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On The Other Hand...

nurses to learn CPR and other such skills. "However, in this organization, a clinical person's likelihood of coming in contact with somebody who's needing resuscitation is probably 10 times less than their likelihood of coming in contact with a person who is not to be resuscitated." But, she adds, there's no mandated training regarding end-of-life care, the way there is regarding life-extending care.

Even the ethics instruction that today's medical students receive—including at Dartmouth—"is done piecemeal," says Bernat. At DMS, he explains, "in the late 1970s and early '80s, there used to be a required [ethics] course in the first year, but that was stopped." There is just toomuch that needs to be incorporated into the curriculumnowadays. "My grandfather was a doctor, went to medical school during World War I," explains Bernat. "His medical school was four years. Our current medical school is four years. Despite the fact that there's a hundred times more information than there was 90 years ago, there are still four years that are devoted to it."

DMS students currently get a smattering of ethics in several different courses. Palac and Bernat present cases involving ethics and palliative care that first- and second-year students discuss in the required On Doctoring course. In the second-year neurology course, Bernat gives a lecture on brain death and the vegetative state. Many thirdyear students encounter an ethics consult during their clinical rotations. And fourth-years discuss medical ethics in the required Health, Society, and the Physician course.

"If I had my druthers," says Bernat, "we would have a required course in medical ethics where we'd start with a textbook and we'd go through it in a systematic way."

But Bernat and the other members of the Ethics Committee do feel— based on feedback from caregivers, risk management personnel, and senior Medical Center administrators —that the committee's work is valued. "We help to enhance communication, to understand what's wrong, and to help people find a mutually satisfactory solution," says Bernat. And in cases where families are angry, an ethics consultation "may take the edge off whatever the anger is. It's been shown in many studies to prevent malpractice suits and save money that way, but it also promotes quality care by enhancing communication." Other studies have

shown that when ethics consults help parties reach a mutually agreeable decision, unnecessary care and suffering are prevented and prolonged hospitalizations are reduced.

Lynn Peterson, M.D., a retired surgeon who is a member of DHMC's Ethics Committee, admits that he was once skeptical of the value of ethics committees. "It's very hard, I think, for a patient or a family to directly disagree with a doctor who's going to take care of them," says Peterson, who headed Harvard Medical School's Division of Medical Ethics from 1989 to 1997 and the Ethics Service at Harvard's Brigham and Women's Hospital from 1997 to 2004.

But a third party like an ethics consult team, Peterson came to realize, can let "the family express their concerns and their point of view without having to necessarily directly confront the caregivers."

Although ethics consults have helped many people, the teamisn't called in as often as it might be. Part of the problem is that some caregivers and many families aren't aware of its existence.

Another problem is that some healthcare providers are so focused on curing illness and fixing injury, at any cost, that they can't face offering less than the most aggressive treatment. "Doctors have been trained to save life," says Rosemary Evans, the public member of the Ethics Committee. "It's . . . very hard for them to let go."

Critical-care nurse Sarah Stableford agrees. "As a society," she says, "we're very comfortable bringing [people] into the world, and very uncomfortable letting them leave the world. Prolonging life is a great thing to do. Prolonging death is unconscionable, [yet] we do an awful lot of prolonging death."

Afurther problem is that some families resist the idea of ameeting with a group of medical professionals. "So many times, I think, people go to an ethics committee consultation thinking of the ethics committee as some kind of a tribunal," says the Reverend Patrick McCoy, a chaplain at DHMC and a member of the ethics consult team. "It is really a chance to problem-solve and to resolve conflict.

"I think the leaders of [the consult team] are really very good at acknowledging the emotional charge that's there," McCoy continues, at "trying to help the whole story unfold . . . the medical story of what

the illness is, what the treatment process has been like, what the options are, what the consequences of the options are . . . so that all of the different layers can be teased out and the family can be helped to articulate what the patient's wishes would be for decisions if the patient could participate."

Despite the committee's success at resolving thorny ethics problems, the number of formal consults has decreased over the years—partly because palliative care is beginning to fill the role that ethics consults used to. Palliative care often involves an ethics-oriented discussion, says Palac, to help patients decide whether to refuse or accept further medical intervention. And more and more patients are seeking assistance from the Center for Shared Decision Making, and so coming to decisions without requiring an ethics consult.

While the Ethics Committee continues its work, there's one problem it has not yet addressed—what Bernat calls the "collision between the financial and the ethical." Others share his concern that limited resources for health-care services could one day play a role in decision-making.

"In the best of all possible worlds," says Bernat, "if money weren't an issue, you could identify an ethical course of action" without thinking about cost. "But the costs are crashing down on us," he continues. "In the future, we are not going to have the luxury that we've had in the past, which is to not pay that much attention to how much things cost. . . . The way we operate is going to have to take [cost] into account."

"There's just no way we're going to be able to keep on doing what we're doing," agrees Paul Manganiello, M.D., an ob-gyn who's been on the Ethics Committee since its inception in the 1980s. Part of what's driven the escalation of medical services, he feels, is that "people just have too much faith in technology."

Bernat and his colleagues recognize some other issues that need to be addressed, too, such as the ethical implications of a dysfunctional health-care system and of millions of uninsured patients. But those may be problems too big for an individual hospital ethics committee to tackle.

So for now, the DHMC Ethics Committee will continue to help caregivers, patients, and families grapple with ethical dilemmas—one case at a time.

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Laura Carter is the associate editor of Dartmouth Medicine magazine. After completing the reporting and writing for this feature, she made sure that her own advance directives were on file at DHMC. All of the ethical scenarios here in italic type are based on actual cases that have come before the DHMC Ethics Committee, but the names and some identifying details have been changed in order to preserve patient confidentiality.

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