Ethics Article: Ethics Guidelines - Faith Regional Health Services

In recent years, progress in medical technology has resulted in many patient services and treatments, which can cure disease, treat injuries or medical conditions, and promote the overall care and treatment of our fellow human beings. With these advances in medical treatments, however, have come many difficult and, often, once-in-a-lifetime decisions for patients and their families. This is particularly true with regard to patient treatments that are now available at the end of life.

End-of-life decisions are being made on a daily basis around the world by and for many individuals. Unfortunately, these decisions are often being made during periods of great personal or family crisis with little or no preparation on the part of the persons being forced to make these decisions.

As we continue to progress in our medical abilities, it is clear that the need for understanding of medical decision-making must improve, on the part of health care providers and lay persons as well. This is especially true as we face the difficult issues of death and the dying process. With this in mind, the purpose of these guidelines is to provide a resource for health care providers, patients, family members and others, which can be used to assist in decision-making processes with regard to initiating, continuing or discontinuing patients’ treatments and, in particular, those treatments provided at the end of life.

Guidelines for Decisions Related to End of Life Treatments

Philosophy
The mission of Faith Regional Health Services is to serve Christ by providing all people with exemplary medical services in an environment of love and care. As a Christian-sponsored, value-based healthcare organization, Faith Regional Health Services holds the following truths as basic to its mission of healing.

Human life is a gift from God of extraordinary value and human beings are called by God to work diligently to preserve and enhance this gift.

Human life on earth is not the ultimate value or reality, and death should be viewed as a natural transformation process, through which we, as human beings, hope to pass to union with God, the ultimate good.

There are limits to our duty to preserve life and resist death. Patients should not be obligated to endure medical treatment that unduly prolongs their dying without offering reasonable benefit.

Because of the great value of human life, decisions to prolong life, or to allow death to come, are seldom easy. Each person and each situation is unique and each decision is profoundly personal, as well as communal.

General Principles
Presumption in favor of treatment and life. Rooted in the mission of Faith Regional Health Services is a commitment to provide high quality medical care to our patients with the objective of sustaining and enhancing life. As an organization therefore, Faith Regional Health Services maintains a presumption in favor of providing treatment to all patients. This commitment, however, must recognize the right that patients have in making their own decisions about their health care and in continuing, limiting, declining or discontinuing treatment, whether life-sustaining or otherwise.

No moral or legal obligation to render useless treatment. Faith Regional Health Services recognizes that there is no moral or legal obligation to perform useless or futile therapy. Therefore, if the goals of treatment are not attainable, (i.e., the use of a particular therapy cannot or will not improve prognosis for recovery) then the treatment need not be initiated or continued. A physician is not mandated, morally or by law, to render treatment which is deemed useless in his/her medical judgement.

The right to refuse life-sustaining treatment. Based on the autonomy and sanctity of the human person, adult competent patients have the legal and moral right of self-determination relative to their medical care. This right is given by God to all persons and it is also confirmed by State and Federal Governments. Patients can refuse life-sustaining treatment when no equal or countervailing rights of other persons would be substantially jeopardized by such refusal, and when such treatments are perceived by the patient as useless or excessively burdensome.

Burden/Benefit principle. Decisions to forego life-sustaining measures should usually be guided by a consideration of the benefits and burdens of treatment. These considerations may include: the quality and/or extent of life sustained; the effect on family, financial resources, personal values and integrity, religious convictions, personal pain and suffering, as well as medical condition. Treatments become ethically unnecessary either when it is perceived by the patient to be of no benefit, or when the burdens resulting from treatment are perceived as disproportionate to the benefits hoped for, or obtained.

Initiating/Discontinuing treatment. There is no significant ethical distinction between failing to institute treatment and discontinuing treatment that has already been initiated. A justification that is adequate for not commencing a specific treatment is also sufficient for ceasing that treatment.

