Clinical Ethics--what Would You Do?

[Gregory Matthews]

As many of you know, I spent 20 years working in a Federal Hospital.  During most of that time I was a member of the Ethics Committee of that hospital.  During parts of that time, I also worked for a private (non-SDA) hospital.  During that period of time, I also served on its Ethics Committee.

In the post below, I am going to describe an actual case that came before the Ethics Committed of that private hospital and ask what you would do.

In considering the case that I will mention, keep in mind that a fundamental rule of clinical ethics is that a competent adult who understands the consequences of their choice has a right to refuse clinical care.  Even if that refusal will result in their death.

[Gregory Matthews]

The case:

An elderly male, who lived in another part of the country, was visiting relatives in our area.  While he was elderly, he was fully able to live independently, and did so.

While visiting his sons and daughters, a clinical crises occurred and he was transported to the Emergency Department of this hospital.  Our staff determined that he had ingested ethylene glycol and began to treat him aggressively for that condition in an attempt to save his life.  It is important to note that none of our staff had ever treated him.  We had no records detailing what he might want as to life-saving treatment.  And we had no records as to who he might appoint to be in charge of his medical care in the event that he was unable to give consent.

His four sons and daughters, and  their spouses, were united in telling us that he would not have wanted the aggressive treatment that we were providing him.  They demanded that we cease all of such treatment.  And they stated that if we failed to cease such treatment they would file a lawsuit against us.

Our clinical staff believed that with the aggressive treatment that we were giving him, we could restore him to the level of independent living that he had prior to his consumption of the ethylene glycol.

Members of the Ethics Committee that met with the  8 family members included myself,  a hospital attorney, the two primary physicians and others.

What do you think that we as an Ethics Committee should have done in this case?

 

 

 

[Outta Here]

Assuming the four sons and daughters (and their spouses) could not produce a statement of medical power of attorney, nor an advanced directive (or possibly even a suicide note), what choice would you have but to continue aggressive treatment? 

Let it be a lesson for us all, get that power of attorney done, and the advanced directive and all other legal documents--especially if your wishes are DNR.

[Gregory Matthews]

Aubrey:  Yes, none such statements could be produced.  You are absolutely correct as to this being a lesson as to the need to have the appropriate legal documents prepared ahead of time.

But,  this case was not a slam-dunk.

Based upon the unified position of the 8 relatives, the Ethics Committee could have    decided to cease the aggressive treatment.

Here are some factors that the  Ethic Committee understood and/or considered:

1) A potential criminal charge could be made against staff if they continued the aggressive treatment.

2) Family members could not get us in touch with any clinical provider who might have the legal documents that Aubrey mentioned.

3) We had to assume that the pt. ingestion of  the ethylene glycol was voluntary.

4) We had no knowledge of the financial benefit, if any, that would come to the 8 family members if he died.

5) We could not determine the state of mind of the patient at the time he ingested the ethylene glycol.

With this as a potential help, what should the Ethics Committee have done?

 

[Green Cochoa]

Since you are asking the question, perhaps you have some lingering doubts about your ultimate decision in the case and are curious if anyone else's perspective might validate yours.  I have no idea, of course, what decision you made.  However, I would offer two points:

1) Many people who commit suicide by jumping off the Golden Gate Bridge regret their decision on the way down.  Some of these manage to survive to tell their story.

2) Physicians have no power to put life back into a dead body.  However, a living person can always choose again to die.

While those give some "perspective" to the matter, they are far from definitive.  Obviously, dead people won't sue you.  But living persons can sometimes be deceitful, and could conspire against you.  I do not know the laws in the jurisdiction of the hospital, but allowing an elderly man to die could go either way in a litigation, if it was in your power to save him.

All of that aside, from a Biblical perspective, I see that God often allows people to kill themselves.  He allows freedom of choice to that extent.  If the man drank antifreeze, having a cogent mind, it would certainly appear he intended to end his life.  Unless you had some indication that he regretted his action afterward, I would have no criticism for allowing his death.  Neither would I have praise for it.

Personally, I would prefer to see him revived.

[Gregory Matthews]

Green: Good thoughts, carefully considered.

No, I have no doubts as to the decision that was made.  I simply thought that it would be of interest to discuss it.

Later I will tell you what happened.

 

[Outta Here]

1 hour ago, Gregory Matthews said:

1) A potential criminal charge could be made against staff if they continued the aggressive treatment.

2) Family members could not get us in touch with any clinical provider who might have the legal documents that Aubrey mentioned.

3) We had to assume that the pt. ingestion of  the ethylene glycol was voluntary.

