Hospice option proves fruitful at last
Hospice option proves fruitful at last
Strong religious beliefs hamper futility decision
The situation: A 57-year-old woman with a history of diabetes, chronic obstructive pulmonary disease, and heart disease lived with her adult daughter. One day while she was alone, the woman suffered a cardiac arrest. She lay unconscious for some time before paramedics arrived to resuscitate her. The event left her with severe brain damage and a dependence on life support.
After her hospital discharge, she was transferred to a nursing home for skilled care. She was permanently vegetative, was on a ventilator, and had lost all renal function. After several trips to the hospital for infections and other acute conditions, the patient had run out of treatment options. Although she had been taken to another nearby hospital in the past, this time physicians at the nursing home realized that her only possible option might be dialysis. The medical director transferred the woman to a second hospital that offered dialysis where her condition could be evaluated.
"The situation involved two of our system hospitals," explains Barbara Barresi, RN, MA, PhD(c), system ethics director for the Mount Carmel Health System in Columbus, OH. "Initially, we were hampered further by the fact that the patient’s regular physician was away from the area," she explains. The emergency physician determined that the woman was not an appropriate candidate for dialysis.
God expects us to do everything we can’
The family argued for the treatment and for a particular medication they maintained would induce urination, based on a religious belief that "God expects us to do everything we can to save mother." The family further told the hospital staff that if they did not give their mother the medication and do dialysis, they would be killing her. "God created the dialysis machine and the people who know how to run it. He wants us to help mother," they argued.
The ethics committee discussion: Clearly, the woman’s care options were futile, Barresi says. Although the committee determined that futility criteria applied, it sought to allay the family’s concerns by asking for the opinion of two additional nephrologists. All three concurred.
At a second committee meeting with the family, the group suggested that the patient be moved to the hospital’s palliative care unit. "The family heard our description of this choice but still wanted to "give her a chance with the medication," Barresi says. Physicians, fearing it would only harm the patient further, refused.
To a degree, the committee tried to acquiesce to the family’s fundamental Christian beliefs: They approved a visit of deacons from the church to lay hands on the patient during a 45-minute ritual.
Committee decides to intervene
When the prayers failed to work immediately, the family said they needed more time to pray. At this point in the conflict, Barresi says, the committee determined that the harm to the patient and to the staff was overwhelming.
"We told the family that they had several options. We would help transfer the patient to another hospital but could not assist them in finding another physician. Or their mother could be transferred to our inpatient hospice unit," she explains. The family responded that they wanted to take the patient home.
The outcome: The committee gave the family 24 hours to make a decision. They could not take the patient home. "You cannot ask for something outside the limits of care," Barresi recalls telling them. Still in limbo the next day, the staff transferred the patient to the hospice unit, where she died 48 hours later.
Retrospective review: In retrospect, Barresi says the staff could have done little more to change the family’s entrenchment. But the analysis did point out the potential benefit of establishing ongoing dialogue with the nursing home about difficult and potentially futile cases.
"There were signs of the family issues in the nursing home that its ethics committee had discussed. We might have been alerted that the patient would require hospital care and that the family’s strong Christian views might become a problem," she says.
All of the ethics committees involved (or a systemwide ethics committee like the one Baressi chairs) should look at what is happening with patients and families in one facility and decide what might have a future effect on care and treatment decisions in another, Barresi and her colleagues decided.
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