Ethical, Compassionate, and Cost-Effective Approach to Health Care Decisions of Unrepresented Patients: A Bioethics Quality Improvement Project.

Abstract

Unrepresented patients are defined as patients who lack capacity and do not have surrogate decision makers. Nonemergent medical treatment of unrepresented patients is often not provided owing to lack of a surrogate or is delayed because of lengthy court proceedings resulting in increased suffering and increased length of stay. Development of an institutional policy that allows a multidisciplinary team to make medical decisions for unrepresented patients provides an ethicallysound, legally viable, medically appropriate, and financially responsible solution. A retrospective review of deidentified bioethics logs over a 2-year period was conducted after the implementation of anUnrepresented Patient Committee policy. The primary outcomes were (1) total number of consults received and (2) average time to convene committee meeting. There was a substantial increase in unrepresented consult requests from an average of 2 requests per year before 2015 to 23 requests in 2015 and 20 requests in 2016. The committee meetings were convened on average within 4.8 days of a consult request in 2015 and within 5.8 days in 2016. Implementation of this policy in lieu of a court petition led to a considerable reduction in the time for decision-making resulting in better clinical care and decreased length of stay with an estimated cost avoidance of $1,968,250 over the study period. Implementing an Unrepresented Patient Committee policy has created an avenue for ethical and collective decision-making, improved quality and efficiency of medical care delivery, reduced length of stay, and decreased health care costs.