Colleen M. Gallagher

Handling Cases of ‘Medical Futility’

Medical futility is commonly understood as treatment that would not provide for any meaningful benefit for the patient. While the medical facts will help to determine what is medically appropriate, it is often difficult for patients, families, surrogate decision-makers and healthcare providers to navigate these difficult situations. Often communication breaks down between those involved or reaches an impasse. This paper presents a set of practical strategies for dealing with cases of perceived medical futility at a major cancer center.

Ethics Consultation on a Gynecologic Oncology Service: An Opportunity for Physician Education

The purpose of this study is to understand the features of gynecologic oncology patients who receive ethics consults in order to identify areas for physician education and improve patient care. A review of ethics consults for gynecologic oncology patients from 1993 to 2008 was performed. Information on all gynecologic oncology patients treated during the study interval was also collected to define a base population for comparison. Forty-one consults were performed. Compared to the base population, a greater proportion of consult patients had pregnancy-related malignancies (7.9% vs. 0.8%, p < 0.0001) and were African American (33.3% vs. 10.9%, p < 0.0001). The most common clinical case types involved identifying levels of appropriate treatment. Support of the health care team and complex family dynamics were key underlying issues. Ethics consultation provides a substantial resource in identifying relevant issues experienced by gynecologic oncology patients upon which physician educational initiatives may be based.

Retrospective Review of Medical Futility and Ethics Consultations at MD Anderson Cancer Center

Ethics consultations, conducted over an 11-year span at a major cancer center, were reviewed and medical futility emerged as the most identified ethical issue. Medical futility is commonly understood as treatment that would not provide any meaningful benefit for the patient. While medical facts help determine what is medically appropriate, it is often difficult for patients, families, surrogate decision-makers and healthcare providers to navigate these complex and immensely challenging situations. This paper presents some of the common and confounding issues that have been brought to the attention of a Clinical Ethics Service and delineates some effective methods for physicians to address medical futilty at the end of life.

Identifying and Managing Undue Influence From Family Members in End-of-Life Decisions for Patients With Advanced Cancer

Undue influence from family members of patients with advanced cancer remains a serious ethical problem in end-of-life decision making. Despite the wealth of articles discussing the problem of undue influence, little has been written by way of practical guidance to help clinicians identify and effectively manage situations of undue influence. This article briefly lays out how to identify and manage situations of undue influence sensitively and effectively. We explain how undue influence may present itself in the clinic and distinguish it from ethically permissible expressions of relational autonomy. In addition, we lay out a process by which any clinician suspecting undue influence may gather additional information and, if necessary, conduct a family meeting to address the undue influence. It is our hope that by providing clinicians at all levels of patient care with such guidance, they will feel empowered to respond to cases of undue influence when they arise.

Cancer Care Ethics in the Emergency Center

The emergency center (EC) is a technical, specialized, fast-paced environment where time is of the essence. Falling into a process by which the need for immediate response overshadows the need for ethical examination of important aspects of patient care is easy. Our purpose is to provide clinicians with some ethical considerations that can be made and reduce challenges to caring for the cancer patient in the EC. Cancer patients are often seen in ECs because of issues at the end of life, uncontrolled physical pain, and psychosocial or coping issues. This chapter deals with some of these and other common issues, including delirium, quickly changing condition, and possible drug-seeking behaviors for coping. Also considered are clinician responses to these as well as issues to recognize when assisting patients and their surrogates with decision-making during these difficult times. Case examples, discussion of the ethical challenges, and suggestions for the clinician and health care team are used to highlight and examine some of the ethical dilemmas faced in the EC.

A Christian Consideration of Human Vulnerability in Healthcare and Research

The International Bioethics Committee (IBC) called for continuing recognition of human vulnerability in healthcare and bioethics sciences in the recent report of June 2011. The report yielded special attention to factors that determine special vulnerability, access to healthcare, the provision of appropriate healthcare, inequalities of power, and vulnerabilities in human research. All of which are true in the use of technologies used to treat illness. Although the IBC is not a religious organization following a specific set of moral teachings or tradition, the following will consider IBC principles through Christian perspective and its scripture as illustrative.

On Human Rights and Freedom in Biomedical Ethics: A Christian Response to Ellen Zhang

In the effort to find convergence of ideas and applications from various traditions, the discussion of human rights and freedom from many religious and cultural perspectives is needed. This response to Zhang seeks to find that convergence among the Buddhist and a broad Christian view. As Zhang presents some compatibility, this response seeks to add to those ideas by speaking about the roles of justice, compassion, and self-determination in the field of medical bioethics.

The Team Based Biopsychosocial Model: Having a Clinical Ethicist as a Facilitator and a Bridge Between Teams

The biopsychosocial model is characterized by the systematic consideration of biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. This model opposes the biomedical model, which is the foundation of most current clinical practice. In the biomedical model, quest for evidence based medicine, the patient is reduced to molecules, genes, organelles, systems, diseases, etc. This reduction has brought great advances in medicine, but it lacks a holistic view of the person. To solve the problem, we propose an early team based approach where the primary care physician leads a group of people that can help her/him address the psychosocial issues while she/he attends to the biomedical issues. This article addresses one case where the clinical ethicist facilitating a team based biopsychosocial model for the care of a patient worked as a bridge between the primary team, the critical care team, and the psychosocial team to advance the argument that good communication among the groups can lead to a true biopsychosocial model where the collaboration of the social worker, psychologist, chaplain, ethicist and the different medical teams can improve the overall patient experience.

A Response to Ellen Zhang’s “On Human Rights and Freedom in Biomedical Ethics: A Philosophical Inquiry in Light of Buddhism”

Applying religious teachings to legal concepts and determinations is always a challenge. Professor Zhang has given us a means to consider Buddhism’s teaching related to human dignity, rights and freedom as stated in the Declaration of Human Rights and the Universal Declaration on Bioethics and Human Rights. She has pointed out that the concept of “human rights” is not directly addressed by Buddhism but is not incompatible with Buddhist tradition. Zhang approaches this by discussing the Declaration of Human Rights (1948) which discussed “the rights of every individual” and how these are protected in legal form. She correctly points out that dignity, rights and freedoms are often based in the idea of self-determination.

Diversity and Health Care

Abstract In an ever globalized society, the need to take the diverse backgrounds of patients and their health care team members into account is ever more relevant. In this chapter, we will discuss the importance of considering the patient’s cultural and religious background for treatment and research as well as discuss ways to effectively engage with patients with diverse backgrounds.