The Maryland Healthcare Ethics Committee Network
The Maryland Healthcare Ethics Committee Network (MHECN) is a membership organization, established by the Health Law Program at Maryland Carey Law. The purpose of MHECN is to facilitate and enhance ethical reflection in all aspects of decision making in health care settings by supporting and providing informational and educational resources to ethics committees serving health care institutions in the state of Maryland. The network achieves this goal by:
- Serving as a resource to ethics committees as they investigate ethical dilemmas within their institution and as they strive to assist their institution acting consistently with its mission statement
- Fostering communication and information sharing among network members
- Providing educational programs for ethics committee members, other health care providers, and members of the general public on ethical issues in health care
- Conducting research to improve the functioning of ethics committees and ultimately the care of patients in Maryland
Managing Director, Health Law Program
If you have questions, want to request information about ethics consultation, or have suggestions for additional helpful resources, please contact: Rebecca Hall,
managing director, Law and Health Care Program firstname.lastname@example.org 410.706.5369
VOLUNTEER FOR COVID RESPONSE HERE! Maryland Responds Medical Reserve Corps registration (to volunteer): http://mdresponds.health.maryland.gov
Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency (2017) Report: Maryland SRA Framework (11/2/21)
- Projected hospital resource use for U.S. and by state (tells projected peak, how many beds, ICU beds, & vents needed): https://covid19.healthdata.org/
- Maryland COVID DOH website: https://coronavirus.maryland.gov /
- Maryland DOH COVID FAQ: https://phpa.health.maryland.gov/Documents/coronavirus_FAQ.pdf
- Maryland Association of Counties' Resource Page: https://www.mdcounties.org/366/COVID-19-Resource-Page
- Maryland Hospital Association's COVID Resources page: https://www.mhaonline.org/resources/coronavirus
- Maryland 211 website: https://211md.org
- MHECN Covid Surge Readiness
- MHECN Covid Hospital Triage Summary
- Epocrates open access updated protocols: http://www.epocrates.com/COVID-response
- Society for Critical Care Medicine – Critical Care for the Non-ICU Physician https://covid19.sccm.org/nonicu.htm
- Begley article about over-use of ventilators for COVID patients: https://www.statnews.com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/
- Preventing COVID transmission – Atul Gwande, The New Yorker: https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers
- Center to Advance Palliative Care COVID resources: https://www.capc.org/toolkits/covid-19-response-resources/
Advance Care Planning/Communication
- MyDirectives: https://mydirectives.com/
- Respecting Choices: https://respectingchoices.org/planning-conversation-in-context-of-covid-19/
- VitalTalk COVID scripts: https://www.vitaltalk.org/guides/covid-19-communication-skills/
- Partnership for Inclusive Disaster Strategies: http://www.disasterstrategies.org/
- Applying HHS’S Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing: https://www.centerforpublicrep.org/wp-content/uploads/2020/04/Guidance-to-States-Hospitals_FINAL.pdf
- COVID language resources: http://equalaccesslanguageservices.com/covid-19-lep/ ; https://mycielo.org/resources-in-indigenous-languages/
- COVID-19 Medical Communication Access for Deaf and Hard of Hearing: https://www.nad.org/covid19-communication-medical-access-for-deaf-hard-of-hearing/
- COVID-19 Deaf and Hard of Hearing Communication Access Recommendations for the Hospital: https://www.nad.org/covid19-communication-access-recs-for-hospital/
- Confronting Disability Discrimination During the Pandemic by Katie Savin & Laura Guidry-Grimes: https://www.thehastingscenter.org/confronting-disability- discrimination-during-the-pandemic/
- COVID-19 Triage and Disability: What NOT To Do by Joe Stramondo: http://www.bioethics.net/2020/03/covid-19-triage-and-disability-what-not-to-do/?fbclid=IwAR1bWRFHA58cveNO4SBvQXEca_sLQSAeRLFOUIz6MIM5pjaH2uwRfkqPvsQ
- Disablism In a Time of Pandemic: Some Things Don’t Change by Jackie Leach Scully: https://www.ijfab.org/blog/2020/04/disablism-in-a-time-of-pandemic-some-things-dont-change/
- Disabusing the Disability Critique of the New York State Task Force Report on Ventilator Allocation by Joe Fins: https://www.thehastingscenter.org/disabusing-the-disability-critique-of-the-new-york-state-task-force-report-on-ventilator-allocation/
- The following is discussion draft of guidance that a hospital may distribute to its physicians. See the following relevant explanation of Maryland’s Health Care Decisions Act from the state attorney general: http://www.marylandattorneygeneral.gov/Health%20Policy%20Documents/dnrauth.pdf
Implementation of the Maryland Health Care Decisions Act Provisions
on Medically Ineffective Treatment
DRAFT 27 March 2020
Scope: The process below addresses implementation of existing Maryland law that authorizes physicians, with legal immunity, to withhold or withdraw an intervention that is medically ineffective – one that is highly unlikely to prevent a patient’s impending death. Before use of this process, to the extent feasible, clinicians should have a goals of care discussion with the patient or family members. If that discussion results in consent for a DNR or DNI order, terminal extubation, or other limitations on treatment, this process will be unnecessary.
