Qualitative Analysis of Healthcare Professionals’ Viewpoints on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas

Abstract

Ethics consultation is a commonly applied mechanism to address clinical ethical dilemmas. However, there is little information on the viewpoints of health care providers towards the relevance of ethics committees and appropriate application of ethics consultation in clinical practice. We sought to use qualitative methodology to evaluate free-text responses to a case-based survey to identify thematically the views of health care professionals towards the role of ethics committees in resolving clinical ethical dilemmas. Using an iterative and reflexive model we identified themes that health care providers support a role for ethics committees and hospitals in resolving clinical ethical dilemmas, that the role should be one of mediation, rather than prescription, but that ultimately legal exposure was dispositive compared to ethical theory. The identified theme of legal fears suggests that the mediation role of ethics committees is viewed by health care professionals primarily as a practical means to avoid more worrisome medico-legal conflict.

Appendix: Survey Instrument

Case Questionnaire

Instructions

You will be presented a series of vignettes based on actual cases from within Allegheny Health Network hospitals, modified to protect the anonymity of the individuals involved. The purpose of this survey is to ascertain your views as a member of the health care team or hospital staff with regard to the issues presented. You are requested to circle the degree to which you agree or disagree with the statements following the cases and will be given the opportunity to add your own free-text impressions or opinions.

Cases

• 1. Estranged Family as Surrogate Decision Maker

AB is a 79-year-old female recently diagnosed with Alzheimer’s Disease. She has been living with her boyfriend for the past 5 years and is largely estranged from her family. Yesterday, she fell and was brought to the hospital unconscious. AB does not have a living will or health care power-of-attorney document, and the hospital social worker reaches out to family to identify whether other surrogate decision makers exist. The social worker is able to contact a son who has not seen the patient in 10 years, but is the only surviving close family member. In the hospital, the patient has developed secondary complications, including pneumonia and septic shock, requiring intubation and pressors via central venous access. The boyfriend feels strongly that AB wouldn’t want to undergo these painful procedures, but the son is demanding that everything must be done for his mother. The attending physician speaks to the boyfriend and son, but is unable to bring them to agreement.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response for each question.

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) The ethics committee should choose a side, rather than just mediate the dispute. 1 2 3 4 5

• (3) The legal status of the potential surrogate decision makers, rather than their overall familiarity with the patient, should govern which path to follow if they are not able to come to a consensus decision. 1 2 3 4 5

• (4) Free Response from Surveyed Subject.

• 2. Dealing with Family Expectations

BL is a 64-year-old male diagnosed with metastatic lung cancer. The attending oncologist believes that there is a 15 % chance of 5-year survival with aggressive chemo-and radiation therapy and a 40 % chance of 1-year survival with palliative care measures. The oncologist asks BL to consult with his family and make a decision. The patient and family decide to go with aggressive treatment because BL is a ‘fighter.’ The patient does well for about a week, but then the course doesn’t go well; BL develops complications with resultant need to delay continued cycles of chemo- and radiation therapy. After a few weeks the attending oncologist believes nothing else of a curative nature can be done and that they should move to palliative care. BL and his family refuse to switch to palliative care saying that he was doing better and maybe he would again. The attending oncologist explains slowly and clearly that while he was initially doing better, the treatment course was unsuccessful. The patient and family disagree with his comments and want another round of chemo- and radiation therapy. They believe that another round will cure him and that the hospital should provide treatment in line with the patient’s wishes.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) As long as the therapeutic option is within the spectrum of reasonable medical practice, the attending oncologist should defer to patient wishes on therapeutic options. 1 2 3 4 5

• (3) It is the role of the attending oncologist to persuade the patient and family to agree upon a course of treatment. 1 2 3 4 5

• (4) It is the role of the ethics committee to persuade either the attending oncologist or the patient/family to pursue a particular course of therapy. 1 2 3 4 5

• (5) Free Response from Surveyed Subject

• 3. Conflict Among Surrogate Decision Makers

RA is a 17-year-old female patient who presents to the hospital unconscious after a motor vehicle accident. RA is unresponsive for several days, but is not showing progression to brain death. After a couple of weeks, it seems that RA will likely require long-term life support and has minimal to no rehabilitation potential. The hospital asks her parents whether they would prefer her to undergo tracheostomy and gastrostomy for long-term life-sustaining treatment or whether they would prefer life-sustaining treatment to be withdrawn. The mother and father both have raised RA since birth and are devastated by having to make this decision. The mother wants to withdraw life sustaining treatment; the father wants long-term life-sustaining treatment. Both say they know their daughter’s wishes. The attending physician explains that a decision must be made one way or the other to avoid complications related to long-term intubation, temporary nutritional support via nasal feeding tube and exposure to infectious complications through long-term ICU care. The mother and father cannot come to an agreement.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) After all mediation efforts have been tried, it is appropriate for the attending physician to choose a side in this dispute to resolve the situation at the bedside level. 1 2 3 4 5

