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
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.