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Bioethics Advisory Committee Curriculum for House Officers
23 June 2014
What an Ethics Committee does
Consults: Consultants are physicians, ethicists, or administrators who have special interest and
training or experience in medical ethics.
Review of Policies for Hospital
DNR policy
Futility policy
Ohio Living Will policy
Policies on Establishing Brain Death and Care after Brain Death is Declared
Education of Nursing and Medical Staff, Students on Policies and procedures
Mentoring of committee members, to be able to speak effectively in the language of Medical
ethics. Residents and students are welcome to attend.
Goals of Palliative, comfort care
DNR does not mean do not treat.
“Comfort care only” means active treatment of the underlying disease will stop, and comfort
measures will continue or be instituted. Antibiotics, dialysis, lab draws, etc will stop.
Legal, financial and quality issues
Legal: The Legal ramifications of having an Ethics committee are obvious, as the policies and
procedures developed do help to protect the hospital and staff. More importantly, improvement of
communication with the patients family has been shown to be the most effective deterrent to lawsuit. As an
example, Hospice care has the worst outcomes but the best communication about the dying process, and
almost never gets sued.
Financial: The hospital does not get reimbursed for the activities of an ethics committee, but
JCAHO requires each hospital to have such a committee, and accreditation by JCAHO is required for
Medicare reimbursement. Indirectly, a functioning and active committee saves the hospital and medical
staff money by preventing lawsuits and limiting futile care.
Quality: In addition to JCAHO requirements, there are numerous quality indicators which reflect
the performance of the ethics committee, including Pain Management, Organ donation, Reporting of
requests for organ donation, patient and family satisfaction surveys. Hospital death rates are lower if
terminal care is provided through Hospice: and Hospice care is more likely to be used when the family
understands that this is an option, and physicians view Hospice care as an ally, not a last resort.
A. Principles frequently used in medical ethical decision making.
1. Paternalism - Doctor knows best, and acts based on the Doctor’s assumptions of what is best for the
patient.
2. Natural Law - a body of law based on reason, discoverable by human rational intelligence. Generally
used by the Church/Clergy, this can be summarized by the right to Life, Liberty, and the pursuit of
Happiness. Allows for the patient to accept or refuse therapy, as Natural law recognizes that the disease is
what is threatening life, not our decisions. For example, high doses of pain medicine may be given to a
terminally ill patient to control pain, even if we recognize that such doses may suppress respiration, blood
pressure, and the gag reflex. The physician is free of blame if the patient dies as a result, as long as the
intent was to relieve suffering. This is the oldest set of principles used in medical ethics, but still is a
powerful and useful force.
3. Autonomy - Act according to the patients wishes, which may be stated in a Level of Care document,
may be implied by other actions or decisions the patient has made, or may be provided by a spokesperson.
(Guardian for an incompetent patient or minor, or the Durable Power of Attorney for Health Care
DPOAHC). Others may act as spokespersons based on their relationship to the patient. (Surrogate)
4. Utilitarianism - Do what is best for society as a whole, which is becoming more important as the costs
of medical care increase beyond society’s ability to pay. There are also pressures being exerted by
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Managed Care, Organized Medicine, and Trial Lawyers. The State of Oregon has used this priciple to
decide which types of treatments and which diseases will receive funding by the state.
5. Non malfeasance - “primum non nocere” First do no harm. Health care providers have a right and an
obligation to withhold care which carries more risk than good. When you are in doubt, the patient is better
off if you do nothing.
6. Futility - an extension of the principle of non malfeasance, which allows the withdrawal of some types
of supportive care when there is no definitive treatment for a patient’s medical problem.
7. Outcomes Analysis - a perspective on current and planned care for a patient which tries to predict the
likely outcome of the sum total of care provided. There are many cases where conflict arises between the
care providers and the patient or spokespersons because each weighs the potential outcomes differently.
Often this is a very powerful perspective to use to help family members/POA recognize the futility of care
they are requesting. In futile cases, if we can show that the best outcome is a prolonged stay in a Nursing
Home with a feeding tube, tracheotomy and dialysis, most patients will agree that they do not wish to end
up this way. It is difficult to do, but it is usually best to provide percentages of the likelihood of possible
outcomes. This requires knowledge of predictors of mortality such as APACHE scores, or recognition of
high mortality diagnoses such as sepsis, Acute Renal Failure, or Multi System Organ Failure (MSOF).
There is also a functional status score which can help determine the best level of rehabilitation after an
illness or the ability to tolerate certain treatments such as chemotherapy. (Karnovsky score).
B. Levels of Care Orders
Each hospital has a procedure for designating the Level of Care if limitations on resuscitation are
requested. The following should be documented in the chart:
Progress note detailing what was discussed and with whom.
Order stating DNR CC-ARREST, DNR CC, or specific limits (No shock, no CPR etc).
Copy of Ohio form, living will, etc. if available.
