PLEASE DON'T "DO EVERYTHING" WHEN I AM IN THE HOSPITAL

Image Source:  CDC.gov

Please Don’t “Do Everything” When I am in the Hospital

Kathy Kinlaw

Every day in every hospital nationwide individuals very like you and me are admitted with serious illness.  Those who have experienced this – or cared for someone who has – know that the very real medical decisions faced can be heart-rending.  And few of us want to think ahead about these decisions.

April 16 is National Healthcare Decisions Day ¹, a day dedicated to encouraging all of us to consider planning ahead about our healthcare choices.  “Advance care planning,” as it is often termed, does not just mean completing an “advance directive” document, though you may wish to do so.   Advance care planning really asks each of us to think deeply about our values and beliefs and to consider what healthcare choices will best reflect who we are and those values we hold most closely. 

It also requires careful reflection on what specific medical choices we might face, and this is particularly difficult.  As a medical ethicist who works with patients, families and healthcare professionals as they struggle with difficult decisions, often about medical care near the end of life, I have learned that we can rarely predict the exact medical decisions we will face.  But what we are capable of is actively partnering with our physicians and other health care professionals to talk about our underlying goals (for treatment and for life), learn about the range of choices we may face, and accept that there are limits to what medicine can actually do.

We do not want to talk about critical illness or to contemplate those places of finitude from which we may not return.  And yet, what we may gain – and give to our loved ones – by courageously thinking about and talking about these difficult realities is compelling.

This is hard work, for it does not entail simply saying yes to every potential intervention.   “Do everything” is not a meaningful request or response in shared decision making.  There are times when trying a treatment is quite reasonable, even when we are unclear about the outcome. And there are times when it is reasonable, perhaps deeply “right”, that one’s life goals will be better served by not trying the next research protocol or invasive intervention but focusing instead on the quality of the life one has yet to live.

In one 2010 study of patients with lung cancer, patients who received palliative care – care whose purpose is to keep patients comfortable, focus on quality of life and address patients’ needs as “whole persons” rather than just as physical bodies – experienced less pain, better function in everyday life, and lived on average almost 3 months longer than those receiving curative therapy only.²  We need to think carefully about what we really want and be empowered to work with our health care team to make well-informed decisions.

Our loved ones also benefit from such thoughtful choices.  One recent study indicates that 60 % of respondents say that making sure their family is not burdened by tough decisions is “extremely important.” Yet 56% have not communicated their end-of-life wishes. ³  When a family member or other “surrogate” decision maker is asked to make decisions, their accuracy in predicting treatment choices of the patient is highly variable (50-74%) ⁴  We can do better in clarifying our values and choices and empowering and supporting our family members in understanding the choices we make.

Surveys indicate that 20 to 30% of Americans have advance directives, legally accepted documents in which one can indicate preferences about treatment and/or the name of the person you wish to make decisions for you if you cannot make decisions for yourself. ⁵  Advance Directives can be helpful records of our preferences;  just as important, however, is the conversation behind these documents.

In the days following National Healthcare Decisions Day:

·      Have the conversation with your family and other loved ones

·      Consider creating an advance directive – contact your local bioethics center, hospital association or hospital

·      Talk to your physician or other health care provider; keep talking with them

Resources:  The Conversation Project; POLST (physician orders for life-sustaining treatment), Choosing Wisely, Values History Form

1.     National Healthcare Decisions Day. http://www.nhdd.org/

2.     Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-742

3.     Survey of Californians by the California HealthCare Foundation (2012). http://coalitionccc.org/documents/FinalChapterDeathDying.pdf

4.     Susan Mockus Parks, Laraine Winter, Abbie J. Santana, Barbara Parker, James J. Diamond, Molly Rose, Ronald E. Myers. Family Factors in End-of-Life Decision-Making: Family Conflict and Proxy Relationship.  J Palliat Med. 2011 February; 14(2): 179–184

5.     Associated Press 2010

Resource links:

http://theconversationproject.org/

http://www.polst.org/

http://www.choosingwisely.org/

http://hsc.unm.edu/ethics/docs/Values_History.pdf

Georgia-Specific Resources:

Health Care Ethics Consortium of Georgia.  Georgia Advance Directive for Health Care

http://www.hcecg.org/library

Georgia Health Decisions’ Critical Conditions

http://www.critical-conditions.org/

Georgia POLST

http://www.dph.ga.gov/POLST/

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Kathy Kinlaw is Associate Director of the Emory University Center for Ethics and Director of the Center's Program in Health Sciences and Ethics. She is an Assistant Professor of Pediatrics, Emory School of Medicine; and Director of the Health Care Ethics Consortium of Georgia. Kathy is deeply committed to shared, informed involvement of patients and families in healthcare decision making.  

THE WHIPPING MAN: FAITH, FAMILY, FUED, FORGIVENESS?

Photos by Carlton Mackey

On February 27^th the Ethics & the Arts Initiative, in partnership with the Alliance Theatre, hosted a dramatic reading of The Whipping Man just before its debut in March.  As the last dramatic reading and discussion the Center will host for this season, the event was very successful. The event began with an introduction of the director (Alexander Greenfield), the dramaturg (Celise Kalke), and the actors (Jeremy Aggers, Keith Randolph Smith, John Stewart) followed by a short discussion.

