The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients

Abstract

Despite increased calls for hospital ethics committees to serve as default decision-makers about life-sustaining treatment (LST) for unrepresented patients who lack decision-making capacity or a surrogate decision-maker and whose wishes regarding medical care are not known, little is known about how committees currently function in these cases. This was a retrospective cohort study of all ethics committee consultations involving decision-making about LST for unrepresented patients at a large academic hospital from 2007 to 2013. There were 310 ethics committee consultations, twenty-five (8.1 per cent) of which involved unrepresented patients. In thirteen (52.0 per cent) cases, the ethics consultants evaluated a possible substitute decision-maker identified by social workers and/or case managers. In the remaining cases, the ethics consultants worked with the medical team to contact previous healthcare professionals to provide substituted judgement, found prior advance care planning documents, or identified the patient’s best interest as the decision-making standard. In the majority of cases, the final decision was to limit or withdraw LST (72 per cent) or to change code status to Do Not Resuscitate/Do Not Intubate (12 per cent). Substitute decision-makers who had been evaluated through the ethics consultation process and who made the final decision alone were more likely to continue LST than cases in which physicians made the final decision (50 per cent vs 6.3 per cent, p = 0.04). In our centre, the primary role of ethics consultants in decision-making for unrepresented patients is to identify appropriate decision-making standards. In the absence of other data suggesting that ethics committees, as currently constituted, are ready to serve as substitute decision-makers for unrepresented patients, caution is necessary before designating these committees as default decision-makers.

Developing Age‐friendly Cities: Policy Opportunities and Challenges

“…Studies in intensive care units revealed that 16 percent of patients admitted have no family or friend guardian (White, Curtis, Lo, & Luce, 2006), and these patients account for 5.5 percent of deaths annually (White et al, 2007). For those assessed in acute care settings, a large proportion of individuals without a family or friend guardian are admitted from nursing homes (Cohen, Benjamin, & Fried, 2019;Courtwright, Abrams, & Robinson, 2017;Griggins, Blackstone, McAliley, & Daly, 2019). Research estimates that older adults under public guardianship comprise 3 to 4 percent of the nursing home population, an estimate based on anecdotal information from focus groups of healthcare leaders (Karp & Wood, 2003).…”

Who Makes Decisions for Incapacitated Patients Who Have No Surrogate or Advance Directive?

“…Generally, there is agreement that "a substituted judgement or a best interest standard" is best to help guide decision making for unrepresented patients, 9 although laws and policies vary in how best to uphold a best interest standard. 4,9 As the Hastings Center notes, "[t]here is as yet no consensus on the proper solution." 10 However, state laws and institutional policies attempt to solve the problem largely through 3 different approaches regarding the choice of decision maker: physician, ethics committee, and guardianship.…”

When There's No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled?

“…6,7 Deontological (duty-based obligation) analysis of error handling is further complicated, however, in situations in which the patient is both incapacitated and unrepresented, as is the case in roughly 8% of hospital ethics consultations nationwide. 2 This essay will propose a 3-part framework for error management pertaining to unrepresented patients. The first part concerns documentation and its role in informing future practice at both the physician and the systemic level.…”

“…Dr K feels that even if the patient were successfully resuscitated following another cardiac arrest, he would have very low quality of life, based on his knowledge of the literature. 1,2 Dr K thinks that it might now be best to change the 82year-old patient's code status to DNAR. However, Dr K is concerned that, given the erroneous first DNAR and the patient's unrepresented status, some members of the team might feel compelled to err on the side of providing more aggressive care.…”