EXECUTIVE SUMMARY
Ethicists are increasingly addressing recurring ethical issues on an organizationwide level, such as helping to develop policies to support clinicians in ethical decisionmaking. Some approaches include the following:
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Encouraging hospital leaders to view ethics in a business context,
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participating in committees which review quality measurements or performance indicators, and
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reviewing employees’ ethical concerns to form appropriate systemwide responses.
While ethics consults typically focus on individual patients’ unique situations, many involve scenarios that recur repeatedly. These are ideally addressed at an organizationwide level, according to Edward J. Dunn, MD, ScD, a fellow in Hospice and Palliative Medicine at Wright State University in Dayton, OH. Dunn is a former director of the Integrated Ethics Program at Lexington (KY) VA Medical Center.
“The more ethically grounded an organization is, the more successful the organization is ultimately going to be,” says Dunn. “There is economic fallout from various ethical conflicts.” The following are three ways in which ethical conflicts can negatively affect organizations financially:
• Ethical conflicts take up resources. It takes time for ethicists to meet with patients, families, and clinicians to resolve a conflict. “Most clinical ethicists are doing this role as a collateral activity, in addition to their primary job,” notes Dunn.
• Ethical conflicts can have legal implications. If a medical team believes that a surrogate decisionmaker is not acting in the best interests of an incapacitated patient, the hospital may petition a local court for legal guardianship to replace the surrogate. Another scenario with legal implications is when the surrogate decisionmaker is in conflict with the patient’s living will. Dunn gives the example of a 82-year-old man rendered unconscious and vegetative from a motor vehicle accident. He is receiving life-sustaining treatment in an intensive care unit (ICU), but his probability for recovery is less than 1%.
His living will executed 13 years previously directs his medical care to remain full support “even if deemed futile or excessively burdensome” to him. However, his wife of 56 years is advocating for withdrawal of life-sustaining treatment, claiming “my husband would not want to be kept alive like this.”
In this hypothetical case, the hospital’s legal team advises the medical team to continue full support, citing state law that a living will has priority over a healthcare surrogate when the two are in conflict. “However, to continue full support of a patient in a vegetative state is futile medical care which violates the physician’s professional code of ethics,” says Dunn.
• Ethical conflicts can increase moral distress. An ICU nurse caring for a critically ill patient may perceive her patient is not benefiting from the care she is giving at the direction of a physician. “Since the nurse is not the ultimate decisionmaker for the care that is provided, she is caught in the middle, which is a significant cause of stress and can often lead to high nursing staff turnover in an ICU,” says Dunn. High nurse turnover rates translate to significant labor costs for hospitals, he adds, especially in local communities where nurses are in short supply.
Dunn says a strong business case can be made for an ethically grounded organization. “It can enhance the professionalism of the organization, and will create some cost savings,” says Dunn.
Dunn encourages CFOs and CEOs to think of ethics in this context. “They never thought about ethics in such a way — they think it’s about, ‘Should we take this guy off the ventilator, yes or no?’ instead of the broader implications for the organization,” he says.
PROACTIVE APPROACH
In Dunn’s view, the traditional ethics committee model needs updating. “That is a very old, traditional model and in my opinion, those don’t work,” he says. This is because conflicts arise at the bedside, such as disagreements between the provider and family, or between providers. “If we are going to be effective as ethics consultants, we have to be very proactive,” says Dunn. “We can’t wait in the conference room for a problem to come to us.”
Most healthcare systems address cases of medical futility raised by clinicians with referral to an ethics committee populated by clinical and administrative leaders of the institution. Dunn suggests that ethicists “take that to a higher level” by examining what policies the organization has in place to address medical futility. “Basically, it’s a disagreement. So is there a process for mediating that disagreement?” asks Dunn.
Many clinical ethics issues that come to the ethical committees are recurring. “Even though the specific players may change, the basic problem is redundant. It is begging for, ‘How do we approach it in a more systemwide way?’” says Dunn.
Hospital leaders have to consider carefully how they want to be perceived outside the organization, says Laura Tenner, MD, assistant professor at the Cancer Therapy and Research Center at University of Texas Health Science Center at San Antonio.
“Bioethicists are very helpful in aligning the working operation of a business with its overarching goals,” says Tenner. Breaches of ethics without oversight and correction can be detrimental to the business’s reputation, she adds, as well as financially. Tenner suggests ethicists use the following approaches:
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participating in oversight committees which audit quality measurements or performance indicators,
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providing opportunities for employees at all levels of the organization to report breaches of ethics without concern for retribution, and
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helping to form appropriate responses to concerns about breaches of ethics.
If a physician is under the influence and should not be performing a procedure or operation, for instance, “there need to be ways for other individuals to report this prior to patient harm, so that it can be addressed quickly and efficiently,” says Tenner.
Adam D. Marks, MD, MPH, a clinical ethicist and associate director of the University of Michigan’s Hospice and Palliative Medicine Fellowship in Ann Arbor, has been involved in several efforts to develop policies to guide ethical decisionmaking. Two recent initiatives involved developing policies regarding deactivation of implantable cardiac devices and the role of documentation of “informal” advance care planning discussions.
“There is a big push by ethicists nationwide to focus on what we call ‘institutional ethics,’” says Marks. The idea is for ethicists to take a broader view of recurring issues, rather than merely reacting to ethical conflicts as they arise.
University of Michigan’s ethicists are rarely called to advise physicians regarding withdrawal of life-sustaining treatments, such as ventilators, dialysis, and feeding tubes. One reason is the institution’s longstanding policy outlining the process for physicians to go through to withdraw treatment at a patient’s or surrogate’s request. The policy reflects court cases which have delineated what is, and is not, appropriate care.
“Very rarely do we get a question about withdrawal of care, because this issue has already been hashed out,” says Marks.
Instead, ethicists get called for cases that “push the boundaries a little bit,” says Marks.
Ethicists strive to educate providers in ethically appropriate care. “Our goal is not to do as many consults as we can,” says Marks. “We want to empower providers to have conversations with families.”
If clinicians are unsure of how existing policies relate to a particular case, ethicists step in to help. A recent consult involved a case of brain death where the family was opposing withdrawal of life-sustaining interventions. “We got involved to help communicate with the family, and also to make sure that the clinicians were following the brain death policy accurately,” says Marks.
The issue was that the patient did not meet the strict criteria for brain death. “The family was pushing for care that the ICU team felt was inappropriate,” says Marks. The ICU team questioned whether they could call the requested interventions “futile” in this particular case. “We had to support the team, and educate them regarding the fact that futility can be applied to cases outside of brain death,” says Marks.
SOURCES
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Edward J. Dunn, MD, ScD, Hospice and Palliative Medicine, Wright State University, Dayton, OH. Email: [email protected].
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Adam D. Marks, MD MPH, Associate Director, Hospice and Palliative Medicine Fellowship, University of Michigan, Ann Arbor. Phone: (734) 764-6831. Fax: (734) 647-8535. Email: [email protected].
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Laura Tenner, MD, Assistant Professor, Cancer Therapy and Research Center, University of Texas Health Science Center at San Antonio. Email: [email protected].