Then, each daily progress note should end with a line restating that the patient is DNR or has a
limited resuscitation. (doesn’t need to list every detail) This last step is most important for the house
officer, as you will usually turn to the progress notes to find out what has been going on with a patient you
are called about. In an emergency, that last line of the note will be the first thing you see, and can help
avoid inappropriate interventions. You will be surprised how often a DNR designation gets lost if it is not
renewed daily in the progress note.
C. Order of utility of these principles:
First do no harm.
When there is a decision to be made, the patient’s own expressed wishes are best, provided they
are informed and free of duress. This means that a discussion has taken place with the physician so the
patient has all the information they need and the physician is comfortable that the patient understands the
implications of their decision. The patient should also be free of pain and not making a decision based on
financial concerns, or feel under pressure by family members or the health care team.
Next best is the word of the patient’s spokesperson or DPOAHC. Again the decision should be
informed and free of duress, and should reflect the spokespersons understanding of the patient’s wish, not
their own. (documentation note: do not write “the patients surrogate requested …” better to say “ the
patient’s surrogate reported that the patient would have wanted …).
If the patient is unable to speak for themselves and there is no surrogate, the caregivers must make
a decision based on what they believe is in the best interest of the patient. Getting the Input of the
physicians who have a long term relationship with the patient can be very helpful. Documentation note: “
based on Doctor X’s interaction with the patient over the course of ..time period.. We believe the patient
would have wanted (or not wanted) ……. Also be sure to document efforts at finding a
spokesperson/family member, to fulfill the requirement of “Due Diligence”. List the phone numbers
called, who you spoke to, what they said.
At any point in the process, the healthcare team may request an Ethics Committee consultation, to
help clarify the issues, or to help identify or educate the patient/surrogate or if needed to identify another
provider if the primary provider is uncomfortable with the decision the patient is making. Most doctors
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will request an ethics consultation when they wish to invoke the futility principle in the absence of a
surrogate.
D. Cultural Issues pertaining to Level of Care decisions.
There are many cultural perspectives on End of Life issues, and these need to be taken into
account too. When there is conflict based on culture, it helps the healthcare team accept the decisions made
even if they would not make the same decision themselves.
A. African American culture holds a deep suspicion of American Medicine, due to historical
mistreatment documented in the Tuskegee experiment, segregation, and certain urban myths related, for
example, to immunizations. This explains the low rate of organ donation in this population and it is
common to see resistance to making family members DNR.
B. Religious beliefs will play a role in medical decision making. Some patients/families will need
to speak to a hospital chaplain or their own religious advisor to help with end of life matters. Most
religions DO allow DNR status and the withdrawal of life support, as well as organ donation.
C. Poverty and illiteracy may result in insecurity and misunderstanding.
E. Definitions of Terms
Advance Directive
A document which instructs physicians on the care the patient wishes to receive
if the patient is incapable of making those decisions when the healthcare decisions are being considered. It
can also appoint someone to make those decisions for the patient.
Brain Death
The point at which all electrical impulses in the brain ends; the brain no longer functions
and no brain function can be restored. The patient is dead by accepted medical and legal standards.
Cardiac Arrest The patient’s heart stops beating.
Comfort Care
Interventions that are not aggressive and are designed to keep the patients free of pain.
Decisional Capacity
The ability of the patient to understand information that is presented to him/her
or to make decisions based on information that is given to him/her.
DNR The physician’s order, based on the condition of the patient and conversations with the patient
and/or surrogate, not to resuscitate the patient in the event of cardiac or respiratory arrest.
DNR comfort care
The identification given to a patient who, in consultation with the physician,
decides that he/she does not want to be resuscitated in case of cardiac or respiratory arrest; the patient has
decided that they want no medical interventions other than comfort care. Usually also the patient does not
want further testing or treatment of the underlying condition either.
DNR comfort care - arrest
The identification given to a patient who wants all medical
interventions up to the point of cardiac or respiratory arrest; when the arrest occurs, they want to be kept
comfortable but do not want CPR, Electric shocks, or other resuscitative measures. Usually also the patient
will consent to further testing or treatment of the underlying condition.
Futile care
Medical interventions that cannot achieve the goals of medical expectations or the
personal expectations of the patient.
Health care Power of Attorney/ DPOA-HC
A document which appoints a person whom the
patient trusts to make healthcare decisions for the patient when the patient is unable to make those
decisions themselves. This person is sometimes called the POA (power of attorney).
Level of Care Orders
The preprinted sheet of orders that a physician completes designating the type of
care the patient is to receive. The focus of level of care orders is cardiac resuscitation and comfort care.
Living Will
A document that expresses the healthcare wishes of a patient when the patient is
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terminally ill and has permanently lost the capacity to make those decisions. Some living wills contain a
section which deals with resuscitation/DNR, some do not. Usually the living will specifies what is to be
done when the patient is in a persistent vegetative state or has a terminal condition, and allows withdrawal
of life support.
