Martha Jurchak, PhD, RN, executive director, Office of Clinical Ethics
Mary Greenwald, administrator, Office of Clinical Ethics
Are any of the following scenarios familiar to you?
You are caring for a patient who has been in your ICU for a long time with complicated medical problems and complex family dynamics. A nursing colleague walks by and says, “What is going on in this room? I can’t believe no one seems to want to have the honest conversation that this woman is dying!”
Your med-surg intermediate care unit prides itself on consistently taking patients with complex psychological and medical problems. The family of one patient insists on doing everything possible but their culture doesn’t support patients hearing about life-threatening illness. On rounds you hear a resident new to the team ask, “Why isn’t there any concern with resource utilization and respect for patient autonomy?”
You are caring for a patient who has been in and out of your unit with increasing frequency. You sense that she is getting tired of repeated hospital and rehab stays. One night she says, “I’m tired and I’ve had enough. But I know my kids and husband won’t let me give up. I guess I just need to keep plugging,” and then starts to cry.
Why are ethical issues in patient care so difficult?
Ethics is about the questions of what’s right or good to do. We all want to do the right thing. Sometimes, raising ethics questions looks like someone is thinking that something isn’t right — and often that can stir reactions within the care team!
One of the reasons ethics questions can be so challenging is that talking constructively about feelings can be difficult. Another reason is that we live in a society that respects diversity — of culture, religion, values, and ideas. This means that there can be many reasonably acceptable answers to the question of “what is right?” Rapid technology development and creative innovations that provide new answers to health problems often have unintended consequences. With constantly evolving complexity, it’s easy to see why questions of ethics are so challenging in health care.
Conflicts among patients, family members and health care team members can arise due to differences in values, difficulties in communication, or the severe stress brought on by critical illness.
But there’s help available. The BWH Ethics Consultation Service (Ethics Service) is a multidisciplinary group of nurses, physicians, social workers, chaplains and other Ethics Committee members that provides consultation and staff education in situations of ethical conflict and stress.
In these situations, an ethics consultation can help to clarify concerns, generate options and foster collaboration, allowing all parties to move forward. This process can involve reviewing the patient’s medical record, meeting with the patient and family, and facilitating discussion among family and caregivers. One of the primary goals of the consultation is ensuring that the voices of everyone involved are heard. While ethics consultants often make recommendations, final decision-making authority remains with the health care team, patient and family. The Ethics Service also holds ethics rounds, regular discussions of ethical issues that come up on a unit or service, to provide staff with another way to address problems.
The Ethics Service is staffed around the clock, and anyone associated with a patient’s care can request an ethics consultation. Call 617-732-5656 and ask for the Ethics Service or for page ID # 18590.
To learn more about the Ethics Service, or to read the BWH Clinical Ethics Case Review,
a newsletter about BWH cases that posed difficult ethical problems, please visit
http://www.bwhpikenotes.org and click on the Office of Clinical Ethics under the Patient Care tab.