HOSPITAL ETHICS COMMITTEES CRITICAL IN RESOLVING PATIENT CARE BASED CONFLICTS
By Dr John Weru, Consultant Palliative Physician and Chair, Hospital Ethics Committee, Aga Khan University Hospital
Modern medical knowledge coupled with the diversity of lifestyles and broad moral and religious values in modern societies has made medical involvement and decision-making processes associated with healthcare more complicated. The economic pressure being experienced by healthcare systems requiring proper well thought out the allocation of meagre resources demands that decisions are made in a well-informed manner.
Implications of any decision made in medicine have been raised through public political and medico-legal discussions about patient independence and autonomy to make self-determining decisions. Though this is being strongly professed and gaining great momentum, our social, cultural and religious norms cannot be ignored in decisions making. To house all these factors, Hospital Ethics Committees are a crucial modern healthcare component.
A Hospital Ethics Committee is a multidisciplinary team set in a hospital that helps patients, families and clinicians to address value disagreement or uncertainty that may arise during health care provision.
The committees are comprised of clinicians, non-clinicians who deal with patients such as counsellors, non-clinicians from other professions and community representatives. It is recommended that such members have basic training in medical ethics. These committees are important in advising and guiding on the best way forward when there is no consensus among all those concerned in a patient’s care, the committee considers the various factors that play a role in the provision of care as well as all the stakeholders in the same.
The HEC is not a decision-making body. Decision-making authority rests with the patient, family and caregivers. The primary responsibility of HECs is thus to facilitate proper understanding of the situation in question peace the pieces together and thus come up with the best way in a given situation. Situations, where there are disagreements on the way forward, can be referred to as ethical dilemmas.
An ethical dilemma occurs when a choice may need to be made that requires choosing between alternatives none of which is absolutely right or wrong. Mostly, conflicts arise based on differences in values, problems in communication, or due to the severe stress of critical illness. An ethics consultation can be helpful in these situations.
Ethical dilemmas may be experienced by patients, family and healthcare providers in situations such as; admission to critical care areas like High Dependency Unit, Intensive Care Unit with the attending clinician, End of Life Care decisions- what treatment to give at this stage, beginning of life decisions, maintenance of confidentiality and privacy, informed consent in healthcare interventions/ examination, family and/or caregiver’s role in medical decision making- who makes decision when a patient is not in a capacity to do so, refusal of recommended treatment, organ donation among other cases
There are various roles that hospital ethics committees can do to solve conflicting interests including; mediate the discussion of differences of opinion among family members about treatment, support a patient or family member in making decisions about what type of care the patient should receive or the goals of that care, facilitate ethical decision-making by physicians and the healthcare team.
The committee can also educate patients, families, and staff on hospital policies affecting patient care, such as resuscitation or life-saving treatments, work with patients, families, and staff to help include personal values, religious, and cultural traditions in decision-making as well as address questions about a patient or Next of Kin’s ability to make decisions about treatment.
The HEC can be consulted by the patient, family member(s), and patient’s caregiver, a community member who is a stakeholder in the patient’s care and well-being, any member of the treating team including the doctors, nurses and allied health care providers. The hospital administration can also consult the HEC.
The Aga Khan University Hospital, for example, has had an ethics committee since 2012, the HEC comprises of members who are available for assistance 24/7. In situations such as outlined above, the patient, family members or a healthcare professional can consult the Hospital Ethics Committee. The HEC is available 24/7 to provide consultations in such situations. On top of ethical consultations, the committee assists the hospital in developing policies and practices that conform to the highest ethical standards and offers ethical education to staff and the community.
In institutions where such a committee is not available, an individual with some knowledge on medical ethics can be consulted for guidance. If no such a member is available, the institution can form a team that can guide on such issues. The biggest challenge in establishing these crucial components of quality healthcare is the paucity of education in medical ethics coupled with lack of proper national, institutional infrastructure, policies and guidelines on establishing the same.
Currently, Aga Khan University Hospital is helping other hospitals to establish similar hospital Ethics Committees to help resolve conflicts arising in the process of care for patients.
Hospital ethics committees (HECs) help clinicians deal with the ethical challenges which have been raised during clinical practice. A comprehensive literature review was conducted to provide a historical background of the development of HECs internationally and describe their functions and practical challenges of their day to day work. This is the first part of a comprehensive literature review conducted between February 2014 and August 2016 by searching through scientific databases. The keyword ethics committee, combined with hospital, clinic, and institution, was used without a time limitation. All original and discussion articles, as well as other scientific documents, were included.
Of all the articles and theses found using these keywords, only 56 were consistent with the objectives of the study. Based on the review goals, the findings were divided into three main categories; the inception of HECs in the world, the function of HECs, and the challenges of HECs. According to the results, the Americas Region and European Region countries have been the most prominent considering the establishment of HECs. However, the majority of the Eastern Mediterranean Region and South-East Asia Region countries are only beginning to establish these committees in their hospitals. The results highlight the status and functions of HECs in different countries and may be used as a guide by health policymakers and managers who are at the inception of establishing these committees in their hospitals.
Key Words: Clinical ethics, Ethics committee, Ethics consultation