A woman with advanced cancer refuses antibiotics for an infection. Family members request that their terminally ill relative receive treatment that is not in his best interest. A patient has no hope of survival, but the family member designated to make care decisions cannot bring himself to authorize a do-not-resuscitate (DNR) order.
Memorial Sloan-Kettering medical staff, patients, and families are faced with difficult situations like these virtually every week. Fortunately, they can seek immediate guidance from the Memorial Sloan-Kettering Cancer Center Ethics Committee, a team of experts who represent all aspects of patient care. The 24-member committee reports directly to the Medical Board and provides a forum for analyzing, discussing, and resolving thorny ethical issues that arise.
The Ethics Committee has existed for more than a decade. In 2006 Robert E. Wittes, Physician-in-Chief of Memorial Hospital, asked it to take on a more activist role. "I wanted the committee to become an even more valuable resource for our staff, our patients, and their families," Dr. Wittes said. "An education program and an active, on-call consult service were two clear institutional needs."
The Ethics Consult Service, made up of seven Ethics Committee members with expertise in bioethics, has greatly increased the committee's activity and visibility. At any time of day, a staff member, patient, or family member can dial a number listed on the Memorial Sloan-Kettering Web site and request a consultation.
The committee also holds regular monthly meetings and has implemented an education program in bioethics for its members. In addition, the committee works with departmental staff to develop case presentations about common ethical issues arising at Memorial Sloan-Kettering.
Mary S. McCabe, Chair of the Ethics Committee, said that the committee is multi-disciplinary with a membership that represents all areas of the hospital in which staff interact with patients and their families. "Although end-of-life issues are the most common ones that the committee is asked to address, there is a range of difficult decisions that can come up," she said. "We certainly want to assist in resolving these problems and conflicts, but our long-range goal is to offer education programs that will reduce these situations in the future."
The committee may be called upon to offer guidance or support when there is disagreement among medical staff -- or between staff and patients or family members -- about how to proceed with a patient's care. Members of the Ethics Committee will meet with those involved and try to frame the discussion around the best interests of the patient. For example, family members may disagree with the clinical staff about a DNR order. "What we try to do is get everyone involved to step back and focus on: What are the goals of care for this patient at the end of life?" Ms. McCabe said. "Once people can agree on that, the problem can often be resolved."
Committee member Nessa Coyle, a nurse practitioner on the Pain and Palliative Care Service, said, "Our role is to try, in a systematic way, to help the staff, the patient, and the family sort out the issues so they are able to arrive at the best possible solution for a particular individual in a particular set of circumstances."
Nina D. Raoof, a critical care physician, said the committee has been helpful to her in a wide range of areas. "The Ethics Committee team has very skilled people who are good at teasing out the implications of the issues at hand," she said. "In addition, I think family members who have questions or concerns are sometimes more open with people who are not directly part of the medical-care-giving team."
Ms. McCabe said that since Dr. Wittes directed that the Ethics Committee take on an enhanced and more visible role in the institution, consultations have increased dramatically -- from four in 2006 to 44 in 2007. "This gives us a sense that clinicians do want help with these difficult decisions," she said.