• (3) After all mediation efforts have been tried, it is appropriate for the ethics committee to choose a side in this dispute to resolve the situation at the bedside level. 1 2 3 4 5

• (4) After all mediation efforts have been tried, it is appropriate for the hospital to pursue a legal remedy (court order) to resolve this dispute. 1 2 3 4 5

• (5) Free Response from Surveyed Subject

• 4. Patients With Intellectual Disability Requiring Institutionalized Care

JC is a 54-year-old male with Down’s Syndrome. He has been living in an institutionalized care setting since late adolescence. JC has done well within this setting but over the past few years has developed signs of early-onset dementia, a common occurrence in Down’s Syndrome patients. His family wishes to initiate do-not-resuscitate status and not pursue aggressive therapy if JC develops an acute or degenerative illness. During a series of examinations, JC’s physician diagnoses him with metastatic melanoma. The oncologist believes that with palliative measures JC will live for 1 year. With chemotherapy, the expected likelihood of 5-year survival is 40 %. The family believes that JC should not receive chemotherapy and should instead be placed in hospice care. The leadership of the institutionalized care setting disagrees, stating that there is a reasonable chance of patient recovery or life prolongation. The leadership of the residential institution states that they are required by law to pursue life-sustaining therapy for their residents and that if the family wishes to not pursue this therapy, JC will need to leave their care. The family doesn’t want aggressive treatment, but would have difficulty with caring for JC outside of institutionalized care.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) The leadership of the institutionalized care setting should have a role in determining the course of therapy in JC. 1 2 3 4 5

• (3) The family of JC should have the ultimate decision making authority for JC’s care. 1 2 3 4 5

• (4) It is the role of the ethics committee to choose a side, as opposed to mediating, in this dispute. 1 2 3 4 5

• (5) It is the role of the hospital to choose a side, as opposed to mediating, in this dispute. 1 2 3 4 5

• (6) Free Response from Surveyed Subject

• 5. POLST

DP is a 54-year-old male patient with end-stage renal disease, poor overall functional status and requires long-term nursing home care. He is transported to the hospital following a fall at his facility. Upon arrival, the treating physicians note a large contusion on the patient’s head, an increased level of confusion from baseline and subsequently diagnose a subdural hematoma. The patient has a POLST form which calls for do-not-resuscitate status and limited additional interventions. However, the patient has a condition that requires acute surgical treatment for him to have any hope of recovery, and to perform this surgery, the patient would require intubation and subsequent clinical care. The patient is too confused to ask his interpretation of the POLST form he previously signed, and there are no available surrogate decision makers.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) Ethics consultation can provide an appropriate recommendation under time pressured circumstances such as in this case and should be available at all hours. 1 2 3 4 5

• (3) The treating physicians should default to full surgical treatment in this circumstance. 1 2 3 4 5

• (4) The do-not-resuscitate status of the patient should not apply during the patient’s surgery if that course is pursued, 1 2 3 4 5

• (5) Free Response from Surveyed Subject

• 6. Moral Distress

RJ is a 40-year-old female who suffered a respiratory arrest following an overdose of prescribed antidepressant medications. She has been hospitalized for 3 months with multiple complications, including episodes of septic shock, GI bleeds and seizures. She has no close family members and instead has a court-appointed guardian. This guardian has elected to continue aggressive therapy despite the patient’s poor prognosis. The attending physician has reconciled herself to this course of therapy, though she agrees the patient’s prognosis is poor. However, the nurses involved with the patient’s care have a deep ambivalence in continuing this treatment plan.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) The ethics committee should perform a consult in this case based on the nursing request, even if the attending physician does not feel this is necessary. 1 2 3 4 5

• (3) The legal authority of the court appointed guardian should cause the entire treatment team to continue the current aggressive medical management. 1 2 3 4 5

• (4) The hospital should facilitate the recusal of any treatment team member who voices objections to the current treatment plan. 1 2 3 4 5

• (5) The hospital has an obligation to continue managing this patient with full life-sustaining treatments. 1 2 3 4 5

