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A focus on ethics

The MGH Life-Sustaining Treatment policy has been recently revised to expand on the principles and procedures to be followed when the appropriateness of life-sustaining treatment must be considered. The policy addresses the spectrum of treatment decisions and procedures for hospitalized and ambulatory patients. It includes information on the Massachusetts DPH Comfort Care/DNR Order Verification and the Medical Orders for Life-Sustaining Treatment (MOLST) forms.

Click here to connect to the MGH Life-Sustaining Treatment
(internal access only)


Unit-based ethics rounds are an opportunity for clinicians of all disciplines in an patient care area to come together and freely discuss cases or topics of ethics concern. Clinicians from other areas are welcome to attend as guests but are asked to first contact the ethics rounds facilitator.
Click here to view a list of Unit-Based Ethics Rounds (internal access only)
CURRENT TOPICS IN ETHICS

Palliative Care and Hospice Care
Palliative care is an approach to patient care, not reserved exclusively for end of life, which focuses on optimizing physical, emotional, and psychological care and comfort by effectively managing symptoms associated with progressive disease.   Hospice Care also provides palliative care that primarily focuses on optimizing care and comfort at the end of life.  Both employ an interdisciplinary team of physicians, nurses, social workers, chaplains, pharmacists, psychologists and other health care workers to relieve suffering related to disease as much as possible in all areas of a patient’s life.


Bedside Manner: Conversations With Patients About Death
National Public Radio (May 6, 2013)

“This is TALK OF THE NATION. I'm Neal Conan, in Washington. All of us prefer to be told the truth - at least, we say we do - even when the diagnosis is terminal. And doctors believe they have an obligation to deliver bad news except that often, they don't. In a survey of nearly 2,000 physicians by the Mongan Institute for Health Policy at Massachusetts General Hospital, a majority said they believe they should never lie to a patient and yet more than half delivered a rosier prognosis than warranted, and 10 percent outright lied.

Telling somebody they're about to die isn't easy, of course, and it's no easier having what's sometimes called "the conversation" with their loved ones. Doctors, is there one of these conversations that's stayed with you? Tell us about a talk that helped shape how you talk with your patients and their families about death.”

Click here to read the full transcript


Goals of care at the end of life.
Proc (Bayl Univ Med Cent). Apr 2001; 14(2): 134–137. Marvin J. Stone, MD

All people have goals and hopes and enjoy having control over their lives. Over time, each person develops a very personal sense of what brings greatest meaning and value and adds most to his or her quality of life. People in the hospital often feel that they are losing control. As their illness progresses, their goals and hopes may change. It is the physician's role to communicate with the patient and family, clarify their goals and priorities, and develop a plan of care based on this information. Regular reassessment of goals and priorities ensures that patient, family, physician, and health care team are working together to maximize the patient's quality of life.

Click here to read full article

ETHICS IN THE NEWS
  • Bioethics and the Dogma of “Brain Death” by Franklin G. Miller and Robert D. Truog (Feb. 3, 2014)
  • Texas court orders brain-dead pregnant woman off life supportLos Angeles Times (1/24/14)
  • MGH Policy on Brain Death (based on Massachusetts State Law)
  • The Hastings Center has released new guidelines for End Of Life Care that are sure to be an interesting read. Click here to view.
  • Medical Orders for Life-Sustaining Treatment (MOLST) supports patient autonomy and the patient’s right to self-determination in identifying his or her treatment preferences based upon individual values and beliefs. A MOLST form is not to be confused with an advance directive: MOLST is not meant to take the place of an advance directive (i.e. Massachusetts Health Care Proxy). It is a medical order versus a legal document (advance directive). However, MOLST establishes a standardized method of communicating and documenting a patient’s preferences for life-sustaining treatments (i.e. CPR, dialysis treatments, having a breathing tube inserted, etc.) and is completed AFTER advance care planning discussions have occurred between the patient and his or her family and health care providers (i.e. physician, nurse practitioner). Once completed, the MOLST form becomes a valid statement of the patient’s preferences for life-sustaining treatment that may be acted upon immediately whether or not the patient possesses capacity when the treatment could be administered. MOLST is appropriate for any patient irrespective of age with a progressively serious medical disease that may include but not be limited to conditions that are life-threatening, a chronic progressive disease including dementia, a life-threatening injury, or medical frailty. Under Massachusetts law, MOLST will be implemented statewide in 2014 and is supported by the Department of Public Health, the Massachusetts Board of Registration in Medicine, and the Massachusetts Boards in Nursing and Physician Assistants.  A patient or the patient’s health care agent (if the patient lacks capacity) may change or cancel the MOLST form anytime. In addition, the patient’s health care provider is responsible for periodically reviewing the contents of the form with the patient to make sure it is consistent with the patient’s wishes over time and documenting this review by signing and dating the “Record of Periodic Review” section located at the bottom of front page of the MOLST form.

