BLOOMINGTON — A chronically ill patient is dying and his physician at the hospital has determined that the patient is not likely to recover.
The patient has no advance directive specifying what steps should be taken when he can no longer make his own health care decisions and who should make those decisions on his behalf. His family has not come to terms with the patient dying.
“The family says ‘Do anything to keep him alive,’” the Rev. Mollie Ward said in her scenario.
The patient experiences sudden cardiac arrest and CPR is performed to help restore blood flow and defibrillation is done to try to restore heart rhythm. But the steps work only briefly, meaning CPR and defibrillation must be performed again.
The patient is frail and further chest compressions are likely to break ribs, putting the patient in more pain, Ward said. The medical professionals attending to the patient question the value of continued treatment that merely will delay the inevitable death.
“The staff may feel ethically uncomfortable continuing this line of care that could further harm the patient,” Ward said.
At that time, a doctor or nurse may call for an ethics consultation with a member of the hospital’s ethics committee.
While largely unknown to the average person, Central Illinois hospitals have ethics committees whose responsibilities include being able to respond to emergency ethical concerns.
The scenario described by Ward — a member of the Advocate BroMenn/Eureka Ethics Committee — is an example of an ethical emergency that committee members address from time to time. Dr. Paul Pedersen — a member of the OSF St. Joseph Medical Center Ethics Committee — provided a similar example.
“We have a trained ethics triage person (a BroMenn staff member and member of the ethics committee) on call for ethics consults 24/7,” said Ward, an Episcopal priest who is Advocate BroMenn manager of spiritual care and clinical pastoral education.
In Ward’s scenario, the ethics triage person would talk with a representative of the staff and family to try to get the two sides to come to agreement that does not violate hospital policy.
Generally, an agreement happens. If the two sides don’t come to agreement, the ethics triage person can call for an emergency meeting of the entire ethics committee, which consists of about a dozen people representing doctors, nurses, social workers, chaplains, clergy and the community.
The frequency of those meetings varies but they happen about once a month. Some committee members join via conference call.
“We can put a committee meeting together in 30 minutes,” said Linda Slotky, a St. Joseph nurse and chairwoman of the hospital’s ethics committee.
The committee would develop a consensus opinion and recommend that course of action to the hospital administrator.
Ethics committees aren’t new. For example, Advocate BroMenn in Normal, Advocate Eureka in Eureka, OSF St. Joseph in Bloomington and OSF Saint James-John W. Albrecht Medical Center in Pontiac have had ethics committees for at least 20 years.
“It is our goal to help people to do the right thing when it comes to making medical decisions and providing treatment,” Ward said.
“At the heart of any discussions is the patient,” said Paula Corrigan, chairwoman of the ethics committee at Saint James, where she also is vice president and chief financial officer.
Availability of ethics consultation is required by regulators, said Pedersen, also St. Joseph vice president and chief medical officer.
“We deal with a diverse population and different belief systems,” Pedersen said. “Trying to understand that — while providing high quality, consistent medical care — can lead to questions.”
Many ethics committees’ emergency responses involve end-of-life decisions affecting patients who don’t have advance directives. In fact, the awareness work of ethics committees in recent years is one reason that advance directives and end-of-life planning have become more popular, committee members said.
“The single biggest category of concern has to do with end-of-life care and the aggressiveness of treatment, particularly when a person does not have an advance directive,” Ward said. When there isn’t agreement among family members and medical professionals on how to proceed, ethics committee members get involved.
“We try to facilitate conversation,” Ward said.
Examples of other scenarios in which ethics committees get involved:
w Medical professionals caring for a patient determine that he or she isn’t mentally capable of making his or her own health care decision. A committee member gets the patient’s family involved. If the patient has no family, the committee may bring in an administrative law judge to conduct a hearing on the patient’s competency, Pedersen said.
w A Jehovah’s Witness has been in a traffic crash and needs a blood transfusion to live. Witnesses believe blood transfusions are not allowed in Scripture.
In that case, an ethics committee member will explain to the patient and family that delaying treatment could be fatal, Pedersen said.
As ethics committee members deliberate, they consider the patient’s medical condition, goals and risks of treatment, probability of success, patient preferences, whether the patient understands his or her options, whether there is an appropriate surrogate for an incapacitated patient and patients’ religious beliefs and cultural factors.
“An advance directive has priority,” Ward said.
“If the patient has an advance directive, we honor that,” Slotky said.
“The underlying goal is to provide an ethical response for patients and providers that meets the ethical and religious directives of our institution,” Pedersen said.
Catholic hospitals are bound by the ethical and religious directives of Catholic health care systems, Slotky said. “If a patient wants to terminate a pregnancy, we won’t do that here.”
But, “there is a misperception that Catholic institutions keep people alive at all costs and that’s not the case,” Slotky said. “It’s what is ethically correct according to our religious directives as well as what’s right for the patient.
“We want to support the family but the patient comes first,” Slotky continued. “With ethics, sometimes it’s not always black and white.”
In addition to responding to ethical emergencies, committees also meet about every other month to discuss their response to emergencies and to review proposed hospital policy changes and new regulations. Committees also encourage awareness of ethical issues. For example, the St. Joseph committee offers two workshops a year on ethical issues for hospital staff, Slotky said.
Ethics committees and ethics consultations re-assure family members that decisions aren’t being made in a vacuum and that everyone’s opinion is validated, Slotky said.
“It gives the family peace of mind.”
Anyone — a doctor, hospital staff person, patient, family member or visitor — can request an ethics consultation at a hospital. If you have an ethical concern, discuss it with your doctor or nurse. If your concern isn’t resolved, tell them you would like an ethics consultation or that you’d like to speak with a representative of the hospital’s ethics committee.
SOURCES: Paula Corrigan, Dr. Paul Pedersen, Linda Slotky, Rev. Mollie Ward