Columns for The Lufkin News

The Role of the Hospital Ethics Committee

Posted Jun 07, 2016 by Sidney C. Roberts, MD, FACR

For most of my 25 years in medical practice, I have been involved in hospital ethics committees. You may not know that ethics committees exist, or that there are ethics consults in hospitals.

An ethics committee is a group of people ranging from physicians to chaplains, nurses, social workers, and sometimes community representatives who may meet to develop policies on topics like end-of-life care or medical decision making. It is easy to understand that conflict may arise, for example, when a patient is unable to voice their desires and family members don’t agree; it is much harder to devise or articulate a process toward a solution. Sometimes state or federal law dictates a path; more often, a Solomon is needed to split the proverbial baby. Hence, the Ethics Committee can be consulted to advise on a course of action.

In each institution I have been associated with, the Ethics Committee does not decide which course of action to take. They merely facilitate discussion between parties, advising on known statutes or regulations, and – more than anything – making sure each party is hearing what the other is saying. Most ethics consults end up being non-issues; once communication is clear between parties, agreement on a course of action is often reached.

On rare occasions, family members insist on care being provided or continued when, from a medical standpoint, that care is considered futile (or, in PC-speak, non-beneficial). This is a perfect example of #firstworldproblems. It was only in the 1960s that coronary care units came into existence. Prior to that, death in the home was the norm, with family at the bedside. With the advent of intensive care, we have come to expect immortality in the Temple of Medicine.

As reported in 2010 by PBS’s Frontline program Facing Death, nearly half of all Americans die in a hospital (nearly 70% in a hospital, nursing home or long-term-care facility), while 7 out of 10 Americans say they would prefer to die at home. More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying. Yet only 25% actually die at home. The difference between desire and actual care is striking.

Why, if we want a certain type of care, do we not get it? For one, we don’t effectively make our wishes known. In that same Frontline series, only 20 to 30 percent of Americans report having an advance directive such as a living will. And, even when patients have an advance directive, physicians are often unaware of their patients' preferences.

The default action in hospitals is to provide any and all care possible. Blame our perverse incentive to do procedures, our desire to avoid litigation, and our misguided belief that we can save everyone, and you get patients dying in the hospital not even knowing they are at the end of life. It is this window where a hospital Ethics Committee is most consulted.

In my personal experience, the ethical conflicts that arise within a religious context are the most frustrating. Some patients or families hold on to the miracle cure lottery ticket, demanding care that is both ineffective and injurious, afraid to let go of “faith”, as if death itself is under their control.

That type of faith – sincere as it may be – is nothing more than magical thinking that binds God to the believer, making God not even a god, but a puppet. As Billy Graham reportedly said, “Prayer is the rope that pulls God and man together. But, it doesn't pull God down to us. It pulls us up to Him.”

In healthcare, there is no “right” to expect or demand care that is not appropriate. Physicians have an obligation to “first, do no harm”. This is nowhere more important than at the end of life, where comfort care and quality of life are paramount. To bridge this unnecessary divide, open and honest communication between healthcare professionals, patients and family is key. When communication breaks down, the Ethics Committee can help.

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Sidney C. Roberts, MD, FACR

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