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 and care.

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 with.

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 to do?

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 are ethical.

"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 issues."

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, 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 this debate.

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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.

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 Debate
Part Four: Patients Have Rights, But Doctors Have Rights, Too
Part Five:
The Pros and Cons of Physician Assisted Suicide

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