Here, we hope you will find some answers to your questions. If you do not find what you are looking for, please email the department at ethics@sutterhealth.org.

• Why clinical ethics?
  
• What is an ethics consultation?
  
• When should you request an ethics consultation?
  
• How do I request an ethics consultation?
  
• What happens after you request an ethics consultation?
  
• Patient Friendly Definitions of Medicine Terms
  
  

Why clinical ethics?

Clinical ethics is a practical discipline that provides a structured approach for identifying, analyzing, and resolving ethical issues in clinical medicine. The practice of good clinical medicine requires a working knowledge about ethical issues, such as informed consent, truth telling, confidentiality, end-of-life care, pain relief, and patient rights. Medicine, even at its most technical and scientific levels, is an encounter between human beings, and the physician’s work of diagnosing disease, offering advice, and providing treatment is embedded in a moral context. The willingness of physician and patient to endorse moral values, such as mutual respect, honesty, trustworthiness, compassion, and a commitment to pursue shared goals, usually ensures that significant conflicts between physician and patient rarely occur.

Occasionally, physicians and patients may disagree about values or may face choices that challenge their values. It is then that ethical problems arise. Clinical ethics concerns both the ethical features that are present in every clinical encounter and the ethical problems that occasionally occur in those encounters. Clinical ethics relies on the conviction that, even when perplexity is great and emotions run high, physicians, nurses, and patients and their families can work constructively to identify, analyze, and resolve many of the ethical problems that appear in clinical medicine.

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What is an ethics consultation?

California Pacific has employed ethics consultants as well as authorized members of the ethics committee that engage in consultations on ethical problems arising in particular cases. Ethics consultation is modeled on the familiar practice of professional consultation: Certain persons who have training in the field of bioethics are available to practitioners and to patients and their surrogates and families, to review the facts of a particular case and offer informed and prudent counsel suited to the case. The consultation service is one of the activities of the Program in Medicine & Human Values.

The central goal of ethics consultation is to improve the process and outcome of care by identifying, analyzing, and working to resolve ethical problems encountered in individual cases. To achieve this goal, it is necessary to identify the issue that precipitated the consultation and to facilitate resolution through patient and staff education and the opportunity for informed and respectful discussion of the problem.

Competency for ethics consultation includes knowledge of bioethics, the relevant professional codes of ethics, and relevant health law. An ethics consultant should also have sufficient knowledge of medicine to assess the clinical situation, demonstrate skill at moral reasoning, and have the ability to build moral consensus in a group.

Ethics consultation has been evaluated in several retrospective studies that showed a reasonably high level of patient and physician satisfaction with the consultation.

The conclusions of the deliberations of the ethics committee and of ethics consultation are usually reported to the attending physician. However, ethics consultants and the ethics committee, risk managers, and legal counsel may collaborate with the attending physician and with patients and families to find informal solutions to ethical conflicts. For example, if physicians and parents disagree about the treatment plan for a severely and possibly terminally ill child, the dispute might be mediated by seeking an outside opinion from someone acceptable to physicians and parents. Even if physicians and parents fail to agree on everything, compromises might be achieved. If that fails, the parents have the option of transferring the child to a different institution. One general goal of an ethics consultation is to identify and manage ethical conflicts by seeking solutions rather than provoking litigation.

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When should you request an ethics consultation?

Ethics consultation can be requested whenever there is a difficult decision to be made. You do not have to wait until a conflict manifests. If you identify a conflict before it happens, and if you think you need help, you should request an ethics consultation.

However, a good rule-of-thumb is to request an ethics consultation when two conditions are met:

1. you perceive that there is an ethical problem in the care of patients, and


2. resolution does not occur after bringing this to the attention of the attending physician.

Most "ethical problems" turn out to be problems due to lack of communication. However, sometimes a true ethical dilemma occurs, frequently because there is a conflict between principles (autonomy, beneficence, justice) or between principles and outcomes.

Some of the problems for which ethics consultation may be requested include:
• Advance directives
• Surrogate decision making
• The refusal of treatment
• Conflicts with caregivers
• Withholding or withdrawing treatment
• Do Not Resuscitate orders
• Other issues perceived as ethical problems

Here's an example of a situation in which ethics consultation is needed:

Your father has just sold the small manufacturing company that he founded and ran for fifty years and is enjoying his first year of real retirement. He is a spirited and vivacious man of seventy-five. But all of a sudden, his plans are interrupted: your father suffers a serious stroke. He is hospitalized and is in intensive care for two weeks, dependent on a respirator and unable to communicate. Doctors tell you that, while he might survive, he will probably have permanent physical and mental damage. Your mother, you and your siblings are left to decide what to do to care for your father.

You, your sister and one of your brothers (the other is in Europe) have dinner at your mother’s. It is clear that there is little agreement about what to do. Mom is very distressed and quite uncertain. You strongly believe that Dad would not want to live disabled. Your sister only expresses hope in full recovery. Your brother firmly states that we have no right to make such a life and death decision: this situation simply has to run its course, he says. None of you is very sure what the course might be, nor are you clear about who has the authority to make a decision. Your mother says she will not be the one to end Dad’s life. Your eldest brother will return from his trip tomorrow.

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How do I request an ethics consultation?