Criteria for medical ineffectiveness: Attempted CPR or mechanical ventilation, whether or not it has already been initiated, should be certified as medically ineffective if the attending physician concludes, based on objective clinical data and the existence of serious comorbidities, that death within six months (the hospice eligibility criterion) is highly probable.
Documentation requirements: If a patient is in the emergency department or any other area of the hospital that is de facto an ED because it is used for triage or evaluation of incoming patients, and if clinical demands are such that only one physician is available to assess a patient, the physician may document that attempted CPR or mechanical ventilation would be medically ineffective; a second physician’s concurrence is not required. If a patient is in an inpatient setting, to the extent feasible the concurrence of a second physician should be documented.
Implementation: Immediately after certification by the attending physician (and for inpatients if feasible, a second physician), DNR/DNI and appropriate comfort care orders should be entered. Ethics or triage committee consultation is not required. Consent of family members is not required for this clinical determination and should not be sought, although informing family members is required. Implementation of the orders should not be delayed even if the family requests transfer to another facility, because in the circumstances of the pandemic, transfer is manifestly impossible.
The development of ethics committees in hospitals, nursing homes and other healthcare institutions was a response to the expanding range of difficult ethical issues confronted by health care providers in the care of patients. Nationwide, approximately 80% of hospitals (100% of hospitals with 400 or more beds) include standing ethics committees within their organizational structures (Fox, Myers & Pearlman, 2007). This is a result of credentialing standards from The Joint Commission on Accreditation of Healthcare Organizations, presidential bioethics commissions, well-publicized court cases, and state laws that support having an internal mechanism to assist physicians, nurses, patients, families, and others to resolve ethical conflicts. Ethics committees function in various ways to address values conflicts among patients, family members, and healthcare providers that raise questions about the right course of action. Ethics committees also work to create a moral environment within health care institutions and to provide education on ethical issues to the institution and the community.
In 1987, Maryland became the first state to enact legislation mandating that all hospitals in the state establish "Patient Care Advisory Committees" or ethics committees, as they are more commonly known. In 1990, this legislation was amended to include nursing homes. In light of this statute, in 1992, Diane Hoffmann, a faculty member specializing in health law at the Maryland Carey Law, and other interested parties established the Baltimore Area Ethics Committee Network (BAEN). The purpose of the BAEN was to provide an opportunity for members of ethics committees to meet one another, share experiences, and learn from one another about how their committees function, what they found to be successful, and difficulties they encountered.
BAEN reorganized in 1998 with the formation of the Maryland Healthcare Ethics Committee Network (MHECN), which is housed within the Maryland Carey Law and supported by membership dues.
- Anne Arundel Medical Center
- Baltimore Washington Medical Center
- Bon Secours Health System, Inc.
- Carroll Hospital Center
- Frederick Memorial Healthcare System
- Future Care Health and Management Corp.
- Greater Baltimore Medical Center
- Harbor Hospital
- Holy Cross Hospital
- Johns Hopkins Hospital
- Kennedy Kreiger Institute
- Keswick Multi-Care Center
- Laurel Regional Hospital
- The Living Legacy Foundation
- Lorien Bel Air
- Lorien Columbia
- Lorien Elkridge
- Lorien Encore at Turf Valley
- Lorien Harmony Hall
- Lorien May’s Chapel
- Lorien Mt. Airy
- Lorien Taneytown
- Lorien Riverside
- MedStar Franklin Square Hospital Center
- Sheppard Pratt Hospital
- Sinai Hospital
- Southern Maryland Hospital, Inc.
- Springfield Hospital Center
- St. Elizabeth Rehabilitation & Nursing Center
- University of Maryland Medical System
- Upper Chesapeake Health System, Inc.
- Wicomico Nursing Home
Shahid Aziz, MD, Chair, Ethics Committee, MedStar-Harbor Hospital Baltimore, Maryland
Diane E. Hoffmann, JD, MS, Maryland Carey Law Professor of Law and Director of the Law and Health Care Program
Anna Moretti, RN, NP, JD, Montgomery Hospice, Rockville, MD
Jack Schwartz, JD, Adjunct Professor, Maryland Carey Law, Baltimore, MD
Anita J. Tarzian, PhD, RN, MHECN Program Coordinator; Associate Professor, UMB School of Nursing, Baltimore, MD
If you are interested in joining MHECN’s Education Committee, please e-mail Rebecca Hall, email@example.com
MHECN provides a diversity of services for the community of ethics committees in Maryland, as well as individuals interested in bioethics. MHECN relies on membership support to provide its full complement of services. MHECN Membership is comprised of three categories:
- Institutional membership for healthcare institutions.
