MMHA 6300 Week 9 Ethics Committee Review Example

Who Can Ask for Help? A Review of the Ethics Committee and End-of-Life Policies at Halvorsen University Medical Center

Student Name

Walden University

MMHA 6300: Law and Ethics in Healthcare

Instructor Name

Month Day, Year

Who Can Ask for Help? A Review of the Ethics Committee and End-of-Life Policies at Halvorsen University Medical Center

Summary of Findings

This review examined the ethics committee of Halvorsen University Medical Center, a fictional 480-bed teaching hospital, using its charter, membership roster, two years of summarized minutes and two policies: advance directives and do-not-resuscitate orders. It reached four findings. Membership is weighted heavily toward physicians. Only attending physicians may request a consultation. The advance directive process at admission does not reliably give patients the information federal law requires. The do-not-resuscitate policy offers no path when surrogates and clinicians disagree. Each finding is explained below with its legal basis and ethical cost, followed by recommendations.

How the Committee Works Now

The committee has 14 members: nine physicians, three nurses, one hospital attorney and one administrator. Its charter assigns three functions: education, policy review and case consultation. Consultations are performed by a rotating pair of physician members, who meet with the requesting attending, review the chart and write a note with recommendations. Over the past two years the minutes record 19 consultations, nearly all from three services: medical intensive care, oncology and neurology. The committee meets monthly and reviews each consultation at the next meeting.

This structure is common. A national survey found that most U.S. general hospitals had an ethics consultation service, that many services handled only a small number of cases each year and that most consultants had learned the work through direct experience rather than formal training (Fox et al., 2007). Halvorsen's committee is typical in that respect, and its members are committed. The findings below concern design, not effort.

Finding 1: Membership Leans Toward Physicians

Nine of 14 members are physicians, and the committee has no social worker, chaplain or community member. Professional guidance on ethics consultation stresses that consultants need knowledge of the institution's patient population and the ability to elicit and represent the values of patients and families, and it recommends that consultation services draw on a range of disciplines (American Society for Bioethics and Humanities, 2011). The Joint Commission expects hospitals to have a process for addressing ethical issues in care, but leaves the design to the hospital (Joint Commission, 2024).

The ethical cost is that the committee hears the physician's account of a conflict more easily than the family's. In a hospital serving many patients whose religious or cultural commitments shape end-of-life choices, the absence of a chaplain and a community member is a gap in competence, not only in appearance.

Finding 2: Only Attending Physicians May Request a Consult

The charter limits consultation requests to attending physicians. Nurses, residents, patients and families must ask an attending to make the request. The minutes show three occasions on which a nurse manager raised a concern at a committee meeting about a case in which no request was made.

No federal law requires open access to an ethics committee, but the limit runs against the reasons such committees exist. Ethical conflicts often arise between the attending and someone else: a family that disagrees with the plan, or a nurse who believes a patient is being treated against her wishes. When the person with the concern must ask the physician on the other side of it for permission to be heard, many will not ask. Respect for patients' autonomy and fairness to clinicians both point toward allowing anyone involved in a patient's care, and the patient or family, to request a consultation directly (Beauchamp & Childress, 2019).

Finding 3: The Advance Directive Question Is a Checkbox

The Patient Self-Determination Act ties several duties to Halvorsen's Medicare agreement. Every adult admitted must receive, in writing, an explanation of what state law lets patients decide about their own care, such as refusing a treatment or naming a decision maker in advance, together with the hospital's policies on carrying out those choices. The chart must show whether an advance directive exists; care may never depend on having one; and the hospital must teach its staff and its community about these rights (42 U.S.C. § 1395cc). The Medicare regulations add a practical rule for patients who arrive unable to understand the notice: a surrogate may receive it, and the hospital must give it to the patient later if the patient recovers enough to take it in (42 C.F.R. § 489.102).

At Halvorsen, registration staff ask, "Do you have an advance directive?" and check yes or no. A brochure is available on request. A sample of 30 admissions from one month showed that 26 records had the box checked, but only 4 noted that written information was provided, and none of the patients admitted while incapacitated had a documented follow-up. The process captures an answer but does not give patients the information the statute requires, and staff education on advance directives was last offered three years ago.

The ethical cost is that patients who might want to name a surrogate or record their wishes never learn that they can, and the question resurfaces later, in an intensive care unit, when the patient can no longer answer it.

Finding 4: The DNR Policy Is Silent on Disagreement

The do-not-resuscitate policy describes how an order is written, documented and reviewed, but it says nothing about what happens when a surrogate insists on resuscitation that the attending believes will not benefit the patient, or when two surrogates disagree. Five of the 19 consultations in the minutes involved such disagreements, and in each the outcome depended on the individual attending. Some states provide a statutory process for these conflicts, and many hospitals adopt a policy that sets out steps: further conversation, a second opinion, an ethics consultation, an offer of transfer and a time frame. Halvorsen has none. The ethical cost falls on families, who experience inconsistent treatment, and on nurses, who are asked to carry out interventions they believe are harmful without any process for raising that concern.

Recommendations

1. Add a social worker, a chaplain and two community members to the committee, and set a goal that physicians make up no more than half of its membership (Finding 1).

2. Revise the charter so that any member of the care team, any patient and any family member or surrogate can request a consultation directly, with a phone line and a page in the patient handbook (Finding 2).

3. Replace the advance directive checkbox with a short script and a written notice given at admission, documented in the record, with a follow-up task when the patient is incapacitated at admission; resume annual staff education (Finding 3).

4. Write a disagreement section for the DNR policy that sets out the steps and time frames for resolving conflicts, consistent with state law, and train attending physicians on it (Finding 4).

5. Ask the committee to report to the medical executive committee twice a year on the number, source and outcome of consultations, so that changes in access can be measured.

References

Agreements with providers of services; enrollment processes, 42 U.S.C. § 1395cc (2023).

American Society for Bioethics and Humanities. (2011). Core competencies for healthcare ethics consultation (2nd ed.). American Society for Bioethics and Humanities.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Fox, E., Myers, S., & Pearlman, R. A. (2007). Ethics consultation in United States hospitals: A national survey. American Journal of Bioethics, 7(2), 13-25. https://doi.org/10.1080/15265160601109085

Joint Commission. (2024). Comprehensive accreditation manual for hospitals. Joint Commission Resources.

Requirements for providers, 42 C.F.R. § 489.102 (2024).