MOLST Medical Order on Life Sustaining Treatment. A new form of advance Directive which is broader
and takes into account other end of life decisions a patient or family may need to make. Incorporates the
existing DNR law and designation forms, but adds things like ventilator, Trach, Organ and tissue donation.
Persistent Vegetative State
A condition of the patient in which they are unresponsive, due to a
specific insult, for a specified period of time, despite treatment.
Respiratory Arrest
The patient is no longer able to breathe without mechanical assistance.
Resuscitation The attempt to revive a patient when the heart stops beating or beats ineffectively, or
when the patient stops breathing.
Surrogate
A person elected to speak for the patient when the patient is unable to speak for
themselves. Could be formally designated in a Living Will or DPOA-HC, or chosen by the patient’s
family, or the closest living relative or friend. The surrogate may need to be reminded that the frame of
reference to use in decision making should be that of the patient. It also can be helpful to ease the fear of
the surrogate, when making end of life decisions, by invoking the Natural Law principle that the disease is
killing the patient, not the decision to withhold or withdraw treatment.
Website for detailed exploration of some of the basic issues that arise in medical practice
http://academic.udayton.edu/LawrenceUlrich/EIMP
THE OHIO LAW ON DNR COMFORT CARE
By Lawrence Ulrich, Ph.D.
The Ohio law on DNR Comfort Care passed in 1998 with its rules published in 1999. The following
website has more information on these issues:
http://academic.udayton.edu/LawrenceUlrich/dnrohio.htm.
The Ohio law creates a portable DNR, through its DNR Comfort Care Identification. When properly
identified, the patient is designated as DNR Comfort Care, and this designation follows the patient from
institution to institution to home to EMS transport. This identification is made during a conference with the
patient or authorized surrogate and the attending physician. The DNR Identification is made visible by a
bracelet, a wallet card, or a form carry the patient’s name, the physician’s name, and the state DNR
Comfort Care logo.
One major advantage of the Ohio DNR Comfort Care law is the clear description of what constitutes CPR –
an issue that has been hotly debated for 25 years. The components of CPR are:
 Administration of chest compressions
 Insertion of an artificial airway
 Administration of resuscitative drugs
 Defibrillation or cardioversion
 Provision of respiratory assistance
 Initiation of a resuscitative intravenous line
 Initiation of cardiac monitoring
The law distinguishes between DNR Comfort Care, in which no component of CPR is to be utilized and
DNR Comfort Care Arrest, in which current interventions may be continued, such as medications for
arrhythmia, ventilator support for respiratory distress, etc., until the patient experiences cardiac arrest. The
protocol for DNR Comfort Care stipulates that when implementing a DNR Comfort Care order, caregivers
WILL NOT:
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Administer chest compression
Insert artificial airway
Administer resuscitative drugs
Defibrillate or cardiovert
Provide respiratory assistance (other than that listed above)
Caregivers must honor the DNR Identification unless there are extremely rare circumstances where DNR is
inappropriate for the patient, or the DNR Identification has been given fraudulently. Caregivers who honor
the DNR Comfort Care Identification are protected from both civil and criminal liability. If it should
happen that any of the care that is prohibited in the DNR Comfort Care protocol has been initiated and the
Identification is subsequently discovered, the intervention(s) must cease immediately.
While this law does create some confusion in some of it particulars, it does provide patients with the
opportunity to discuss their care with their physicians with the result that they will receive the care that is
appropriate for their condition.
References:
Policies of Grandview Hospital as listed above
Ohio Revised Code 1337.17 approved in 1998 and endorsed by :
Ohio Hospice
OSMA OHA OOA OSBA
AMA program on End of life care
Physician’s Guide to End of life Care. Snyder, Quill eds. available through the American College of
Physicians. (ACP-ASIM: acponline.org, 800-523-1546)
Caring for the Dying: Identification and Promotion of Physician Competency, available from the American
Board of Internal Medicine (ABIM: www.ABIM.org, phone 215-243-1562)
The SUPPORT Studies: Study to Understand Prognoses and Preferences for Outcomes and Risks of
Treatments.
Annals of Int Med Vol 130, No 2, 116-126, 143-152, 19 Jan 1999.
Includes a report from the SUPPORT investigators, the Tavistock Group, and The Trouble with Families:
Toward an Ethic of Accommodation.
Faber-Langendoen and Lanken. Dying Patients in the Intensive Care Unit: Forgoing Treatment,
Maintaining Care. Ann Int Med. 2000:133: 886-893.
Steinhauser, Clipp et al. In Search of a Good Death: Observations of Patients, Families, and Providers.
Ann Int Med. 2000; 132: 825-832.
Bergevin, Bergevin. Discussing DNR Issues. AM J of Hospice and Palliative Care. May/June 1995: 1011.
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