Jane Greenlaw

Where are We Going with Do-Not-Resuscitate Policies?

Whenever there are technologic advances in medicine, there are necessarily questions concerning their appropriate use. Cardiopulmonary resuscitation (CPR) is a noteworthy exception to this statement. Questions about CPR concern the appropriateness of not using it. Developed as a means to respond to sudden, unexpected cardiac or respiratory arrest, CPR has given rise to a technologic imperative that mandates its use and which has spawned a sizable body of medical, legal, and bioethical literature, as well as institutional policies and procedures pertaining to decisions not to use it. In New York State, the Governor’s Task Force on Life and the Law has even issued a proposal for legislation governing such decisions [4].

An Integrated Biopsychosocial Approach to Palliative Care Training of Medical Students

In 1996 the University of Rochester School of Medicine, Rochester, New York, began a major curricular reform called the Double Helix Curriculum, integrating basic science and clinical training over 4 years of medical school. This transition provided a unique opportunity to develop and implement a fully integrated, comprehensive palliative care curriculum. In this three-part paper, we will describe: (1) our process of finding curricular time, setting priorities, and deciding on pedagogical strategies; (2) an overview of how palliative care teaching was integrated into the general curriculum, including examples of different teaching opportunities; and (3) our evaluation process, and some ongoing challenges. Because palliative care is a core element in the care of all seriously ill patients, we chose to integrate our teaching into multiple courses over 4 years of undergraduate medical education, and not isolate it in a particular course. We view this report not as an ideal curriculum to be emulated in its entirety but as a work in progress that may be somewhat unique to our institution. We intend to illustrate a process of incremental curriculum building, and to generate some fresh teaching ideas from which palliative care educators can select depending on their own curricular needs and objectives.

Ethics consultation: High ideals or unrealistic expectations?

