The Journal of Clinical Ethics, 28, number 2, Summer 2017

 

At the Bedside

Going from What Is, to What Should Be, to Care Better for Our Patients and Families

Edmund G. Howe, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 85-96.

      This piece discusses ways in which clinicians may go beyond their usual practices. These include exploring the limits of old laws, consulting with colleagues and ethics committees earlier and more often, and giving patients’ family members new choices they didn’t have previously. This could include asking patients and family members whether clinicians should prioritize staying in the single, unconflicted role of serving patients and families, even when this might preclude simultaneously serving another interest, for example, that of a hospital.

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Features

Controversies in Cardiopulmonary Death

Michael G. Fara, Breehan Chancellor, Aaron S. Lord, and Ariane Lewis, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 97-101.

      We describe two unusual cases of cardiopulmonary death in mechanically ventilated patients in the neurological intensive care unit. After cardiac arrest, both patients were pulseless for a protracted period. Upon extubation, both developed agonal movements (gasping respiration) resembling life. We discuss these cases and the literature on the ethical and medical controversies associated with determining time of cardiopulmonary death. We conclude that there is rarely a single moment when all of a patient’s physiological functions stop working at once. This can pose a challenge for determining the exact moment of death.

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How Do Healthcare Providers Feel About Family Presence During Cardiopulmonary Resuscitation?

Alicia Pérez Blanco, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 102-16.

      The presence of patients’ families during cardiopulmonary resuscitation (CPR) is a controversial topic, due to its repercussions for clinical practice. While family members’ presence may help them to overcome their grief, it could be detrimental, as it may case posttraumatic stress disorder (PTSD), and there is the possibility that family members may interfere with the procedure. For these reasons, families’ presence during CPR has rejected by some healthcare providers.

      To research concerns about families’ presence among providers dealing with CPR in the Fundación Hospital Alcorcón (Madrid), I performed this study. Of the 190 providers surveyed, 115 submitted a complete questionnaire. The most frequently reported concerns were interference (78.3 percent of respondents), and PTSD (69.6 percent of respondents). Fewer pediatric providers were concerned about PTSD than other providers (41.2% percent versus 74.5 percent, p = 0.01). Providers were reluctant to offer families the option of being present unless they had requested it, and would only permit it under certain conditions. Having a staff member to support the family was of great value to most respondents. The author believes families have a negative right to be present during CPR and so should be invited to stay.

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A Patient (Not) Alone

Lauren Sydney Flicker, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 117-21.

      This case analysis examines questions that arise when an ethically appropriate recommendation initially appears to be in conflict with the legally appropriate recommendation. The case involves a dying, incapacitated octogenarian who had friends who were willing to share her values, but not to make decisions on her behalf. These circumstances put the patient in the unique position of being legally considered a “patient alone,” but who was ethically like a patient with surrogates—distinctions that are crucial when making end-of-life decisions under the New York Family Health Care Decisions Act. A strict interpretation of the law initially seemed to be in conflict with an ethically appropriate outcome. By gaining a deeper understanding of the patient from those who cared about her, however, and by considering a broader interpretation of the law, an outcome was reached that worked within the framework of the law and honored the patient’s reported values.

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The Role of Relational Knowing in Advance Care Planning

Kate Robins-Browne, Kelsey Hegarty, Marilys Guillmen, Paul Komesaroff, and Victoria Palmer,

The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 122-34.

      Medical decision making when a patient cannot participate is complicated by the question of whose voice should be heard. The most common answer to this question is that “autonomy” is paramount, and therefore it is the voice of the unwell person that should be given priority. Advance care planning processes and practices seek to capture this sentiment and to allow treatment preferences to be documented and decision makers to be nominated. Despite good intentions, advance care planning is often deficient because it is unable to facilitate a relational approach to decision making in cases when the patient’s competence is reduced. In this article we present findings from a study of the ways in which older people and their significant others understand decision making in such circumstances. Critical to the participants’ understanding was the emergent concept of “relational knowing,” a concept that is poorly articulated in the advance care planning literature. Our findings suggest that the dominant understanding of decision making in conditions of impaired competence is incomplete and obscures much of what matters to people. We conclude that, having recognized a broader set of ethical concerns, it is necessary to develop a relational and narrative based approach that applies in appropriate settings.

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Knowing About Others: On "The Role of Relational Knowing in Advance Care Planning"

Jamie Lindemann Nelson, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 135-6.

