have her removed from the ventilator, though she continued to be fed and hydrated artificially and lived for another nine years before dying of pneumonia.

My family had talked about the Quinlan case over the years, and I'm sure that at some point my mother had made it clear to my father that she would never want to live out her days "as a vegetable," the way Quinlan had.

Since then, laws have been passed that allow end-of-life treatment decisions to be made by patients (when they're able to play a role) and their physicians and families, without resorting to the courts. But what if the parties don't agree? Who decides what happens in that case? Today, at most hospitals, an "ethics consult" can be requested to objectively resolve such questions. Many concern end-of-life issues.

Dartmouth-Hitchcock Medical Center has one of the oldest hospital ethics committees in the United States. It was created in 1983 and since 1994 has been led by James Bernat, M.D., a neurologist and an internationally recognized medical ethicist. The 28-member committee includes physicians, nurses, social workers, administrators, a chaplain, a lawyer, and a medical student, as well as a public member—someone with no connection to Dartmouth or to medicine.

The DHMC committee not only consults on cases in which the appropriate course of treatment isn't clear, but also educates DHMC caregivers about bioethics, develops ethics policies, coordinates the New Hampshire-Vermont Ethics Network, collaborates with Dartmouth's Committee for the Protection of Human Subjects, and

James Bernat: The committee's "goal is to provide a forum for discussion"

James Bernat, who has chaired DHMC's Ethics Committee since 1994, is an internationally recognized ethicist. In 1997, he was one of ten scholars invited to Rome to advise the Vatican on how to define death.

Laws have now been passed that allow end-oflife treatment decisions to be made by patients (when they're able to play a role) and their physicians and families, without resorting to the courts. But what if the parties don't agree? Who decides what happens in that case?

occasionally lobbies on ethics-related legislation. But it's the ethics consult subcommittee—or "ethics SWAT team," as some members of the group call it—that grapples directly with ethical dilemmas.

Herman, a man in his eighties, is admitted to the hospital with a twisted intestine that only surgery can correct. He has dementia as well as other chronic health problems and is not competent to make his own medical decisions. He vehemently objects, however, whenever anyone tries to put him on a gurney, insert a nasogastric tube, or perform any other kind of medical procedure—screaming, "No! No! No!" He isn't able to eat and vomits whenever anyone tries to feed him. His doctors and nurses don't want to force care on him. His daughter agrees with the health-care team, but his son thinks that his father should have the surgery.

So the ethics consult team—which is led by Bernat and Diane Palac, M.D., a palliative-care specialist—was called in. Some ethical dilemmas can be resolved with a telephone conversation between a member of the consult team and the physician. Or the consult team might meet with the patient's caregivers and coach them on how to communicate with the family in a way that helps them to understand what's best. But in other cases, like this one, a full-blown ethics consult is required. The team first gathers information to try to understand the facts of the situation: they check the medical charts and then talk separately with the patient's physicians and nurses, the patient if that's possible, and family members. Then the ethics consultants facilitate a meeting with everyone present