Euthanasia distinguished from foregoing treatment. The Catholic Church, Lutheran Church Missouri Synod (LCMS) and Faith Regional Health Services differentiate between “assisted suicide” or “euthanasia” and “allowing a person to die.” The Catholic and LCMS faith traditions affirm that there comes a time in all people’s lives when they should be allowed to die. “The fact that death occurs because one withholds or withdraws useless or burdensome treatments is not euthanasia or suicide, since the intent is not to assist another person to take his or her own life”. Also, “it is not euthanasia to give a dying person sedative and analgesics for the alleviation of pain, even though they may deprive the patient of the use of reason, or shorten his/her life.” (per “Ethical and Religious Directives for Catholic Health Facilities”).

Judicial review as a last resort. Physicians, nurses, social workers, spiritual care staff and other health care providers should work together with families to make decisions for patients who lack decision making capacity. When consensus cannot be reached, the Faith Regional Health Services’ Ethics Committee may be consulted for assistance. Recourse to the courts should be reserved only for those occasions when adjudication is clearly required by state law or when concerned parties have disagreements that cannot be resolved by other means.

Availability of guidelines to patients/families. These guidelines shall be freely available to all patients and their families, employees, medical staff, visitors and community members served by Faith Regional Health Services. Copies of these guidelines may be obtained, upon request, from the Spiritual Care Department, Social Services Department or the office of the Vice President for Mission Effectiveness at Faith Regional Health Services.

Limits of staff responsibility. A patient or family member may not force a physician, nurse or other health care provider to provide or forego any treatment which, in the clinical and/or moral judgment of that health care provider is inappropriate. Faith Regional Health Services recognizes and supports the right of individual physicians, nurses or other employees of the hospital to decline to participate in the initiation or withdrawal of life support systems or other patient treatments (refer to Matters of Conscience Policy). In exercising this right, however, the physician, nurse or other employee may not jeopardize the patient’s care nor impose personal beliefs on a patient or family member, in these cases, health care providers must take appropriate steps to transfer the care of the patient to another qualified individual and do this with appropriate professional discretion.

Guidelines
When the patient has decision making capacity:
Patient self-determination. It is the ethical and legal right of each patient who possesses the capacity to make decisions regarding his or her health care to do so. It is also the ethical and legal right of each patient to be provided with sufficient and clearly understandable information about the diagnostic and therapeutic options (including risks, benefits, nature and purpose of those options) which are reasonably available. This decision making process should happen in the context of a collaborative discussion with competent health care professionals.

Patients’ right to privacy. Patients should be encouraged to discuss foregoing life sustaining treatment with family members, friends, clergy and their physician, as appropriate. A patient’s right to privacy, however, requires that respect must be given to his or her wishes not to include family members in decision making or not to divulge to family members a decision to forego life sustaining treatment. In such situations, the patient’s wishes must be documented in the medical record.

Provision for adequate information. There is a strong presumption that all information needed to make an appropriate decision about health care treatment will be provided to the decision maker.

Information may not be withheld from a patient or surrogate decision maker because of the belief that its disclosure would upset the patient or decision maker. Only if, in the exercise of professional judgement, the physician believes that disclosure would lead to an

immediate and serious threat to the patient’s or surrogate decision maker’s health or life, may information be withheld from a patient or surrogate decision maker.

Information may also be withheld from a decision maker who clearly makes known that he or she does not wish to have the information in question, as long as the decision maker has previously been informed of his or her right to have such information.

When disclosure of information is purposely limited, the reasons for the limited disclosure must be documented in the medical record.

Determination of medical decision making capacity. Patients should be considered, in the first instance, to posses the capacity to make health care decisions. A patient’s authority to make his or her own decisions may be overridden only after a clear demonstration of lack of capacity. (Normally, the formal assessment of capacity will be a process that is performed and documented by the attending physician. A psychiatric consultation may be indicated if psychological factors are thought to be compromising capacity. The consultation is not required, however, if the attending physician is able to assess capacity without it.)

Refusal of specific treatment to which most patients would agree does not mean that the patient lacks decision making capacity. However, this may be viewed as cause to initiate an inquiry into the matter of such capacity.

Decision making incapacity can be a transient condition and may need to be reassessed from time to time.

