Next Sessions

1. Next Sessions 11/10/08. 8:30am City-Wide Canceled: MOLST Conference: Millennium Hotel; all day 12/08/08. Biomedical Ethics Ontology Robert Arp PhD

2. CME Disclosure • Industry Support—None • Unapproved Uses—None

3. Relationship Between Ethics and Palliative Consult Services Jack P Freer, MD Professor of Medicine Daniel J Miori MS, RPA-C Palliative and Ethics Kaleida Gates Clinical Instructor of Medicine

4. Relationship Between Ethics and Palliative Consult Services • Development of ethics and palliative services (Freer) • Nationally • Locally • Description: combined service at Gates (Miori)

5. US Hospitals with Ethics Committees • 1983—1% • 1989—>60% • 1999—>93% • Today—JCAHO requires a “mechanism” for addressing ethical issues. Aulisio MP. Arnold RM. Role of the ethics committee: helping to address value conflicts or uncertainties. (2008) Chest. 134(2):417-24

6. Mechanisms for Addressing Ethics Issues • Committee • Lone Consultant • Hospital Ombudsman Office • Combination

7. US Hospitals with Palliative Programs • 1998—very few • 2000—5% • 2003—25% • Today—Common in larger, teaching hospitals: • 50% of hospitals with >250 beds • 75% of Council of Teaching Hospitals sites Aulisio MP. Arnold RM. Role of the ethics committee: helping to address value conflicts or uncertainties. (2008) Chest. 134(2):417-24

8. …We devote the majority of our discussion to ethics consultation and its relation to the emerging area of palliative care. In so doing, we highlight three important differences: (1) the scope or range of cases for which they may be appropriate, (2) focus in any particular case, and (3) general orientation—between ethics consultation and palliative care that clinicians should take into account in deciding to seek the assistance of either or both. (CHEST 2008; 134:417–424)

9. The above studies suggest that regular communication in the ICU regarding the goals of care yields tangible benefits in terms of patient satisfaction, shorter length of stay, and more "appropriate" transition from a "cure" to a "comfort" mode of care.

10. They do not suggest, however, whether this is most appropriately done through ethics consultation or palliative care. This is likely to be institution, even practitioner, dependent.

11. The functions of the two services are often seen as separate,with palliative care (PC) addressing the domains of symptom management and clarifying goals of care in severely ill patients, whereas ethics consultants assist with conflict resolution and medicolegal questions.

13. Buffalo Hospital Palliative Services • VA—Consult service, Fellowship • BGH—Multiple consultants • RPCI—Pain, +/- Palliative • ECMC, Subn, SBMercy, Sisters—Hospice physician consult service • Gates—Combined Ethics/Palliative

14. Millard Gates—CombinedEthics/Palliative Service Timeline • 1984—Peter D’Arrigo invites Ronald Cranford to Gates to speak about ethics committees. • 1985—D’Arrigo names Jack Freer chair of Millard Fillmore Ethics Committee. • 1998—Freer certified by ABHPM; begins doing sporadic palliative consults at Gates • 1999—UB Palliative Med course starts • 2006—Dan Miori joins Ethics/Palliative Service; full time consult availability begins

18. Millard Fillmore GatesPalliative and Ethics Description of Combined Service

19. Millard Fillmore GatesPalliative and Ethics • Hybrid ethics consultant and ethics committee models • Consultant puts ethics on the inside • Backup for conflict of interest • Committee maintains the ability for an unbiased outside opinion

20. Identified advantages • More visible service produces a much lower bar for referrals • Hallway consults • Consultant tracks referrals and identifies trends. • Consultant can tailor committee makeup to specifics of case

21. Identified Disadvantages • Consultant can tailor committee makeup to specifics of case. • Palliative service can tend to be a natural generator of ethics cases, therefore providing the appearance of conflict of interest.

22. The NumbersNovember 06 to October 08 • 36 Total ethics consults • 9 full ethics committee meetings • 11 hallway consults • Cases referred to • 7 to Risk Management • 1 to Hospice • 1 to law enforcement

23. More Numbers • Other outcomes • 1 mediation with family member who was in conflict with all actions by hospital and staff • 1 referral to ethics as a last resort in frustrating and manipulative patient • 1 patient discharged prior to ethics committee meeting • 1 ethics referral made and subsequently withdrawn

24. Best case scenario • Mrs. X admitted to the hospital on the eve of a major holiday weekend. • Referral made by nursing staff directly to ethics consultant in the process of routine rounds. • Clear ethical issues identified. • Full ethics committee convened 4 days later

25. More Best Case ScenarioThe reoccurring theme…. • 11 cases involved decisions on artificial nutrition in patients without Health Care Proxy. • Of those, there was a core of patients who lacked capacity but were awake and alert enough to resist or refuse artificial nutrition.

26. The Response • Early identification • Treat on case by case basis using…. • a set of precedents which help to identify issues within each case and provide both good and bad examples of how to handle

27. Worst Case Scenario • You tell me

28. References • Julie W. Childers, Richard Demme, Jane Greenlaw, Deborah King, and Timothy Quill: A Qualitative Report of Dual Palliative Care/Ethics Consultations: Intersecting Dilemmas and Paradigmatic Cases Journal of Clinical Ethics, In Press • Aulisio MP. Arnold RM. Role of the ethics committee: helping to address value conflicts or uncertainties. Chest. 134(2):417-24, 2008 Aug. • Aulisio MP. Chaitin E. Arnold RM. Ethics and palliative care consultation in the intensive care unit.Critical Care Clinics. 20(3):505-23, x-xi, 2004 Jul.