    Click here to see the MOLST website for more information.


    Click here to view sample form
Archived items

 

ETHICS RESOURCES @ MGH
FYI

Optimum Care Committee
MGH has an ethics committee to review and consult with staff about ethical issues regarding the care of adult patients at MGH. click here for more information

(internal access only)

End of Life Care

Life Sustaining Treatment

Life Sustaining Treatment:
Resolving Intractable Conflict

Pedi Ethics Committee
MGH has a Pediatric Ethics Committee to review and consult with staff about ethical issues regarding the care of children who are MGH patients.

MGHfC Pediatric Ethics Consults
(internal access only)

Ethics in Clinical Practice Committee
The Patient Care Services Ethics in Clinical Practice Committee is a interprofessional committee, formed to develop and implement strategies to support the integration of ethical judgment into professional practice and provide consultation at unit and organizational levels related to ethical issues in patient care.

Ethics Task Force
This interprofessional group of ethics leaders has liaison and service functions.  The liaison mission is to provide opportunities to share ideas, programs and projects so that we can reflect, refine, support and collaborate.  The services provided are: planning and presenting the “Ethics Forum” series; staffing the ethics beeper *; and maintaining an ethics interest group email distribution list.  We also have fielded ethics questions that fall outside the purview of other MGH ethics committees.

Institutional Review Board (IRB)
MGH has an oversight committee for all research.

click here for more information
(internal access only)

The Vincent Reproductive Medicine & IVF Code of Ethics
The Vincent Reproductive Medicine and IVF Service understands and values the ethical dilemmas that arise as part of the extraordinary treatment that we provide.  Our approach to these issues are multifaceted and involve identifying the decision makers, collecting data and establishing the facts, identifying all medically appropriate options, evaluating options according to the values and principles involved, identifying the ethical conflicts and setting priorities, selecting the option that can be best justified, and reevaluating the decision after it is acted on.

 

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Ethics in Clinical Practice Committee

Meets:
1st Wednesday monthly
1pm - 3pm
Trustees Conference Room

 

 

ADVANCE CARE PLANNING

Ethics information booth

 

 

 

 

 

 

 

 

 

Above: 13th Annual Advance Care Planning Information Booth
Click here to read more...

Advance Care Planning (ACP) is a process that promotes autonomy for individuals so that their treatment preferences will be known and respected should they be in a situation where they are unable to speak for themselves. The Ethics in Clinical Practice Committee supports ACP initiatives.

The Annual ACP Information Booth for Patients, Families, and Staff is held every April in the White Lobby on the Main MGH Campus.  The booth provides information on advance care planning, types of advance directives, considerations when selecting a healthcare proxy, and other important concerns.

  • Advance Directive & Health Care Proxy Internet Resources
  • Five Wishes Aging with Dignity
    Five Wishes is a living will that helps adults of all ages plan how they want to be cared for in case they become seriously ill. This document addresses the concepts of a health care agent, living will, and the issues of comfort, dignity, and reconciliation. It is available in 27 languages and Braille and can be obtained on-line or in print. Voicing My Choices: A Planning Guide for Adolescents & Young Adults and My Wishes are guides to help express and communicate preferences of seriously ill adolescents and children based on the Five Wishes. These documents are available at: https://www.agingwithdignity.org/five-wishes-resources.php - This link will bring to resources that are provided for children and adolescents; as well as translations in other languages.
  • Shared Decision Making DVDs are available on advance care planning:

    Peace of Mind: Personal Stories about Advance Directives is developed for a general audience and is appropriate to enhance the discussion about advance directives for all patients in any status of health.

