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Ethical Gray Zones


 

A distraught daughter demands you place a feeding tube in her father, your patient, who has not eaten in three days. The patient’s advanced dementia, anti-coagulation therapy, and other co-morbidities suggest such a move may not be in his best interest. How do you respond?

Ethical dilemmas rarely are simple or clear cut. They often involve revisiting the same issues time and again. That’s where an ethics committee comes in, says Maj. Heather Cereste, MD, U.S. Air Force, co-director of the geriatric medicine service and chair of the bioethics committee at Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas.

Ethics committees provide oversight and assist the institution in creating policies to guide staff through ethical dilemmas, Dr. Cereste says.

“Our job at the ethics committee—and we try to make this very clear—is not to solve people’s problems or dictate care,” she says. “Our job is to provide a perspective and a way of thinking about an issue to better equip people to get through it.”

Though it seems straightforward, the notion is fraught with myriad complications.

A Range of Issues

Pediatric Hospitalist Sheldon Berkowitz, MD, medical director, Minneapolis Children’s Clinic (MCC), Children’s Hospital and Clinics of Minnesota, has been involved with ethics issues for 24 years. He currently is the ethics committee chair at MCC. In his experience, he says “most [ethics committee] consults come from intensive care settings, relating to life-and-death issues.”

The issues become trickier for patients from cultures with specific traditions and beliefs surrounding death. Anita Gandhy, MD, a hospitalist board certified in hospice and palliative care, works at Saint Francis Memorial Hospital in San Francisco. The family of a patient she was treating wanted to continue care for its loved one despite the fact the patient was dying. “I later found out that a baby had recently been born into the family,” Dr. Gandhy says. “In the Chinese culture, if someone dies around the time that a baby is born, that spirit will follow the baby. So the family’s desire to prolong care was consistent with their cultural beliefs.”

Ethical dilemmas surface in a variety of situations—not just related to end-of-life treatment—and between a variety of parties: patient surrogates and medical staff, members of the care team, patients and family, or among family members themselves. Physicians will face many types of conflicts:

  • Who makes decisions regarding the rights and preferences of unidentified patients without designated surrogates or advance directives;
  • Whether to allow medical training on the newly dead;
  • Whether to agree to requests for exorbitant or unorthodox treatments;
  • Whether family members can ably deliver home care for a patient who is being discharged; or
  • Whether to grant sterilization requests from families of adolescent children with Down syndrome.1

Underutilized Service?

With such a wide swath of potential ethical dilemmas, it would seem intuitive for physicians to use an ethics committee when one is available. Yet, a 2005 survey of 600 U.S. hospitals by The National Center for Ethics in Health Care tells a different story. The survey found 81% of the general hospitals responding to the survey had ethics consultation services, and 100% of hospitals with more than 400 beds had such services. However, the staff sought the ethics consultation services a median of only three times in the year prior to the survey.2

Hospitalist Olivia Wendy Zachary, MD, has worked for two years at California Pacific Medical Center in San Francisco. In that time, she has requested a total of four ethics consults. One recent consultation helped her determine the source of durable power of attorney for a patient who was a prisoner and who, because he was a felon and a ward of the state prison system, could not make his own healthcare decisions.

There are other situations, however, when Dr. Zachary refrains from asking for an ethics consult. For example, as a geriatrician conversant in the potential adverse outcomes of tube feeding patients with dementia, she makes the judgment calls in these instances.

“I feel very comfortable giving family members the data, in a way that they can understand, on the conflicts of tube feeding in demented patients,” Dr. Zachary says. “The role of the ethics committee, in my opinion, should be to answer conflicts for which you do not have the answers. … If that’s beyond your expertise—if you don’t know the studies and aren’t a geriatrician—then in that case, it might be appropriate.”

In other words, don’t call the ethics committee because you don’t have the time to clearly communicate with the family.

Call on the Committee

Medical ethics dilemmas aren’t always as straightforward as knowing the possible negative consequences of placing a feeding tube in a dementia patient. So when should you call on the ethics committee? Physicians at St. Joseph’s Hospital in St. Paul, Minn., fill out an ethics consultation request form to help the hospital determine the need for the consult.

Robert C. Moravec, MD, medical director, director of hospital medicine, and chair of the ethics committee at St. Joseph’s, says the form was created to prevent physicians from requesting consults prematurely, before they have attempted a family care conference or fully understand the issue at hand. For example, providers occasionally request ethics consults when the problem really is poor communication.

