Sometimes, the California hospitalist continues, the family needs permission from the hospital to halt futile care. Without a durable power of attorney, the care team may find itself bowing to the wishes of one family member—the outlier—who insists the patient be kept alive with aggressive measures. The inpatient palliative care team often fills the ethics gap, helping the medical team discuss end-of-life issues, goals, and desires with the family. Hospitalists, she says, sometimes need an authoritative body to say, “It is no longer ethical to do this to this patient.”
“Having a hospital committee say it’s OK to withdraw a feeding tube or stop dialysis gives a comfort level to physicians,” Dr. Moravec says, “especially if the committee involves clergy, as well as administration. That is powerful support for that doctor.”
Med Students & Residents
The key to making ethics committees more effectively and widely used is education, Dr. George says. “We need to be educating our medical students and residents a lot more aggressively than we are right now,” she asserts. “How to talk with families about end-of-life issues, what is appropriate or inappropriate care, how should you be using your ethics committees—none of that is taught.”
At Children’s Hospital and Clinics, Dr. Berkowitz meets with residents and medical students every six weeks to discuss cases with ethical dilemmas. He says house staffers have little background or experience with ethics. The American Medical Association’s Liaison Committee on Medical Education 2007-2008 survey of 126 U.S. medical colleges found medical ethics was included in one required course at all 126 colleges, and was an elective course in 61. For some perspective, a course in end-of-life care was required at 124 schools and was an elective at 69. A course in palliative care was required at 120 schools, and was an elective in 60.3
Dr. Berkowitz agrees outreach is one solution. “The longer you have an ethics committee available and doing consultations in an institution, the more you expand the knowledge about how to handle problems,” he says. “People who may have previously requested an ethics consult may now have the skills and ability to handle these issues on their own, without needing to call a consult.”
Dr. Gandhy, of Saint Francis Memorial, believes such additional knowledge helps her focus on a patient’s family, not her own plan. “If the family is not ready to withdraw the care, I realize that forcing my agenda on them can also cause suffering,” she says. “When I change my focus to ask, ‘What is going to help the patient and the family?’ sometimes I don’t even need the ethics committee, because I am then able to address the family’s concerns.”
And that’s when everybody gains. TH
Gretchen Henkel is a freelance writer based in California and a frequent contributor to The Hospitalist.
References
1. Snyder L, Leffler C;, for the Ethics and Human Rights Committee, American College of Physicians. Ethics Manual. 5th ed.,2005.
2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007 Feb;7(2):13-25.
3. Barzansky B, Etze SI. 2007-2008 annual medical school questionnaire part II. JAMA 2008;300(10):1221.