  • Looking Ahead: Choices for Medical Care When You Are Seriously Ill is intended for people who have advanced serious illness and may face important decisions about treatment, palliative care and hospice options in the near future.

Patients who are interested in borrowing one of these DVDs may stop by the Blum Center to request a copy. Alternately, clinicians with ordering capabilities through Oncall or LMR may prescribe a DVD for the patient. The DVD will be mailed out to the patient within 48 hours.

Clinicians are welcome to stop by the Blum Center to request a review copy of a DVD. The Blum Center is located in the White Building, First Floor, Room 110.

For additional information, please contact the Shared Decision Making team at SDMInfo@partners.org.

(internal access only)

ADVANCE CARE PLANNING:
resources & information for staff


Inpatient (internal access only)

Massachusetts Health Care Proxy
Every patient has a right to appoint a Health Care Agent according to state and federal law (see Advance Directives Policy in the MGH Clinical Policy & Procedure Manual).

  • Patient education brochures on "Advance Care Planning" and "Advance Directives" are available through Standard Register (#84669).

    The Massachusetts Health Care Proxy Form can be used by patients to appoint a competent adult they know and trust to be their Health Care Agent. For information,instructions, and the form,click here.
  • If your patient or their family's preferred language is other than English, always work with an MGH Medical Interpreter when you ask your patient about Advance Directives, or when you present information about Advance Directives. Call 6-6966 to schedule a medical interpreter.

    Arabic, Chinese (Traditional), English, French, Greek, Haitian Creole, Italian, Khmer, Portuguese, Russian, Spanish and Vietnamese forms can be downloaded and printed here.





Outpatient/Ambulatory Staff

Advance Care Planning and Mass. Health Care Proxy Forms can be found on thePrimary Care Office Onsite (PCOI)web site. Click on "Patient Information" under the topics "Senior Health" or "End of Life." There are links to allow download and printing of HCP forms and the patient education brochures "Planning Advance for Your Health Care and "Preparing to be a Health Care Agent" for patients who express interest during a patient encounter.

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POLICIES, PROCEDURES & GUIDELINES (internal access only)

MGH has many policies related to ethics that guide staff to assure best practices in providing ethically appropriate care to patients and families and support an ethical work environment.

PROFESSIONAL CODES OF ETHICS
EXTERNAL REVIEWERS

Joint Commission logo

The Joint Commission standards guide health care organizations towards having structures and processes in place that ensure that rights of individuals are met and that business practices are ethical. The standards focus on the identification of fundamental, overarching patient rights:

  • The right to effective communication
  • The right to participate in care decisions
  • The right to informed consent
  • The right to know care providers
  • The right to participate in end-of-life decisions
  • Individual rights of patients
  • Patient responsibilities

For more information, see The Joint Commission Hospital Manual, Rights and Responsibilities of Individuals (RI).

Magnet Recognition

Magnet_logoThe American Nurses Credentialing Center (ANCC) requires Magnet-designated organizations to track nationally-benchmarked nursing sensitive indicators (NSIs) to continually inform improvement efforts related enhance patient outcomes. Examples of NSIs include, but are not limited to: patient falls, hospital-acquired pressure ulcers, blood stream infections, ventilator-associated pneumonia, and restraint use.

 

 

 

 

GLOSSARY OF TERMS

This month's featured term: Brain Death
Death by brain criteria is defined under Massachusetts state law as the total and irreversible cessation of spontaneous brain functions, in which further attempts of resuscitation or continued supportive maintenance would not be successful in restoring such function. Stated more simply, brain death is the irreversible loss of all function of the brain, including the brainstem. A patient determined to be brain dead is legally and clinically dead. (MGH Policy on Brain Death, 2.1)

MGH Policy on Brain Death (based on Massachusetts State Law)

Glossary of Ethics Terms click here

Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.

If you have questions or suggestions related to the EED portal, please contact Georgia Peirce at (617) 724-9865 or via email at gwpeirce@partners.org.

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updated 10/8/14

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