4) We had no knowledge of the financial benefit, if any, that would come to the 8 family members if he died.

5) We could not determine the state of mind of the patient at the time he ingested the ethylene glycol.

With this as a potential help, what should the Ethics Committee have done?

 

 

Re:

• 1) Why is that true? I understand that the family said they'd pursue a case, but would it be true that the charge would have held up in a court of law? Physicians are supposed to be healers, aren't they?
• 3) Why assume that it was voluntary? An investigator might assume that it was poisoning by a family member?
• 4) The aspect of finances, IMO, should never come into the decision of whether a person lives or dies.
• 5) Without this information, it is impossible to know what the man wanted.

In my opinion, physicians should be obligated to pursue the aggressive treatment toward keeping the patient alive. 

[Gregory Matthews]

Aubrey:

My response to your numbered comments:

1) Correct, it  might not hold up in court.  However, there is a potential for some clinical providers to be convicted of Battery if the Court was to believe that the family was correct in asserting that the man would not want such aggressive treatment.  Keep in mind that a competent adult, who understands the consequences of their decision, has the right to refuse clinical care, even    if such would result in death.

3)  An assumption has to be made.  An assumption that it was voluntary does not require a high standard of proof, absent evidence to the contrary.  An assumption that it was not voluntary would require some level of reasonable basis for that assumption with referral to police for investigation.

4) Perhaps you did not understand my comment:  If knowledge existed that family members would greatly profit by the death of a person, that would cast doubt on their assertion that he would not want aggressive treatment.

5) Exactly.

NOTE:  I would be interested to see if any of our physician members of CA    would contribute to this discussion.

[rudywoofs (Pam)]

In the absence of a written directive from the patient, I would err on the side of continuing the treatment, until such time (if ever) that the patient's private physician could be found and consulted.  The fact that treatment would most likely be restorative to the patient's previous level of living seems like the issue was a "no-brainer" — and if the family members were informed of that likely outcome, it's very suspicious that they would fight the treatment.

What'd they do?.... put antifreeze in his brownies?

[Gregory Matthews]

O.K.  This is what happened:

1)  The family members were told that the aggressive treatment would continue until there was a major change one way or another.

2)  The patient was discharged   from the hospital, walking out on his own and restored to his previous level of independent functioning.

3)  A son visited one of the physicians, on behalf of the family thanked the hospital team for giving them their Father back and apologized for the demands that they had previously made.

 

 

 

[Outta Here]

A great ending all around! 

[Gregory Matthews]

With 20 years of sitting on a hospital ethics committee, I can say that issues are often not slam-dunk.  They are often complex.  Such committees and their members often struggle with the complex issues and how they may relate to people and their daily lives.  But, in my experience, the recommendations that we on the Ethics Committee made were taken very seriously by the clinicians.

I will give you one example:

Background:  We were a teaching hospital.  One the senior physicians involved in training Internal Medicine Residents was in charge of the care of a patient.  NOTE:  I knew this physician well as for more than a year I rounded with him and his Internal Medicine Residents.

The family of this patient got into conflict with this senior physician.  So, the physician requested that the Ethics Committee become involved.  A decision was made that the entire committee did not need to be involved. and that The chair of the Ethics Committee, who was also a senior physician, and I would evaluate the case and make a recommendation.

The two of us interviewed the family as well as the physician.  The Committee Chair and I became convinced that the issue was not that of a fault on the part of the physician in question.  Rather we decided that the  patient-doctor relationship had been broken and could not be restored.  As a result, we stated that the care of this patient should be transferred to another clinical team.

We communicated that to the physician involved.  He immediately accepted it and the patient was transferred to another team.  It should be noted that he did not argue the point.  He did not attempt to change our minds.  He immediately accepted our recommendation.

In actual fact he  was dumbfounded by our recommendation.  He had not expected such in his wildest dreams.  He did share this perspective with some of his clinical friends.

But, in his teaching he had taught his residents the value of the Ethics Committee and the responsibility that they had in the practice of medicine to ask for and accept such recommendations.  He was willing to live by the principles that he had taught.

NOTE:  At a  later time, he resigned from his leadership position and reverted to the role of just  an ordinary physician providing care when the time came that he believed certain policies in place conflicted with his ethical norms.

 

 

[Stan]

@Gregory Matthews   these are great questions and add value..  thank you for this and so many others.

[Gregory Matthews]

Thank you.  You are gracious.

 

[Nan]

I have come to the original discussion late but agree that in the first case mentioned, continuing treatment was the appropriate choice of action.