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Ethics committee debates end-of-life treatment
Palliative sedation policies reviewed
As hospitals add more palliative care services, ethical issues arise that sometimes cannot be handled solely by a hospital ethics board because a broader community perspective is necessary.
For instance, what is the hospital's policy regarding cardiopulmonary resuscitation (CPR) when all attending clinicians agree the patient cannot be resuscitated? Or should physicians provide palliative sedation, and how should this be described to patients and families?
The Harvard Community Ethics Committee is a potential model for how these issues might best be handled. The committee is comprised of 16 men and women who are diverse by age, profession, language, ethnicity, religion, and in other ways.
"The Harvard Community Ethics Committee was set up within the division of medical ethics as a resource for faculty and fellows of the Harvard-affiliated community to have access to a diverse group of lay people when they wanted to ask for a public response to things," says Christine Mitchell, MTS, MS, associate director of clinical ethics in the department of global health and social medicine at Harvard Medical School in Boston, MA.
A recent example of how the committee fulfills its role occurred when a couple of physicians from the Harvard Medical School community asked the committee how the public understood and felt about palliative sedation.
The committee met with experts in palliative sedation, reviewed various policies on the subject, and eventually wrote a report that answers a list of questions, such as these:
During the committee's discussions, members expressed discomfort with the terminology, Mitchell recalls.
"People asked, 'Why don't we call it what it is?'" she says. "So we ended up deciding to call it 'continuous deep sedation as comfort care until death.'"
The ethics committee defined a whole set of terms used in the report, including addressing the issue of what it meant to say someone was imminently terminal, Mitchell says.
"They noted that these were patients for whom other ways of treating their pain have not been successful, she says.
The committee looked at how palliative sedation might be linked to euthanasia or physician-assisted suicide, beginning at first with some member confusion over the various terms and their meanings. They ended up being convinced that there is no legitimate link between palliative sedation and the intent to end a sick patient's life, Mitchell says.
"It's not close to the illegal or controversial methods of dying, the committee said," she adds. "This is something that should be considered as a reasonable treatment option for patients dying of pain and who couldn't be treated in other ways."
The aim of euthanasia and physician-assisted suicide is to end a patient's life; the primary goal of palliative sedation is to relieve a patient's pain, the committee decided.
"We had people lined up in opposing camps at the beginning, saying, 'You can't do it,' and others saying, 'Of course you want to treat someone's pain if they're dying even if they're asleep,'" Mitchell says.
After conversations with nurses and physicians in palliative care, the committee members' views evolved.
The Harvard committee handles its broad diversity in opinion and experience by drafting a survey of questions for each member to consider and answer. The questions include those with just "yes" and "no" responses and those that require a more detailed description of the member's thoughts. This ensures each member's thoughts and concerns are taken into account, Mitchell explains.
Committee members are seeking input on these ethical issues from friends, as well.
"We have a second step that gets the issue beyond this committee that has thought about it and out to people who don't think about it," Mitchell says. "Everybody completes the survey and gives their reasons on paper for their thoughts."
The palliative sedation discussion lasted for nearly a year, with some interruptions for other ethical considerations. Each part of the report's wording needed full committee agreement and review.
The final report is not the same as policy, but it's sent to members of the Harvard Ethics Leadership Group, the division of medical ethics at Harvard, and to ethics committees at Harvard teaching hospitals and health care facilities.
Each institutional ethics group could use and adopt the report as policy, if desired.
Sometimes a hospital will use the report to inform and assist with policies, Mitchell says.
"I know within the Children's Hospital at Harvard, they were working on a policy about social media, and our committee's report on the topic influenced their policy," she adds.