A healthcare worker’s job is undoubtedly tough, with long hours and the intensity of holding patients’ health and survival in their hands, but medical staff also face deep moral and ethical issues as part of their job.
Medical workers attended a packed forum hosted by the Health Services Authority’s Ethics Committee last week to hear about and discuss the types of difficult ethical questions that face them, sometimes on a daily basis.
Dr. Zahida Anwar, in her presentation, spoke of the need to make decisions “with compassion in the best interest of the patient”.
She pointed out that often ethical issues arise at the end of life – with the very elderly or those at the end stage of a terminal disease.
One issue that has come before the Ethics Committee is “do not resuscitate” or DNR orders. Those are instructions to medical staff not to resuscitate a person if the heart stops. However, Cayman does not have any legislation that allows DNR orders, she said.
“DNR… unfortunately has not gone through legislation. We’re still awaiting it,” she said, adding that the Ethics Committee had already prepared an extensive report for government on the issue.
“DNR is usually for people who have reached the end stage of their disease and treatments are usually futile, even though they do them. It’s a very sad status – a person aged 92 or 97 years is subjected to having cardiac compressions, all their ribs break. It is actually painful for us to do it, but we have no choice at the moment because there is no policy for it, every person who goes unresponsive, we had to call a code,” she said.
She also touched on the subject of advance directives, which are legal documents made by someone of sound mind who has made a decision about future medical care. “It’s not just DNR. It can be ‘if I’m 87 years old and my kidneys fail, don’t put me on dialysis. I don’t want to have transfusion if I am terminally ill and I’ve decided I’m accepting my time’,” Dr. Anwar said.
Other ethical issues doctors have to face involve the harrowing ones of dealing with a pregnant mother and a foetus with a serious, perhaps lethal, condition and a bad prognosis. Paediatrician Dr. Earl Robinson discussed the controversial element of medical ethics at the beginning of life.
But even the subject of his talk brings controversy as to discuss ethics at the beginning of life, one has to consider exactly when life begins. “It is seen differently by different individuals, different groups, cultures and religions. The thing about the Cayman Islands is, as you know, we do have different groups, different cultures represented here and different religions,” he said.
Referring to the age at which a child can survive outside the womb, he said, 40 years ago, a baby would have little chance of survival at 28 weeks, but nowadays most babies at 24 weeks can survive and some survive as young as 22 or 23 weeks. There is a limit to the time when “no matter what you do, what medical intervention, the baby is not going to live”, he said.
A foetus has no independent legal status but once born, babies have the same right to life as an older child or adult, he said.
He asked the audience how certain they had to be before bringing to a mother a diagnosis and prognosis about her baby or about her own risk if she carries the baby to term that would lead to advice to undergo a termination as a medical necessity.
And the ethical dilemmas don’t end there. Following birth, if a child has such a serious condition that makes survival unlikely, at what point does a doctor stop intensive care, he asked. “At what point, do you say ‘enough’?” Dr. Robinson asked.
Dr. Ginny Hobday, medical director of Cayman HospiceCare tackled the ethics involved in caring for hospice patients, highlighting the rights of these patients and their end of life issues.
She presented a number of case studies that laid out some of the ethical issued involved in dealing with patients in their last days. For example, should patients be told they have a terminal illness if their family requests they not be informed? Dr. Hobday gave a case study of a 76-year-old woman with cancer whose family did not want her to be told she had the disease because they thought she would give up hope. However, the hospice doctor asked if she wanted to know and she did, so she was given her diagnosis. She was subsequently given palliative chemotherapy and was doing well two months later. “That may not have happened if the patient had not been told what her outcome was,” said Dr. Hobday.
Ethics are often mixed up with money issues too, she pointed out, especially in healthcare where costs can be astronomical. To illustrate this, Dr. Hobday gave examples of elderly sisters going into debt and re-mortgaging their home to pay to airlift their uninsured cancer and stroke suffering brother for expensive medical treatment, which ultimately did nothing to aid him and he came home in a worse condition than he left. “The patient did not benefit and you could argue harm was done to him and to his family,” she said.
The Ethics Discussion Seminar was held at the Cayman Islands Hospital on 10 April.
The aim of the HSA Ethics Committee is to provide support and advice to all healthcare providers and patients and their families if needed when faced with an ethical dilemma. The committee hosts monthly meetings, on the second Wednesday of each month at 6pm in the Hibiscus Conference Room at the hospital, at which healthcare providers can consult and discuss ethical decisions in confidence. Anyone can bring an issue to the committee by calling 244-2814.