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Ethics consults: Procedures at OHSU and Mass Gen
Policies illustrate complexities
Susan Tolle, MD, director of the Center for Ethics at the Oregon Health & Sciences University in Portland, takes very seriously the center's role in providing consultative services to smaller, critical access hospitals in that state.
Perhaps not surprisingly, she says, "The most frequent issue by far, and that benefits from our policy, is withholding and withdrawing life-sustaining treatment. It's ever so much more common, by more than a hundred-fold."
Critical access hospitals are defined by the number of beds they have - in this case, 25.
"It's a trauma definition, but what it tells you is they're not very big," Tolle explains. "And so what is needed by our large hospitals, of which there are only a few large [ones], with interlocking health systems, and then by our critical access hospitals, is different, depending on the resources they have and their need for support.
Typically, the role of the OHSU ethics center is consultative, she says, although sometimes the center helps smaller hospitals in the state by providing a specific policy to a specific situation.
"Probably our most popular policy — [judged] by these hospitals calling — is our policy on conscientious objection," she says.
The state of Oregon has special needs for specific policies, as it is one of two states in the United States, including the recently passed measure in Washington state, to allow physician-assisted suicide
"It has helped us think through much more exactly where boundaries are regarding moral conscience and involvement, and I would guess that our policy is much more sophisticated than most, because we have been put in so much of a spotlight about what is highly contested even in the state where it's been legal for 11 years," Tolle explains.
Tolle says that even though physician-assisted suicide is legal in Oregon, there are still a "substantial number — but not quite a majority" of health care providers who continue to oppose the practice and think it's morally wrong "and don't wish to be a party to it," she says.
"You're beginning to see why a very sophisticated policy might be useful," she says.
Developing policy is key to having good ethics consults, it would seem, giving providers, patients, and family a reference point for decision-making.
At Massachusetts General, clinical nurse specialist in ethics, Ellen Robinson, RN, PhD, is a member of that institution's Optimum Care Committee, which out of several ethics committees at the institution, focuses exclusively on end-of-life issues.
"We do some work with education and work with policy," says Robinson. "We actually have a set of policies that sort of guide us in our work, and we take responsibility for keeping those on what we feel are the cutting edges in ethics — end-of-life ethics."
The Mass General model for ethics consultations are utilized when there's "conflict or uncertainty regarding value-laden issues that come up in end-of-life care."
"For example, there . . . are certain tenets that have emerged ethically and legally pretty much through case law about the right to refuse life-sustaining treatment, in that withholding and withdrawing life-sustaining treatment are ethically and legally equivalent concepts."
At times, the medical staff or nursing staff may have questions about whether certain actions are appropriate.
"They'll place a consult for clarification, if you will, around end-of-life practices, and so then, in addition, if there is conflict between the health care team and the family, or conflict within the health care team, or conflict within the family, or sometimes both, our committee would be pretty much immediately thought of as being called in in a consultative mode," Robinson explains.
The overriding goal of any end-of-life ethics consultation at Massachusetts General is to achieve consensus, i.e., consensus "within the ethical and legal end-of-life standards."
Robinson points out that it is not within various professions' codes of ethics "to intentionally kill with an injection of medication.
While the primarily goal of a consult is consensus, Massachusetts General Optimum Care Committee also bases its decision on this "overriding idea: what would best promote a patient's dignity, and working toward a goal of creating consensus."
At Mass General, any member of the health care team, from the physician to a therapist, can call for a consult, Robinson says. Even the patient or the patient's family can request an ethics consult.
"It's not typical, but it's increasing," she says.
[Editor's note: Look for more examples of procedures and processes from OHSU and Massachusetts General in the May issue of Medical Ethics Advisor.]