- Individual membership for those with an interest in bioethics.
- Affiliate membership for those organizations that do not meet the criteria of a healthcare institution, such as academic institutions, professional associations and private organizations, and wish to support MHECN’s mission.
MHECN collects dues in January for the upcoming year. If you wish to join during the year, you can request a pro-rated dues invoice by contacting Gehan Girguis, at firstname.lastname@example.org, (410) 706-7042.
The Mid-Atlantic Ethics Committee Newsletter is a publication of the Maryland Health Care Ethics Committee Network, an initiative of the University of Maryland Francis King Carey School of Law’s Law and Health Care Program. The newsletter combines educational articles with timely information about bioethics activities. Each issue includes a feature article, a calendar of upcoming events, and a case presentation and commentary by local experts in bioethics, law, medicine, nursing, or related disciplines.
- Shahid Aziz, Ethics Committee MedStar-Harbor Hospital Baltimore, Maryland
- J. Wayne Brannock, Chief Operating Officer, Lorien Health Services
- Rebecca Daley, Assistant General Counsel, Greater Baltimore Medical Center
- Marion Danis, Head, Section on Ethics and Health Policy at National Institutes of Health
- Joseph DeMattos, President and CEO, Health Facilities Association of Maryland
- Evan Derenzo, Assistant Director, MedStar Washington Hospital Center
- Jackie Dinterman, Director, Care Management at Frederick Health Hospital
- Margaret Garrett, President of American Society of Health Care Risk Management
- Diane Hoffmann, Director, Law & Healthcare Program, UM Carey School of Law
- Tamara Kile, Medical Director, Care Management at Frederick Memorial Hospital
- Daniel Kleiner, Director of Psychology Services, Kennedy Krieger Institute
- David Moller, Chief of Clinical and Organizational Ethics, Ann Arundel Medical Center
- Christen Paradissis, Program Coordinator, Maryland Health Care Ethics Committee Network (MHECN)
- Karen Rothenberg, Marjorie Cook Professor Emeritus of Law, UM Carey School of Law
- Cynda Rushton, Anne & George Bunting Professor of Clinical Ethics, Johns Hopkins University
- Jessica Schram, Clinical Manager, the Living Legacy Foundation
- Lee Schwab, Physician Advisor, Holy Cross Health
- Jack Schwartz, Adjunct Professor, UM Carey School of Law, Baltimore, MD
- Henry Silverman, Professor, UM School of Medicine
- Anita Tarzian, Deputy Executive Director, Veterans Health Administration
- Yoram Unguru, Chairman, Sinai Hospital Ethics Committee, Johns Hospital University
Projects & Services
MHECN members receive a 20% discounted registration fee to MHECN-sponsored educational events. Programs have addressed issues such as advance directives and Maryland law, ethics in an intercultural society, the process of ethics consultation, the importance of communication in ethics consultation, spirituality and the role of ethics committees, disability rights and ethics, and legal/ethical aspects of clinical informed consent and capacity.
Past MHECN Conferences
- Seventh Annual Interprofessional Forum on Ethics and Religion in Health Care: Unraveling Vaccine Science, Faith, and Public Discourse Virtual Forum, November 10, 2020
- Sixth Annual Interprofessional Forum on Ethics and Religion in Health Care: What the Golden Rule Really Means in Serving the LGBTQ+ Community, November 7, 2019
- Fifth Annual Interprofessional, Interfaith Ethics Conference: Exploring Mental Health and Trauma-Informed Care, November 8, 2018
- Fourth Annual Interprofessional Forum on Ethics and Religion in Health Care: TRANSFORMING APPROACHES TO SUBSTANCE USE DISORDERS. Tuesday, Nov. 7, 2017, 8:30 a.m. - 3:30 p.m., Southern Management Corporation Campus Center
- Challenges in Organ Donation & Transplantation. Tuesday, Nov 1; 8:30 – 3:15., University of Maryland Southern Management Campus Center.
- Second Annual Interprofessional Forum on Ethics and Religion in Health Care: How to Maintain Dignity, Respect and Familial Cohesion as our Loved Ones and Patients Age. Monday, November 2, 2015; 9:00 a.m. – 3:15 p.m., University of Maryland Southern Management Campus Center.
- "Practical Clinical Ethics: Patient, Practitioner & Policy,"
Sponsored by Harbor Hospital's ethics committee
Thursday, June 4, 2015, Medstar Harbor Hospital, Baltimore, MD.
