Ethical Issues in Terminal Health Care
Part Two: Ethics Committees
How regional healthcare professionals wrestle with tough decisions.
by Ed Newman
For a week the two sisters had been at an impasse. Maggie Nelson, who had
been taking care of her father at home for the past five years, felt his
time had come and said dad "is ready to go home and be with the Lord."
Her sister Lois, however, was outraged that the physician and Maggie weren't
planning to do everything possible to keep dad living. Dr. Orr, the primary
physician treating their unconscious father, regretted that no written documents
had been drawn up to present Mr. Nelson's actual wishes regarding his treatment
By late Thursday, it became evident to Dr. Orr that a critical decision
needed to be made. Because Lois continued to insist that the "everything
possible" should be done and Maggie believed her father would not have
wanted that kind of intervention, Dr. Orr called for an ethics consultation.
The meeting took place Friday morning. An ethics team sub-committee of two
doctors and a social worker met with Dr. Orr and the two sisters. For twenty
minutes Dr. Orr presented the special difficulties of the case to the ethics
team. Then Maggie explained how she and her father had talked many times
about some of these very issues, how he did not want CPR or to be hooked
up to machines. Maggie was angry because it seemed unfair that Lois might
have her way because current laws favor the most conservative care option
when there is disagreement. "It's not what Dad would have wanted,"
she said almost bitterly.
For a while, the mood was tense and uncertain. An ethics team member then
began to present some of the options and their implications. She ended by
saying, "You realize, Lois, that your father will never regain consciousness."
Lois began crying and reached out for her sister's hand. "Maggie, I'm
sorry I've been so impossible to deal with in all this." Lois then
told how she regretted having been so far away while dad was sick. "If
only I could have had one more chance to make things right with dad before
he died. That's all I really wanted."
In the end, with the help of the ethics team, the physician and the family
were able to agree on a course of treatment which they could all feel comfortable
Last month we looked at some of the dilemmas facing physicians, patients
and their families as a result of recent advances in health care. In response
to these complex issues Americans have seen the development of the hospice
movement, living will legislation, and a greater understanding of cancer
and pain management. Another important development -- one that has not received
a great deal of media attention but which is playing a growing role in our
health care today -- has been the creation of hospital ethics committees.
When the two children of an unconcsciouse dying patient disagree on a course
of treatment -- as in the above hypothetical account -- what's a doctor
According to an article in Healthcare Executive magazine, more than half
the nation's hospitals have created ethics committees for the purpose of
understanding and addressing the various ethical dilemmas health care professionals
are facing today. On the local scene, all three Duluth hospitals and an
increasing number of nursing homes have ethics committees. This article
is about the role these committees play in decisions made in our local hospitals,
clinics and nursing homes.
According to Barb Elliott, Ph.D. and a director at the Family Practice Center
who serves on all three hospital ethics committees, the committees serve
three basic functions. "The first is education," said Dr. Elliott.
"Education of its staff as well as its patients and the community about
the ethical dimensions of health care.
"The second is policies, making sure the policies in that institution
"The third is to review cases and care that is provided in the institution
and to work as a consultant in those times when the cases are difficult."
The people who serve on ethics committees come from many walks of life,
though in many instances a majority are doctors.
Pat Diessen, Director of Social Services at the Benedictine Health Care
Center described the center's committee. "In general we've tried to
get a balance on the committee. We have an education person on the committee,
the assistant director of nursing, our medical director Dr. Peasly, Fr.
Brennan, who is also a resident but who represents pastoral care, a nun,
an ethicist, a representative family member and our administrator. It seems
to be a pretty good mix."
Ms. Diessen noted that the Benedictine's ethics committee is still evolving.
"The first portion of our ethics start-up was involved more or less
with defining the terms, and (defining) what the issues are -- like Benefit/Burden
-- and those kinds of things. It takes a while for an ethics committee to
start up and define the issues for themselves."
