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BioethicsWalk addresses
bioethical issues that chaplains face in their day-to-day work. PlainViews invites
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Migrating Machines
Click here to read responses
This summertime (July/August) column includes a required reading assignment, a research question, and some recommended readings. (Bioethics never takes a holiday.)
Required reading: The continuing migration of life-sustaining technologies from the hospital to the home raises a set of ethical questions relevant to chaplains who work in settings that provide care to Medicare-eligible populations. Cardiovascular implantable electronic devices (CIEDs), such as pacemakers and implantable cardioverter-defibrillators (ICDs), have allowed individuals with chronic progressive conditions to stabilize the function of major organ systems and go on with their lives. These medical devices are not cure-alls, whether for mortality itself or for other progressive conditions an individual may develop. But because these devices are so common, and no longer associated exclusively with acute-care setting, we may forget to think about them under the category of “life-sustaining treatment,” and so we may fail to clarify the consequences of a decision to start, continue, or forgo the use of these devices. In a recent article in The New York Times Magazine (June 14, 2010) , Katy Butler describes what happened in, and to, her family when her father received a pacemaker following a stroke, and prior to surgery to correct a painful hernia. She also describes what her mother learned from the experience of being her husband’s surrogate and caregiver, and how these experiences informed her mother’s subsequent decisions concerning life-sustaining treatment as her own health deteriorated. I welcome your comments on this article and the ethical questions it raises that may be relevant to the chaplain’s role in facilitating discussions about the goals of a patient’s care.
Research assignment: Butler’s research into the circumstances surrounding the decisions faced by her parents remind us that patients and surrogates may not be fully aware of the extent to which device manufacturers and insurers shape physicians’ recommendations and patients’ choices. As she writes, her mother received more consumer-protection information when she bought a car than when she was asked to decide whether her husband should receive a pacemaker. Her article also describes the consequences of gaps in ethics guidance, in coordination among medical specialists, and, simply, in thinking through the moral dimensions of medical treatment, as the progression of her father’s dementia and other health problems begins to accelerate with the pacemaker still in place. She notes the recent release of a consensus statement clarifying the ethics of CIED deactivation, guidance that might have prevented confusion and consequent suffering at the end of her father’s life. Near the end of the article, Butler captures another cardio-ethics question requiring clear thinking and clear guidance from professions and within care setting: Should patients with DNR orders have the option of keeping the order in place during surgery for a correctable problem, or should DNR orders be suspended during surgical procedures?
And so, your research assignment: What is the status of your institution’s ethics policy on these two issues: 1) CIED deactivation in the context of treatment withdrawal and 2) surgery involving patients who have DNR orders? If no ethics guidance is in place, are these issues being discussed in your institution? Butler’s article is an excellent way to get a discussion going.
Recommended readings: And finally, if you’re looking for some reading to help you recover from all this work, here is a terrific and well-organized collection of research and analysis, Palliative Care: Transforming the Care of Serious Illness, edited by Diane Meier, Stephen Isaacs, and Robert Hughes, part of the Robert Wood Johnson Foundation Health Policy Series. For more information, visit the website of the Center to Advance Palliative Care (CAPC).
Happy summer, everyone!
Responses
I work in a small community hospital outside of Boston. I LOVE this column and have an abiding interest in medical ethics and the many turns it takes with new technology. #1Our hospital, and in fact 2 other hospitals where I have worked, all had a policy of suspending the DNR during surgery unless there are specific requests to the contrary. #2The question of implanted devices and suspending or deactivating them has not come up to our ethics committee but you can bet I intend to share this article with my colleagues! #3An issue which may only be an issue for a small community hospital, but which I have encountered in several places in my near twenty year career in chaplaincy: Information shared only with the spouse who forbids the staff from telling the patient s/he has cancer or some other life threatening issue. In this country where autonomy seems to reign in most arenas, there are some (usually spouses) people who are able to prevail upon a doctor NOT to share information gleaned in surgery or other testing with the patient. 'It would make him give up' was the last spouse's reason for requesting this restriction. Usually there is a long history between the family and the doctor. It always amazes me to find this secretive behavior in our modern day. Wondering if you have encountered this and if others have.
Ginny Grimes Allen, D. Min.
Pastoral Care Department
Milton Hospital
Milton, MA
I presented these questions to our nurses and social worker. The nurses and social worker responded that the surgeons would suspend the DNR orders for about 48-hours or more, if necessary. There is no written policy where this is concerned, but the surgeon usually discusses the issue with the patient. Regarding the CIED, they are usually disactivated, but pacemakers are kept on. A doctor at the hospital stated DNR is always rescinded, but not as a policy. The patient is probably not consulted. It's a practice, not a policy. On the other hand, we have a "Prescriber Order Form Do Not Resuscitate-Suspension During Surgery or Procedure.”
Rev. Carlos R. Smith
Chaplain DeMay Living Center and
Newark Wayne Community Hospital
Newark, NY
Nancy Berlinger is Deputy Director and Research Scholar at The Hastings Center, an independent, nonprofit, nonpartisan bioethics research institute located in Garrison, New York.
Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; ethics in cancer care; conscientious objection and moral distress in health care; patient safety and the resolution of medical harm; and ethics education for pandemic planners. Broader interests include narrative ethics and medical humanities.
Currently, she directs a research project that is revising the influential Hastings Center guidelines on end of life care. This project is funded by the Patrick and Catherine Weldon Donaghue Medical Research Foundation and the Albert Sussman Charitable Remainder Annuity Trust. She recently completed a research project, funded by the Arthur Vining Davis Foundations, which examined how professional chaplains define “quality” within their own practice and profession, and how these definitions correspond to how chaplaincy is represented in the health care “QI” movement and in efforts to advance patient-centered care.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness (Johns Hopkins, 2005, paperback 2007) and is currently developing a book project on cancer “survivorship” and the future of cancer care.
She serves on the ethics research group of the Joint Commission; the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM); the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, a longterm care facility; and the editorial board of Medical Ethics Advisor. She teaches health care ethics at the Yale School of Nursing, and is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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