THE PATIENT WAS DYING and the family was in conflict. The patient’s wife wanted an end to his suffering and to make him DNR “Do Not Resuscitate.” His daughter disagreed, holding out hope for a miracle. His mother wanted the doctor to be even more aggressive in looking for other intensive potentially life-saving treatment. The physicians and nurses were frustrated. The patient had no advance directive to guide his care. Finally, one of the residents suggested calling for an ethics consult.
Clinical Bioethics: Bringing Resolution
to Conflict in Patient Care
Center for Bioethics Marks Five Years at CUMC
BY RUTH L. FISCHBACH, PH.D., M.P.E., PROFESSOR OF BIOETHICS AND DIRECTOR OF THE CENTER FOR BIOETHICS
Kenneth Prager, M.D., chair of the New York-Presbyterian Hospital Ethics Committee, was soon on the scene. With everyone in the room, Dr. Prager, using expertise honed by years of experience and deep compassion, asked the right questions to elicit what the patient would have wanted if he could make his preferences known. At the end of the consultation, everyone’s opinion had been heard. All seemed to accept the consensus that aggressive care would only prolong the dying process and that comfort care and a DNR order were what the patient would have wanted. What was especially important was that the family felt at peace with the decision.
Conflict situations like this take place all too frequently. Dr. Prager, who conducts almost all ethics consults himself, estimates at least 20 cases per month. His detailed notebooks contain more than 1,500 descriptions of often exquisitely complex cases. He has observed that hospital residents are increasingly unprepared to resolve these situations. High volume and rapid turnover in patient load, limited time to get to know patients and their families and to observe senior physicians, and increasing reliance on powerful instruments of medical technology leave inexperienced physicians with a need for guidance in dealing with terminally ill patients. “We need more education and training in end-of-life care to provide physicians with the necessary skills and resources to care for these patients with competence, confidence, and compassion,” Dr. Prager says. It is in this need that the Center for Bioethics has an increasingly important role to play.
Established in 2002, Columbia’s Center for Bioethics has raised the stature of clinical bioethics in the schools of Columbia University Medical Center and in NYPH. With a mission to provide education, promote research, and offer service, the center has made end-of-life education a central focus of activity. Dr. Prager and John Lorenz, M.D., chair of the Children’s Hospital of New York Ethics Committee, are integral to the center’s successful Gold Foundation Ethics for Lunch case-based discussions promoting humanistic end-of-life care.
I serve on Dr. Prager’s Ethics Committee, and Dr. Prager is a faculty member in my bioethics course offered to fourth-year P&S students. Together we are designing a unique clinical bioethics fellowship that will prepare future leaders in both clinical consultation and empirical bioethics research. The center will present a symposium on Jewish medical ethics at the end of life featuring Dr. Prager and notable religious leaders who will show how modern technology can inform religious theology and vice versa. In addition, the center promotes palliative care and education in advance directives through workshops, course development, publications, and the center’s Web site, www.bioethicscolumbia.org.
Clinical bioethics is a vital component of medical education. The Center for Bioethics helps to fill a gap in the medical and residency curricula. Even so, we need to provide more opportunities to discuss troubling cases, end-of-life procedures (such as requesting donor organs), and how to provide comfort at the end of life for pediatric and adult patients and their families. Defining those needs and identifying ways to meet them are at the core of the Center for Bioethics.
For more information about the Center for Bioethics, contact Ruth Fischbach at firstname.lastname@example.org
or 212-305-8387. Kenneth Prager can be reached at email@example.com or 212-305-5535.