Ethics Committees

[Ploppit]

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I am really interested in continuing work on ethics committees and hospital ethics boards / etc in my career. Obviously some specialties interact more with ethical issues on a day-to-day basis (ie neonatology, etc) than other specialties.

My question is - are there certain specialties that make it much easier to allow for an ethics component in one's career, or is this something that any MD can do if he/she really wants to get involved?

I imagine it also depends on the location (ie hospital vs. community-based) and the environemtn (academics vs. private practice).

So to take two extremes - I can see an academic neonatologist very much involved in ethics, but what about someone who is a private practice ENT? Or a community-based urologist? Or a private ophthalmologist?

 

[gutonc]

I am really interested in continuing work on ethics committees and hospital ethics boards / etc in my career. Obviously some specialties interact more with ethical issues on a day-to-day basis (ie neonatology, etc) than other specialties.

My question is - are there certain specialties that make it much easier to allow for an ethics component in one's career, or is this something that any MD can do if he/she really wants to get involved?

I imagine it also depends on the location (ie hospital vs. community-based) and the environemtn (academics vs. private practice).

So to take two extremes - I can see an academic neonatologist very much involved in ethics, but what about someone who is a private practice ENT? Or a community-based urologist? Or a private ophthalmologist?

If you volunteer to be on an ethics committee, after they get done laughing at you (because nobody ever actually volunteers to be on the ethics committee), they will look to make sure you have some sort of connection with the hospital or the community (most hospital ethics committees include not just docs, nurses and other hospital workers but community stakeholders as well), then look to make sure they don't have another one of you on the committee already (how many pediatric urologic oncologists does one ethics committee need after all?), then they will tell you when and where the next meeting is.

Your examples are kind of ridiculous. Any specialty with patient interaction has significant ethical issues to deal with on a daily basis. Do what you want to do and, when all is said and done, if you still want to be on an ethics committee, go for it.

 

[docB]

I'm on my hospital's ethics committee. As Gutonc points out it is not a highly sought after gig but I volunteered after I got involved because of some pet issues of mine. I continue to do it because I like it.

Realistically anyone can be on the committee. I think that doctors who are generalists and take care of sick patients probably bring the most to the table. Docs who don't really deal with sick patients and those who are highly specialized or have limited patient care will not be able to draw on their clinical experience.

Neonatologists do have a lot of interface with ethical issues and ethics comittees however that is only a small portion of the overall scope of the field.

Some of our recent issues:
Should we code the brain dead if the patient's family demands it?
Should we code patients on multiple pressor drips?
Can a patient who has attempted suicide be made DNR?
Which family member gets the final say on issues like code status or organ donation?
Can we give patients placebos?

 

[VA Hopeful Dr]

Some of our recent issues:
Should we code the brain dead if the patient's family demands it?
Should we code patients on multiple pressor drips?
Can a patient who has attempted suicide be made DNR?
Which family member gets the final say on issues like code status or organ donation?
Can we give patients placebos?

No, yes, no, spouse-oldest child (or parent if no kids)-hairdresser in that order, yes.

Can I be on the committee?

 

[oldbearprofessor]

If you volunteer to be on an ethics committee, after they get done laughing at you (because nobody ever actually volunteers to be on the ethics committee)

It is generally considered a privilege and well-respected hospital position in a Children's hospital for a faculty to serve on the ethics panel. I've never heard a negative comment ever about it.

Hospital pharmacy committee? Well, no physician in a Children's Hospital would volunteer for that.😛

and, no, I'm not on the ethics committee and never have been. But faculty can make it a major aspect of their careers in pedi specialties and do all the time, especially, neo, cards, picu and pedi neuro.

BTW, for the OP, ethical issues come up in private practice neonatology too at big centers. Academics isn't what determines this. Private practice neos serve on hospital ethics committees commonly.

 

[dpmd]

Some of our recent issues:
Should we code the brain dead if the patient's family demands it?

Can a patient who has attempted suicide be made DNR?

Maybe it is just a california law, but brain dead is legally dead and therefore the family wanting you to do anything (including leaving them on the vent) does not even come into play.

When I was a student I had a patient who was on his 180th ICU day after a suicide attempt that resulted in severe injuries. He was awake and no longer depressed or suicidal, but he was constantly becoming septic and was rapidly exhausting central access sites for his TPN. With my team's ok I talked to him about his situation (being able to speak spanish resulted in me having lots of discussions that are typically not student level) and he was considering making himself DNR. I don't know if that ended up happening (rotated off service before a decision was made), but I don't see any reason that it shouldn't be allowed). However if the patient just did something then as they are brought in are saying not to treat/resuscitate I wouldn't agree with that.

But what about someone who already has a DNR/DNI and durable power of attorney who then attempts suicide? That also came up as a student (the status wasn't known until she was already intubated), and the DPA went against the written instructions and asked for her to be full code. She was coded a total of 23 times in 2 days before she couldn't be brought back. According to the way the document was written that never should have happened, but no one else questioned it.

 

[docB]

No, yes, no, spouse-oldest child (or parent if no kids)-hairdresser in that order, yes.

Can I be on the committee?

Maybe it is just a california law, but brain dead is legally dead and therefore the family wanting you to do anything (including leaving them on the vent) does not even come into play.

As you can imagine these cases get absurdly complicated.

The issue about coding the brain dead arose with a case where the patient's family refused to accept the diagnosis and had demanded a second opinion from a different neurologist. The second consult had been called but had not seen the patient yet when the patient coded. The patient did have ROSC after epi and atropine and a few minutes of CPR. The etchics nurse was consulted with the question of medical futility and should this patient be coded again. The primary wanted to go along with whatever the family wanted due to fear of causing a suit if he withdrew any care.

The issue of coding patients on multiple pressor drips is a common one for my center. We get called out daily to code patients who are on the maximum amount of life support we can give but failed. Doing ACLS in that environment really amounts to futile care.

 

[dpmd]

Ah, I see. Never had anybody question it after two different physicians trained in recognition of brain death have done their own exams and come to the same conclusion (again, california law-don't know if it's the same everywhere). Plus I usually have the luxury of time or have the patient reach cardiac death before being certain of the brain death part. I can see how that would be hard. What did the committee recommend?

 

[docB]

Ah, I see. Never had anybody question it after two different physicians trained in recognition of brain death have done their own exams and come to the same conclusion (again, california law-don't know if it's the same everywhere). Plus I usually have the luxury of time or have the patient reach cardiac death before being certain of the brain death part. I can see how that would be hard. What did the committee recommend?

We were looking at this after the fact, ie. the patient had already expired. We reiterated that it is futile care to code a brain dead patient and that it shouldn't be done. The problem is that we can only make recommendations, not rules. It's also a problem that the docs will say anything to get their way. In cases like this the primaries tend to come up with stuff like "I agreed with the family that brain death had not yet been conclusively diagnosed. Consequently I intend to flog this carcass until I am certain that the family will not sue me."