“ Al l t ruths are easy to unders tand once they ar e d is cov er ed; the poi nt is to d is cov e r the m” - Gal i le o

Inside this edition

Message from the Director......1

A Few Words Of Thanks to the Editor.................1

A Glimpse InsideEthics in RiskManagement..2-3

ENC Lineup…...…....3

EducationalSessions andMeetings..........4

Suggested Readings..…....4

C.H.E.s Newsletter is

distributed threetimes each year by

the Center for

Healthcare Ethicsat Cedars-Sinai Medical Center

CC enterenter for for HH ealthcareealthcare EE thicsthicsNewsletter Volume 4, Issue 2: Winter 2012

A message from the Center’s DIRECTOR....

Stuart G. Finder, Ph.D

A Few Words Of...Thanks to the Editor!

“Sticks and stones may break mybones, but words will never hurt me.”

This phrase, which most people know, is rela-tively new. The first recognized literary occur-rence is said to be from 1872, in the children’sbook, Tappy’s Chick: and Other Links BetweenNature and Human Nature (it’s found on p. 78).G.F. Northall, the English folklorist, also mentionsit in his 1894 book, Folk Phrases of Four Coun-ties. As for its meaning, this is well-understood:don’t allow cruel or taunting words to bother you.

We teach this to our children in order to helpthem deal with situations in which other childrensay things with an explicit intention to causeharm – although the lesson is valuable for thosesituations in which unintentionally hurtful phrasesare encountered as well.

This latter context is particularly relevant tohealthcare, especially direct patient care. Forwhile we do not intend our words to be hurtful,sometimes the words we use may be so. Con-sider, if only briefly, two examples.

There are many ways to refer to a hospitalizedpatient, although all collapse into 2 basic ways:by name or by description.

If by name, a patient may be referred to by firstand/or last name or by last names preceded by asalutation (Mr., Mrs., Ms., Dr.).

If by description, reference may be made to the patient’s illness or injury (“the guy with the gang-rene foot”), to the patient’s room location (“the lady in 880”) or the treatment being given (“that kid on ECMO”), to thephysician (or others) primarily responsible for direct-ing care (“Dr. Nobel’s patient”), or to combinations ofany of the various means for describing patients.

The question is, what may be, or is, implied whenone or another of these different ways of referring toour patients is used? And for whom do the differ-ences in meaning make a difference, e.g., conveysomething negative or hurtful?

This becomes particularly significant when thinkingabout the words we use to talk about something aspowerfully charged as limiting or discontinuing whatwe do as part of end-of-life care. For example, con-sider the differences between saying “the withdrawalof care” versus “the withdrawal of therapies” versus“the withdrawal of treatments” versus “the withdrawalof interventions” – let alone any of the aforemen-tioned phrases versus “the removal of burdens.”

The words we use matter. Knowing which words touse requires paying direct and explicit attention tothose with whom, and before whom, we use them.Words, like sticks and stones, can be hurtful, evenwhen unintended. We cannot assume that our pa-tients and their families – like we hope we havetaught our children – are prepared to hear what maybe, for them, terrible words indeed.

Back in the first week of January 2008, Julie Choudhury, then recently graduated with a BS inHealth Care Management, joined the staff of the Center for Healthcare Ethics as its MA 1(Special Assistant to the Director). Julie jumped into this part-time position with enthusiasmand vigor, and in the process helped launch this Newsletter (for which she has served as Edi-tor ever since) and led the effort to re-design the Center’s Intranet and Internet web sites (forwhich she has served as Web Master as well); she also provided invaluable assistance withmany different projects and research. From the beginning, though, it was clear that Julie hadaspirations reaching beyond the Center. While having pursued additional schooling part timeover the ensuing three years, Julie now is beginning the final semester of her M.P.H. at USC,a full-time endeavor. As such, her time with the Center has come to an end. The Center’sfaculty and other staff are all deeply grateful for what she has given, and we wish Julie thebest of luck in all her new adventures.

CHE Newsletter page 2 of 4

A GLIMPSE INSIDE...Ethics in Risk Management

The CSMC Risk Management Department hasthree Nurse/Attorneys, all of whom have previouslaw practice experience as well as bedside careexperience. We work closely with the ClinicalEthics Consultation Service whenever issues arisein which interpretation of applicable healthcare-re-lated laws and regulations are needed. Examplesinclude issues of patient capacity and surrogatedecision-making, the right to refuse treatment, endof life care, and withholding/withdrawing treatment.

Consider, for example, implications flowing fromthe Patient Self Determination Act of 1990, whichrequires hospitals to inform patients at the time ofadmission of their right to make health care deci-sions. This Act was based on the well estab-lished legal principal of “patientself-determination”—the idea that every humanbeing with capacity has the right to make deci-sions about what shall be done with his or herbody. This means that patients have the legaland ethical right to refuse any treatment, includ-ing life-saving treatment even if the refusal ofsuch treatment is against the advice of thehealthcare providers.

