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The Listenersby Ruth SoRelle, M.P.H. The elderly man hovers unconscious in the twilight of life. Tubes exude from every orifice. Physicians and nurses have no magic bullets or miracles that will allow him to waken and continue the activities he had once so enjoyed. He is dying. Treatment causes more pain than succor. His physician says it is time to stop and keep him comfortable to the end. In most cases, this advice comes as no surprise, but some families have difficulty accepting the sad truth. If there is no guidance in writing from the patient himself, they are left with choices difficult enough to divide siblings or cause a rift between health care providers and the patient's relatives. In the hospitals affiliated with Baylor College of Medicine, a special group can come in and mediate, providing a neutral ear to the disputes in these tragic cases. A page to a beeper worn by a member of the ethics consultation or "consult" service starts the process. Dr. Baruch Brody, director of the Baylor College of Medicine Center for Medical Ethics and Health Policy, once called it "beeper ethics." which means there is help when values collide in the medical environment. The Center coordinates ethics consult services at most of BCM's affiliated hospitals. The consult service is one of those unexpected developments that Brody has seen evolve since the Center began as a joint program with nearby Rice University in 1982. A telephone call that interrupted a recent conversation demonstrated how integrated the program is into everyday activities. A BCM physician was calling about a challenging case that presented an ethical issue. He thought it would be valuable to schedule a meeting between Brody and his residents to discuss the problems involved. Such teaching is an integral part of the program. Had the problem been more pressing, Brody would have scheduled the meeting immediately, intervening quickly. While some cases reach the courts and make headlines, more often members of the ethics consult service resolve the issue through quiet and skilled intervention. "We are sort of designated listeners," said Dr. Mary Anderlik Majumder, the assistant professor in the Center who, with Brody, coordinates the ethics consult service at The Methodist Hospital. Listening establishes rapport with those involved when there is a dispute between the family and the health care team. "Five minutes before, you were a stranger, and now you are weeping with people over a tragic situation," she said. "We try to focus the family on what the patient would have wanted. We talk about the patient as a person. It can be cathartic and healing." In Houston hospitals, the process of resolving such disputes is carefully laid out, and some of the steps are even required under Texas law. However, much of what goes on is mediation among the parties involved. "Usually what happens is that, in the end, it converges on a plan of care to which everyone agrees," said Majumder. "Many of the problems can be resolved by sitting down and talking about them," said Dr. Daniel Glaze, head of the ethics committee at Texas Children's Hospital and a professor of pediatrics at BCM. "We offer solutions. Maybe we tell the doctors, 'Have you explained in detail to the parent what you are talking about?' I would imagine that in 70 to 90 percent of the cases, it stops there and is resolved." Anyone can request an ethics consult, and the issues are wide-ranging. Is a patient competent to consent to or refuse treatment? Can a child reject treatment? Who is the proper surrogate decision-maker? Is it time to stop life-sustaining treatment and focus on comfort, even when family members request that everything be done? At most of the hospitals, the consult service initially involves a team of two. One carries the beeper but depends on his or her colleague for backup in difficult cases. They are on-call 24/7, but that rotates among consult members regularly. The ethics consult teams have varied backgrounds. For example, Brody, Dr. Richard Sharp, assistant professor, and Dr. Laurence McCullough, a professor in the Center, are trained in philosophy, and Majumder is both an attorney and has a Ph.D. in religious studies. Glaze is a pediatric neurologist. Depending on the hospital, ethics consultants can be physicians, attorneys, nurses, social workers or chaplains. When they answer a page to the ethics consult service, they step out of those roles to be a neutral party who can bring the ethical issues to the fore in helping to reach a compromise. "It is usually a matter of sitting down and making sure the family members understand the patient's conditions, the alternatives to inappropriate treatment, and elicit advance directives or prior statements about what kind of care the person would want in this situation," said McCullough, who heads the ethics consult service for St. Luke's Episcopal Hospital. "Sometimes the families need a couple of days to think about it," he said. There is time as long as the patient can be kept comfortable. Once every three months, McCullough reviews the cases that go to ethics consult at St. Luke's. He finds these kinds of chart notes gratifying: "Patient comfortable. Family at bedside at the end. Led family in prayer." "That's what happens when palliative (comfort) care and chaplaincy are involved," he said. "Professional integrity and protecting the patient go hand-in-hand," said McCullough. "If as a clinician, you think what you are doing