Helping Answer the Hard Questions 24-7
.jpg "Carol Taylor, RN, PhD, director of the Ethics Consult Service")
.jpg "Georgetown University Hospital, home of the Ethics Consult Service")
As treatments to prolong life become more readily available in medicine, the ethical questions surrounding treatment decisions grow in parallel.
Georgetown University’s Center for Clinical Bioethics offers a service to physicians, patients, family, and surrogates that can help make these decisions easier. The Ethics Consult Service is available 24 hours a day, seven days a week.
The service works simply. Georgetown’s eight consultants, all of whom have formal expertise in bioethics as well as degrees in medicine, nursing, or science, carry beepers and take turns for weeklong duty, ready for a call anytime during the day or night. Their role, says Carol Taylor, RN, PhD, director of the program and of the Center for Clinical Bioethics, is not to manage or coordinate care of a patient, but to address uncertainties, help mediate conflicts, and provide ethical expertise. And given that Georgetown University Hospital is Jesuit, some calls raise issues related to the ethical and religious directives that govern Catholic health care institutions – concerns that she says “range from how we care for the most vulnerable to the services we offer at the beginning and end of life.”
The majority of calls, however, reflect the thorny issues seen at most advanced academic medical centers.
“At Georgetown University Hospital, we often see patients surrounded by life-sustaining medical technologies and subject to myriad diagnostic testing. Easier to start than to discontinue, these life-sustaining medical technologies often outlive their usefulness, and may even painfully prolong dying,” Taylor says. “Although health care professionals know this, many simply aren’t skilled in talking with patients and families about stopping a therapy that has become ineffective, disproportionately burdensome, or futile."
When family members and health care professionals disagree about treatment goals and plans of care, the ethics consultation service can be a helpful resource. “Even the most skilled physician or nurse often encounters families that demand continued life-sustaining technologies even when compassionately confronted with their uselessness,” Taylor says.
Taylor says consults see common themes in their work. Among them is determining who is the appropriate decision-maker for treatment – “think for a moment about the nursing home resident with end-stage Alzheimer’s disease who is sent to the emergency room needing amputation for a gangrenous limb who has no family or record and no advance directive.”
Clarifying the criteria to be used in weighing alternatives is another. “Take, for example, a case involving a three-month infant with numerous congenital anomalies who, against all odds, is surviving, but who needs high-risk surgeries to achieve even adequate quality of life.”
Mediating conflict is another common issue, as seen in the case of a husband who made a promise to his wife not to turn off life support, but who is being asked to authorize a Do Not Resuscitate order and a transition to purely palliative goals for his wife who is actively dying.
Georgetown’s bioethics consult service started out as a committee but, in the interest of patient comfort, was quickly expanded into a team of one-on-one consultants. The service reports to the hospital ethics committee, which reviews consults quarterly and addresses organizational culture issues raised by the consults. Taylor and the Center for Clinical Bioethics faculty are also actively engaged in the University’s educational mission for Georgetown’s professional students as well as to hospital employees.
While federal requirements say that all hospitals must have a mechanism to address ethical concerns, at Georgetown, the level of expertise is so high that Taylor and others are often invited to train ethicists around the country and internationally, and the Center for Clinical Bioethics frequently hosts visiting scholars interested in developing ethics consultation resources in their own institutions.
Taylor says that in all the years she has been carrying the service beeper, the “bread and butter, life and death” issues have remained remarkably constant, but with some important distinctions. “In the 1980s we were still battling the abuses of paternalism and promoting patient autonomy. Now the pendulum has swung to the opposite extreme and the most common problems stem from patients or their surrogates believing they can order up cafeteria-style whatever health care they want.
"What Terri Schiavo and her family painfully illustrated is that even when we think we have all the necessary legal protections and clear guidelines about when to initiate, withhold or withdraw treatment there are no guarantees that all will be well.”
By Renee Twombly, GUMC Communications
