Joseph J. Fins

End-of-life decision-making in the hospital: current practice and future prospects.

Chart review of patients who died in the hospital was used to describe the pattern of end-of-life decision-making and care for hospitalized dying patients and to propose a structured process of assessing the suitability of patients for palliative care. The setting was a large urban academic medical center, and the sample comprised 200 of 205 consecutive adult deaths during the first 4 months of 1996. The main outcome measures were identification of the patient as dying, do-not-resuscitate (DNR) orders, and comfort care plans. Charts of 72% of the patients had evidence that they were considered dying. DNR orders were in place for 77% of all the patients, and 46% had comfort care plans. Presence of a health care proxy was significantly associated with DNR orders and comfort care plans (P < 0.001). On average, comfort care plans were put in place 15 days after admission, as compared with an overall mean length of stay of 17 days. Substantial proportions of patients with comfort care plans continued to receive antibiotics (41%) and blood draws (30%). Only 13% of the patients on mechanical ventilation and 19% of those on artificial nutrition and hydration underwent withdrawal of these interventions prior to death. These findings suggest opportunities and challenges for improving practice patterns for hospitalized dying patients. We recommend several measurable objectives for evaluating end-of-life decision-making and care and propose the development of a goals of care assessment tool to guide appropriate transitions from life-sustaining treatment to comfort care and plan palliative services.

Framing the Physician‐Assisted Suicide and Voluntary Active Euthanasia Debate: The Role of Deontology, Consequentialism, and Clinical Pragmatism

he debate surrounding physician-assisted suicide and T voluntary active euthanasia has generated a wealth of scholarship and become the focus of significant media coverage. Despite this attention, the debate continues to confound both scholars and the lay public. Although some of this confusion stems from principled differences, much of it results from the difficulty of organizing the range of arguments and positions that inform this debate. To this end, we examine a series of representative positions’ and offer a conceptual classification or typology in which to analyze and frame the arguments employed in this debate. We also introduce the concept of clinical pragmatism and its potential contribution to better understanding this complex issue. We hope that our typology will assist all who participate in this public discussion. In particular, readers of the Journal may find the framework useful in understanding the position on voluntary active euthanasia’ and the care of the dying patient taken by The American Geriatrics S~c ie ty ,~ as well as the article by Sachs et a1.: that appear in this issue.

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.

Gaining insight into the care of hospitalized dying patients: an interpretative narrative analysis.

Narrative ethics is a useful tool for gaining insight into the care of hospitalized dying patients. We used narrative analysis to interpret the medical records of 200 adult deaths at our institution. Prominent subjects which emergedfrom this review include documentation of care; relationships between patients, families and clinicians; and the influence of time, uncertainty, ambiguity, resource allocation, and spirituality on the course of care. Research on narratives can help script more empathic and compassionate care of the dying by demonstrating that every death is a story waiting to be told.

The Economics of Clinical Ethics Programs: A Quantitative Justification

The restructuring of the healthcare marketplace has exerted pressure directly and indirectly on clinical ethics programs. The fiscal orientation and emphasis on efficiency, outcome measures, and cost control have made it increasingly difficult to communicate arguments in support of the existence or growth of ethics programs. In the current marketplace, arguments that rely on the claim that ethics programs protect patient rights or assist in the professional formation of practitioners often result in minimal levels of funding and preclude program growth. Where ethics programs could once sustain themselves on goodwill alone and values arguments in an expanding healthcare market they are now encountering—at least by anecdotal reports—cutbacks and even elimination. To respond to these challenges, we offer an economic model that can be used to demonstrate the “value” of an institutionally based ethics program.

Acts of Omission and Commission in Pain Management: The Ethics of Naloxone Use

In this paper the under-use of opioids for pain and symptom management is considered by explored by examining the history of the use of the opioid antagonist, naloxone.

Extracorporeal Membrane Oxygenation as a Bridge to Chemotherapy in an Orthodox Jewish Patient

OBJECTIVEnVenoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as a bridge to recovery, involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA-ECMO in patients who, in the absence of recovery or transfer to longer-term therapies, might assert religious or cultural objections to the terminal discontinuation of life-sustaining therapy (LST). We present a novel case of VA-ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes.nnnPATIENTnA 40-year-old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA-ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patients religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA-ECMO.nnnINTERVENTIONSnMeetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA-ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor.nnnCONCLUSIONnTraditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA-ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA-ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology.

The ethics of managed care: report on a Congress of Clinical Societies.

n October 1996, the Anierican Gcriatrics Society and the I Hastings Center convened a Congress of Clinical Societies to address the ethical issues raised by the advent of managed care. The fourth in a serics of conferences that began in 1987,1-3 this effort brought leading scholars in medical ethics, health policy, law, and medicine together with rcpresentatives of the managed care industry to discuss how the integrity of medical practicc could be maintaincd and strengthened in a capitated marketplace. Invited speakers were joined by representatives of major clinical societies (See Appendix for a listing of the represcnted clinical societies). The formal papers from the 1996 meeting are published in this issue of tlie journal. Too often in discussions about managed care, we romanticize thc past and demonize the present. Sentimentally, wc remember a physician’s care of patients as a page from Sinclair Lewis’ Arrowsmith. In the opening pages of that classic, we recall a general practitioner in his horse and buggy making a house-call to attend to the sick.4 Today, we might imagine a physician-administrator driving her Lexus to a managed care organization’s corporate headquarters to determine how disputed healthcare benefits might be adjudicated. The first image evokes nostalgia for simpler times when physicians practiced alone and had unquestioned clinical discretion. The second illustrates the growing corporatization of medical practice and the decline of professional autonomy. Today, forces external to the traditional doctorpatient relationship dictate how medicine is practiced and what care is received.