is not helping and may harm the patient, then it's not that you are free to stop – you must stop." Often, he said, the ethics consultant can help family members understand that their requests could cause pain to their loved one. "Most of the time, rational discourse works," said McCullough. "Give the family some time and they will make good decisions." In some cases, when the differences are too great, the consultant may suggest that the family might be more comfortable moving the patient to another facility. Often, the hospital helps in making such transfers possible. When the health care providers and patient family cannot get together, the situation goes to a full ethics committee meeting for review. "These are heart-breaking cases," said McCullough. "The rooms are full when the committee meets," he added. "There is a strong culture of service." Having the voices of many experts and divergent points of view can help family and health care providers come to an acceptable compromise that benefits the patient. Again, both the physician involved in the case and members of the family are encouraged to attend. All points of view are heard. The committees are not rubber stamps. Sometimes, they suggest the physician consider other options. Texas law gives the groups authority to decide whether the attending physician has made a case that requested treatment is inappropriate. Even if the committee agrees with the physician, the family is given time (at least 10 days under state law) to transfer the patient to another facility. Dr. Joslyn W. Fisher, assistant professor of medicine at BCM and head of the consult service at Ben Taub General Hospital, went through BCM's ethics track as a medical student and began heading the Ben Taub service when she became a physician there. The hours are long and difficult while the task is often emotionally wrenching, but she has remained committed to it. "I'm passionate that it is a necessary service," Fisher said. Frequently, the ethics service finds itself addressing issues of whether treatment requested by families is appropriate. They never discuss withdrawing care. "Providing care—comfort, pain control and palliation—is always appropriate," said Brody. Making Ethics RealAs a guide on the road to becoming a doctor, you teach medical students biochemistry, anatomy and the art of taking a history and physical. But how do you teach ethics? At Baylor College of Medicine, you make it real. During the spring semester, 170 first-year medical and 30 physician assistant students will don white coats and enter the intensive care unit—many for the first time—as part of a required ethics course. "We understand that it can be difficult for students to realize how ethical studies will apply to them, so we take them into the ICU to show them what they are going to be dealing with in the clinical environment," said Dr. Amy McGuire, assistant professor in the BCM Center for Medical Ethics and Health Policy, who directs the course. The course consists of two one-hour lectures each week and one small group session in which clinical faculty lead the students through discussions of two hypothetical cases. The small group facilitators—mostly clinicians with some ethicists and lawyers—give students a real feeling for day-to-day issues, said McGuire. Topics include end-of-life decisions, research ethics, genetics and molecular medicine, pediatrics and decisions regarding minors. "We try to focus on very practical approaches," said McGuire. "We teach them how to think through cases that they will actually see in the clinic. One type of case they study is the kind that generates controversy because there is no consensus on what is the appropriate course." Her job, and that of her colleagues, is to teach students to make a justified ethical argument that supports their decisions. In many cases about which there is consensus, communication makes it possible to manage the case appropriately. "How do you handle someone who is refusing something you think is medically necessary? We try to teach them the skills to accomplish that goal." Some students become so interested in these issues that they go on to take part in the "ethics track," which involves special courses in ethics each year of medical school. "The ethics track emerged as a response to student requests," said Dr. Baruch Brody, professor of medical ethics and the Center director, who coordinates the ethics track. As the ethics curriculum has evolved, Brody has seen it change medicine and those who practice it. Hospitals have ethics consult services. Ethicists play major roles on committees that set governmental and professional guidelines. He said Dr. William T. Butler, chancellor emeritus at BCM, who was president when the Center started, warned him that the ethics studies would not have an immediate effect. "You had to have patience and confidence that in the end, it would make a difference. I think it has," said Brody. |
Patient CareHealthy Living for a Thousand, Alex ResearchFighting Obesity one Molecule at a Time Doctors are from Jupiter, Patients are from Saturn EducationA Lot's Changed in 40 Years... Sort Of Community ServiceAlumni & DevelopmentBuilding BCM and Biochemistry History Following Father's Bedside Manner More than a Street Sign: Advocates for Medicine College NewsAn Artist in the Medical Arena
Educating the Next Generation of Leaders
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Volume 2, Issue 3, Fall 2006 |
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