The Institute of Medicine's quality imperatives include the need to provide safe, effective, patient-centered, timely, efficient, and equitable care. Less attention has been paid to quality metrics as they relate to the assessment of clinical ethics consultation and its impact on care. A better understanding of how ethics consultation influences the quality of care might identify opportunities for improvement. A descriptive pilot study, involving 7 hospitals in the New York-Presbyterian Healthcare System, was conducted to identify key elements of the ethics consultative process that might impact clinical and psychosocial outcomes. A majority of consults involved medical or intensive care unit patients and end-of-life decision making; 75.5% had or received a do-not-resuscitate order, 90.6% lacked decision-making capacity, 43.4% had an advance directive. Conflict existed in a majority. Future research should include surrogate decision making, patients on nonmedical services who may have unrecognized ethical dilemmas, and the role of conflict in clinical care.

Objective. Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as “a bridge to recovery,” involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA‐ECMO in patients who, in the absence of recovery or transfer to longer‐term therapies, might assert religious or cultural objections to the terminal discontinuation of life‐sustaining therapy (LST). We present a novel case of VA‐ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes. Patient. A 40‐year‐old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA‐ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patient's religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA‐ECMO. Interventions. Meetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA‐ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor. Conclusion. Traditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA‐ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA‐ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology.

The authors discuss the damaging influence of informal and hidden curricula on medical students and describe a two-week clerkship in palliative care and clinical ethics at their school (Weill Medical College of Cornell University). This required clerkship, begun in 1999, uses reflective practice and a special pedagogic technique, participant observation, to counteract the influences of the informal and hidden curricula. This technique seeks to immerse the participant observer in the context of care. In their role as participant observers, students are relieved of any direct clinical responsibilities for two weeks so they have time for the careful observation and reflection required and also can consider the humanistic dimensions of practice, which are often displaced by the need to master diagnostic and therapeutic skills. Course objectives include identifying psychosocial and contextual factors that influence care, principles of pain and symptom management, and ethical and legal issues at the end of life. Students are expected to learn how to apply ethical norms to patient care, describe methods of pain and symptom management, communicate in an effective and humanistic manner, and articulate models of patient-centered advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity, and the student's ability to assume responsibility for developing competency in these areas. Although it is too early to know whether this clerkship will ultimately affect the practice patterns of students who experience it, short-term evaluation has been very favorable.