Does your hospital have an ethics committee? Nine of ten hospitals have such committees, and the decisions they make affect your relationships with patients, directly and indirectly. Should PAs be active members of such committees? In this month's column, we focus on one PA's encounter and engagement with the ethics committee at a hospital where he was employed.
THE CASE OF MS. G.
Ms. G. is a 74-year-old woman with a history of dementia and repeated cerebrovascular ischemic events. She has been hospitalized for several days after her most recent ischemic event. She is unconscious and on a ventilator, unable to breathe without mechanical support.
She has three adult children. She has lived with her two daughters for several years, and her son has been estranged from the family and has not spoken with his mother or sisters for 5 years. The son recently arrived at the hospital at the request of his sisters, who have been with their mother since her most recent hospitalization. Ms. G. does not have an advance directive; however, the daughters do have durable power of attorney for health care decisions.
Ms. G.'s medical team has met with her family and has told them that in their opinion, their mother is unlikely to be able to survive without mechanical ventilation or to return to her previous level of cognitive function. Ms. G.'s son has brought in a neurologist from an outside facility to examine Ms. G. The visiting neurologist disagrees with the medical team and has issued a consultant's report stating that he feels Ms. G. has a “better than 50% chance of regaining nonventilatory breathing function.”
After meeting several times with their mother's medical team, the daughters have requested that the ventilator be turned off and their mother be allowed to die. They are distraught but clear in their wishes, and they describe their mother's multiple requests to not be kept alive on a ventilator. They are upset with the actions of their brother, and they refuse to meet with him or with the legal and medical team he has assembled.
After the last meeting with the medical team, a social worker and a physician member of Ms. G.'s medical team ask to meet with the daughters. The social worker and physician say that they disagree with their team's attending physician and believe that withdrawing ventilator support amounts to “killing your mom.” They urge the sisters to reconsider. They question them about the advance directive and ask if the sisters are posi tive that such a document does not exist. The daughters are angry at the position taken by the two providers and tearfully ask to speak with the charge nurse about their concerns. They say that they feel abandoned by the medical team. Their brother continues to push for continued ventilation and has fi led a motion in local court to prevent ventilation from being stopped.
THE ETHICS COMMITTEE STEPS IN
The charge nurse contacts the attending physician, the hospital patient relations director, the risk management office, and the on-call clinician member of the hospital ethics committee. Soon the entire ethics committee is requested to attend an urgent ethics consultation the following day. Six members say they can attend, two of them physicians. (While ethics committee membership draws on many professions, the policies at this medical center require physician presence at all ethics consultations.) The two ethics on-call clinicians (a physician and a physician assistant) decide that the consult will be divided into two parts. The first will be a meeting of the committee without the family to establish the factual framework of the consultation. A second consultation will include family members and may take place later in the week.
At the first consultation, an on-call clinician facilitates, starting with introductions and moving into a case report from the attending physician. The facilitator stands at a chalkboard, placing information into one of four boxes. Following the commonly used Jonsen “four box method,” the boxes are labeled medical indications, patient preferences, quality of life, and contextual features. Using this method allows the facilitator to order the facts of the case and for the discussion to address the more expansive bioethical principles of autonomy, nonmalefi cence, beneficence, and justice.
In this and other consultations, members of the ethics committee work to draw out facts, order them in a systematic way, and support the clinicians and family involved. Finding common ground and ways for patients, family, and staff to achieve collaborative decision-making, rooted in bioethical principles, is the highest priority.
At the initial consultation, a resident involved in the case voices her hope that the committee can make a ruling and take pressure off of the medical team. In response, ethics committee members help clarify for the medical team that the ethics committee is not the “ethics police” and in fact does not fremake decisions. Committee members discuss the limitations of the bioethical four-box approach, including the challenge of prioritizing the four principles. The facilitator notes that both oversimplification and an inability to balance ethical principles in a manner that hears and addresses the wishes of patient, family, and staff can limit the effectiveness of bioethical interventions. The role of the ethics committee is reviewed.
In cases such as Ms. G.'s, clinicians can be overwhelmed by the complexity, narrative, and contextual nature of the process since such cases are seldom simple and linear. Outcomes may not always result in all parties feeling resolution, although formalizing and clarifying relevant issues often brings participants to a more collaborative and open understanding of the progression of events.