There are other situations, however, when Dr. Zachary refrains from asking for an ethics consult. For example, as a geriatrician conversant in the potential adverse outcomes of tube feeding patients with dementia, she makes the judgment calls in these instances.
“I feel very comfortable giving family members the data, in a way that they can understand, on the conflicts of tube feeding in demented patients,” Dr. Zachary says. “The role of the ethics committee, in my opinion, should be to answer conflicts for which you do not have the answers. … If that’s beyond your expertise—if you don’t know the studies and aren’t a geriatrician—then in that case, it might be appropriate.”
In other words, don’t call the ethics committee because you don’t have the time to clearly communicate with the family.
Call on the Committee
Medical ethics dilemmas aren’t always as straightforward as knowing the possible negative consequences of placing a feeding tube in a dementia patient. So when should you call on the ethics committee? Physicians at St. Joseph’s Hospital in St. Paul, Minn., fill out an ethics consultation request form to help the hospital determine the need for the consult.
Robert C. Moravec, MD, medical director, director of hospital medicine, and chair of the ethics committee at St. Joseph’s, says the form was created to prevent physicians from requesting consults prematurely, before they have attempted a family care conference or fully understand the issue at hand. For example, providers occasionally request ethics consults when the problem really is poor communication.
“Sometimes, when our ethics committee is consulted, we discover that there is so much emotional energy going into the issue that the participants are simply not communicating,” Dr. Cereste says. “We can help them identify that.”
Other times, the issue lies in a conflict between the physician and the patient’s family. The physician may want to move from aggressive care to a pain and palliative care approach. The family, of course, wants to stay the aggressive course. It’s not the committee’s job to resolve this conflict, Dr. Berkowitz cautions. “The role of the ethics committee should be helping to identify, delineate, and resolve ethics issues,” he explains. “The committee should not be there simply to help the attending physician accomplish their goals.”
Committee Credibility
Even if physicians know when to ask for help from an ethics committee, they only will do so if they trust the enterprise, Dr. Moravec says. Using a multidisciplinary approach has worked at St. Joseph’s, where the ethics committee is comprised of nursing clinical directors, physicians, social workers, chaplains, hospice and palliative care directors, and even dietitians, who meet monthly.
When the St. Joseph’s ethics committee convenes, members fill out a multi-page record for each patient. In addition to a summary of the patient’s medical history, goals of treatment, preferences, and expected quality of life with proposed treatments (or withdrawal thereof), the record documents the committee’s conclusions, Dr. Moravec says. One copy of the document gets incorporated into the patient’s chart, one is sent to hospital administration, and a third gets channeled to the hospital system’s organization-wide ethics committee. This reporting through the medical staff fosters physician buy-in, Dr. Moravec says.
Physicians are less likely to use the consultation services if they feel the ethics committee doesn’t have teeth, says Rachel George, MD, MBA, hospitalist at Aurora St. Luke’s Hospital in Milwaukee, and regional director of five west coast hospitalist programs for Cogent Healthcare, Inc.
The same is true for one Southern California hospitalist who preferred to remain anonymous. “I rarely call for an ethics consult because they’re rarely helpful,” she says. “Generally, the issues we bring to the ethics committee are those where the family is pushing us to provide care we think is futile, and the ethics committee really doesn’t make a decision. You don’t get the backup you need, and you end up very frustrated.”