Resolution of decision-making problems. When all efforts to resolve uncertainties or disagreements in the decision making process are unsuccessful, the Faith Regional Health Services Ethics Committee may be used for consultation. The attending physician, any members of the health care team, patient, surrogate decision maker or any family member may request such a consultation. Requests from patients or family members must be channeled through their physician, a nurse supervisor, social services staff member, or a spiritual care team member, to the chairperson of the Ethics Committee.

The Ethics Committee provides a forum for dialogue and information to clarify issues in complex situations so that decision making, by those with the responsibility to do so, can be facilitated.

When the patient lacks decision making capacity and has written an advance directive: Individuals may prepare a Living Will, Durable Power of Attorney for Health Care or other written documents and signed documents regarding health care instruction while competent. If such documents are available and reliable, they should be given due consideration in determining the wishes of the patient concerning his/her medical treatment.

In cases where there is intense conflict between the written advance directive and the wishes of the patient’s surrogate decision maker or when there is substantial doubt as to the authenticity of the advance directive, consultation with the Ethics Committee Judicial Review should be sought.

When the patient lacks decision making capacity and is without an advance directive:
When family members are available. When an adult patient lacks the capacity to make treatment decisions and has not executed an advance directive, surrogate decisions makers must assume decision making responsibility.

Ordinarily, the surrogate decision makers will be the closest family members: spouse, adult children, parents, and adult siblings. However, in some circumstances the surrogate decision maker may not be a family member even though family members are available. No one family member or surrogate alone has legal authority for decision making without clear legal designation (i.e., legal guardianship).

The family as a whole, may legally make decisions and provide “substituted judgement” for a patient if they are in full and unanimous agreement.

In cases where on-going discussion with all family members is not possible, the physician may request the relatives to designate a family spokesperson. Physicians may request that the family spokesperson countersign the patient chart where the family’s wishes are recorded. However, the physician’s description in the medical record of discussion with the family and their concurrence with treatment decisions is considered adequate documentation.

When family members have differing opinions which cannot be resolved through discussion with the attending physician, spiritual care, social services, and/or Ethics Committee should be requested for consultation. Decisions by family members must be reached by a consensus.

The standard for surrogate decision making. Surrogate decision makers function under the legal doctrine of “Substituted Judgement” and must seek to choose as the patient would if he or she were able. Because the strength of the evidence of the patient’s preferences will vary, the decision makers should apply one of the following standards:

Follow the patient’s explicit directives; or when not known,

Apply the patient’s known preferences, values and past behaviors; or when not known,

Choose as a reasonable person in the patient’s circumstances would.

When family members are not available. If the patient has no immediate family available, then other relatives or close friends who know the patient’s wishes, personality or values may be used to assist the physician in assessing treatment options. In these situations, however, neither the friends, distant relatives nor physician can function as legal decision makers, and legal counsel or a judicial appointment of a surrogate decision maker (i.e., legal guardian) should be sought.

Designating the physician as decision maker. In Nebraska the attending physician or any health care providers involved in the patient’s health care may not serve as the patient’s surrogate decision maker.

Serious conflict or uncertainty. Whenever a physician is uncomfortable for any reason with the decision making process, or whenever serious conflict in the decision making process cannot be resolved, a consultation with spiritual care, social services, the administrator on call or Ethics Committee should be requested. When such consultation does not result in resolution or when there is not an appropriate decision maker available, legal counsel or a judicial appointment for a decision maker should be sought.

Children and infants. Generally, parents or legal guardians will function as decision makers for children and infants. Many children, however, are capable of participating in the decision making process, even though they are unable to give legal consent, and they should be involved as much as possible.

If the parents or other surrogates make a treatment choice contrary to the child’s expressed preference, every effort should be made to resolve the disagreement. For this purpose, spiritual care, social services, the Ethics Committee and judicial review should be used as is deemed appropriate and necessary.

Whenever a physician has misgivings about the moral or legal appropriateness of the parent’s decision, the physician should consult with the hospital Ethics Committee.

