On The Other Hand...
so all parties get a chance to explain their perspectives on the case, hear the other sides of the story, and learn about the patient's own values and wishes.
At the meeting about Herman, the physicians and nurses went into detail about his health status and explained that the only way to force treatment on him would be to either tie him down—since an abdominal incision wouldn't heal well if the patient thrashed around—or sedate him. They didn't want to do either, pointing out that rehabilitation after surgery is a long and difficult process that requires cooperation from the patient in order for healing to occur. "You can't rehabilitate a patient who's sedated," says Palac, recalling the case.
The daughter felt that it was unlikely her father would do well after surgery and that he probably wouldn't even understand what was happening to him. But it was "clear that the [son] was the decisionmaker," says Palac. It turned out he was worried that by refusing treatment, his father would be committing passive suicide, a mortal sin in his eyes. But a Catholic priest, brought in by the consult team, assured the son that refusing surgery and dying from an underlying bowel obstruction was not an act of suicide.
"One thing we really don't want is people participating in these decisions walking away feeling that they made a decision to kill a person," says Palac. "We take a great deal of pains to [emphasize] that this is nature taking its course and that we are trying to follow the wishes of the patient . . . the patient's own values with respect to life-sustaining treatment." Eventually everyone agreed in the case of
In 1971, DMS became one of the first medical schools in the nation to offer a course on medical ethics. And in 1981, the School received a grant from the Ira W. DeCamp Foundation to support ethics instruction.
The son was worried that by refusing treatment, his father would be committing passive suicide, a mortal sin in his eyes. But a Catholic priest assured the son that refusing surgery and dying from an underlying bowel obstruction was not an act of suicide.
Herman, Palac adds. "The treatment goal shifted from fixing the obstruction to allowing him to live comfortably in the time he had left."
Good communication is essential in order for an ethics consultation to be helpful. "We bring a framework and a source of information to the players so that we can reassure them, 'Yes, you're the appropriate decision-maker. Yes, it's ethically okay to go ahead and make this decision, whichever way you make it,'" says Kate Clay, a member of the Ethics Committee and the director of DHMC's Center for Shared Decision Making. "I wish more people knew that they had access to us."
People need reassurance that they are making the right decision, agrees Hilary Ryder, M.D., a hospitalist who became a member of the committee two years ago when she was still a resident. "A lot of times the families and the physicians are communicating on two completely different levels. One of the jobs of the ethics committee is to translate what the families are saying to the physicians, but also what the physicians are saying to the families."
Communication is key, agrees Timothy Lahey, M.D., a specialist in infectious diseases who is another member of the Ethics Committee. "A lot of time," he says, "the ethical issues just fade away once trust is restored and everybody's had their say."
One of the things that complicates end-of-life decision-making is the lack of advance directives. That's the official term for two documents—a living will, in which patients indicate their wishes about