A major teaching hospital of Harvard Medical School Ethics Programs at BIDMC Lachlan Forrow, MD Director, Ethics Support Service Beth Israel Deaconess Medical Center Associate Professor of Medicine Harvard Medical School
Good Work : 3 Dimensions 1. High Quality,Skilled: passes the expert test 2. Responsible: ethically good 3. Meaningful: work that feels enjoyable, satisfying Source: Howard Gardner et al. The Good Work Project
What Is an Ethics Issue? What can I do? What should I do?
Ethical Issues: Two Approaches Ethics of OBLIGATIONS» What are we obliged to do? Ethics of IDEALS» What do we aspire to do?
Clinical Ethics at BIDMC -- History First Hospital Patient Bill of Rights (1972) Orders Not to Resuscitate : NEJM (1976) First Hospital CPR Not Indicated Policy (1992?) One of the last hospitals to establish an Ethics Committee
BIDMC Ethics Service Axioms The greatness of BIDMC historically has been at least as much a matter of its core values as its technical excellence BIDMC s ethics = the sum of all of the actions, values, and character of all the people who work here In a healthy organization, the Chief Ethics Officer is the CEO
BIDMC Ethics Service Axioms: II Ethics is not primarily a matter of fulfilling obligations or following rules it s a matter of living up to ideals and aspirations Many (most?) ethics problems are really failures of preventive ethics Moral and Morale are closely linked» Few things are as de-moralizing as dissonance between one s work and one s core values; few things are as energizing as true pride in one s work moral and morale (and thus staff recruitment, retention, and productivity) are tightly linked.
Ethics Support Service: Consultations 24/7 Coverage for Real-time Ethics Issues» Available to any staff, patient, or family member, at any time, for any reason no permission to call is needed! NO decision-making authority Consults range from informal guidance (e.g. via telephone) to 4-person consult team with typed note in medical record
Ethics Support Service: Case Examples 68 year old man with metastatic cancer on ventilator in ICU with prolonged sepsis and renal failure; son insists on continuing all life support, while staff believe this is wrong 50 year old with diabetes x 40 years, blind, severe neuropathy, refuses amputation, admitted with intentional insulin OD, says he wants to die 36 year old illegal immigrant, congenital heart disease, no insurance, erratic about f/u, and life-threatening pulmonary hypertension and hypoxemia; complex drug Rx would cost $100,000/year Request to photograph, for a book on Women in Medicine, a hysterectomy on Alzheimer s patient whose husband/proxy Resident physician suffers needle stick during code; patient survives on vent but can t provide legally-required (per 1988 law) consent to HIV testing
Educational Programs Monthly Unit-Based Ethics Rounds (15-20/month): All ICU s: East MICU/SICU CSRU MICU-7 SICU MICU-6 NICU/L&D CCU Others: Inpt Oncology Inpt Psychiatry Interpreter Services Nutrition Services PLUS: Monthly BIDMC-wide Ethics Case Conference Monthly Schwartz Center Rounds Monthly Nursing Orientation
Ethics Work-Up 1. Facts» diagnosis, prognosis, pt s views, other 2. Values at Stake» pt s autonomy v. pt s welfare» prolonging life v. alleviating suffering» what s best for pt v. what family wants 3. Possible Courses of Action» How can you promote all values you are responsible for?» if not (and only then), which take priority? 4. Preventive Ethics
Shared Decision-Making: I Two Components of a good clinical decision: 1. What goals/values are most important? 2. Of these, which are possible? How can those best be accomplished?
Shared Decision-Making: II Roles of Pt/Family and Clinical Team Pt/Family Goals Values Clinical Team Possible? Best Way(s) to achieve PLAN
Clinical Decision-making FUNDAMENTAL PRINCIPLE: A clinical intervention (diagnostic or therapeutic) is justified if and only if the expected benefits outweigh the expected burdens from the perspective of the patient.
Physician/Professional Integrity You should never do anything that you think is seriously wrong. Never. Example: But what if the family insists? It is the policy of the Beth Israel Deaconess Medical Center that no patient should be forced to undergo, nor should any physician or health professional be forced to provide, a treatment that is ineffective or harmful. A medical treatment is ineffective if there is no reasonable likelihood that it will achieve a medical benefit to the patient. A medical treatment is harmful if the likely suffering or risk of other harm caused by the treatment grossly outweighs any medical benefit to the patient. Help for trainees: Chief resident, other senior MD, or 24/7 Ethics Support Service via page operator
Preventive Ethics Most ethical crises have a predictable pathophysiology that provide the basis for effective preventive interventions
Grow into your ideals, so that life can never rob you of them. --Dr. Albert Schweitzer