- Religious, Medical, Ethical and Legal Perspectives on End of Life Issues, Presented by the Institute for Jewish Continuity,The University of Maryland Schools of Medicine, Nursing, Pharmacy, and Social Work, and The Maryland Healthcare Ethics Committee Network; Monday, November 10, 2014; UM Carey School of Law
- Ethical and Legal Issues in Dementia: Navigating Difficult Decisions
October 11, 2014; Holy Cross Hospital, Silver Spring, MD
- Maryland Medical Orders for Life-Sustaining Treatment (MOLST)—A Six Month Check-Up
Monday, December 9, 2013, UM Carey School of Law, Baltimore, MD
- Health Care Decision Making & the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) Form
Tuesday, April 2, 2013, UM Carey School of Law, Baltimore, MD
- Navigating Communication Landmines in Ethics Consultation.
Wednesday, June 13, 2012, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD
- Medically Ineffective Treatment Under Maryland Law: A Round Table Discussion with Maryland Hospital Attorneys & Risk Managers.
Wednesday, September 28, 2011, SMC Campus Center, Baltimore, MD
- Ethics Consultation & Beyond: A Primer for Health Care Ethics Committee Members
Wednesday, June 29, 2011, Harbor Hospital, Baltimore, MD
- Medical Futility and Maryland Law
Tuesday, November 30, 2010, University of Maryland Baltimore campus
- Disability, Health Care & Ethics – What Really Matters
Wednesday, April 28, 2010, Kennedy Krieger Institute, Baltimore, MD
- The Ethics of Pandemic-Driven Health Care Resource Rationing
Tuesday, October 27, 2009, University of Maryland School of Law, Baltimore, MD
- Fine Tuning Clinical Ethics Consultation – A Workshop for Health Care Ethics Committee Members
Monday, June 8, 2009, Franklin Square Hospital, Baltimore, MD
- Ethics Committees and Maryland Law – Time for a Change?
Wednesday, December 3, 2008, Broadmead Continuing Care Retirement Community, Cockeysville, MD
- The Ethics of Health Care Reform
Monday, April 7, 2008, University of Maryland School of Law, Baltimore, MD
- Ethics Committees in Action
Thursday, July 26, 2007, Bon Secours Spiritual Center, Marriottsville, MD
- Money & Medicine: Bedside Ethics of the Medical Marketplace
Tuesday, January 30, 2007, Greater Baltimore Medical Center, Towson, MD
- Should Conscience Be Your Guide? Exploring Conscience-based Refusals in Health Care
Tuesday, June 20, 2006, University of Maryland School of Law, Baltimore, MD
- Troubleshooting the Patient’s Plan of Care Form
Tuesday, November 29, 2005, Broadmead, Cockeysville, MD
- ‘Healthcare Ethics in Action’ – Basic Ethics Education Conference
Tuesday, June 28, 2005, Franklin Square Hospital Center, Baltimore, MD
- ‘Still Hazy After All These Years’ – DNR Orders: Problems & Solutions
Wednesday, November 17, 2004, Charlestown Retirement Community, Catonsville, MD
- Not in My ER, Not in My Nursing Home: Regulatory, Legal, and Ethical Insights about Dying in Institutions
Friday, December 12, 2003, Franklin Square Hospital, Baltimore, MD
- Clinical Informed Consent and Capacity: Law versus Ethics
June 2, 2003, University of Maryland School of Law, Baltimore, MD
- Spirituality, Healthcare and the Role of Ethics Committees
Monday October 28, 2002, Franklin Square Hospital, Baltimore, MD
- Two Topics in End-of-Life Care: African American Perspectives and Conflict Resolution
June 15, 2001, Franklin Square Hospital, Baltimore, MD
- Capacity Assessment, Tube Feeding and Other Vital Issues of Importance Before the End-of-Life
Thursday, November 15, 2001, North Arundel Hospital, Glen Burnie, Maryland
- Communication: The Heart of Ethics Consultation
Saturday December 2, 2000, Bon Secours Spiritual Center, Marriottsville, MD
- Tailored Basic Ethics Education Courses
Fall, 2000 – Greater Baltimore Medical Center
September 8, 2001 – Shore Memorial Hospital, Easton, Maryland
- Healthcare Ethics in a Multicultural Society
June, 1999, Harbor Hospital, Baltimore, MD
- Hopkins v. Wright: A Panel Discussion
November 18, 1999, Harbor Hospital, Baltimore, MD
- Sustaining the Life of Your Ethics Committee
May, 1998, Bon Secours Spiritual Center, Marriottsville, MD
In 1998, MHECN received funding from The Greenwall Foundation to study the competency of individuals who are members of hospital ethics committees to perform ethics consultations. The findings of that research project are published in the Journal of Law Medicine & Ethics, 2000, Volume 28, 30-40 [link to the abstract: https://journals.sagepub.com/doi/abs/10.1111/j.1748-720X.2000.tb00314.x ]
In 2009-2010, MHECN surveyed ICU physicians and hospital attorneys or risk managers to clarify interpretations of which medical treatments, if any, could be withheld or withdrawn based on determinations that they were "medically ineffective," as defined in Maryland's Health Care Decisions Act. Read the summary reports here for ICU physicians and for hospital attorneys/risk managers.
