In hospitals, medical-ethics teams are increasingly the arbiters of agonizing health decisions:
Helping parents and doctors plan care for a dying child.
Mediating among family members who disagree about removing a parent from life support.
Steering patients in denial about a terminal illness toward end-of-life care.
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As the number of hospitals with ethics consulting services has grown in recent years, so have questions about how qualified some of these professionals are to render life-and-death advice.
The complex ethical issues arising from new life-prolonging medical technologies are throwing up new challenges. And hospitals face potential legal liability if patients and families feel they haven't been properly counseled or provided with all the information they need to make decisions.
Who is qualified?
“Hospitals would never permit staff to engage in medical procedures for which they are untutored, untrained and unsupervised, but there are less-than-qualified persons intervening in serious ways in the lives of patients and families” on medical ethical issues, says Nancy Dubler, director of the bioethics program at Montefiore Medical Center in the Bronx, N.Y.
Dubler, co-author of the training handbook “Bioethics Mediation,” conducts a certificate program in bioethics, or the study of ethical problems in medicine.
Some hospitals have taken note of deficiencies in their bioethics consulting and are taking steps to fix them.
The Department of Veterans Affairs, one of the largest hospital operators, found in a nationwide survey last year that only 28 percent of ethics consulting services had a formal process for evaluating their own work, and just 4 percent of such services were formally evaluated by anyone else at the hospital.
The VA is now asking the 153 hospitals in its system to evaluate ethics consultants for competency and provide mandatory training for consultants, says Ellen Fox, director of the VA's National Center for Ethics in Health Care and author of the survey. Other hospitals have begun requiring ethics consulting teams to document sessions in a patient's chart.
Some critics of mandatory bioethics training and credentialing say that the health-care professionals on ethics committees are plenty knowledgeable in dealing with ethical issues from years of practice.
Giles Scofield, a former law professor who comments frequently on ethics issues, wrote in the current issue of the Journal of Law, Medicine and Ethics, that bioethicists are merely trying to preserve their livelihood by overstating the risk of using untrained ethics consultants.
Lots of consultations
At Overlook Hospital in Summit, N.J., ethics and palliative-care coordinator Jeanne Kerwin and her team are called on to do almost 300 consultations a year.
They often mediate conflicts, such as a second wife fighting with children over who makes decisions when Dad has a stroke.
“There are complex family issues folded into complex medical issues, and it boils down to families and patients trying to deal with a fragmented health-care system where there are so many specialists,” says Kerwin.
“Physicians have no time to sit with these families for two hours, but we can do that, and help them understand what their options are and help guide them.”
Diane Clemson says she resisted help from Kerwin and her team before her mother died last year.
“I avoided her like the plague because I felt I was in control as the caregiver and didn't need anyone giving me advice,” says Clemson, who manages a pediatric dental office in Westfield, N.J.
But after the trauma of making decisions about her mother's final days, Clemson felt differently and reached out to the ethics consultant when her father, nearing 90, fell ill with respiratory distress and a severe infection.
“I realized I needed the help and support of professionals who could guide me” in making the decision to stop medical intervention and begin hospice care at home.
Her father died peacefully in January seven days after returning home.
“You never get over it, but they do help you get through it,” Clemson says.
“It was so much easier on our family this time.”