As Risk Managers, we sometimes get calls fromclinical staff members faced with difficult situa-tions, often after hours, sometimes in the middleof the night, and often when time is of theessence. An example of such a situation is whena patient who is experiencing a dissecting AorticAneurysm is a Jehovah’s Witness and requeststhat she not be given blood. The tenets of theJehovah’s Witness religion prohibit its followersfrom receiving a blood transfusion, even if refus-ing such a transfusion means inevitable death.Surgical intervention for a dissecting AorticAneurysm involves the transfusion of blood in vir-tually all cases. Performing such a procedure ona patient who will not accept blood significantlyincreases the mortality of such a procedure. Onthe other hand, a patient with a dissecting AorticAneurysm who does not have the procedure hasa 100% mortality risk.

This places the care team in a very difficult posi-tion, to say the least, as they struggle with theconflict between the patient’s wishes and theirown sense of needing to “do” something.

As Risk Managers, we can sometimes assist theclinical staff with navigating through these difficultsituations by providing a clear understanding ofthe law.

One of the more common issues for which we re-ceive calls is that of patient capacity. Capacitydiffers from “competence” in that determination ofcapacity is actually a clinical decision (whereas“competence” is a legal determination). The lawdefines “capacity” as “the ability to understand thenature and consequences of the proposed healthcare, including its risks, benefits and alternativesand the ability to make and communicate a healthcare decision.” You can see from this very defini-tion that it can be specific to the clinical situationand the seriousness of the risks involved.

For example, a very risky procedure such as aheart transplant or certain cancer treatmentswould require a high level of capacity for judg-ment to accept or refuse the medical intervention.To complicate matters further, capacity is not nec-essarily stable over time. A good example of thisis a patient with hepatic encephalopathy. Oftenthe incapacity from such a metabolic condition istemporary and capacity returns when the pa-tient’s ammonia levels return to normal. Determi-nation of capacity, therefore, is a decision madeby the physician at the bedside. However, RiskManagement can sometimes assist the physicianwith applying the law pertaining to capacity.

In the case of a patient who lacks capacity, thelaw is very specific about following the wishes ofthe patient if they are known and particularly ifthey are set forth in writing in an Advance Direc-tive.

CHE Newsletter page 3 of 4

A glimpse Inside cont’s...

Winter 2012 Ethics Noon Conference (ENC)This is a monthly conference that is open to all who work within, are affiliated with, or receive care at Cedars-Sinai Medical Center. The primary aim of these sessions is to raise the level of awareness and degree of understanding of emerging issues and concerns in the realm of healthcare ethics.

Cedars-Sinai Medical Center designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit

JANUARY 18, 2012“From the Vegetative To Minimally Conscious State: Neuro-Ethics and the Severly Injured Brain”Joseph J. Fins, MD, is the E. William Davis, M.D., Jr. Professor of Medical Ethics and Chiefof the Division of Medical Ethics at Weill Cornell Medical College where he also serves asProfessor of Medicine, Professor of Public Health, and Professor of Medicine in Psychiatry.He is also an Attending Physician and Director of Medical Ethics at New York-PresbyterianWeill Cornell Medical Center. He is a co-author of the 2007 Nature paper describing the firstuse of deep brain stimulation in the minimally conscious state. His most recent book is A Pal-liative Ethic of Care: Clinical Wisdom at Life’s End (2006).*

Sometimes questions arise as to the validity of an Advance Directive, or in the case of a patient who lackscapacity with no advance directive, Risk Management can assist with interpreting that portion of the law thatallows the caregivers to look to the “closest available relative” as an appropriate surrogate decision maker.

Healthcare law is in a continuous state of evolution and seeks to balance individual patient autonomy withthe challenges faced by healthcare providers. Thus we anticipate that we will continue to assist the healthcare team with achieving patient goals within the boundaries of our currentlegal and ethical framework.

FEBRUARY 15, 2012“Another Kind of DNR (Do Not Record): Documentary Films, Patient Rights, and Social Responsibility”Theresa Jones, Ph.D., is an Associate Professor of Internal Medicine and the Director of theArts and Humanities in Healthcare Program in the Center for Bioethics and Humanities atThe University of Colorado, Anschutz Medical Campus, Denver. She is Editor of the Journalof Medical Humanities and is widely published in the areas of literature, film and medical ed-ucation. She is an active leader in several national Literature and Medicine professionalgroups as well as for the Visual Arts Affinity Group of the American Society of Bioethics andHumanities (for which she has also served on the Board of Directors and as Treasurer).

