the program date will receive a full refund unless otherwise noted. Cancellations received between two weeks and up to 48 hours prior to the program date will receive a 70% refund or full credit toward a future MAHEC program unless otherwise noted. No refunds will be given for cancellations received less than 48 hours prior to the program date. Substitutes are welcome but please notify us in advance of the program. All cancellations must be made in writing (fax, mail, or email).

Full payment must accompany all registrations unless a payment plan has been approved in advance. Registrations received without accom-panying payment will not be processed.

Early Registration deadline: September 11, 2015

Registration fees:

Directions will be included with your confirmation letter.

Want to register? Online Registration: www.mahec.net

Or use the registration form at right and return by fax or mail:

Fax Registration: 828-257-4768 Mail: MAHEC Registration 121 Hendersonville Rd., Asheville, NC 28803

Have a question?

Registration Information: 828-257-4475

Special Services: 828-257-4485

loDging

DoubleTree Hotel 115 Hendersonville Road Asheville, NC 28803 828-274-1800

A block of rooms has been reserved for Ethics Conference attendees . Reserve your overnight accommodations online or by calling 828-274-1800. Be sure to ask for the “MAHEC Ethics Conference”.

Click here for online reservations for the MAHEC room block.

Book by August 26th to reserve your room.

Biltmore Village Lodge 117 Hendersonville Road Asheville, NC 28803 828.277.1800

A special rate has been negotiated for Ethics Conference attendees. Reserve your overnight accommodations by calling 828-277-1800. Be sure to ask for the “MAHEC Ethics Conference”.

If you have additional questions or concerns regarding your room reservation, please contact Karen Lambert at 828.257.4481 or karen.lambert@mahec.net

Both hotels are located just one block from the entrance of the historic Biltmore Estate and adjacent to the MAHEC Campus. They are within walking distance of the historic Biltmore Village offering quaint shopping, an assortment of dining opportunities and stunning architecture.

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BREAK OUT SESSION SELECTIONS

Break out Session #1 (Choose one) 1A. By Word or By Action: Patients and No

1B. When Surrogate Decision Makers Say, “No”, How Should Clinicians Respond

1C. WhenCliniciansSay,‘No’:ConscientiousRefusalsinMedicine

Break out Session #2 (Choose one)

2A. When the State Says “No”: Toward Local Solutions in Caring for Undocumented Immigrants

2B. Exploring the Legal Consequences of Saying No

2C. Categorically No: “Upstream” Decisions on Screening, Testing, and Treatment

EARLY REGISTRATION FEES thru Sept. 11, 2015:

FEES after Sept. 11, 2015:

Send completed registration form to: MAHEC Registration 121 Hendersonville Rd.,Asheville, NC 28803 Fax to 828-257-4768 #16ID002/46804

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Friday, September 18, 2015Saying No: Exploring the Ethical Dimensions of Refusals in Healthcare

$129 per person

$103 per person for CENNC Professional Member Level, Benefactor Level and Founder Level

$109 per person for CENNC Individual Member Level, and Sponsoring Institution Level

$65 per person for full-time students (proof of student status required at check-in)

$144 per person

$118 per person for CENNC Professional Member Level, Benefactor Level and Founder Level

$124 per person for CENNC Individual Member Level, and Sponsoring Institution Level

$80 per person for full-time students (proof of student status required at check-in)