EARLY EXPERIENCES OF AN ETHICS CONSULT TEAM

Abstract

To the editor: We were troubled by the recent article by Olson et al1 describing the function of their ethics consult team. It appears that the major issues they deal with relate to family members’ requests to withhold or withdraw tube feeding for demented relatives. What was most disturbing to us were two aspects of their process. Our first concern is their nearly exclusive focus on the application of New York's “clear and convincing” evidence standard as the underlying guiding principle to follow in decision-making. Clearly this is a legal standard, not an ethical one, and yet there are no representatives of the legal profession on their consult team. Indeed, several of the decisions to deny requests to withhold or withdraw a feeding tube appear to have been based on incorrect interpretations of New York law. For example, the consult team unilaterally determined that one resident's proxy was acting in bad faith and that another resident had not been competent to sign a proxy form; the New York Health Care Proxy law clearly anticipates that these sorts of challenges must be brought before a court.2 Secondly, it appears that the ethics consult team is heavily involved in medical management itself. The development of care plans is described, and a high frequency of refusing requests to withhold or withdraw feeding tubes is reported. This makes one wonder whether the “consult team” is really a medical decision-making body rather than an ethics-based consultation for the primary team. In fact, it is unclear what ethical principles are used in the process. The team's function seems related more to risk management, in terms of protecting the institution from presumed liability. In defense of the team the article describes, there are few standards or guidelines on which to base ethical consultation in long-term care facilities. As greater numbers of facilities develop ethics committees, it becomes increasingly important that guidelines, at least for the composition and process of the committees, be developed. As part of its professional education and consultation services, Choice In Dying's lawyers, health care providers, and educators assist members of ethics committees address the questions that come before them. Ironically, the article immediately following the Olson paper describes the thoughts of a physician having trouble sleeping after learning that a nursing home patient for whom he refused to authorize a feeding tube had died peacefully. One wonders if Dr. Kane's Doctor Arden would have lost a few more hours of sleep if he had been visited by the Olson ethics consult team. Editors note: The above letter was referred to the authors of the original paper, and their reply follows.