title: The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients.
abstract: Despite increased calls for hospital ethics committees to serve as default decision-makers about life-sustaining treatment (LST) for unrepresented patients who lack decision-making capacity or a surrogate decision-maker and whose wishes regarding medical care are not known, little is known about how committees currently function in these cases. This was a retrospective cohort study of all ethics committee consultations involving decision-making about LST for unrepresented patients at a large academic hospital from 2007 to 2013. There were 310 ethics committee consultations, twenty-five (8.1 per cent) of which involved unrepresented patients. In thirteen (52.0 per cent) cases, the ethics consultants evaluated a possible substitute decision-maker identified by social workers and/or case managers. In the remaining cases, the ethics consultants worked with the medical team to contact previous healthcare professionals to provide substituted judgement, found prior advance care planning documents, or identified the patient's best interest as the decision-making standard. In the majority of cases, the final decision was to limit or withdraw LST (72 per cent) or to change code status to Do Not Resuscitate/Do Not Intubate (12 per cent). Substitute decision-makers who had been evaluated through the ethics consultation process and who made the final decision alone were more likely to continue LST than cases in which physicians made the final decision (50 per cent vs 6.3 per cent, p = 0.04). In our centre, the primary role of ethics consultants in decision-making for unrepresented patients is to identify appropriate decision-making standards. In the absence of other data suggesting that ethics committees, as currently constituted, are ready to serve as substitute decision-makers for unrepresented patients, caution is necessary before designating these committees as default decision-makers.
authors.affiliation: Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA. acourtwright@partners.org.|Division of Pulmonary and Critical Care, Center for Chest Disease, Brigham and Women's Hospital, 15 Francis Street, Boston, MA, 02115, USA. acourtwright@partners.org.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Courtwright
authors.affiliation: Office of General Counsel, Partners HealthCare, Boston, MA, USA.
authors.forename: Joshua
authors.initials: J
authors.lastname: Abrams
authors.affiliation: Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA, USA.|Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Robinson
mesh_terms: D016223:Advance Directives; D000368:Aged; D003657:Decision Making; D026822:Ethicists; D017041:Ethics Committees; D033061:Ethics Consultation; D005260:Female; D006282:Health Personnel; D006801:Humans; D007600:Judgment; D008020:Life Support Care; D008297:Male; D016743:Mental Competency; D008875:Middle Aged; D019727:Proxy; D012189:Retrospective Studies; D013727:Terminal Care
keywords: Best interests; Decision-making; Ethics committees; Ethics consultation; Surrogates; Unrepresented