• (6) Free Response from Surveyed Subject

• 7. Conflict within Healthcare Team

KN is a 77-year-old male who is diagnosed with colon cancer that can be treated surgically. The patient has early dementia and his daughter serves as his surrogate decision maker. The daughter elects for surgery, but after surgery, the patient cannot be extubated and requires pressor support. Three days post-operatively, the patient’s daughter requests that life-sustaining treatment be withdrawn, stating that her father would never want this level of aggressive care. The surgeon feels this is premature while the critical care consultant is unsure of the patient’s prognosis, but has no objection to the daughter’s request.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) Assuming that the parties cannot agree on a course of treatment, the ethics committee should choose a side rather than simply mediate a consensus solution. 1 2 3 4 5

• (3) The fact that there is disagreement among the health care professionals on prognosis should result in the daughter’s request being followed. 1 2 3 4 5

• (4) Free Response from Surveyed Subject.

• 8. Futility

DK is a 90-year-old female with end-stage dementia who has been hospitalized recurrently with urinary tract infections and septic shock. She has no close family members, but has a long-standing primary care physician. The physician states that the patient never wanted limitations in her treatment options, even with the onset of dementia. During this hospitalization, the patient has developed c. difficile related diarrhea, an infected decubitus ulcer and appears in pain during turning and position transfers in bed. When this is brought to the primary care physician’s attention, he states that he will treat the patient’s symptoms, but still believes that treating the patient as “full code” is what is in line with the patient’s previously stated wishes.

1 (Strongly Disagree)—3 (Neutral)—5 (Strongly Agree)—Please circle your response

• (1) The ethics committee has a role in resolving this dispute. 1 2 3 4 5

• (2) The ethics committee should advocate for palliative care measures for this patient despite the stated views of the patient’s primary care physician. 1 2 3 4 5

• (3) If the ethics committee is in agreement, it is appropriate for the hospital to limit further aggressive care measures, such as intubation or central line placement for pressors, if the patient’s condition deteriorates. 1 2 3 4 5

• (4) If the ethics committee is in agreement, it is appropriate for the hospital to declare ongoing attempts at curative treatment futile and force the treating primary care physician to initiate palliative care measures. 1 2 3 4 5

• (5) Free Response from Surveyed Subject

Demographic Questionnaire

Study Categorization Number (Please enter number provided in email request to participate in study) NOTE—This number is only used to evaluate the facility and distribution of the responses:

Gender:

• 1. Male

• 2. Female

Subject Age:

• 1. 18–30

• 2. 31–40

• 3. 41–50

• 4. 51–60

• 5. 61+

Ethnicity:

• 1. Hispanic or Latino

• 2. Not Hispanic or Latino

• 3. Choose Not to Answer

Race:

• 1. Caucasian

• 2. African-American

• 3. American Indian/Native American

• 4. Asian-Pacific Islander

• 5. Other/Mixed Race

• 6. Choose Not to Answer

Religion:

• 1. None

• 2. Christian (Church of England, Catholic, Protestant and all other Christian denominations)

• 3. Buddhist

• 4. Hindu

• 5. Jewish

• 6. Muslim

• 7. Sikh

• 8. Other

• 9. Choose Not to Answer

Highest Level of Education:

• 1. High school

• 2. Some undergraduate

• 3. Undergraduate

• 4. Some post-graduate

• 5. Master’s

• 6. Professional (medical) degree (MD, Pharm.D, MSN)

• 7. PhD

Role within healthcare organization (may choose more than one):

• 1. Attending Physician

• 2. Nurse

• 3. Resident

• 4. Fellow

• 5. Legal Staff

• 6. Other Healthcare Provider (e.g., nurse practitioner, PA, pharmacist, nutritionist)

• 7. Other Healthcare Organization Staff (e.g., Social Worker, Case Management)

• 8. Member of Hospital or Health System Administration (e.g., VP, CMO)

Are you currently or have you ever been a hospital ethics committee member:

• 1. Yes

• 2. No

Do you now or have you ever served as a clinical ethics consultant, participated on a clinical ethics consult subcommittee or directly participated in the resolution of a clinical ethics consult in real time?

• 1. Yes

• 2. No

Have you previously requested a clinical ethics consult?

• 1. Yes

• 2. No

Primary Practice or Employment Location:

• 8. Tertiary Care, Academic Center

• 9. Large Community Hospital 1

• 10. Large Community Hospital 2

• 11. Small Community Hospital 1

• 12. Small Community Hospital 2

• 13. Large Community Hospital 3

• 14. Health System Administration—Multiple Sites