Abstract
Making difficult healthcare decisions is often helped by consultation with a bioethics committee. This article reviews the main bioethics principles, when it is appropriate and how to call a bioethics consult, ethical concerns, and members of the consult team. Bioethics resources are included.
HOW TO CALL A BIOETHICS CONSULT
Each hospital has a preferred method for requesting a bioethics consult that is usually determined by medical staff policies. Many hospitals have a bioethics committee as one of the medical staff committees, with a designated chair appointed by the medical staff. This article focuses on the procedures at Ochsner Medical Center-Jefferson Highway that are typical of procedures used at larger hospitals throughout the United States.
Ochsner policy states that to request an ethics consult, a patient, family member, or member of the healthcare team can contact anyone on the ethics committee. The chaplain (System Manager of Pastoral Care) is usually the first one contacted. As Smith and Morgan have pointed out, “Patients and families have regularly consulted hospital chaplains and their own clergy for help in making difficult healthcare decisions, but the increased complexity of decisions generated by scientific and medical advances seems to have increased the frequency as well as the perplexity of such consultations.”1
The person requesting the consult is asked to provide the following information: patient name, patient location, staff physician name, current condition of the patient, ethics dilemma for consultation, name of the requestor, and relationship of the requestor to the patient. Additional helpful information is the availability of the attending physician for the consult. Ochsner's Biomedical Ethics portal on the internet will soon be expanded to add a method for requesting an ethics consult online. The form will look similar to the template in the figure.
Ochsner's form for requesting a bioethics consultation.
Once the request for a consult is received, the chaplain contacts key bioethics committee members to schedule a consult. The bioethics committee's case reviews are guided by the 4 primary biomedical ethics principles: patient autonomy, beneficence, nonmaleficence, and justice. Patient autonomy is based on the principle of respect for persons, which holds that individuals have the right to make their own choices and develop their own life plan even if that plan includes allowing natural death. In the realm of healthcare, autonomy often is implemented by informed consent. Beneficence is that which is good or beneficial for the patient. Nonmaleficence is to do no harm. Justice is the fair distribution of goods and services.2
APPROPRIATE REQUESTS FOR A BIOETHICS CONSULT
A number of scenarios can prompt an ethics consult. The following examples are conflicts that have triggered a request for an ethics consult in the past:
Physician and patient disagree over the goals of care
Patient and family disagree over the goals of care
Family and physician disagree over the goals of care
Family members disagree with one another over the goals of care
Physicians and nurses disagree over the goals of care
These disagreements often result from a conflict between one or more of the primary biomedical ethics principles: patient autonomy, beneficence, nonmaleficence, and justice.
ETHICAL CONSIDERATIONS IN AN ETHICS CONSULT
Factors that influence the deliberation of the bioethics consult committee include questions of bias and quality of life.3,4
When examining the question of bias, the committee will consider the following:
Healthcare team and family bias
Valuing the patient as a person
Vulnerability of the patient
Whose interests should prevail? Patient's, family's, physician's, others'?
When examining the quality of life question, the committee will consider the following:
How does the patient define quality of life?
How does the family define quality of life for the patient?
Is it ethical to consider the family's quality of life?
THE BIOETHICS CONSULT TEAM AT OCHSNER
Wagner and Higdon have defined useful bioethics committee members as “…reasonable individuals who can step outside of their respective roles and genuinely explore what ought to be done in a particular case.”5 Bioethics committees typically include
Physician chair of bioethics
Physician chair of bioethics consult service
Chaplain
Risk management/attorney
Administration personnel
Nursing staff
Social worker
Physician with expertise in clinical area of consult, but not participating in the care of the patient
Palliative care providers
The consult team should minimize conflicts of interest by not including members of the team caring for the patient in the specific ethics consult. However, some of the following people may be invited to the ethics consult to introduce the case, concerns, and issues:
Physician taking care of the patient
Nurses taking care of the patient
Social worker taking care of the patient
Chaplain taking care of the patient
Person(s) with healthcare power of attorney
Key family members
Family's clergy
SELECTED BIOETHICS RESOURCES
The National Institutes of Health website (bioethics.od.nih.gov) has a compilation of bioethics resources that are available on the web. Along with federal and general bioethics resources, the compilation includes links to information about research ethics, genetics, and medicine and healthcare.
Bioethics.com has more than 30 categories of links devoted to bioethics news and information. Categories include Biotech/Pharma, Clinical/Medical, Disability Ethics, Emerging Tech, End of Life, Euthanasia/Suicide, Human Dignity, Informed Consent, and Medical Tourism. The site also includes a section called Bioethics 101 that has information about genetic ethics, end-of-life decisions, reproductive technologies, and stem cells.
Bioethics.net is the website of The American Journal of Bioethics. The site includes articles from the journal and features such as Bioethics for Beginners, Bioethics on MSNBC, Bioethics on NBC's ER, and Genetics and Bioethics.
Bioethics.gov is the online presence of the Presidential Commission for the Study of Bioethical Issues. The site has information about studies on bioethics, links to news articles dealing with the presidential commission, information about the commission's meetings, and a bioethics blog. The US Department of Health and Human Services manages this official government website.
A number of bioethics podcasts are free on iTunes. The University of Oxford offers a podcast called Bioethics Bites. The Center for Practical Bioethics: Guidance at the Crossroads of Decision has produced Lectures in Bioethics.
The DNAR Orders brochure included in this journal contains important bioethics information about do not attempt resuscitation orders.
This article meets the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, and Systems-Based Practice.
- Academic Division of Ochsner Clinic Foundation