MARCH 21, 2012 - Siegel Lectures in Humanism and Medicine“Literacy and Commuication: The Ethical Import of Stories for Patient Care”Perri Klass, M.D., is Professor of Journalism and Pediatrics at New York University and theMedical Director of “Reach Out and Read,” a national childhood literacy program that worksthrough doctors and nurses to encourage parents to read aloud to young children, and togive them the books they need to do it. She is a member of the National Advisory Council ofthe National Institute of Child Health and Human Development, and has been nominated bythe President of the United States to the Advisory Board of the National Institute For Literacy.Dr. Klass is the author of numerous books, including Treatment Kind and Fair: Letters to aYoung Doctor (2008).*

* Books available at the CSMC Medical Library

- Pamela S. Hamilton, R.N., Esq.Risk ManagerCedars-Siani Medical CenterLos Angeles, CA

Page 4 of 4 CHE Newsletter

Center forHealthcareEthics

Address:8700 Beverly Blvd

TSB - Suite 240Los Angeles, CA

90048

Phone:310-423-9636

ConsultHOTLINE:310-423-9634

FAX:310-423-9638

Internet:www.cedars-

sinai.edu/ethics

Intranet:web.csmc.edu/ethics

Winter 2012: Educational Sessions & Meetings

Jan 2012 Feb 2012 Mar 2012 Apr 2012Jan 5 - Bioethics Cmt Feb 2 - Bioethics Cmt Mar 1 - Bioethics Cmt Apr 2 - Ethics SeminarJan 9 - Ethics Seminar Feb 6 - Ethics Seminar Mar 5 - Ethics Seminar Apr 5 - Bioethics CmtJan 17 - NICU Ethics Feb 15 - ENC Mar 20 - NICU Ethics Apr 17 - NICU EthicsJan 18 - ENC Feb 21 - NICU Ethics Mar 21 - ENC Apr 25 - SICU EthicsJan 25 - Ethics Forum Feb 22 - SICU Ethics Mar 28 - Ethics Forum

*ENC = Ethics Noon Conference *NICU Ethics = Neonatology Ethics Session*SICU Ethics = Surgical ICU Residents/Fellows Ethics Conference

For descriptions of the Ethics Seminar and Ethics Forum, please visit either our Intranet or Internet websites and go to the link “Educational Opportunities.”

For more information about any of the above events as well as for times and locations, please callthe Center at 310-423-9636

Good Reads...

C.H.E. Newsletter is a publication of Cedars-Sinai Medical Center.

Director: Stuart G. Finder, Ph.D.Assistant Director: Virginia L. Bartlett, Ph.D Julie A. Choudhury, BS, CHES: Newsletter Editor &Associate Director: Kenneth Leeds, M.D. Special AssistantSenior Advisor: Leon Morgenstern, M.D. Susanne Tiffer: Management Assistant II

Books featured in “Good Reads....” are availble in the Medical Library. Please call 310-423-3751 for book availablity and reserve a copy today!

If you have missed one of our Ethics Noon Conferences (ENC) Series and are interested inviewing them, the Medical Library has copies of the series dating back to Nov 2007.

We invite you to check them out!

Note from the Editor...On behalf of the Center for Healthcare Ethics, we would like to thank Pamela Hamilton for her insighful contribution to

“A Glimpse Inside.”

A Palliative Ethic of Care: Clinical Wis-dom at Life's End. By Joseph J. Fins(Jones & Bartlett Publishers, 2006) Dr.Fins, an intensivist physician, blends ethi-cal theory and clinical practice by present-ing readers with theoretical and historicalconsiderations about end of life care. Heexplains how to develop a set of patientand physician goals for improving qualityof life, resolving end of life issues, andtreating dying patients.

The Picture of Health: Medical Ethics andThe Movies. Edited by Henri Colt, et al.(Oxford, 2011) Film and literature have longbeen mined for interesting examples andcase studies in order to teach biomedicalethics to students. This volume presents acollection of about 80 very brief and accessi-ble essays written by international expertsfrom medicine, social sciences, and the hu-manities, all of whom have experience usingfilm in their teaching of medical ethics.

Stories Matter: The Role of Narrativee inMedical Ethics (Reflective Bioethics). Edited by Rita Charon and Martha Montello(Routledge, 2002) This book examines themany ways narrative methods of analysis andinterpretation are transforming the work ofmedicine and ethics. With contributions fromphilosophers, literary scholars, psychologists,and physicians, this book's double attention totheory and practice provides both clear concep-tual content and a practical guide to using nar-rative ethics in the service of patients care.

Treatment Kind and Fair: Letters to aYoung Doctor. By Perri Klass (Basic Books,2008) Dr. Klass, a pediatrician, addressesthe primary issues in the life of any doctorand, by extension, the lives of those forwhom they care. She explores the moraljudgments of doctors, questions of deathand physician-assisted suicide, the daily lifeof a doctor, doctors as patients, and more.Klass offers a fascinating glimpse inside thedoctors office for aspiring physicians andmedical buffs.