A recent report describes the structure and operation of the Boston-based Massachusetts General Hospital (MGH) ethics committee from 2007-2013.1

“We were fortunate to form a research arm of our ethics consultation committee,” says MGH nurse ethicist Ellen Robinson, PhD, RN, one of four ethics committee leaders.

The committee, founded in 1974 as one of the nation’s first hospital ethics committees, has primarily focused on the optimum use of life-sustaining treatments. The report outlines the following:

• specific sociodemographic and clinical characteristics of consult patients during this period;

• demographic differences between the adult inpatient population and patients for whom the ethics committee was consulted;

• salient features of the consults themselves.

“We have long wanted to look objectively at our case themes,” says Robinson. “The stars aligned, and we were able to do so.”

These three consult themes were identified:

• disagreement between the surrogate decision-maker and the healthcare team about goals of care;

• the need for assistance in identifying the appropriate surrogate decision-maker;

• families persisting in requesting life-sustaining treatment that is deemed to be nonbeneficial or harmful.

The ethicists expected to see an even greater percentage of cases that involved disagreements between surrogate decision-makers and the clinical team about goals of care. “In our everyday practice as ethics consultants, it feels like greater than 41%,” says Robinson.

Forming a research/evaluation/quality improvement group with multiple areas of expertise is the best approach to conducting systemic analyses of ethics consults, says Robinson. Consult notes and the patient’s end-of-life or life going forward trajectories also are rich sources of data. “Ethics consults are not strictly ‘quantitative’ data that lend themselves to only statistical analysis,” she explains.

The report details how the ethics committee developed and utilized policies on end-of-life care, including a “Do No Harm” section that was added to its Life-Sustaining Treatment Policy. The newly added section states that physicians “are not obligated to offer or provide life-sustaining treatments that have no clinical indication or have no reasonable likelihood of providing benefit to the patient in the context of his or her values and prognosis.”

The change was made due to a number of ethics consults involving dying patients whose families were struggling with do not resuscitate (DNR) decisions. “The policy section basically asks physicians to consider in certain cases of imminent death whether cardiopulmonary resuscitation would be harmful rather than beneficial,” says Robinson.

In cases of clear projected harm, such as for a patient dying with metastatic cancer, physicians are asked to consider a “medical decision” for DNR. Families are compassionately informed of the decision. “Most are relieved that their loved one will be allowed to die peacefully, surrounded by those who care about the patient, and cared for well by nurses and physicians,” says Robinson.

Further detail about the approach to some of these difficult cases is described in a recent paper.2 “We were pleased to see objective evidence of fair and appropriate application,” says Robinson.

REFERENCES

1. Robinson EM, Cage W, Erler K, et al. Structure, operation, and experience of clinical ethics consultation 2007-2013: A report from the Massachusetts General Hospital Optimum Care Committee. J Clin Ethics 2017; 28(2):137-152.

2. Robinson EM, Cadge W, Zollfrank, et al. After the DNR: Surrogates who persist in requesting cardiopulmonary resuscitation. Hastings Center Report 2017; 47(1):10-19.

SOURCE

• Ellen Robinson, PhD, RN, Massachusetts General Hospital, Boston. Email: erobinson1@mgh.harvard.edu.