      Kate Robins-Browne and her colleagues have written a conceptually daring, empirically grounded article that is rich in scholarship and just conceivably might have a salutary effect on the theory and practice of advance care planning. It is, alas, just as easy to believe that its appreciation will be restricted to like-minded theorists. Writing from a posture of great admiration for this article’s agenda and achievements, I will consider why non-relationally-based understanding of deciding for others are so enduring, and what might be done about that.

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Developing Clinical Ethics Consultation and Committees

Structure, Operation, and Experience of Clinical Ethics Consultation 2007-2013: A Report from the Massachusetts General Hospital Optimum Care Committee

Ellen M. Robinson, Wendy Cadge, Kimberly Erler, Sharon Brackett, Julia Bandini, Alexandra Cist,

M. Cornelia Cremens, Eric L. Krakauer, and Andrew M. Courtwright, The Journal of Clinical Ethics

28, no. 2 (Summer 2017): 137-52.

      We describe the structure, operation, and experience of the Massachusetts General Hospital ethics committee, formally called the Edwin H. Cassem Optimum Care Committee, from January 2007 through December 2013. Founded in 1974 as one of the nation’s first hospital ethics committees, this committee has primarily focused on the optimum use of life-sustaining treatments. We outline specific sociodemographic and clinical characteristics of consult patients during this period, demographic differences between the adult inpatient population and patients for whom the ethics committee was consulted, and salient features of the consults themselves. We include three case studies that illustrate important consult themes during this period. Our findings expand knowledge about the structure and workings of hospital ethics committees and illustrate how one ethics committee has developed and utilized policies on end-of-life care. More generally, we model a sociological approach to the study of clinical ethics consultation that could be utilized to contextualize institutional practices over time.

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Development of a Clinical Ethics Committee De Novo at a Small Community Hospital by Addressing Needs and Potential Barriers

Bonnie H. Arzuaga, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 153-8.

      Hospital ethics committees are common, but not universal, in small hospitals. A needs assessment was completed at a 155-bed community hospital in order to adapt an academic tertiary center model for a clinical ethics committee to fit the needs of the small hospital community. Of 678 questionnaires distributed, 209 were completed. Data suggested that clinical staff frequently experienced ethical dilemmas. Significantly more nonphysicians indicated that they would utilize a consultation service, if available, compared to physicians (p = 0.0067). The data also indicated that the majority of staff (>80 percent) desired more education in clinical ethics. Physicians preferred annual or bi-annual hospital-wide grand rounds, compared to nonphysicians, who preferred more frequent department-based teaching (p < 0.001). The data presented in this article were used to subsequently develop a clinical ethics support committee, the process of which is also described.

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Do Not Resuscitate, with No Surrogate and No Advance Directive: An Ethics Case Study

Jamie Diamond, Umesh Gidwani, and Rosamond Rhodes, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 159-62.

      Do-not-resuscitate (DNR) orders are typically signed by physicians in conjunction with patients or their surrogate decision makers in order to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR). Both the medical literature and CPR guidelines fail to address when it is appropriate for physicians to sign DNR orders without any knowledge of a patient’s wishes. We explore the ethical issues surrounding instituting a two-physician DNR for a dying patient with multiple comorbidities and no medical record on file, no advance directives, and no surrogate decision maker. Through this case we also highlight the issues of poor prognostication and the reversal of a DNR in such circumstances.

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Law

Legal Briefing: Unwanted Cesareans and Obstetric Violence

Thaddeus Mason Pope, The Journal of Clinical Ethics 28, no. 2 (Summer 2017): 163-73.

      A capacitated pregnant woman has a nearly unqualified right to refuse a cesarean section. Her right to say “no” takes precedence over clinicians’ preferences and even over clinicians’ concerns about fetal health. Leading medical societies, human rights organizations, and appellate courts have all endorsed this principle. Nevertheless, clinicians continue to limit reproductive liberty by forcing and coercing women to have unwanted cesareans. This “Legal Briefing” reviews recent court cases involving this type of obstetric violence. I have organized these court cases into the following six categories:

1. Epidemic of Unwanted Cesareans

2. Court-Ordered Cesareans

3. Physician-Coerced Cesareans

4. Physician-Ordered Cesareans

5. Cesareans for Incapacitated Patients

6. Cesareans for Patients in a Vegetative State or Who Are Brain Dead

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Going from What Is, to What Should Be, to Care Better for Our Patients and Families

Edmund G. Howe

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