In 2014-2015, MHECN received funding from The Maryland Department of Health and Mental Hygiene to evaluate the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) program. Read the Study Final Report here: MOLST Evaluation Study Final Report.
Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency (Framework PDF).
Learn about the following Bioethics Topics at the UW Medicine's Department of Bioethics and Humanities Ethics in Medicine website, at https://depts.washington.edu/bhdept/ethics-medicine
Common Topics in Health Care Ethics
Advance Care Planning & Advance Directives
Breaking Bad News
Clinical Ethics and Law
Cross-Cultural Issues and Diverse Beliefs
Difficult Patient Encounters
Do Not Resuscitate during Anesthesia and Urgent Procedures
Do Not Resuscitate Orders
Ethics Committees and Consultation
HIV and AIDS
Interdisciplinary Team Issues
Maternal / Fetal Conflict
Neonatal ICU Issues
Parental Decision Making
Public Health Ethics
Spirituality and Medicine
Termination of Life-Sustaining Treatment
Truth-telling and Withholding Information
Brain death (check out these videos explaining brain death in different languages, prepared by the Halachic Organ Donor Society, a Jewish organ transplant advocacy group: https://hods.org/halachic-issues/videos/animation/ )
Disability Rights & Healthcare Ethics
Devaluing people with disabilities (National Disability Rights Network White Paper)
Maryland MOLST, National POLST
Neuroethics and disorders of consciousness
Post Intensive Care Syndrome
Perinatal genetic testing
Posthumous sperm retrieval (listen to this Radio Lab podcast featuring one woman’s experience)
Principle of Double Effect
Religion & ethics
Sterilization of youth with intellectual impairment
Voluntarily Stopping Eating & Drinking (VSED)
Withholding life support (moral distress & moral residue; see also https://www.aacn.org/clinical-resources/ethics-moral-distress)
- Arizona Bioethics Network
- Bioethics Network of Ohio
- Bioethics Society of the English-Speaking Caribbean (BSEC)
- Center for Practical Bioethics
- Colorado Healthcare Ethics Forum
- Florida Bioethics Network
- Global Network of WHO Collaborating Centres for Bioethics
- Midwest Ethics Committee Network
- Minnesota Center for Health Care Ethics
- United Kingdom Clinical Ethics Network
- Vermont Ethics Network
- West Virginia Network of Ethics Committees
Do you know of a local ethics network website that’s not listed here? Please let us know! E-mail MHECN@law.umaryland.edu.
Information & Resources for Healthcare Ethics
- Maryland State Attorney General (Advance Directives, Health Care Decisions Act, Attorney General Opinion Letters)
- Maryland MOLST
- Maryland Patient Care Advisory Committee Act
- Chesapeake Regional Information System for our Patients (CRISP)
- Respecting Your Choices
- 5 Wishes Document
- Halachic Living Will Forms
- Disability Rights - The Jenny Hatch Justice Project
It is often said that most ethics consultations are not about ethical dilemmas or even ethics in the strict definition, but result from breakdowns in communication. Here are resources to improve communication competence of health care providers. Please share additional resources you have by emailing email@example.com.
- American Medical Association (2006). An Ethical Force Program: Improving Communication, Improving Care.
- Go Wish end-of-life card game
- Vital Talk. Website to improve oncologists’ communication skills through research-based approaches."
- Visit the Institute for Healthcare Communication, whose mission is to advance "the quality of healthcare by optimizing the experience and process of healthcare communication."
- Visit the Academy of Communication in Healthcare, at https://www.achonline.org/
- Palliative care providers and resources
- ToughTalk. Teaching Module: Talking about Harmful Medical Errors with Patients.
Ethics committees generally focus on three main functions:
- Ethics consultation. The American Society for Bioethics and Humanities’ (ASBH, 2011) Core Competencies for Healthcare Ethics Consultation defines ethics consultation as “a set of services provided by an individual or a group in response to questions from patients, families, surrogates, health care professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care.” A distinction is made between “case consultations” [involving an identified patient for whom one or more recommendations is made by the ethics consultant(s)] and “non-case consultations” (basically, all other consultations). The Core Competencies document is available for purchase at http://www.asbh.org/. It is also summarized in the article, “Health care ethics consultation: An update on core competencies and emerging standards,” published in the American Journal of Bioethics (Tarzian & the ASBH Core Competencies Update Task Force, 2013, 13(2), 3-13). Also, review this list of Pearls and Pitfalls of Ethics Consultation, drafted by ASBH’s Clinical Ethics Consultation Affairs (CECA) Committee in 2011.