                  The play’s inception came from an observation/discovery of a key historical fact: the signing of the surrender at the Appomattox Court house was on April 9^th, 1861, one day before Passover. The play is set in Richmond, Virginia, on Friday, April 14^th, 1861, five days after the end of the war.

 

                  The three characters of the play are Simon (Smith), an older, newly freed slave who has a wife and daughter, John (Stewart), a younger, newly freed slave who can read and has ambitions to travel north, and Caleb DeLeon (Aggers), the rebel soldier and son of the plantation owner. The play involves these three men coming together for Passover after the war has ended.

                  

What makes this play interesting is, partially, the time frame. Most stories take place during or after the war.  This time is always rife with complications. Officially new policies have set in and people know change has come, but they have not figured out what that change means. Simon refers to John and Caleb both as his family and says that they are both part of each other’s family. In the scene performed, John has just returned from looting. In the same scene, Caleb begins to deal with the recovery from losing a leg. There is anger and frustration and a clear lack of direction. The relationship has changed legally, but this leads to a lot of tension as none of the three men are quiet certain what this means in reality.

                  From the play excerpt, The Whipping Man deals a lot with faith. Caleb was born into the faith, but from what he saw on the battlefield he no longer believes in God. Simon was taught and raised to be Jewish. John was also raised to be Jewish, but when he began to be able to read he started to question that faith. He found his faith in books, not in religion. The play ends with the three men taking part in the Seder.

                 

From my interpretation, one of the key questions that the play asks is, “Who is the better Jew”? Is it man who sticks to the spirit of the faith but cannot read or engage in the actual text? Is it the one who knows the law and the book but does not necessarily believe? Is it one who was born into the faith, but no longer believes? Are these important? From my experience of the Christian faith, a lot of people no longer actually read the text, but go along with what is taught to them in church and try to be good people. There are also a lot of Atheists who do read the Bible.  There can also be a feeling in a church (whether spoken out loud or not) that someone who was born from a good Christian family is better than a convert. For Jewish faith this last aspect is even more particular. It is possible to be a Jewish Atheists, while it is impossible to be a Christian or Muslim Atheist?

                 

The play also brings up the issue of family. Are these three men a family? During the talk, the actors explained that Simon is more of a father to Caleb than Caleb ever had in his own father. Caleb and John were even as close as brothers at one point. They fight and argue, loudly, but there is a very strong family dynamic between them. For all of them this is the only family they have ever known, however wrong and broken it might seem. The history only seems to turn up the heat on the fight and conflict that already exists in their relationships.

                  

The characters’ anger and frustration with the world collide against each other. It is not just a question of race dynamic, or family dynamic. Caleb fought in the battle of Petersburg, one of the bloodiest battles of the Civil War; in fact he served in a lot of bloody fights. The scene presented asked the audience if John, who had always been a slave, but who had been able to stay home and had food and a roof over his head had it better than Caleb who had been raised free, but who lived through some of the most horrific battles in American history.

                  The audience was incredibly enthusiastic about the piece. What stuck out for me personally was how many modern struggles are represented in the play. There is a complexity to the characters and the questions they ask of themselves and each other. The Civil War still really affects the South, and not just dealing with the horrors of slavery. As a child I felt terribly conflicted when learning about the Civil War because while I strongly, strongly supported the ideals of the Union, the South is my home and so I felt torn. I wanted the Union to win, but I still felt like the Confederate soldiers were close to me, and I didn’t like reading about them getting hurt. I have heard people say that we still are fighting the Civil War, because there is still that question of where our loyalty lies.

The scene the actors read for us talked about war and slavery, family and faith, love and guilt. The scene dealt with Jewishness, which I think allows it to not get so caught up in the stigma that comes with the time period. It does not ignore slavery, or the ideals around the war, but it seems like the play deals more with the humanity of the situation than charged rhetoric and dancing political correctness. A lot of audience members did express an interest in seeing the play after the reading and for good reason. The Whipping Man plays at the Alliance theatre from March 8-April 7.

Opinion Editorial by Emily Anne Thomas

-Journalism and Social Media Student Assistant

Emory University Center for Ethics

An Ethical Response to Rumors

What is the ethical thing to do when you hear a rumor? Corporate Secretary editor Matthew Scott says consider how people will react to information spread about you.
by Matthew Scott

Many governance professionals complain about a lack of ethics in business. After all, you often find yourselves on the front lines of the movement for better corporate governance, fighting fraud and improving the ethical culture at your company.
 
But ethics can break down when rumors start to fly. How many people can honestly say they would pass up an opportunity to make money or eliminate a competitor if information contained in a rumor could help them do that?
 
So what is the ethical thing to do when you hear a rumor?

Original Story by Matthew Scott featured on Corporate Secretary.

Read Complete Article at:
http://www.corporatesecretary.com/articles/compliance-and-ethics/12410/ethical-response-rumors/