|
|
|
|
|
|
|
|
|
|
|||||||
 |
 |
 |
 |
|||||||
|
Clinical Ethicists Help Patients, Families, and Staff Resolve Difficult Dilemmasby Karen Stuyck
A patient lies in the intensive-care unit, in critical condition and unable to communicate. He has no living will and no family member or friend with medical power of attorney to make health-care decisions for him. Who, then, decides whether life-sustaining measures such as ventilation or nutritional support are started? Who decides at what point these measures should be stopped? Another patient refuses treatment that her doctors agree would be medically beneficial. What recourse do her physicians and family members have? What if the patient doesn’t understand what the health professionals are telling her? Fortunately, there are professionals available at many hospitals to help resolve these and other dilemmas. At The University of Texas M. D. Anderson Cancer Center, the Clinical Ethics Service conducts about 100 ethics consultations a year, according to Martin L. Smith, S.T.D., chief of the service. About 95% of the consultation requests come from M. D. Anderson health professionals, with the rest requested by patients and their families. More than half of these consultations, Dr. Smith said, center around end-of-life issues, such as whether to stop or start life support, including whether to put a patient on a ventilator, start dialysis, or initiate resuscitation. About 30% of the Clinical Ethics Service’s consultations involve patients in the intensive-care unit. Often “in the intensive-care unit, there is a critically ill patient with multiorgan failure, for example, and the health-care professionals are questioning how aggressive they should be,” Dr. Smith said. Clinical ethicists at M. D. Anderson help identify, analyze, and resolve ethical issues by gathering information and discussing the problem with the involved health professionals, the patient, and the family. The ethicists offer advice, make recommendations, and help identify options, but they don’t make decisions for the persons involved. Making sure that those involved have a common understanding of the issue is a big part of these consultations, Dr. Smith said. He related one case in which an ethicist was asked to help determine who should make decisions for a heavily sedated patient in intensive care who had left no written instructions. The patient had told his physician earlier that he did not want his wife to make any medical decisions for him because he was planning to divorce her once he recovered. Now the patient was unable to communicate his wishes. Was he serious about his intentions? If so, who instead should make the decisions? The ethicist talked to some of the staff members involved with the patient, and a nurse suggested decreasing the patient’s medication so that they could have a conversation with him. The ethicist supported the nurse’s recommendation. When the patient’s level of sedation was reduced, the nurse and a social worker spoke to him, and he said that he wanted his wife to be the decision maker. About 85% of the ethics consultations are conducted by one ethicist, Dr. Smith said, but sometimes “very significant conflicts or tough dilemmas” require the services of a four-person Clinical Ethics Consult Team. In addition to an ethicist, this team consists of an M. D. Anderson physician, a nurse, and an “ancillary other,” such as an allied health professional, or a social worker, chaplain, or patient advocate, none of whom is involved in the patient’s care. The physician, nurse, and ancillary other are always members of M. D. Anderson’s Clinical Ethics Committee. More than half of these difficult cases concern end-of-life issues. “A frequent theme is that a patient, in the judgment of the healthcare team, is dying, but the family continues to insist on aggressive treatment,” Dr. Smith said, whereas the medical team believes that the disease process cannot be reversed and that the goal should now be to keep the patient comfortable. The consult team meets with the patient’s family and the professionals who are treating the patient. Everyone is assembled in one room to voice their different perspectives, and the consult team makes sure that each understands the others. After that, the consult team meets alone to arrive at ethically supportable options, strategies, and recommendations, which are then communicated to the family and the medical team. In addition to conducting ethics consultations, the Clinical Ethics Service has developed an online clinical ethics course designed to help medical professionals address ethical issues. The course is available at Net Medical Ethics. “Assessing decisional capacity and informed consent are a daily occurrence for physicians,” Dr. Smith said. “Part of good patient care is knowledge and information about good ethics.” The clinical ethicists at M. D. Anderson come from different educational backgrounds. Dr. Smith has a doctorate in theology. The other M. D. Anderson clinical ethicist, Anne L. Flamm, has a law degree, and the service’s clinical ethics fellow, Barbara J. Evans, has a Ph.D. in earth science and a law degree. Despite their varied backgrounds, clinical ethicists base their recommendations and advice on a shared body of knowledge regarding ethical norms and standards, Dr. Smith said. These common values include supporting patient autonomy, respecting a patient’s confidentiality, promoting patient benefit while minimizing harms and risks, and applying basic principles of justice and fairness to patient care. “We have an obligation to treat medically similar patients similarly. We owe everyone equal quality care. For most people of good will, these basic principles reflect shared values and generally acceptable professional responsibilities,” Dr. Smith said. For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789. Other articles in OncoLog, April 2004 issue:
Home/Current
Issue | Previous
Issues | Articles
by Topic | Patient Education ©2008 The University of Texas M. D. Anderson Cancer Center |
|||||||
TOP