Medical ethics at Emerson

At Emerson Hospital in Concord, ethics rounds provide a forum for discussion and understanding

Ethics consultations and Ethics Rounds play an important role in the day-to-day provision of care at Emerson Hospital. (Photo by Tony Rinaldo/Emerson Hospital [)

The Ethics Committee at Emerson Hospital in Concord, Massachusetts, is one of many support services the hospital provides for patients and their families. According to their Web site, the committee's purpose is to provide advice and help in clarifying medical situations in which ethics play a role. But patients and families are not the only people the committee is there to help. Staff, too, benefit from these deliberations

Ethics Rounds: a considered look at the issues
It's Tuesday morning and the weekly meeting of Ethics Rounds is in full swing. David Green, MD, opens the forum for discussion:

The patient, Ms. P, is a 35-year-old woman, HIV positive for 10 years, but not taking the prescribed antiviral regimen. She is on methadone but her behavior suggests that she is actively using heroin. Ms. P was admitted to the hospital for cough, fever, flank pain, question of tuberculosis, and worsening renal failure. The staff suspects that her friends are bringing her heroin in the hospital, and they worry about a fatal overdose since she is receiving methadone. Ms. P will soon require a shunt for hemodialysis, but they know there is a chance she will inject drugs through the shunt. Several staff members feel frustrated because Ms. P has been repeatedly noncompliant with treatment, and they wonder whether they can refuse to care for such a patient. They also question whether they can search her belongings for drugs and how to handle the public-health issues if she does have tuberculosis and insists on signing out against medical advice.

Today's case is taken from the ethics literature, but more often the situation being discussed involves a patient in the hospital or in an affiliated community setting. Green, chair of the Ethics Committee and the Human Rights Committee at Emerson, raises challenging questions for those present about the ethical issues invoked by this case:

• What are our responsibilities as care providers?
• To what degree does someone's self-destructive behavior influence what care we provide?
• Is IV drug use any different than other detrimental behaviors such as smoking or alcoholism?

Several doctors and nurses share their opinions and discuss their own experiences of caring for patients in similar situations. A social worker asks what the patient says she wants for treatment as her health declines. Together, they explore some of the reasons why Ms. P might be behaving this way, including physiological factors. In a far-ranging discussion, opinions and feelings are aired, and then possible approaches to Ms. P's care are explored in order to ground them in ethical and legal tenets - and hospital policy.

As the meeting breaks up, small clusters of clinicians continue to discuss the case, ask each other questions, and swap stories on their way out. According to Green, Ethics Rounds serves as an educational resource for greater numbers of staff to become aware of and remain attuned to ethical issues in patient care.

Thoughtful discussions and useful suggestions
The ethical principles of autonomy, nonmalfeasance (do no harm), justice, and beneficence are delineated and elaborated in the discussions that occur at each rounds. Any staff member may bring an issue to Ethics Rounds for discussion, and the forum often serves as a sounding board when a staff member feels uneasy about a situation.

One issue that often arises is futility, which comes up because staff can find it difficult to proceed with care when they think additional treatment would be futile, but the patient's family wants everything possible done. When the topic comes up, Green encourages care providers to ask the family questions about what they think will happen if the patient has a particular procedure. What are their hopes and assumptions? Are they realistic?

The intent is to involve everyone in considering the pros, cons, and goals of therapy. The discussion and questions are also meant to focus attention on issues such as duration of treatment, patient's comfort, and what the person would want if he or she were able to decide for him or herself.

In discussing an issue brought up during rounds, the assembled physicians, nurses, social workers, chaplains, and administrators might ask what has been tried so far, and what has not. The environment of the rounds is deliberately nonthreatening and nonjudgmental so people feel willing to pursue troubling issues.

Thoughtful discussion and useful suggestions emerge from the depth of expertise and experience of the staff in attendance. As a result, both clinicians and their charges benefit.

