The Work and Issues for Clinical Ethics Committees: Some Examples
Clinical ethics is the ethics of how medical care and treatment of patients is carried out by the various responsible professionals and others. Currently, the practice of clinical ethics is carried out in hospitals and nursing facilities by a hospital ethics committee or some committee in these other facilities. Multidisciplinary clinics may also have a committee but physicians and their patients in independent office practice have no direct consultation regarding ethical issues except hospital ethics committees may take on their requests.
The consultative component of a hospital ethics committee is made up either by a single consultant, so-called “clinical ethicist” or by consultative ethics committee made up of 3 or 4 members of the main committee.
The role of the consultation is toward reviewing the history of a case, assessing conflicts or concerns and then providing the stakeholders (physicians, nurses, patients, family members, hospital administration and other staff members) with education of the ethics and the laws applicable to the case and the ethical alternatives as the committee attempts to mediate any conflicts.
There are a host of issues that currently would be and should be considered in the domain of clinical ethics committees. Jeffrey Spike, professional ethicist and teacher, has outlined a series of 22 such issues.
1. disputes about a patient’s decision making capacity
2. choosing the right surrogate for an incapacitated patient
3. deciding surrogate decision making standards
4. interpreting advance directives
5. disagreements among staff or family members
6. questions about withholding or withdrawing treatment
7. end of life options of last resort
8. difficult and noncompliant patients
9. patients refusing beneficial treatment
10. negotiating futility (requests for non-beneficial treatment)
11. negotiating complementary and alternative medicine
12. patients’ rights for vulnerable groups (Mentally Retarded Developmentally Disabled, illegal immigrants)
13. the rights of minors as patients and the role of their family
14. issues concerning pregnancy, termination, and delivery
15. what to include in full disclosure for informed consent
16. informed consent for HIV testing and surrogate tests
17. PVS, ‘Brain Death’ and transplantation
18. disclosure of mistakes
19. ‘Quality of Life’ and Disability
20. safe discharge plans vs. right to live at home with risk
21. deciding when (or whether) to call state agencies
22. uncertainty about health law or hospital policy
There are more, nevertheless this list is good for a discussion on this thread. A number of these issues have already been discussed in one fashion or another on a number of the over 670 topics on this blog. I thought, however, I would like to put a potpourri of them on one thread and have the visitors ask questions about any of them and discuss my or others responses. Many of these issues have no absolute right or wrong solutions, some have established consensus of ethical opinion or written state or federal laws to follow. Not all these issues are fully understood by the public or by physicians. Pick one and write what your suggestion would be to an ethics committee on how the committee should handle the issue. ..Maurice.
posted by Maurice Bernstein, M.D. @ 11:20:00 PM
5 comments
5 Comments:
I am doing a paper on the ethics committe specifically for my hospital and comparing to other hospitals. No where am I finding information as to when the hospital ethics committee moves forward with an official proceeding with the courts. How and why does that come about and what is the process involved?
The courts are available as the last resort. Virtually all ethics dilemmas and conflicts are settled by the parties involved ("stakeholders") with education and facilitation by the hospital ethics committee. It would only be if no settled decision could be reached that the courts would be involved. In my 25 years of experience in ethics committees in two hospitals, I have never seen a case end up in the court system. Actually, I have read that judges would more likely want the ethics committee to mediate a settlement and decision rather than bring it to the courts.
One use of the court system is to have a court-appointed surrogate to attend to the medical decision making of patients who have no mental capacity at the time to make their own medical decisions. However, again this generally is felt to be unsatisfactory and the ethics committee may use other means to provide surrogate or other ethical decision-making for the patient. ..Maurice.
We have had three cases since I have worked for the hospital in where I work in which patients were considered unable to make their own decisions, yet it was clear that they weren't accepting of their life. They were trached on a vent in the ICU, one of them for over A YEAR! The ethics committee was very uninvolved. They gave up quite easily because the family was very sure that they wanted to continue treatment, whcih we all felt they should have pursued other options. I mean a year on life support in an ICU. This poor woman ended up losing circulation to her leg and her foot turned black and her toe actually fell off before she eventually died! All the time her son came in and sat at her bedside (she wouldn't even look at him any longer, which we all thought because of him letting her suffer). Couldn't the ethics committee have pursued court action?
Jen R, it is not the "family" making medical decisions for the patient nor is it the hospital ethics committee making a decision for the patient. It is the patient who makes the decision. If the patient at the time has no capacity to make a personal medical decision then it is up to the legal surrogate to make a decision which would be consistent with what the surrogate knows the patient would have made if the patient had the capacity. If there are no legal surrogates and those who know the patient can't come to a common understanding regarding the patient's wishes then the ethics committee can suggest a decision made not on "substituted judgment" (speaking for the patient deciding what the patient would have wanted) but on "best interest" which is a decision made on the basis of what the "average person" who was faced with such a decision would have wanted. If a family was unsatisfied with a decision made on "best interest", the family can take the case to the court system.
In any event, a patient you have described really should be managed in a sub-acute unit and not the Intensive Care Unit. ..Maurice.
Jeffrey Spike, professional ethicist and teacher, has outlined a series of 22 clinical ethics that could come to an ethics committee.
Is anyone familiar with other lists or criteria regarding what issues should come to and ethics committee and what issues might not be appropriate?
Thanks Paul
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