Ethicists at Springfield, IL-based Memorial Medical Center have been seeing increased volume of consults for some time. Recently, they have noticed many are occurring outside of the ICU setting.
“The ethics service has recently seen more requests for consults involving discharge and treatment questions in mentally ill patients who lack adequate social support,” reports Christine Gorka, PhD, director of the Clinical Ethics Center.
The service began in 1991 with one part-time volunteer ethicist and now has three full-time ethicists. “Even with those staffing levels, volume can become an issue,” says Gorka. While only one or two consults normally come in per day, sometimes volume is greater. “In those circumstances, consults are triaged for urgency and responded to in that fashion,” says Gorka.
The ethics center database tracks about 40 reasons that a consult can be called. “Ethics reports annually to hospital administrators on volume of consults, the requesting professions, reasons for consults, location in the hospital, and overall patient demographics,” says Gorka. Here are three reasons for the recent surge in outside-the-ICU consults:
• Difficult family dynamics.
A common question is: Under what conditions is it ethical to prevent (or allow a surrogate to prevent) a family member from visiting a patient or from receiving information about the patient?
“The solutions to these problems can be more complicated outside an ICU than inside that environment,” says Gorka. “Access is more difficult to control.”
An example of a case where one might limit visitation is when there is a clinical reason, such as a neurological injury, for why a patient is ordered to a quiet environment, free from stimuli, to promote healing. The same is true for any patient where the presence of a visitor causes agitation or distress.
“Limiting information can be trickier,” says Gorka. Decisions to disclose or limit information should be made considering what the patient would have wanted.
“That said, sometimes they are not,” says Gorka. Ethicists have encountered instances where information was being improperly used, including social media postings, for example.
• Questions about decisional capacity.
Consults involving a wide variety of ethical issues cannot proceed without a capacity assessment. “In an ICU, by contrast, patients are often so obviously unable to make decisions that a capacity assessment isn’t necessary,” explains Gorka.
• Potentially unsafe discharges.
Some consults involve patients who want to leave against medical advice. Others involve patients for whom few resources are available, being discharged to a potentially unsafe setting. Sometimes, 24-hour supervision is recommended, but the family cannot or will not provide it.
Recently, an ethics consult was called about a wheelchair-bound patient with congenital physical disabilities who had several recent hospitalizations due to respiratory problems. Some clinical team members felt the patient, who lived in a house with help from friends and paid support staff, needed a guardian to force placement into a nursing home. The attending physician believed the patient had capacity to decide upon discharge.
Ethicists had numerous lengthy conversations with the patient. Ultimately, they agreed with the attending physician that the patient had capacity and that guardianship did not seem appropriate.
“Maintaining independence was the highest priority to this patient,” explains Bethany Spielman, PhD, JD, a member of Memorial’s Human Values and Ethics Committee.
Ethicists met with providers, the patient, and the outside support network consisting of friends and paid help. The group discussed ways to address care concerns and other needs, and the patient was discharged to the home setting.
Another case involved a young stroke patient left with severe cognitive and physical disabilities. The patient had a large support network of siblings, with the eldest sister identified as proxy decision-maker. “The team was pushing for discharge to a nursing home because of the feeding tube placed during the admission,” says Spielman. The family objected because they wanted the patient to return home. Ethics gathered the family and providers to discuss discharge needs and next steps. “As the family indicated they were committed to any training that the hospital felt was needed, ethics supported their request to discharge patient home,” says Spielman.
Another case involved a morbidly obese patient who was transferred to the hospital from a nursing home for treatment of respiratory problems. “The patient had been making all healthcare decisions the entire admission,” says Spielman.
When approached about discharge options, the patient indicated a desire to return home instead of to the nursing home. Some members of the team felt this was unsafe because the patient was essentially bed-bound. “A question about capacity was raised, and ethics was consulted to assist,” says Spielman.
After meeting with the patient, it became clear that the patient had capacity. In anticipation of returning home, the patient had already started working on re-establishing a home support network to help with most activities of daily living. The patient expressed frustration with the care received in the nursing home and was willing to participate in at-home physical therapy. The attending physician agreed, and the patient was discharged home. In this case, says Spielman, “Ethics reaffirmed the patient’s right to make discharge decisions, even if some believed they might not be the ‘best’ decisions.”
• Christine Gorka, PhD, Clinical Ethics Center, Memorial Medical Center, Springfield, IL. Phone: (217) 757-2353. Email: firstname.lastname@example.org.
• Bethany Spielman, PhD, JD, School of Medicine, Southern Illinois University, Springfield, IL. Phone: (217) 545-4261. Email: email@example.com.