Regina Burzynski, RN, BSN, MBA, director of patient safety/quality improvement/risk management, says, "I don't remember any time when a presenter walked out disappointed. Their questions may not all be answered or solved, but they understand the issues, and what to consider next."

After each week's Ethics Rounds, Green prepares a summary of the topic, case discussion, issues, interventions recommended, and conclusion. These summaries then are used as a reference for future discussions.

Validating the right for concern
Julie McMahon, RN, BSN, CNA, BC, is nurse manager on Wheeler 4. She attends Ethics Rounds regularly and works with her staff to identify cases to review and explore. McMahon's unit comprises 11 pediatric and 12 adult med-surg beds, so many varied issues arise.

McMahon coaches her staff about presenting at Ethics Rounds, exploring different perspectives and concerns and guiding them through a consideration of the options and resources appropriate for the issues raised. Working with her staff to help them formulate their ethical concerns is part of how she views her job as a manager. In the process of developing ethical awareness, she says, it's crucial for a manager to validate the staff nurse's right to be concerned in a clinical situation.

The ethics consultation team
Emerson Hospital has had an Ethics Committee to provide consultation and education not only for staff but also for patients and families for over 10 years. A consultation can be requested by any patient, family member, staff member, or employee, and many of the challenges that warrant ethics consultation are the same as those explored in Ethics Rounds, including end-of-life care, patient competence to make a decision, disagreements among family members, healthcare provider rights, decisions to discontinue treatment, and differences of opinion between the patient and doctors about a treatment plan.

When a consultation is requested, Green gathers three members of the ethics core group to serve in an advisory capacity. The person requesting the consultation can remain anonymous if he or she requests.

The consultants review the medical record, interview everyone involved, and provide an opportunity for each participant to present their perspective. When disagreements arise among scattered family members, the team arranges a conference call to clarify perspectives and improve cohesion when possible.

Cases the consultants deal with often involve uncertainty or conflict and are often complicated by societal values and moral or legal issues relating to patient autonomy. The consultants help to identify common points of interest and then assist the involved parties with problem solving. After trying to reach consensus on the ethical issues and on recommendations, the team summarizes the consultation in the medical record, often including information about what leaders in the ethics field currently consider the best way to think about a particular situation. Green says, "I like to think of us as an educational resource." To that end, Ethics Committee members are always available for follow-up discussion.

Mark Shelford, LICSW, director of psychiatric managed care, is a member of the ethics core group and has a long-standing interest in how decisions get made in healthcare. He has a particular interest in decisions surrounding end-of-life issues, especially in light of the extensive treatment options that are now available. Shelford considers one of his roles - both at Ethics Rounds and in consultations - as reminding providers to talk to the patient and regard her or him as an adult who has self-determination and autonomy. He believes the best outcomes are afforded when the patient can be involved as a member of the team planning and delivering care.

Burzynski is also a core member of the Ethics Committee. "The committee is there to bring issues to the surface so fears and anxieties are understood, and can be resolved," she says, emphasizing that communication involving a patient, whether with family members, between patient, family members, and healthcare provider, or among staff, is paramount. "How are people listening to each other?" she says, and "How do they come across?" are two key questions that need to be asked.

Burzynski and others who deal with the ethics of healthcare at Emerson Hospital know it is important for staff providing care for an extremely ill patient to feel positive about what they are doing. Without considering the ethics involved, that is sometimes impossible. The rounds and access to consultation provide them a way to face and sort through the issues, so they can do their job with greater peace of mind.

How to find out more:
Mark Shelford, LICSW, recommends these Web sites to learn more about a wide range of ethical issues:

Association for Practical and Professional Ethics.

The Society for Ethics.

This is the third in a three-part series on medical ethics in the Greater Boston area. Janet Cromer is a freelance writer and regular contributor to On Call. She received the Will Solimene Award for Excellence in Medical Communication for her On Call article "Drawing Out the Best in People" (September 2005).