Profession

An ethics consult can help build consensus

Why ask for an ethics consult when nobody is behaving unethically?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted July 7, 2008.

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Scenario: Some clinicians hold the view that ethics consults are adversarial or that they come between doctors and their patients. How can physicians make the most of an ethics committee consult?

Response:

Consider a clinical case in which "Angie," a 75-year-old woman in declining health has had a severe left-sided occlusive stroke and has been in the intensive care unit for six days. During two brief times off the vent, she was aphasic, agitated and could not follow commands. She was reintubated each time for her inability to handle oral secretions.

For the previous five months she had been on home oxygen for her emphysema. Her electrocardiogram shows ventricular pacing from the pacemaker implanted three years ago for third-degree heart block after a myocardial infarction. She is fed through a nasogastric tube. A percutaneous endoscopic gastrostomy tube and a tracheotomy are being recommended by the intensivist.

The stroke induced a fall causing a left humerus fracture that gives Angie intermittent pain, especially during daily care activities. Her profound right-sided hemiplegia and arthritic, frozen left hip limit her potential for rehabilitation, even if cognitive function returns.

Before the stroke, Angie lived semi-independently in her home of 30 years. Her husband died five years ago. She has three grown children; one son and one daughter live in nearby cities and take turns assisting her. At least one of them has been bedside every evening during this ICU stay. The third child, a daughter, lives 800 miles away and visits home yearly.

Angie's primary internist never discussed advance directives with her. She signed a living will five years ago which doesn't apply to her current condition. She did not create a health care power of attorney. Decisions about ICU care have been made after discussions with the two local adult children. When making a decision, the daughter, overwhelmed with emotion, defers to her older brother. Last night, the son refused consent for the tracheotomy and PEG. He said, "She would never want to live that way."

This morning the adult children meet with the neurologist, who paints a bleak prognosis. The physiatrist comes by and outlines a plan for rehabilitation. This afternoon the son repeats his refusal of consent for surgery. The intensivist broaches withdrawing care and the son agrees. The daughter wonders about waiting a few more days but, when her brother lists all their mother's problems, she becomes silent. An hour later, when asked if she agrees to withdrawal of support, she defers to her brother. A short time later, the patient's nurse becomes aware of this conversation and reveals to the primary internist that in her two long-distance phone conversations with the other daughter, the daughter is adamant that "everything be done for my mother." Meanwhile, the intensivist calls the cardiologist to discuss turning off the pacemaker. The cardiologist is not sure that would be legal. The tech who actually programs the pacemaker objects to doing it, saying it would kill the patient.

That is a very long scenario. Why? Good ethics begin with good facts. The text demonstrates the type of information acquired in a full ethics consult. The history can be longer and broader than a fourth-year medical student's note. Getting a full and accurate history is a major reason to get an ethics consult. Like any specialist, the clinical ethicist makes time to obtain a detailed history. But the ethicist has the skills to obtain accurate and complete information about certain topics in which most doctors lack experience.

Could a doctor just get a curbside ethics consult? Sure, if you truly need answers to straightforward legal or ethics questions, like, "Is stopping a pacemaker ethical?" (It is) or "Which next of kin comes first for surrogate decision-making?" A phone call may be all that is needed. But many medical specialists hesitate to give advice under those circumstances. This clinical scenario is too complex to be considered curbside. Clinical ethicists share this reluctance.

A formal ethics consult doesn't mean the doctor is doing anything unethical. Almost never is that the issue. Ethics committees are not ethics police. Allegations of truly aberrant behavior would be handled by the medical director and medical staff committee. In many hospitals, a thorough social work consult is very similar to most ethics consults. While hospitals used to have an ombudsman to advocate for patients, particularly those from vulnerable groups, that role now frequently falls to the ethics committee.

Differences in values like those present in this scenario are the most common prompt for ethics consults. Identifying differences of opinion among family members and others, clearing up misunderstandings and resolving poor communication, clarifying values, and, if necessary, helping mediate the decision-making are all common functions of an ethics consult.

I prefer to frame ethics consults like any other consult I perform. I interview, review data, consult literature and write a recommendation in the chart. That is a paradigm other doctors understand. There are other methodologies. While clinical ethicists have begun to collect evidence, there is still no consensus on the most effective approach(es) for conducting and documenting consults. Approaching Angie's situation, first I identify all the stakeholders. In some states, the doctor can rely on the consent of a single surrogate. In other states, the health care team must make reasonable efforts to contact all adult children, as each has a vote. Majority rules, but the minority can appeal to a judge. The family's vote in this scenario could be 2 to 1 or could be called a tie with one abstention. A physician might use an ethics consult to help sort out the conflict. Clinical ethicists can cite the legal rules but also have skills at resolving miscommunication and developing a consensus that avoids a polarizing vote. The estranged relative living far away who demands everything be done for her dying parent is a cliché among clinical ethicists. They have experience dealing with those situations.

How else could the ethics consult be helpful? It can review a prognosis. A judge may ask for a second opinion when a patient's legal guardian suggests withholding life support. Many hospitals use ethics committees to review futility cases to help resolve differences in the goals of care. In Angie's scenario, a consult could clarify the differing prognoses from various consultants. What are the potential outcomes of rehabilitation? How long will it take? What can be done to minimize suffering? Just what is the life expectancy of someone already on home oxygen? Not all doctors are proficient at explaining a prognosis in language lay people can understand. Clinical ethicists do that well.

After the 1976 New Jersey Supreme Court decision in the case of Karen Ann Quinlan, ethics committee consults on withdrawal of life support became commonplace.

Good ethicists educate staff during the consultation, so doctors now usually proceed without getting an "Angel of Death" consult. Many hospital ethics committees were formed as a response to the Patient Self Determination Act of 1990. In hospitals without adequately trained staff, many ethics consults are called to help fill out advance directives. That function includes encouraging primary care doctors to have the conversation about end-of-life care with their patients. While there are many barriers to creating advance directives, certain sentinel events should trigger action. A myocardial infarction, pacemaker implantation and being started on home oxygen each should certainly have triggered the discussion in Angie's case. Bad care can always be called unethical, but I prefer to label the primary care doctor's omission here as a failure to meet professional norms.

Inadequate communication remains the primary issue for the vast majority of ethics consults. It is the sole issue in many. The pacemaker issue in Angie's scenario is the exception, not the rule.

Clinical ethicists rely far more heavily on communication skills than on expertise in philosophy. They are therefore involved in finding systemic solutions to communication problems. They may also be helpful when there is a need to disclose an error in medical treatment.

There are reasons for ethics consults that don't involve the patient. The pacemaker tech in this scenario is undergoing moral distress. Ethics consults can advocate for staff as well as for patients. Some hospital bylaws don't allow for this. Some don't allow for an ethics consult without the attending physician's permission. This is unfortunate because, in modern medicine, with its team approach, ethics is everyone's responsibility. I recommend that any physician consider these many reasons to consult an ethics specialist.

Kevin Powell, MD, PhD, hospitalist physician, St. Louis Children's Hospital

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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