Ethics consultation evolved out of the field of bioethics, which was itself largely a product of the 1970s. Thus, when the American Society for Bioethics and Humanities report Core Competencies for Health Care Ethics Consultation was commissioned 4 years ago (1), the oldest ethics services had been in existence for barely 20 years and were in the adolescent stage of developmentwith high ideals and unrealistic expectations. The report represented the opportunity to evaluate the progress of and set future agendas for ethics consultation. The report makes an informative starting point for someone interested in learning about ethics consultation. However, because it is the work of a consensus panel, the report softens or avoids some points of disagreement. This commentary tackles four such points and highlights the critical weaknesses of some of the approaches that the consensus panel presents as viable options. The four issues that we find problematic concern committees versus individual consultants, interdisciplinary competency, practical wisdom versus character, and financial support for ethics services. Committees versus Consultants The committee approach to ethics consultation may be effective in long-term care settings. However, it becomes unwieldy in acute care settings because it is difficult to convene a quorum of a 12- to 15-member committee in less than 72 hours. A second problem with committees performing consultations concerns the common practice of appointing members because of their job descriptions rather than because of their interest or experience in ethics. A third problem is the danger of groupthink. One member, such as the most politically powerful person (a member of the hospital administration or the hospital attorney, for example), can easily and sometimes inadvertently dominate the decision-making process. But in our view, the greatest problem with the committee approach is that ethics consultation must allow patients, family members, and staff the opportunity to tell their personal perspectives of the case. Attempts by a committee to conduct a personal, private discussion become impersonal interviews at best or inquisitions at worst. An alternative model would cast the ethics committee as a source of colleagues with whom individual ethics consultants can discuss a case as it unfolds. In addition, the committee would provide a forum for review of consultations after the fact as part of quality control. Each ethics consultant at the facility should be a member of the ethics committee, although not every member of the committee needs (or ought) to be a consultant. Interdisciplinary Training The real problem with certification of ethics consultants, especially in bioethics, is the difficulty in establishing consensus about training requirements in an interdisciplinary field. Training programs in health care law are located in law schools, and some clinical ethics programs at medical schools are open only to physicians. Yet philosophy is the academic home of ethics, and most of the theorists whose texts are taught in these programs are trained in philosophy. Bioethics requires contributions from law, medicine, and philosophy, in addition to input from such disciplines as theology, cultural anthropology, health care economics, and policy. One person cannot satisfy all of the required competencies in all of these fields. A national accrediting body such as the Joint Commission for the Accreditation of Healthcare Organizations might assess consultation services as groups to see whether its members possess expertise in at least the three basic professional fields. In our opinion, every ethics consultation service should have at least three members: one who holds an MD, one who holds a JD (and who should not be employed by the institutions administration or malpractice office), and one who holds a PhD in an academic field of ethics or bioethics. Each member should also have some specific training in bioethics, whether from a degree program, from a certificate program, or as part of a fellowship program. Although one consultant could well have two or more of these professional backgrounds, we believe that an ethics consultation service should include a minimum of three persons to help balance the group dynamics of problem solving and to prevent domination of any one discipline. The standards that we propose are much higher than those proposed by the consensus panel, which require only access to medical and legal expertise for the consultant or committee. The report recommendations would condone a nurse with a masters degree in bioethics, for example, as an individual consultant reporting to a committee. Such a policy would allow much more rapid expansion of ethics consultation at less cost to institutions, but at great cost to the credibility of the field. Practical Wisdom versus Character The panel recognizes that some cases are common and straightforward and some are complex. In our experience, these occur in roughly equal numbers. Most clinicians do not need an ethics consultation when the situation is straightforward, and in complex cases, they often request a consultation late, when the case has become complicated and opinions are polarized. An ethics consultation team therefore needs advanced skills and advanced knowledge on a regular basis. Although character is closely associated with ethics in the minds of many and is the essence of ethics in the Aristotelian tradition of virtue ethics, good character is arguably immeasurable. Certainly the three professional fields of law, medicine, and philosophy do not rank it highly among their entrance requirements, and their curricula do little to promote it. We suggest using another Aristotelian concept to designate this sought-after quality: practical wisdom (phronesis). Ethics consultants may not have character that is superior to that of the practitioners, but they should have more experience in analyzing ethically complex cases. This accumulated experience and the refinement of judgment that it produces is an advantage that they bring to the consultation process as specialists in addition to their disciplinary knowledge. Financial Support for Ethics Consultation Services Perhaps the greatest threat to integrity and good character in the popular mind is the profit motive. Thus, financial support for an ethics consultation service is an issue in which conflicts of interest are of grave importance. An institution must support ethics consultation, but in a way that will not compromise the consultants. Any form of payment that is provided on a unit basis has the potential to cause conflict of interest, or at least the appearance of one. The institution should estimate the amount of time that the ethics service will require, convert it into a percentage of the full-time salaries of the consultants, and reimburse their departments for that part of their salaries. For an average tertiary care teaching hospital, this figure may amount to 25% to 50% of each consultants salary. For a smaller hospital with fewer critically ill patients, it may amount to 10% of their salaries. Annual reviews should be a time to evaluate whether the reimbursed time was a reasonable approximation of the time used. This system is similar to that already in place in many institutions to support chaplaincy services. Conclusions Our ethics consultation service at the University of Rochester is now 10 years old, placing it in the second generation of programs. As a result, we were able to identify and address these four problems before we established our service. The hospital provides 25% of the salaries of two members, a physician and a lawyer, and 50% of the salary of the ethicist (who is also chair of the Ethics Committee). In return, the hospital has 24-hour consult coverage, provides substantial ethics teaching for 26 residency programs, and has monthly rounds in 6 intensive care units. Our procedure for case consultation is for one consultant to respond to the initial consultation request and gather information, including talking with members of the health care team, the patient, and the family. This lead consultant then confers with at least one other consultant to define the issues and frame an approach. The lead consultant drafts the consultation note and reviews it with at least one other consultant before it goes into the patients chart. Because many family members and specialists are often involved, the process is deliberate rather than rushed, as seems appropriate to promoting careful reflection on a serious problem. Those who have no experience of ethics consultation or who are skeptical of it will learn a great deal from reading the American Society for Bioethics and Humanities report. Most readers will agree with the reports nine conclusions. Yet, because ethics consultation is still unavailable at many hospitals, the report should also be useful to those who are deciding whether and how to implement ethics consultation at their own institutions.

Ethics Consultation: Persistent Brain Death and Religion: Must a Person Believe in Death to Die?

Case summary We first heard about this case from nurses in one of our intensive care units (ICUs) while we were conducting an inservice. When the session was over, we discussed it between ourselves, and decided that it must have been misrepresented. The case had been presented as one of a teenager who was brain dead, had been so for six months, yet had been brought into the ICU for treatment. We have run into this before, we thought: medical professionals confusing brain death with persistent vegetative state (PVS). But, of course, we reasoned, no one can be brain dead for six months. To us, as it would to many, the case sounded like a clinical and ethical impossibility. A week later, we were called by an attending physician from another ICU, at the urging of that unit’s nursing staff. They had a patient who was brain dead, whose presence was causing distress among the staff. Ronald Chamberlain, a fifteen-year-old boy, had been a patient at a nearby longterm rehabilitation facility that is equipped to care for ventilator-dependent patients. Ronald had undergone a cardiac arrest with electromechanical dissociation, and was brought to the hospital emergency room as part of a full resuscitative effort. It took twenty minutes of cardiopulmonary resuscitation to recover a pulse. With his cardiopulmonary status stabilized, Ronald was admitted to the ICU. Ronald was the patient we had heard about. The ICU attending doctor who called us accepted the admission because he believed it appropriate to evaluate the validity of the diagnosis of brain death, which reportedly had been made six months earlier at another facility. (We later learned that the staff of the ICU from which the patient had been discharged two weeks earlier believed that

Failure to Use Siderails: When Is It Negligence?

