Pulse
Tough Calls
Hospital ethics committees help patients, family, and staff wrestle with medical decisions.
But that’s only part of their job.
A middle-aged man, who for years has pronounced to his family that he “just wants to be left to die,” drinks heavily, falls asleep, and accidentally sets his house on fire with a burning cigarette, leaving him hospitalized with severe but potentially treatable burns and injuries. A victim of a motorcycle accident is about to be pronounced brain dead, when his fiancée suddenly asks for a sampling of his sperm so she can bear his child. A mother and father must decide whether to allow their terminally ill daughter to die a natural death or to pursue aggressive, costly, and painful treatments to keep her alive for a little while longer.
These may sound like plots from the television series “ER,” but they are actual scenarios that have played out in hospitals in Minnesota. Such cases pose questions that don’t have clear-cut answers: Should family members decide to turn off life-sustaining equipment if their loved one isn’t likely to emerge from a coma and has no document indicating his or her wishes? At what point should a patient who is running out of options agree to stop aggressive treatment? What should staff do when family members can’t agree on how to care for a loved one?
It’s in those gray areas of medicine that hospital ethics committees are called on to help patients, their loved ones, and staff make decisions that are in the best interest of everyone involved. “We’re not just going to parachute in and start telling people what to do,” says Helen Wells O’Brien, chair of the ethics committee at Gillette Children’s Specialty Healthcare in St. Paul and a staff chaplain there and at Regions Hospital. “We’re here to structure a safe conversation so people can talk about their values and beliefs in relationship to medical care and the big medical decisions they are making for themselves or their loved ones.”
Situations Vary
Virtually every hospital in Minnesota has at least some mechanism for handling ethical dilemmas. In 1992, the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) made having such a process a requirement for accreditation. Today, about half of Minnesota’s health care systems are JCAHO-accredited and, thus, have ethics committees or consult services in place at their hospitals, according to the Minnesota Hospital Association. Many more that are not JCAHO-accredited have such committees as well.
Not the Ethics Police
Patients, family members, physicians, and others can call on a hospital’s ethics committee any time they’re wrestling with a difficult issue regarding care or treatment.
Although each hospital’s committee has its own way of dealing with cases, when doing a formal consultation, several members usually meet with the patient, his or her loved ones, the physician, and others involved in the patient’s care. Afterward, they convene to discuss the issue, taking into consideration ethical principles, the patient’s values and preferences, and religious directives, if applicable. The committee members then recommend a range of appropriate actions, a report about which goes to the person who called for the consult and into the patient’s medical record. The recommendations are strictly suggestions. The patient or his or her surrogate ultimately makes the decision.
Most hospital ethics committees in Minnesota are composed of 12 to 30 people—physicians, nurses, social workers, clergy, former patients, or family members of patients. Some members may be professional ethicists; others complete training after they come on board through such institutions as the University of Minnesota’s Center for Bioethics or the Minnesota Center for HealthCare Ethics.
“The point of the committee is to have some people who have specific training, but then also to bring together a group of people with a wide variety of views,” explains Don Brunnquell, Ph.D., director of the office of ethics at Children’s Hospitals and Clinics of Minnesota.—J.M.
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The situations ethics committees and consult services encounter can vary according to the type of institution they serve. At Hennepin County Medical Center, a Level 1 trauma center in Minneapolis, ethics cases often involve critically ill or injured patients. At Regions Hospital in St. Paul, the committee might discuss who the decision-maker is for an incapable patient. At Children’s Hospitals and Clinics of Minnesota, where the ethics service assists with more than 50 cases a year, many consultations involve end-of-life care for a terminally ill child.
Individual variables matter in every case. “What we try to do is to go back to the broad picture of what people’s goals are and what they value to try to get a sense of what makes life worth living to them, for example, or what makes them want to get out of bed in the morning,” says Martha McCusker, M.D., a geriatrician and chair of the ethics committee at Hennepin County Medical Center. “Oftentimes, when you factor in the patients’ preferences, their comorbidities, and all the other aspects that spice it up, there is really only one best course of action. What we do is help to identify if that approach happens to be ethically appropriate.”
Enter Faith
For the most part, committee members help people arrive at ethically sound decisions by using principles that were adapted by medical ethicists in the 19th century—beneficence, nonmaleficence, autonomy, and justice. But sometimes religious beliefs play a significant role.
At St. Gabriel’s Hospital in Little Falls, the ethics committee follows a specific set of ethical or religious directives set forth by the United States Community of Catholic Bishops. “That makes our ethics community a little different because it is focused on what Catholic bishops have made as a statement,” says Lisa Hanowski, R.N., director for home care and hospice and chair of the ethics committee. “My thinking is that we as an ethics committee have an advantage in our facility because we have some additional guidelines to go by.”
According to Hanowski, if the family and physician disagree with what a Catholic hospital ethics committee recommends, the patient, family, and physician “still retain the right to do as they see best.” If the patient or family should be seeking a treatment that falls outside of the church’s beliefs, Hanowski says the physician would refer them to another hospital.
An Underused Resource?
Although ethics committees are a resource at most hospitals, patients, family members, and staff may not always be willing to seek them out. A study of 500 hospitals published in the February 2007 American Journal of Bioethics showed that hospital ethics committees handled a median of three cases per year. Although the number of ethics consults in the Minnesota hospitals in this story are much higher (case loads ranged from six to 52 cases per year), getting physicians and others to understand the importance of ethics committees is an ongoing challenge.
“Are we being underutilized? Yes, in the sense that not every physician recognizes an ethical issue as being an ethical issue, and so there is always room for improvement in that respect,” says Don Postema, Ph.D., chair of the ethics committee at Regions and HealthPartners and ethicist-in-residence at Gillette. “Physicians are trained to be the final decision-makers, to accept responsibility for their patients’ well-being. Sometimes the sense of expertise carries them beyond what they are able to see as an ethical issue.”
To increase visibility, ethics committees take on duties that extend beyond consultations. Most also help craft policy recommendations and provide education to staff, patients, and the community. At HealthPartners and Regions, for example, Postema and his team created a policy on organ donation after cardiac death and have made presentations on such issues as guardianship for incapacitated patients, vaccine rationing during a flu pandemic, the organization’s responsibility for uncompensated care, and ethical considerations for palliative or terminal sedation. Don Brunnquell, Ph.D., director of the office of ethics at Children’s, has created information sheets on topics such as “allow natural death” directives (similar to do-not-resuscitate orders) and adolescents’ involvement in health care decision-making. O’Brien and Postema attend staff meetings and hold quarterly seminars at Gillette. They also participate in rounds at the hospital, allowing physicians and nurses to informally consult with them about cases that may have ethical considerations.
“Part of our responsibility as ethics committee members is to integrate ourselves into daily patient care,” O’Brien says. “It encourages all of us on staff to be better listeners, to continually pay attention to the values and beliefs of patients and families when they are struggling with major medical decisions.”
The ultimate result of these efforts—what many ethics chairs call “preventive ethics”—could be fewer crisis consultations. Postema believes that could be one measure of success. “When you’ve developed solid policies and done the education, staff may only need to make a quick phone call to know they’re making ethically appropriate decisions. That’s when we would know we’re doing our job well.”—Jeanne Mettner