Supportive Care
For patients choosing to forego life sustaining treatment, supportive care plans are to be developed. Active support will be provided for the psychological, social, emotional and spiritual needs of the individual and family. When “supportive care only” has been agree upon, the following factors will usually be considered and discussed:

Fluids, intravenous therapies

Nutrition and Hydration

Symptom and/or pain management

Invasive diagnostic and therapeutic procedures

Documentation of Decisions
When it has been determined that a particular treatment is to be limited, terminated or withheld an order must be written into the patient’s medical record by the attending physician or a physician designate.Once the order has been entered into the medical record, it is the responsibility of the physician who has written the order to insure that the order and its meaning are discussed with appropriate members of the hospital staff so that all involved professionals understand the order and its implications.

At the time an order to limit life sustaining treatment is written, a companion entry should be made in the progress notes, which includes, at a minimum, the following information:

An account of the patient’s diagnosis and prognosis;

Written statement of the patient’s competency or lack of competency;

Description of the specific discussion with the competent patient and the patient’s concurrence with the treatment decision (s); or, when the patient is incompetent, a description of the discussion with the family or legal guardian and their concurrence with treatment decision (s).

Organ Donation
When a person has indicated a desire to be an organ donor, or when family members or the patient’s legal guardian have made the patient’s wishes known, discussion and clarification of organ donation issues should be initiated at the time decisions to limit, discontinue or withhold treatments are made.

When a patient has been determined to be brain dead*, the decision to terminate all life-sustaining treatment may be made by the physician, after consultation with the family members and the Nebraska Organ Retrieval System about organ donation.

* NOTE: The Nebraska Organ Retrieval System defines brain death as the total and irreversible cessation of all brain functions, including brain stem activity.

Conflict Resolution
In difficult cases or when conflicts arise or appropriate action is unclear, any of the following may be contacted for consultation or assistance

Social Services DepartmentSpiritual Care DepartmentMedical Staff Department ChairpersonChief of Staff

Hospital Ethics Committee

Legal Services (NOTE: Legal counsel may only be contacted by hospital administration or their designee)

Euthanasia Prohibited
Nothing in this policy shall be construed to condone, authorize, or approve mercy killing or euthanasia, or to permit any affirmative or deliberate act or omission to end life other than to permit the natural process of dying.

Definitions
Advance Directive. An Advance Directive is a declaration that is written and signed by a competent adult, in accordance with the law. Advance Directives include Living Wills and Durable Power of Attorney for Health Care documents in which patient choices for health care decisions are outlined.

Death. For the purposes of these guidelines, the term “death” is defined as the permanent cessation of functioning of the physical human organism.

Decision-making Capacity. Decision-making capacity is the ability of an individual to understand the ramifications of a decision that must be made, consider the benefits and burdens of various choices, and communicate his or her choices to others either verbally or non-verbally. In general, patients with decision-making capacity are regarded as capable of providing informed consent to medical treatment.

Euthanasia. An act or omission, which, of itself, or by intention, causes death.

Family Member. For the purposes of these guidelines, the term “family member” refers to any individual who is directly related, by blood or legal documentation, to the patient or who is considered by the patient to have a close or intimate personal relationship with the patient.

Forego. For the purposes of these guidelines, the term “forego” is used to include both stopping treatment already begun as well as not starting a treatment.

Health Care Provider. A Health Care Provider is a physician, nurse or any other trained medical professional who is directly involved in the care and treatment of a patient.

Human Being/Human Person. For the purposes of these guidelines, the terms “human being” and “human person” refer to the entire, living individual – body, mind and spirit.

Life-Sustaining Treatment. Life-Sustaining Treatment is any procedure or intervention that is judged likely to be effective in prolonging a patient’s life or that is being used to sustain a patient’s life.

Supportive Care. Supportive Care is care and treatment provided to an individual to preserve comfort, hygiene and dignity, but not to prolong life.

Surrogate Decision Maker. A Surrogate Decision Maker is any competent adult, 19 years or older, appointed by the patient through the Durable Power of Attorney for Health Care to make health care decisions for a patient when he/she is unable to do so. The powers of the surrogate decision-maker may be as broad or as narrow as provided by the patient or allowed by law. This may include the right to be informed, consent to refuse or withdraw any type of medical treatment. The surrogate may not be the patient’s physician or any health care providers involved in the patient’s health care.

Treatment. For the purposes of these guidelines, the term “treatment” is defined as the management and care of a patient for the purpose of combating a physical or mental disease or disorder.

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