- Ethics education. Many ethics committees engage in activities to educate others, both formally and informally. Informal education occurs during ethics consultations (i.e., explaining ethical concepts and issues to those involved in the consult) and other interactions with staff or family members. Formal education can include giving ethics lectures, sponsoring conferences, orienting new staff to ethics, or educating staff and family members about the ethics committee’s services. Ethics committees also must educate their own members. ASBH’s Improving Competence in Clinical Ethics Consultation: An Education Guide is a useful resource for identifying ethics knowledge content and ways to educate ethics committee members or staff.
- Policy development. Policies are generally considered to be any governing principle, plan or course of action that an institution has adopted. Protocols are the means to implement the policies. Ethics committees traditionally weigh in on developing, reviewing, and revising policies that impact ethical decision-making in their organization. Examples of topics that ethics committees have addressed in policies include Do Not Attempt Resuscitation (DNAR, or “Allow Natural Death”) orders, artificial nutrition and hydration, informed consent, surrogate decision making, guardianship, determination of decision-making capacity, do not hospitalize orders, and advance directives. In addition to guiding health care providers, policies help advise patients/residents and family members prior to admission to help them make a more informed decision and to seek alternative care if the facility cannot accommodate their treatment preferences. For example, currently in Maryland, as stipulated in Maryland’s Health Care Decisions Act, if two physicians certify that cardio-pulmonary resuscitation attempts would be medically ineffective for a dying patient, they can write a DNAR order and inform the patient or family about everything that will be done to care for the patient, explaining that CPR attempts will not be attempted because they would not be appropriate or effective for a person whose death is imminent and unavoidable. Formalizing this in an institutional policy promotes transparency and increases the likelihood that “like cases are treated alike.” Read more about how one Maryland hospital did this in MHECN’s Winter 2014 newsletter »
There is often conflation between the functions of ethics committees and the goals of ethics committees. Proposed goals of ethics committees include:
- Offering an alternative to the legal system for resolving conflicts about what the right course of action is in providing care for a particular patient. While landmark legal cases such as Elizabeth Bouvia, Karen Quinlan, and Nancy Cruzan have informed bioethics, once a standard is established (e.g., regarding when it is acceptable to withhold or withdraw life-sustaining interventions), ethics committees can help ensure that disputes are handled fairly, without having to resort to courts. In these cases, it is important to distinguish between the practice of law and the practice of ethics case consultation.
- Leveling power hierarchies within health care institutions to ensure that all voices are heard when dealing with ethical issues or conflicts, as depicted in David Rothman’s classic book Strangers at the Bedside. Read Robert Baker's review of how this book impacted bioethics.
- Providing ethics expertise. While the nature of medicine has been described as a “moral enterprise” and requires a basic understanding of professional and applied ethics, the scope of expertise required to address the range of ethical issues that arise when delivering 21st century health care across the lifespan has outpaced what most health care providers master in their primary discipline’s education and training. Ethics committees are one place within an institution where others can access ethics expertise, which is generally categorized as skill-based (e.g., facilitating communication, mediating conflict, ensuring that all relevant voices are heard, clarifying values, identifying ethical issues, accessing relevant ethics literature) and knowledge-based (e.g., explaining the difference between mental competence and decision-making capacity, or the distinction between persuading a patient or family member to consider a beneficial course of action and coercing). Foundation publications outlining the scope of expertise that ethics committee members should have, published by the American Society for Bioethics and Humanities, include the Core Competencies for Healthcare Ethics Consultation and Improving Competencies in Clinical Ethics Consultation: An Education Guide. A summary of the second edition of the Core Competencies is published in the American Journal of Bioethics (Tarzian & the ASBH Core Competencies Update Task Force, 2013, 13(2), 3-13).
- Raising the level of administrators’ and staff members’ ethics proficiencythroughout the institution. This goal is an extension of the goal above. While ethics committees can house ethics experts who are available to weigh in when needed to address questions or concerns, they can also take a more proactive approach to integrate ethics competency and comportment throughout an institution. This is partly achieved by the ethics committee’s education initiatives (e.g., sponsoring conferences, giving grand rounds talks, educating new staff about ethics, advertising the ethics committee’s services, offering journal club or book/film club discussions). But it can also take the form of other services, such as “ethics advisement” or “coaching,” debriefing on difficult cases, doing ethics rounds, and implementing ethics quality improvement initiatives. The National Center for Ethics in Health Care provides several resources to support this Integrated Ethics approach, A Brief Business Case for Ethics, which provides justification to health care administrators for funding an ethics program.
