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The Ethics of Intervention

ethicsAs of this April, residents working in the intensive care unit at the Washington Hospital Center in Washington, D.C., are required to wear “ethics checklists” on lanyards around their necks when treating terminally-ill and severely disabled patients.

The eight-item checklist covers the major ethical issues that might arise in the hospital setting, such as:

  • “Is the patient able to make medical decisions?”
  • “Is there a do-not-resuscitate order?”
  • “Is there a disagreement amongst family members about how care should proceed?”

Doctors must review the 8-point list before making major decisions regarding a patient’s care.

The checklists are the brainchild of medical ethicist and researcher Daniel K. Sokol, Ph.D., who is employed by the University of London, St. George’s Hospital.

Dr. Sokol observed the success of similar “surgical checklists” in decreasing mistakes, infections and mortality rates associated with major surgeries.

While serving as a visiting scholar at the Washington Hospital Center this past winter, he helped administrators to design and implement this ethics program.

In our post-Terri Schiavo world, this program is certainly encouraging.

While helping hospitals to avoid costly lawsuits, the program also requires doctors to consider and review a patient’s wishes before administering additional care. 

Our readers likely remember the drawn-out legal battle between Terri Schiavo’s parents, Robert and Mary Schindler, and her husband, Michael Schiavo, over whether or not to remove a feeding tube that was keeping Terri alive in a vegetative state.

Mr. Schiavo eventually succeeded in his efforts to convince the courts that Terri would not have wanted to be kept alive given her extensive brain damage.  She was removed from life-support in March, 2005, and died roughly 10 days later.

This particular case sparked intense interest in advance directives, also known as living wills, nationwide.

An advance directive is a written document that specifies what type of care and degree of medical intervention a person would want in the event of a life-threatening condition, including directions regarding the use of life-prolonging procedures.  Living wills may also name a family member or other individual to speak on a patient’s behalf if she is unconscious.

One-third of all Americans have written a living will.  And as Americans age, they are more likely to have a living will: 55% of Americans 55 and older have one.

As of 2006, there were only a couple of states (including Oregon, Washington, and Wisconsin) that recognized living wills as legal documents that carried the weight of a physician’s orders.

In most other states, living wills are not regarded as legal documents, and instead provide a general guideline for administering care.

Some doctors argue that living wills should not be treated as legal documents since it is impossible for an individual to plan for all of the potential situations that might occur.  Patients have also been known to change their minds after treatment begins and complications arise.

Many times, doctors and family members also decide to intervene and override a patient’s wishes.

A 2004 study conducted by the Archives of Internal Medicine asked doctors to determine how they would act in six hypothetical medical cases involving patients who had written living wills.

  • The doctors in the study made decisions that were contrary to the patients’ advance directives 65% of the time.
  • Take this real-world case for example: A patient with severe dementia was hospitalized for an ailment unrelated to her chronic condition and placed on a ventilator to help her breathe.  She had specified in her living will that she did not wish to receive such an intervention, but her doctor and daughter decided to go ahead with the ventilator because she was expected to recover.  She did recover and lived for another two years.
  • This is a difficult example: What do you think should have been done in this case?

The complex questions raised here include:

  • Are patients’ wishes being followed by ER doctors?
  • Will ethics checklists make a difference in an emergency situation?
  • Should doctors and family members intervene on behalf of a patient in dire situations?

But these issues only scratch the surface when it comes to the topic of end-of-life care.

Ethics checklists deal with care administered in the final hours of a patient’s life.

In our newest As We See It article, we look at the much broader question of how to best administer care to a terminally-ill patient in the months, or even years, leading up to his death.  We also examine how such care decisions are made, and the financial costs associated with various treatments.

Tips for Completing a Living Will:

  • Consult with a lawyer about the appropriate way to complete and file a living will to make sure that it will be recognized by caregivers in your state.
  • File your advance directive with the U.S. Living Will Registry, an online database that stores the wills and makes them available to physicians nationwide.
  • Give copies of your advance directive to your doctors, hospitals and family members.
  • Revisit the document from time-to-time to make sure that your directions have not changed.

For state-by-state rules and other information on living wills, click here.

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