“Sometimes, when our ethics committee is consulted, we discover that there is so much emotional energy going into the issue that the participants are simply not communicating,” Dr. Cereste says. “We can help them identify that.”

Other times, the issue lies in a conflict between the physician and the patient’s family. The physician may want to move from aggressive care to a pain and palliative care approach. The family, of course, wants to stay the aggressive course. It’s not the committee’s job to resolve this conflict, Dr. Berkowitz cautions. “The role of the ethics committee should be helping to identify, delineate, and resolve ethics issues,” he explains. “The committee should not be there simply to help the attending physician accomplish their goals.”

Committee Credibility

Even if physicians know when to ask for help from an ethics committee, they only will do so if they trust the enterprise, Dr. Moravec says. Using a multidisciplinary approach has worked at St. Joseph’s, where the ethics committee is comprised of nursing clinical directors, physicians, social workers, chaplains, hospice and palliative care directors, and even dietitians, who meet monthly.

When the St. Joseph’s ethics committee convenes, members fill out a multi-page record for each patient. In addition to a summary of the patient’s medical history, goals of treatment, preferences, and expected quality of life with proposed treatments (or withdrawal thereof), the record documents the committee’s conclusions, Dr. Moravec says. One copy of the document gets incorporated into the patient’s chart, one is sent to hospital administration, and a third gets channeled to the hospital system’s organization-wide ethics committee. This reporting through the medical staff fosters physician buy-in, Dr. Moravec says.

Physicians are less likely to use the consultation services if they feel the ethics committee doesn’t have teeth, says Rachel George, MD, MBA, hospitalist at Aurora St. Luke’s Hospital in Milwaukee, and regional director of five west coast hospitalist programs for Cogent Healthcare, Inc.

The same is true for one Southern California hospitalist who preferred to remain anonymous. “I rarely call for an ethics consult because they’re rarely helpful,” she says. “Generally, the issues we bring to the ethics committee are those where the family is pushing us to provide care we think is futile, and the ethics committee really doesn’t make a decision. You don’t get the backup you need, and you end up very frustrated.”

Sometimes, the California hospitalist continues, the family needs permission from the hospital to halt futile care. Without a durable power of attorney, the care team may find itself bowing to the wishes of one family member—the outlier—who insists the patient be kept alive with aggressive measures. The inpatient palliative care team often fills the ethics gap, helping the medical team discuss end-of-life issues, goals, and desires with the family. Hospitalists, she says, sometimes need an authoritative body to say, “It is no longer ethical to do this to this patient.”

“Having a hospital committee say it’s OK to withdraw a feeding tube or stop dialysis gives a comfort level to physicians,” Dr. Moravec says, “especially if the committee involves clergy, as well as administration. That is powerful support for that doctor.”

Med Students & Residents

The key to making ethics committees more effectively and widely used is education, Dr. George says. “We need to be educating our medical students and residents a lot more aggressively than we are right now,” she asserts. “How to talk with families about end-of-life issues, what is appropriate or inappropriate care, how should you be using your ethics committees—none of that is taught.”

At Children’s Hospital and Clinics, Dr. Berkowitz meets with residents and medical students every six weeks to discuss cases with ethical dilemmas. He says house staffers have little background or experience with ethics. The American Medical Association’s Liaison Committee on Medical Education 2007-2008 survey of 126 U.S. medical colleges found medical ethics was included in one required course at all 126 colleges, and was an elective course in 61. For some perspective, a course in end-of-life care was required at 124 schools and was an elective at 69. A course in palliative care was required at 120 schools, and was an elective in 60.3

Dr. Berkowitz agrees outreach is one solution. “The longer you have an ethics committee available and doing consultations in an institution, the more you expand the knowledge about how to handle problems,” he says. “People who may have previously requested an ethics consult may now have the skills and ability to handle these issues on their own, without needing to call a consult.”

Dr. Gandhy, of Saint Francis Memorial, believes such additional knowledge helps her focus on a patient’s family, not her own plan. “If the family is not ready to withdraw the care, I realize that forcing my agenda on them can also cause suffering,” she says. “When I change my focus to ask, ‘What is going to help the patient and the family?’ sometimes I don’t even need the ethics committee, because I am then able to address the family’s concerns.”

And that’s when everybody gains. TH

Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.

References

1. Snyder L, Leffler C;, for the Ethics and Human Rights Committee, American College of Physicians. Ethics Manual. 5th ed.,2005.

2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007 Feb;7(2):13-25.

3. Barzansky B, Etze SI. 2007-2008 annual medical school questionnaire part II. JAMA 2008;300(10):1221.

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