An ethics consultation can be in initiated by either:

Placing a call to the Medical Ethics Hotline at (415) 600-3991. When you call, leave a detailed message that explains the nature of the situation and ethical problem with which you need consultation. Make sure you fully identify yourself and the patient and a method for which you can be contacted. Leave any special instructions as well. The hotline is monitored from 9:00 a.m. to 5:00 p.m. Monday through Friday. After hours and on weekends, if the situation is an emergency, the Medical Center’s Administrator-on-Call can be contacted for consultation by calling the hospital operator. If the situation is not emergent, please follow the normal procedure and the case will be reviewed the next business day. All information provided on the hotline is confidential.

You can also submit a request for consultation via email. These are monitored in the same manner as the hotline and all the same procedures apply. Email us at ethics@sutterhealth.org.

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What happens after you request an ethics consultation?

Once you have requested a consultation, someone from the Program will contact you. You may be asked for more information. The Program may decide to perform a problem-focused or a comprehensive ethics consultation. Comprehensive ethics consultations bear directly on some aspect of patient care decision making because they may involve substantive discussions between medical ethics consultants and attending physicians and families. These result in recommendations on how to proceed and chart notes. If the Program decides that a problem-focused consultation is necessary, in which ethical issues related to patient care are raised and considered, the process will be much less formal. These discussions function primarily to identify and clarify moral concerns voiced by healthcare providers or patients, and typically involve conversations between medical ethics consultants and physicians, nurses, and other hospital personnel. Although primarily educational in nature, informal consultations may evolve into formal consultations.

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Glossary

Patient Friendly Definitions of Medicine Terms

Patients and their families often meet with doctors and nurses to discuss the medical issues that arise during a hospital stay. Often, the clinicians use terms that may not be clear to patients or family. Here is a list of such terms with simple definitions:

Diagnostic Terms

Brain death

This term describes a person whose brain has ceased to support all essential functions of the body, including thinking, feeling, breathing, and most other bodily functions. People with this condition, even if their heart is beating, never recover. If the brain dead person is attached to a breathing machine, some signs of life, such as heart beat and skin color, will be present but the person is actually physically and legally dead.

Persistent vegetative state (PVS)

This term describes the physical destruction of those parts of the brain that support thinking, perception and feeling, leaving only those parts of the brain that support breathing, digestion, heart regulation and other metabolic functions; “persistent” refers to the medical judgment that the destruction is so severe that recovery will not occur. Unlike patients pronounced “brain dead”, persons in PVS are not legally dead, but they are completely and permanently unaware of their surroundings.

Treatment Terms

Dialysis

A technique to substitute for the function of failed kidneys by circulating blood out of the body and through a purification process. It can occur continually in an ICU setting or for several hours each week as an out-patient.

Hydration

Providing fluid needed for support of life. Most of us stay hydrated by drinking liquid orally. If a patient cannot do this, a tube can be inserted into their vein, nose or even directly into their stomach to provide nutrients and fluid.

Pressors

Certain drugs that cause constriction of the blood vessels that are used to maintain blood pressure in seriously ill persons.

Tube feeding

Providing nutrients, usually combinations of protein, carbohydrates and vitamins processed into a liquid, and delivered through a tube inserted down the throat or surgically fixed into the intestines.

Ventilator/Respirator

A machine designed to supply air to lungs when they are incapable of natural inhalation, to which patient is attached by a tube passed down or inserted in the trachea.

Intensity of treatment Terms

Code status

A medical term that states whether procedures called CPR should be used when a patient’s heart stops or they stop breathing.

Cardiac resuscitation (CPR)

A method of attempting to restart heart beat and breathing when these functions suddenly fail. These methods include chest compression, mouth to mouth breathing, use of drugs and electric shock.

Full code

In the event of sudden failure of the heart or lungs, the medical team will use aggressive measures including CPR to restore heart and lung function.

Do not resuscitate (DNR)

The decision by a patient or appropriate decision makers not to use the methods of cardiac resuscitation to restart heart beat and breathing. If these methods are not used, the patient will quickly die.

Comfort Care

The decision to stop efforts to keep a person alive and to emphasize medical efforts to relieve pain and discomfort in expectation of death.

Palliative Care

Similar to Comfort Care; a medical and nursing specialty that emphasizes relief of pain, and physical and psychological discomfort for patients whose condition cannot be definitively cured. Some of the patients seeking palliative care have a long and chronic condition while others are near the end of their lives.

Other Terms

Ethics Committee

An official committee of the hospital medical staff which reviews and advises physicians, patients and families on difficult ethical decisions such as withdrawing life-support. These committees apply the concepts of ethical literature, legal precedents and hospital policy to particular cases that are referred to them.

Hospice

Organizations that specialize in comfort care of patients during the final phase of life, usually by home nursing services and sometimes in institutions.

Quality of Life

A judgment that the experience of living, in whole or in part, is worthwhile or satisfying to the person living that life.

Transplant/Organ donation

Certain major organs of the body, such as heart, lungs, livers, kidneys and pancreas, can be removed from one person and placed in body of another person, substituting for their failed organ. Organs must be donated by deliberate choice of the donor or their family and can be taken at death or, in case of kidneys and partial livers, during life.

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