N urses frequently wonder about the legal aspects of using siderails to prevent patient falls from bed. Questions arise as to when siderails are clinically indicated; whether a patient may refuse the use of siderails; whether, when a patient does fall from bed, the fall resulted from negligent failure to use siderails; and whether a decision to use siderails is a medical or nursing judgment. This article examines the legal issues involved in the use of siderails and provides some recommendations for the use of siderails and other restraints.

Case Consultation: When to Invoke State Agencies to Treat: The Cases of a Minor and a Mentally Disabled Adult

Case 1 Ian Bykovsky is a twenty-six-month-old child of recent immigrants from a former Soviet-bloc country. He had been a well child, but, because of fever and cough, he was taken for a pediatric visit. Physical examination and laboratory studies led to a presumptive diagnosis of acute lymphoblastic leukemia. Ian was admitted to the hospital, and the diagnosis was confirmed by bone marrow aspirate and biopsy. Communication with Ian’s parents was complicated because neither spoke English. A family member who did speak English attended meetings between the physician and Ian’s parents, to interpret the explanation of Ian’s condition and the medical recommendations. The physician explained that standard treatment for Ian’s condition included one month of inpatient treatment with steroids and chemotherapy, followed by two years of weekly outpatient treatment with steroids and chemotherapy. A Broviac catheter would be necessary, as well as a series of spinal taps. The physician explained that with this standard course of treatment, Ian had an SO percent chance of permanent remission. The physician also explained that side-effects of the treatment would include hair loss and nausea. Furthermore, she explained that some long-term effects on Ian’s learning ability and heart function were possible. These would be minor changes if they occurred-Ian’s ability to

Case study: ethics consultation.

ith this case study, we begin a series of discussions taken from the Ethics Consultation SerW vice at Strong Memorial Hospital, a 700-bed tertiary care center in Rochester, New York. The consultation service was set up with the goal of responding promptly to requests from staff and patients for review of ongoing clinical situations where valid differences in value systems are obstacles to decision making. When possible, we talk individually with the patient, family members, and staff who are involved in the dilemma. Generally, it takes about one week to gather information, analyze the situation, identify and research the issues, and make typewritten recommendations complete with references. Our foremost concern is ethics, with law and medicine providing relevant precedents, analogies, and parameters for our case analyses. Where appropriate, we will have obtained the patient’s (or family’s) permission to write about the case for publication.

Should Hospitals Be Responsible for Informed Consent

D oes a hospital bear a responsibility independent of that of the attending physician to ascertain that a patient has given an informed consent? Until recently, state appellate courts have provided a decidedly negative answer to this question.’ However, in Magma u. Elie,’ an Illinois appellate court recently adopted a different position, opening the door to a new area of hospital responsibility and, therefore, increased potential liability for hospitals. This column provides a brief review of the informed consent doctrine, discusses the traditional and the Magana approaches to the issue of hospitals’ responsibility to obtain informed consent, and analyzes the implications, particularly for nurses, should the Magana approach be more widely followed.

Orders Not to Resuscitate: Dilemma for Acute Care as well as Long Term Care Facilities

“Do not resuscitate” orders are one of the most controversial and troubling issues confronting today’s health care providers. Questions arise as to the appropriateness of such directives, who may issue them and how, and whether they must be followed. Nurses-almost always the ones who are called upon to effect “nocode”directives-are often uncertain how they can or should act because of the complex ethical and legal dilemmas inmlved. A reader, a nurse in a long term care facility, wrote seeking guidance:

Delivery Rooms: For Women Only?

D o e s a hosDital have the rkht to prevent a qualified male nurse from working in its labor and delivery section? In Backus v. Baptist Medical Center, this question was answered in the affirmative by a United States District Court in Arkansas. I The case, now on appeal, serves as an obstacle to professional nursing and an affront to the rights of female patients. The plaintiff, Gregory Backus, is a registered nurse who, while employed by the defendant hospital, twice requested and was refused full time placement in its labor and delivery section. The refusals were based upon an unwritten policy that the hospital “did not employ male R.N.s in OBGI” positions because of the concern of our female patients for privacy and personal dignity which make it impossible for a male employee to perform the duties of this position effectively.” Backus subsequently filed charges with the Equal Employment Opportunity Commission (EEOC) alleging, among other things, that the hospital’s refusal to transfer him to the labor and delivery section was discriminatorily based on sex. The EEOC allowed Backus the right to sue, and anonjury trial was held before Federal District Judge Elsijane T. Roy. Under the applicable provisions of the Civil Rights Act,* when sex discrimination of this type is alleged the employer must prove that sex is a bona fide occupational qualification. To do so, the employer must establish that the challenged policy is reasonably related to the essence of its business and that it is impossible or impractical to deal with persons on an individual basis.) The defendant hospital claimed