The complexity of medical care, the advancements in technology, the development of new medications and treatments, the aging of our population, the earlier survival of premature babies, and the longer survival of people with multiple chronic illnesses all have come together to create far more ethical challenges for families and caregivers than we in health care have seen in the past.
We are fortunate at St. Luke’s to have a strong clinical ethics program. One of the reasons this program has been so successful is the contributions of very caring, compassionate physicians, nurses, clinical social workers, and clergy members who work together to help those involved navigate these very emotional, challenging, and complex issues.
I have had the pleasure of knowing Chaplain Alex Chamberlain since soon after I arrived here about five years ago. Alex is passionate about his work, and I thought it fitting to ask that he share how our clinical ethics program is making a difference in the lives of our patients and their families. Here’s Alex’s report:
As coordinator for clinical ethics for St. Luke’s Treasure Valley, I consult when asked with patients, families, and staff members in challenging situations. Here’s an example of the sort of ethics opportunities that come my way.
I answered my phone one day to hear, “This is Dr. M. I need an emergency ethics consultation.”
Rarely does someone present an ethics consultation as an emergency and in this case, the “emergency” aspect was only partially based upon the patient’s medical condition.
My physician caller went on to say that this elderly patient had an extensive cardiac history. She’d had aortic valve replacement and five-way bypass surgery eight years ago.
After a diagnostic procedure in our heart catheterization lab, he told me, she suffered a heart attack that had severely damaged her heart muscle.
“She is not a surgical candidate and will probably die within a week,” he said, “regardless of what treatment we provide. As she was recovering from the procedure, I updated the family with the disappointing diagnosis and grim prognosis, and her husband said, ‘Don’t tell her.’”
The woman’s husband said that when she had been a hospice patient a few years earlier, she’d become very upset when, at the information visit, they began to talk to her about dying.
The physician told the family that her code status would have to be addressed. Accompanied by a staff nurse, her son asked, “Mom, you wouldn’t want a breathing tube put down your throat, would you?”
She replied, “No, no way.”
They stepped outside and the son said, “Well, that was pretty clear; Do Not Resuscitate orders can be in place.”
The nurse was uncomfortable with how code status was discussed, so the receiving nurse returned to the patient’s bedside to clarify with her what “Do Not Resuscitate” means, at which point the family chastised him for upsetting her.
I spoke first with the bedside nurse who, with a great deal of passion, told me he had been on the verge of tears for the first time in his career upon being told that he shouldn’t provide his patient with basic information about the care being provided.
He was uncomfortable with being instructed to not discuss code status, to not tell his patient what medications were being provided, and to avoid clarifying that she was not going to be treated aggressively but instead would be on “comfort care.”
The charge nurse supported the bedside nurse in his perspective, and the physician concurred. The family was told that a hospital representative would work with them toward a solution, and to let both parties gain some space and perspective, a different nurse was assigned to the patient’s care.
I met with the family and learned of their concerns, summarizing what they were saying with, “It is good to see families who are such passionate advocates for a loved one.”
I told them that we like to form partnerships with patients whenever we can, and that patients are entitled to request that we speak primarily to the family.
I asked to speak to the patient so that we could explore her preferences in the presence of the family. When I went on to ask whether she preferred that we share everything with her directly or would rather we talk with her family, she replied, “Of course, the first choice. I want to know everything as it unfolds.”
“What if the information we share is potentially unpleasant or disturbing?” I asked.
“Well, I still need to know, and then we will deal with it,” she said.
Her children later expressed relief, saying, “It is so much easier now since Dad doesn’t have to be tied up in knots trying to catch everyone who has a conversation with Mom. Now we can simply take care of her.”
Here are some takeaways for me:
When policies, procedures, and treatments threaten to get ahead of our service to those who come to us seeking healing and hope, the Ethics Committee and bedside ethics consultants keep us all anchored in values.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.