- Protecting “moral spaces” in fast-paces health care delivery settings. In Margaret Urban Walker’s landmark article, “Keeping Moral Spaces Open,” published in the Hastings Center Report in 1993, ethics consultation and ethics committee work is conceived as an opportunity to protect a “moral space” around complex or troubling situations. It can be conceived as way to call a “time out” to sort through complex facts and emotions in an otherwise fast-paced health care delivery system. This is thought to mitigate build-up of moral residue or moral distress that so commonly plagues health care providers in settings where ethics is not integrated throughout the organization and thus not viewed as a priority.
- Raising the quality of patient care delivery. This is the ultimate goal of ethics committee work. When health care providers are more knowledgeable about ethics and feel supported in the work they do, this should raise the quality of care provided to patients and families.
Make obligations of membership clear. All too often, ethics committees are comprised of individuals who attend a monthly meeting and do little else. Taking the time to identify obligations and clarify expectations will make it less likely that only a small subset of over-burdened committee members do the bulk of the work.
Choose the right members. Make sure the committee membership is representative of those who are involved in ethical questions and dilemmas that arise at the institution. The committee should be appropriately diverse in its membership, and should include a lay member or patient representative. Pick a chair or co-chairs who have excellent leadership and delegation skills.
Evaluate members & the committee. Check out these committee evaluation tools developed by Ascension Health. Also review the VA's IntegratedEthics assessment tools, but don’t stop at evaluating. Be prepared to act on what you learn!
Read these Benchmarks of Ethics Committee Success identified by Anita Catlin, DNSc, FNP, FAAN, in the Fall 2006-Winter 2007 issue of the MAEC Newsletter.
Adequately educating and training ethics committee members is an ongoing challenge. The type of training each member undergoes will depend on whether all members will be involved in ethics consultation, or only a subset of members. The following suggestions are good places to start training members.
- American Society for Bioethics & Humanities (ASBH) (2011). Core Competencies for Healthcare Ethics Consultation, (2nd Ed.). Glenview, IL: ASBH. Available for online purchase at http://www.asbh.org
- Tarzian, A.J. & the ASBH Core Competencies Update Task Force (2013). Health care ethics consultation: An update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ Core Competencies Update Task Force. American Journal of Bioethics, 13(2), 3-13.
- American Society for Bioethics & Humanities (ASBH) (2009). Improving Competence in Clinical Ethics Consultation: An Education Guide. Glenview, IL: ASBH. Available for online purchase at http://www.asbh.org
- National Center for Ethics in Health Care’s IntegratedEthics resources (Ethical Leadership, Ethics Consultation, Preventive Ethics)
- Local certificate programs requiring days to weeks of training in health care ethics are available through:
- The Berman Institute of Bioethics at Johns Hopkins University in Baltimore, MD
- The Kennedy Institute of Ethics at Georgetown University
- University of Pennsylvania Department of Medical Ethics and Health Policy
- Montefiore-Einstein Center for Bioethics
- Harvard Clinical Bioethics
- The Department of Bioethics & Humanities at the University of Washington School of Medicine and check out their Bioethics Topics resources at https://depts.washington.edu/bhdept/ethics-medicine
- Graduate programs in clinical/healthcare ethics are listed by the American Society for Bioethics and Humanities
The following is excerpted, with minor adaptations, from Hoffmann, Levin & Boyle’s Nursing Home Ethics Committee Handbook.
Statement of need for the policy or protocol
The policy should explain why it was developed, i.e., in response to what need.
Statement of purpose
The purpose of the policy is its underlying reason and what it purports to accomplish.
Statement of the principles underlying the policy
This provides staff with some sense of the basis for the policy so that they understand its rationale.
Definitions of the terms used
It is important that a policy be clear and not use vague or undefined terms that could be interpreted in different ways. For this reason a policy should have a definition section where such terms are clearly defined.
Substantive rules or guidelines
This is the meat of the policy. It should set out the decisional criteria the institution wants caregivers to use and under what circumstances. For surrogate decision making, for example, it might state when surrogates may make medical decisions for incapacitated patients and who qualifies as a surrogate.
For decisions to withhold artificial nutrition and hydration for incapacitated patients, it should state when such decisions can be made (e.g., when the patient is terminally ill or in a persistent vegetative state) and who can make them.
Process for implementation
The policy and procedures should spell out who does what, and when. Specifically, Choice in Dying recommends that the following issues be addressed:
- who initiates the use of the protocol, and when;
- what needs to be included in the patient's records;
- what consultations may be required;
- what notification may be required and to whom;
- how to resolve disagreements among those involved in using the protocol;
- what sanctions can be imposed for violation of the protocol. (p. 3)
Once the policy or protocol has been developed, it must be approved by the appropriate authorities within the facility. This may include the medical staff, the director of nursing, the administrator, and the board of directors or trustees. In some cases, provisional approval may be appropriate so that the policy can be evaluated after a set period of time and revised to correct any problems or deficiencies.
