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Ethics committees in nursing homes: applying the hospital experience.

Ethics Committees in Nursing Homes: Applying the Hospital Experience

The need to develop effective methods for addressing ethical issues in clinical care is even greater in nursing homes than acute care hospitals. Institutionalization in itself raises a basic concern about the privacy and self-determination of long-term care patients. This is heightened by the fact that although 50-70 percent of these residents suffer some impairment of their decisional capacity, many lack legal guardians or involved family members to serve as surrogate decisionmakers. [1] Lack of clarity about the role of aggressive treatment, the comparative frequency with which decisions about the use of potentially life-sustaining treatment must be made, and the minimal presence of physicians in daily care in nursing homes increase the need to create institutional means to respond to the ethical dimensions of patient care in these facilities.

Ethics committees, although still rare, are being formed with growing frequency in nursing homes. [2] Discussion of the role and composition of these committees in the literature is based largely on experience in the acute care setting. Ethics committees in hospitals recommend institutional policies, educate participants in the decisionmaking process, consult about ethical dilemmas in individual cases, and provide emotional support for professionals who confront ethical dilemmas in patient care. While both hospitals and long-term care facilities benefit from the policy development function of ethics committees, the relative importance of the remaining functions of ethics committees differs for each. The unique ethical issues that arise in long-term care suggest that a cautious approach should be taken to applying the lessons of the hospital experience to the nursing home when developing ethics committees.

There should be a more limited need for ethics committees to review individual cases in nursing homes, since the trajectories of illness there tend to follow a more predictable course and can be more readily foreseen and planned for by residents and staff. Efforts to identify patient preferences can be initiated on admission or in the early months of placement before a crisis erupts. When patients are cognitively impaired at the time of placement, appropriate policies for identifying surrogate decisionmakers can also minimize the need for crisis-based committee review.

The high rate of staff turnover in long-term care facilities, in contrast with the greater stability of primary caregivers in the acute care setting, dictates the need for continual emphasis on education in clinical ethics in nursing homes. The educational role of ethics committees, consequently, seems even more important in nursing homes than in hospitals.

The function of providing emotional support to professionals also takes on greater significance in the nursing home context. The close relationships that can develop between nursing staff and patients make the emotional impact of ethical conflict even greater in this setting. Further, the frequency with which questions about life-extending care are faced by nursing staff, and the greater involvement of staff in the reactions of families to difficult decisions, make the need to provide emotional support especially pressing in long-term care.

The composition of ethics committees in nursing homes should also be somewhat different from that in hospitals. The former should have a substantial number of nursing staff, as well as patients or their representatives. The need for greater nursing representation on committees in long-term care facilities stems from three factors: (1) the more central role of nursing staff in directing patient care; (2) the greater knowledge nurses develop about patients, especially about the values and treatment preferences expressed earlier by patients who have become cognitively impaired; and (3) the greater burden of responsibility nursing staff often bear in meeting facility policies about end-of-life care decisions. The data suggest that nursing homes realize that input from nurses is central to case review by ethics committees, for a greater proportion of them have nursing representatives than do committees in hospitals. [3]

Further, the relationship between patient and institution is so fundamentally different in nursing homes from hospitals that the need for patient representation on ethics committees in the former is even greater. Most older patients who enter nursing homes spend the remainder of their lives there. Rarely do they have options for care, which creates a dependency of a different sort from that characteristic of acute care patients. They often have no close family to represent them effectively and may be unable to represent themselves due to cognitive impairment. These features of nursing home placement raise serious questions about patient autonomy, privacy, and voluntariness that suggest that need for greater efforts to protect the rights of nursing home residents.

One direct mechanism to correct the balance of professional dominance is to ensure that one or more mentally capable residents are present at committee meetings. This raises major problems of confidentiality, however. Since a nursing home is a community, and most residents stay for extended periods of time, it is inevitable that a patient committee member would know those who are the subject of discussion. Training in how to deal with personal information about their fellow residents appears a prerequisit for admitting patients to membership on committees in these facilities. Alternatively, greater representation by patient advocates, such as family members or ombudsmen, might serve to promote patients' rights while protecting their privacy.

The single most obvious factors that promises to allow ethics committees to flourish and make a real contribution to the quality of care in nursing homes is time. Patient preferences, attitudes of involved staff, and the relevant ethical and legal literature can be explored in greater depth than is possible in an acute care situation when an immediate recommendation must be made.

The increasing number of older people in our society, of whom a considerable proportion will need long-term care, speaks to the need to develop functioning ethics committees in nursing homes. Recent cost containment strategies, which are resulting in the transfer of larger numbers of sicker patients to nursing homes from hospitals, underscore the probability that ethical issues will arise with greater frequency in long-term care facilities in the future. Yet it is not only a matter of numbers. The intensity of ethical dilemmas will increase in nursing homes as the reality of long-term disability increasingly confronts the growing powers of modern medicine to extend life. This will create qualitatively more difficult ethical questions whose resolution will benefit from the assistance of ethics committees.

References

[1] J.C. Beck et al., "Dementia in the Elderly: The Silent Epidemic," Annals of Internal Medicine 97 (1982), 231-41.

[2] B.A. Brown, Steven H. Miles, and Mila A. Aroskar, "The Prevalence and Design of Ethics Committees in Nursing Homes," Journal of the American Geriatrics Society 35 (1987), 1028-33; G.G. Glasser, Nancy R. Zweibel, and Christine K. Cassel, "The Ethics Committee in the Nursing Home: Results of a National Survey," Journal of the American Geriatrics Society 36 (1988), 150-56.

[3] Stuart J. Youngner et al., "A National Survey of Ethics Committees," Critical Care Medicine 11 (1983), 902-05; Glasser, Zweibel, and Cassel, "The Ethics Committee in the Nursing Home."

Nancy R. Zweibel is director of research in Geriatrics and Christine K. Cassel is chief of the Section of General Internal Medicine at The University of Chicago Medical Center.
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Author:Zweibel, Nancy R.; Cassel, Christine K.
Publication:The Hastings Center Report
Date:Aug 1, 1988
Words:1189
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