How do ethics committees influence hospital medical decisions? Dr. Tom Elliott,
an oncologist at the Duluth Clinic who has served on a commitee in the past,
explains. "I would guess that half the members are doctors, so that
you have eight or ten members on each committee at each hospital that are
physicians, and then there are nurses, lay people, clergy, lawyers, behavioral
scientists and ethicists. The committees provide a forum for the exchange
of ideas. They follow the literature from all of the disciplines -- the
legal literature, the religious literature, the scientific literature, the
political literature -- and meet on a regular basis to discuss the difficult
issues. So they are sort of a think tank that keeps abreast of all these
The knowledge and understanding that has been gained through study and discussions
within the committee is then spread by various means through the medical
community -- to physicians and nurses. "Some of it simply by talking
to people," Dr. Elliott said. "Some of it by bringing an issue
to the entire medical staff, inviting the medical staff to come and listen
to a presentation on an ethical issue that is confronting the hospital or
the doctors and the nurses on a regular basis." They also issue position
papers, and share what they have discussed in medical staff newsletters
and committee reports or minutes.
In addition to these activities, Dr. Elliott added, committee members are
also available as formal or informal consultants to doctors dealing with
difficult issues. When an ethics committee consultation is called for, "members
of that committee will meet with all involved in that particular case, the
physicians, the nurses, the patient, the family, and others that may have
any direct concern, ...to try and solve the ethical dilemma that's facing
the people at that time."
Each institution has its own way of structuring their ethics committee,
so that it fits into their administrative and management style. According
to Doug Lemons, Director of Social Services at St. Luke's Hospital and a
member of the committee there, "About four or five years ago we started
a consultation team in which any physician or staff member of the hospital,
if they had questions about the ethics in a given situation, could ask for
a consultation." The consultation can be requested by anyone involved
with the patient, including nurses, family members or the patient himself
or herself, Mr. Lemons said. At that point, according to the hospital's
policy, the key team leader of the committee is called in and and he or
she reviews the particular case. (On a rotating basis, one of the physicians
on the committee is the key team leader.) "If the feeling is that there
should be a full sub-committee consultation, the patient's physician is
informed that this request has been made."
"And it's really an educational role," Mr. Lemons said. "We
of the biomedical ethics committee do not make the decisions. We play a
consultative role." The one who makes the decision is the attending
physician who is ultimately responsible for the medical treatment, though
always as an advocate for the patient's best interest. The attending physician
hears what we say, and the family hears what we say, and our job is to form
marriages of ideas between people." The consultation helps clarify
a course of treatment by enabling people to see different sides of an issue.
What we have seen here is that ethics committees play a variety of roles
in today's hospitals. Not only have they become a valuable source of ethical
insight and support for hospital and health care staff, committee teams
are playing an increasing role in assisting physicians and their patients
resolve specific, and sometimes troubling dilemmas.
They have also become especially useful for helping local health care institutions
stay abreast of national health care issues.
One such issue that has been consciously addressed over the past six months
in area committees has been the patient self-determination act which went
into effect December 1, 1991. In October, committees from all three hospitals
worked together to educate regional physicians, nurses and staff in regards
to this significant new law.
A second topic which has been discussed in committees, because of the Dr.
Kervorkian cases, is doctor assisted suicide. It is a subject with far-reaching
implications, and one that has achieved a great deal of media coverage in
recent months. Next month we shall explore in greater detail the heart of
- 30 -
Any information in this article pertaining to legal or medical matters
is not to be construed as professional advice. Copyrights remain the property
of the authors.contact: firstname.lastname@example.org
Original versions of these articles originally appeared in The Senior Reporter
in the spring of 1992.
Part One: Issues and Their Implications
Part Two: Ethics Committees
Part Three: Local Perpsectives on the Right-to-Die
Part Four: Patients Have Rights, But Doctors Have Rights,
Part Five: The Pros and Cons of Physician Assisted
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