Sample Do-Not-Attempt-Resuscitation (DNAR) Policy
Need for Policy—Between 1 January and 30 June 2012, sixteen cases involving a conflict between a physician and a patient's family over the writing of a do not attempt resuscitation (DNAR) order came to the ethics committee. In 4 of the 6 cases, the physician wrote the order without obtaining the consent of the family members. In 2 of the 6 cases, the family members wanted the physician to write a DNAR order but the physician felt that such an order would not be appropriate. This policy has been developed to provide guidance to physicians and other health care providers in drafting DNAR orders.
Purpose—The primary purpose of this policy on DNAR orders "is to ensure that decisions regarding cardiopulmonary resuscitation (CPR) for particular patients are made through a medically responsible, ethical, and sensitive process that protects the rights of the patient. The secondary purpose is to ensure that there is adequate communication between the patient and those involved in the patient's care."
A. A DNAR order may be appropriate in a variety of clinical situations and may be compatible with aggressive and intensive medical care or participation in research. A DNAR order has no implication for any other treatment decision. For example, it does not imply that any other forms of medical care or research be withheld. Decisions about other medical interventions should be made independently.
B. All treatments that impose undue burdens on the patient without overriding benefits, or that simply provide no benefits may justifiably be withheld or withdrawn. There is no ethical distinction between failing to initiate and stopping therapy. A justification that is adequate for not commencing treatment is also sufficient for ceasing it.
Cardiopulmonary arrest. The cessation of cardiac or respiratory function.
Cardiopulmonary resuscitation. Immediate, aggressive treatment of cardiopulmonary arrest.
DNAR order. A specific order from a physician not to attempt cardiopulmonary resuscitation if a patient suffers cardiac or respiratory arrest.
Terminal illness. An incurable or irreversible condition caused by injury, disease or illness which to a reasonable degree of medical certainty makes death imminent and from which there can be no recovery despite the application of life-sustaining procedures.
Decision-making capacity. The ability to comprehend information relevant to a decision, deliberate about choices in accordance with personal values and goals and communicate such choices to caregivers.
No medical benefit. CPR is defined as having no medical benefit when, in the considered medical judgment of the responsible senior physician, the patient would not survive CPR.
In the absence of a DNAR order, cardiopulmonary resuscitation must be attempted. However, there are circumstances under which it is medically, legally, and ethically appropriate to consider not providing CPR attempts. This section sets forth criteria for determining when such circumstances are present.
A. CPR should not be initiated when:
- A patient with decision-making capacity or his/her legal guardian has requested that CPR be withheld.
- A patient who lacks decision-making capacity has previously executed a valid living will or durable power of attorney that expresses a wish not to be resuscitated or names a surrogate who makes the decision to withhold CPR, and that advance directive is still in effect (e.g., has not been rescinded by the patient, has not expired, etc.)
- In the considered medical judgment of the responsible senior physician, the patient would not survive CPR.
B. A decision not to initiate CPR should be considered and discussed with the patient or the patient's surrogate under any of the following circumstances:
- The patient is terminally ill.
- The patient has a severe and irreversible illness or disabling condition.
- The patient has suffered an irreversible loss of consciousness.
- The patient is likely to lose decision-making capacity.
- There is likely to be no medical benefit from CPR.
A. Patients with decision-making capacity:
- Thorough knowledge of the patient's medical condition is necessary before consideration of a DNAR order. The responsible senior physician should communicate all pertinent facts regarding the patient's medical condition to the patient. The physician must provide the patient with adequate information regarding potential resuscitative measures to enable the patient to make an informed decision. The information provided should include that CPR may involve such procedures as chest compression, administration of various medications, electrical shocks to restart the heart, intubation, and placement on a ventilator.
- Discussions about resuscitation should occur as early as possible in the patient's course, when the patient can participate and make an informed decision. Discussions about resuscitation may also include primary care physicians, primary care nurses, and any other staff members who may have pertinent input about the patient. Discussions may include family members if the patient consents.
- The responsible senior physician should obtain clear oral or written consent from the patient not to initiate CPR.
- If CPR is judged to be of no medical benefit, the responsible senior physician must inform the patient and discuss it with him/her. If the patient disagrees with the physician's recommendation not to initiate CPR, the disagreement should be resolved as described in paragraph C.
- The DNAR order should be reevaluated and renewed anytime there are significant changes in the patient's condition or treatment circumstances, at the patient's or surrogate's request, or periodically as required by procedures of the patient care unit.
- When the patient is discharged from the institution, the DNAR order must be noted in the final written progress note and discharge summary. Patients previously discharged from the institution with a DNAR order should have their clinical status reassessed upon subsequent admissions, and, if indicated, have a DNAR order rewritten.
B. Patients without decision-making capacity: