Center for the Study of Ethics in the Professions at IIT

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The purpose of this Code of Ethics is to express standards of ethical behavior for Mercy Hospital and Medical Center (MHmqemployees in their professional relationships. These relationships include patients or others served, the organization, colleagues, the community and society as a whole. This Code of Ethics also incorporates standards of ethical behavior governing personal behavior., particularly when that conduct directly relates to the role and identity of the employee.

• The fundamental ob ectives of Mercy Hospital and Medical Center employee staff are to enhance overall quality of life, dignity and well-being of every individual needing healthcare services; and to create more equitable, accessible, effective and efficient systems of healthcare delivery, in accordance with the Mercy Hospital and Medical Center mission and core values, themselves rooted in the Catholic Christian faith tradition.

Mercy Hospital and Medical Center healthcare staff have an obligation to act in ways that will merit the trust, confidence and respect of healthcare professionals and the general public. To do so, healthcare employees must lead lives that embody exemplary values and ethics.

In fulfilling their commitments and obligations to patients and others served, healthcare employees function as moral agents. Since every decision affects the health and well-being of both individuals and communities., healthcare employees must evaluate the possible outcomes of their decisions and accept full responsibility for the consequences. They must safeguard and foster the rights, interests and prerogatives of patients or others served. The role of moral agent requires that healthcare employees speak out and take actions necessary to promote such rights, interests and prerogatives if they are threatened.

L EMPLOYEE RESPONSIBILITIES TO PATIENTS AND OTHERS SERVED
The MHMC employee shall:

• A. Participate in the hospital performance improvement process to evaluate the quality of care or service rendered;

• B. Avoid exploitation of relationships for personal advantage;

• C. Avoid pra ' cticing or facilitating discrimination and institute safeguards to prevent discriminatory practices, as these relate to race, creed, color, sex, ethnic origin, age or disability;

• D. Participate in the hospital communication process that advises patients or others served of the rights, opportunities, responsibilities and risks regarding available healthcare services;
  Participate in the hospital process that assures the autonomy and self-determination
  of patients or others served;
  Safeguard the confidentiality and privacy of patients in the hospital; and
  Respect the customs and practices of patients or others Served.
  
  EMPLOYEE RESPONSIBILITIES TO THE ORGANIZATION
  
  The MHMC employee shall:
  
  A. Uphold the values, ethics and mission of Mercy Hospital and Medical Center;
  B. Conduct all personal and professional activities with honesty, integrity, respect,
  
  
• fairness and good faith in a manner that will reflect wellupon the hospital and the

• healthcare profession;

• Comply with all local, state and federal laws in carrying out their role as a MHMC employee;

• Maintain competence and proficiency as a healthcare practitioner by implementing a personal program of assessment and continuing professional education;

• Avoid the exploitation of professional relationships for personal gain;

• Respect professional confidences;

• Refrain from participating in any endorsement or publicity that demeans the

• credibility and dignity of MHMC and the healthcare profession;

• Refrain from using the Mercy Hospital and Medical Center's credential or

• affiliations to promote or endorse external commercial products or services;

• Provide healthcare services consistent with available resources and in a way that considers ethical ramifications;

• Be truthful and timely in all forms of professional and organizational communication and avoid information that is false, misleading, and deceptive or information that would create unreasonable expectations Take an active role in creating a physical environment that is clean and safe;
  
• EXECUTWES AND MANAGER'S RESPONSIBILITIES TO EM:PLOYEES
  
  The MHMC executives and managers have an ethical and professional obligation to employees they manage that encompass but are not limited to: A.
  
• Creating a working environment conducive to valuing and encouraging employee ethical conduct and behavior; Assuring that individuals may freely express ethical concerns and providing mechanisms for discussing and addressing such concerns; Assuring a working environment that is free from harassment, sexual and other;
  
  coercion of any kind, especially to perform illegal or unethical acts; and discrimination on the basis of race, creed, color, sex, ethnic origin, age or disability; Assuring a working environment that is conducive to proper utilization of employees' skills and abilities; Paying particular attention to the employee's work environment and job safety; Respecting the religious beliefs and practices of employees;
  
  Establishing appropriate grievance and appeals mechanisms; and Lead the organization in the use and improvement of standards of care and sound business practices.
  
• IV. EXECUTIVE AND MANAGER'S RESPONSIBILITIES TO COMMUNITY AND
  SOCIETY
  
• The MHMC executive and manager shall:

• A. Work to identify and meet the healthcare needs of the community;

• B. Work to assure that all people, including the poor, have reasonable access to

• Healthcare services;

• Participate in public dialogue on healthcare policy issues and advocate solutions that will improve health status and promote quality healthcare in the communities Served by Mercy Hospital and Medical Center;
• Consider the short-term and long-term impact of management decisions on both the local community and on society;
• Provide prospective consumers with adequate and accurate information, enabling them to make enlightened judgments and decisions regarding services; and
• F. Engage in cooperative efforts which promote community health.

CONFLICT OF INTEREST

A conflict of interest may be only a matter of degree, but exists when a healthcareemployee:

A. Is in a position to benefit directly or indirectly by using authority or inside

Information, or allows a friend, relative or associate to benefit from such authority or information.

B. Uses authority or information to make a decision to intentionally affect the organization in an adverse manner.

The healthcare employee shall:

A. Conduct all personal and professional relationships in such a way that all those affected are assured that management decisions are made in the best interests of the organization and the individual served by it;

Disclose to the appropriate authority any direct or indirect financial or personal interests that might pose potential conflicts of interest;

Accept no gifts or benefits offered with the expectation of influencing a management decision; and

Inform the appropriate authority and other involved parties of potential conflicts of interest related to appointments or elections to boards or committees inside or outside Mercy Hospital and Medical Center.

VI. EMIPLOYEE'S DUTY TO REPORT VIOLATIONS OF THE CODE
A MHMC employee who has reasonable grounds to believe that a colleague or associate
has violated this Code has a responsibility to communicate such facts to his/her immediate
supervisor or to the Director of Pastoral Care/Ethics

Life support systems may be removed from a patient who has suffered brain death i.e., the irreversible cessation of all functions of the entire brain, including the brain stem. Removal of life support systems may be deemed appropriate in circumstances other than brain death (refer to Hospital Policy B-52).

Attending physician will determine that brain death has occurred according to the criteria established by the Medical and Scientific Staff/Faculty of Mercy Hospital and Medical Center:

A. Nature and Duration of Coma is Known

1. Known structural disease or irreversible system metabolic cause.

2. No chance of drug intoxication or hypothermia; no paralyzing or potentially anesthetizing drugs recently given for treatment.

3. Body temperature must be above 34 degrees Celsius.

4. Six hour observation of no brain function is sufficient in cases of known structural cause when no drug or alcohol is involved in causation or treatment; otherwise, 12 hours plus negative drug screen required.

B Criteria for Absence of Cerebral and Brain Stem Function
1 . No behavioral or reflex response to noxious stimuli above foramen magnum level.
2. Fixed pupils.
3. No oculovestibular response to 50 ml. ice water calorics.
4. Apneic during oxygenation for 10 minutes.
5. Systemic circulation may be intact.
6. Purely spinal reflexes may be retained.
7. EEG isoelectric for 30 minutes at maximal gain. (Optional)
8. Brain stem-evoked responses reflect absent function in vital brain stem structures. (Optional)
9. No cerebral circulation present on angiographic examination. (Optional)

Current criteria of brain death (see above II. A and B) do not apply in cases of children five years of age and younger.

Controversy exists regarding the required duration of observation and the need for confirmatory tests with these patients. Until better scientific data are available upon which to base the diagnosis of pediatric brain death, this diagnosis remains a clinical determination by the attending physician, with consultation as appropriate.

IV. Determination of death is a medical diagnosis made by a physician. In cases of brain death, the time of the physician's

pronunciation of death should be recorded in the patient's chart as the time of death. The consent of the patient's family, legal guardian, or surrogate decision-maker is not required either for determining the patient's death or for discontinuation of artificial means of maintaining the patient's organ or metabolic functions

V. Communications with the patient's family, legal guardian, or surrogate decision-maker should be respectful and

• compassionate, fully informing them of the patient's condition and prognosis in a sensitive and supportive fashion.

• Attending physician will notify appropriate healthcare personnel (resident, nurse, social worker, chaplain, patient representative), and together with them will develop a coordinated plan for approaching and supporting the patient's

• family, legal guardian, or surrogate decision-maker.

• VI. Attending physician, together with appropriate healthcare personnel, will inform the patient's family, guardian, or surrogate of the patient's death, cause of death, and that all medicines and equipment will be stopped and/or removed from the patient's body. Support should be offered and provided as appropriate, according to the wishes of the surrogate(s).

• VIL Artificial ventilation and metabolic supports of the deceased patient's body may continue in cases of organ/tissue retrieval for transplant, or to respond to special family needs. Attending physician will exercise his or her discretionary judgment in these instances.

• VIII. Attending physician will document the occurrence and time of brain death in the patient's chart, indicating that the patient meets criteria for brain death and that the patient's family, guardian, or surrogate(s) have been informed of the patient's condition.

• IX. Attending physician will write an order to discontinue organ and metabolism monitors and supports, both chemical and mechanical.

X. Attending physician may authorize that the family, surrogate, or guardian be approached regarding the option of

• organ/tissue donation. Artificial supports of the patient's organs and metabolism for reasons of maintaining organ per-fusion may be ordered by the physician when an appropriate process of discussion and informed consent has led to a decision to retrieve organs and/or tissues from the patient's body.

• XI. Should ethical questions or disagreements arise among the family, surrogate, and guardian, among the patient's surrogate(s) and the healthcare team, or among members of the healthcare team, consultation to assist in resolving the issue may be obtained from the Medical Ethics Committee by contacting the Ethics Chair, or from the President of the Medical and 4cientific Staff Faculty.

INTRODUCTION

The ongoing development and availability of a wide range of life saving and life-sustaining technologies often raises questions about their appropriate use in the care of patients. Mercy Hospital and Medical Center is committed to providing the best care possible consistent with good medical practice, its ethical values as a Roman Catholic institution, current law, and the availability of resources. Providing the best care does not always mean employing whatever medical technologies are at hand. In some instances, it involves the non-initiation, limitation, or discontinuation of lifesustaining measures. This document outlines principles and procedures to guide health care professionals and patients or their proxies in making decisions to limit or forgo lifesustaining treatment, especially as these relate to the following instances:

B-52 (A) Forgoing Life-Sustaining Treatment for Patients with Decision-Making Capacity

Forgoing Life-Sustaining Treatment for Patients Lacking Decision-Making Capacity Who Have Advance Directives

Forgoing Life-Sustaining Treatment for Patients Lacking Decision-Making Capacity Who Do Not Have

Advance Directives, But Do Have an Identified

Surrogate Decision-Maker

B-52 (D) Forgoing Life-sustaining Treatment for Patients Lacking Decision-Making Capacity Who Do Not Have

Advance Directives or an Identified Surrogate

Decision-Maker

B-52 (E) Forgoing Life-Sustaining Treatment for Infants and Minors

B-52 (B)

B-52 (C)

II. STATEMENT OF PRINCIPLES

A. RELIGIOUS CONVICTIONS

Mercy Hospital and Medical Center recognizes and appreciates the religious and cultural diversity of its staff and patients. Its own mission and character are shaped by Christian beliefs and values in the Roman Catholic tradition. Within this tradition, human beings are seen as persons made in the image and likeness of God and, for this reason, possess an intrinsic and inviolable dignity, worth and respect. Their lives are gifts of the Creator and they are stewards of that gift. Theirs is a responsibility to respect, care for, and use appropriate means to prolong life, recognizing that, while life is sacred, it is not an absolute good. When a person is no longer able to effectively pursue life's mission, the moral obligation to prolong life ceases and the person may refuse refuse lif e-sustaining measures knowing that death may result. Dying, and death itself, though usually the source of considerable fear, suffering and sorrow, are not regarded as unmitigated tragedies. The Christian tradition empowers persons to hope beyond death for a new existence.

B. FORGOING LIFE-SUSTAINING TREATMENT

• 1. The Moral Basis of Forgoing Treatment. As noted above, there are situations when it is morally permissible to forgo life-sustaining treatment. These situations exist when the treatment is nonbeneficial (see definitions), when the burdens (see definitions) imposed by the treatment are disproportionate to the benefits hoped for or obtained, or when it is the considered wish of the patient that such treatments be forgone.

• 2. Limitation of Treatment

• A decision to forgo one form of life-sustaining treatment does not imply withholding or discontinuing any other forms of treatment. Forgoing one life- sustaining treatment may be compatible with maximal therapeutic care of other types.

• Forgoing Treatment and Comfort Care

• Withholding or withdrawing unwanted non-beneficial or unreasonably burdensome treatment does not mean abandoning the patient. In all cases, the patient's dignity, comfort, hygiene, and psychological, social, and spiritual support should be maintained. No Moral Difference Between Withholding and Withdrawing

• While there may be a psychological difference between withholding and withdrawing treatment, there is no moral difference. The same reasons justify withdrawing as withholding, namely, if the treatment conflicts with patient wishes, or is non-beneficial and/or seriously burdensome.

• Artificial Nutrition and Hydration

• Artificially administered hydration and nutrition may, in some circumstances, impose burdens on the patient that are disproportionate to the benefits obtained, or may be non-beneficial to the patient-, and, consequently, may be declined or forgone.

C. MAKING DECISIONS TO FORGO TREATMENT

• • 1. Who Makes Treatment Decisions? Patients with decisionmaking capacity have the moral and legal right to make decisions on their own behalf, including decisions to forgo life- sustaining

1. Who Makes Treatment Decisions? can't. .

treatment, in accordance with their freely chosen beliefs, values, personality, and lifestyle. This is generally referred to as the right to self -determination. These decisions are normally made in collaboration with the attending physician and members of the patient's family and/or significant others. other members of the health care team may be consulted. Decisions are based on the patient's medical condition as well as what the patient perceives to be his or her overall well being. They involve a consideration not only of medical facts. but also such factors as the patient's values, beliefs, personality, lifestyle and life goals. The attending physician has a responsibility to honor and implement patient's decisions regarding treatment options. If the attending physician has moral reservations, grounded in conscience, regarding a patient's decision, he or she should arrange to transfer the care of the patient.

Presumption of Competency. Decisional Capacity means (a) the ability to understand and appreciate the nature and consequences of a decision regarding forgoing lifesustaining treatment; and (b) the ability to reach and communicate an informed decision in the matter. A patient's decisional capacity is ordinarily determined by the attending physician. It is presumed that patients have decisional-making capacity unless patient's attending physician determines that the patient does not meet the requirements for decisional-making capacity.

3. Communication and Informed Consent. Patients have a moral and legal right to the information they need in order to make medically and ethically appropriate decisions and to give their informed consent. This information would normally include diagnosis, prognosis and available treatment options along with their risks and benefits including the option of forgoing any or all treatments offered. Obtaining ethically valid informed consent is an ongoing process of shared communication between physician and patients. An important component in this process is healthcare professionals facilitating patients' ability to make decisions on their own behalf.

4. Patients Without Decision-Making Capacity . Patients without decision-making ability do not lose their right to self -determination. That right is exercised in a different way: that is, a surrogate (proxy) makes decisions on the patient's behalf. The surrogate's decisions about treatment should attempt to check what the patient would have decided if competent (referred to as a substituted judgment). If the patient's wishes are not known, then the surrogate should discern what would seem to be in the patient's overall best interests.

This would include attention not only to the patient's medical condition, but also to the patient's values, beliefs, personality, and lifestyle, insofar as these can be determined.

 

Choice of a Surrocfate Decision-Maker. Some patients may, while still competent, have appointed a surrogate (proxy) through a Durable Power of Attorney for Healthcare (DPAHC). In the absence of DPAHC, the choice of a surrogate will be made in accordance with the Illinois Healthcare Surrogate Act (see Procedures).

Living Wills. If the patient has a living will, every effort should be made by the patient's surrogate and the healthcare team to respect the patient's wishes. if, however, a) the patient wishes are in conflict with current law or the hospital's religious and moral beliefs; or b) the living will is so outdated or the circumstances so altered as to raise serious questions or doubts about interpreting the patient's wishes, the living will need not be followed. This does not eliminate decision-makers' responsibility to make a decision based on promoting the patient's overall well being as the patient would likely perceive it.

Rights of Healthcare Professionals.

Healthcare professionals are not obliged to follow through on patient's or surrogate's decision to forgo life- sustaining treatment if that decision conflicts with their own moral and/or religious convictions. If the disagreement cannot be resolved, the healthcare professional(s) should offer to withdraw from the case after making provision for a transfer of the patient's care.

A patient's request or a physician's order to forgo lifesustaining treatment should normally occur only after an evaluation of the patient's condition and a discussion with the patient (and others the patient may wish to involve) of the patient's condition, the treatment options, their likely risks and benefits and potential impact on prognosis, the physician's recommendations, the patient's concerns, questions! preferences, hopes and expectations regarding the future.

2. The attending physician has the responsibility of ascertaining the patient's preferences regarding any treatments the patient wishes to forgo.

3

once a decision has been made to forgo some or all treatment, the attending physician should complete a Limitation of Treatment order form to facilitate communication among treatment team members. Specific orders related to treatment limitation are to be written on this form. This Limitation of Treatment order form must be signed by the attending physician (or authorized resident after consulting with the attending physician) and placed in the front of the patient's medical record. The attending physician must countersign verbal orders to authorized resident within 24 hrs. of issuance of the orders.

4. Attending physician will document in the progress notes, when writing orders, the decision of the patient, and a summary of relevant discussions held with the patient, the patient's family, and involved healthcare personnel.

5. If treatment limitation is not documented, as set forth in this policy, the presumption is that life-sustaining interventions, including cardiopulmonary resuscitation, are to be provided.

6.
If treatment limitation calls for removal of a ventilator, the attending physician or his/her designated physician, after consultation with the attending physician, must be present at the time of the removal. Attending physician, together with other healthcare personnel, should assist in arranging for emotional, physical and spiritual support for the family members.

7. Following the limitation or withdrawal of life support therapy, the attending physician together with other healthcare personnel, will design a supportive care plan to ensure the patient's comfort, pain control, and dignity.

8. Attending physician, who for any reason, cannot comply with the terms of a decision to forgo life-sustaining treatment shall notify the Administrator On-Call, then provide for a timely transfer of the patient to another physician and/or facility willing to comply with the wishes of the patient or the surrogate.

9. In the event of questions or disagreement among either patient, family, surrogate or healthcare team members about the appropriateness of the management of patient or treatment decisions, consultation should be obtained from the hospital Ethics Committee by contacting the Ethics Chair, or from the President of the Medical and Scientific Staff faculty, to assist in resolving the issue.

 

The discontinuation of some or all life-sustaining treatment may be proposed after judicious consideration of the desires of the patient as expressed in the patient's advance directive and after appropriate professional, family and ethical consultations.

The attending physician will review patient's advance directive, as well as patient's condition treatment options with consideration of pertinent burdens and benefits, and will respond to questions and concerns of the patient's representative/family members. Ideally, such a review would involve all involved healthcare personnel.

3. The desires of the patient as expressed in the patient's advance directive shall receive primary consideration. In the case of Durable Power of Attorney for Healthcare, the desires of the patient's representative based on knowledge of the patient's wishes or beliefs, personality and lifestyle shall be given primary consideration.

4. once a decision has been made to forgo some or all treatment, the attending physician should complete a Limitation of Treatment order form to facilitate communication among treatment team members. Any specific orders related to treatment limitation are to be written on this form. This Limitation of Treatment order form must be signed by the attending physician (or authorized resident, after consulting with the attending physician) and placed in the front of the patient's medical record. The attending physician must authenticate and countersign verbal orders to authorized resident within 24 hrs. of issuance of the orders.

5. Attending physician will document in the progress notes, when writing orders, the patient's preferences as expressed in the advance directive, as they relate to the treatment decisions made, and relevant discussions held with the patient's proxy, surrogate, family, and involved healthcare personnel.

6. If treatment limitation is not documented, as set forth in this policy, the presumption is that life-sustaining interventions, including cardiopulmonary resuscitation, are to be provided.

If treatment limitation calls for removal of a ventilator, the attending physician or his/her designated physician, after consultation with the attending physician, must be present at the time of the removal. Attending physician, together with other healthcare personnel, should assist in arranging for emotional, physical and spiritual support for family members.

 

Following the limitation or withdrawal of life support therapy, the attending physician, together with other healthcare personnel, will design a supportive care plan to ensure the patient's comfort, pain control, and dignity.

9. Attending physician, who for any reason, cannot comply with the terms of a decision to forgo life-sustaining treatment shall notify the Administrator On-Call, then provide for a timely transfer of the patient to another physician and/or facility willing to comply with the wishes of the patient or the surrogate.

10. In the event of questions or disagreement among either patient, family, surrogate or healthcare team members about the appropriateness of the management of the patient or treatment decisions, consultation should be obtained from the hospital Ethics Committee by contacting the Ethics Chair, or the President of the Medical and Scientific Staff Faculty, to assist in resolving the issue.

The Illinois Healthcare Surrogate Act (9/26/91) mandates the
following:
a. Attending physician and one other concurring licensed
physician shall determine and document in medical record
that patient lacks decisional capacity to decide whether
to forgo life-sustaining treatment.

C.

e.

b. Attending physician and one other concurring licensed
physician shall determine and document in the medical
record that patient has one or more of the following
conditions:
1) Terminal
2) Permanent Unconsciousness
3) Incurable or Irreversible Condition
Attending physician, together with other healthcare
personnel, shall determine the appropriate surrogate
decision-maker, with person's name, address, telephone
number and relationship to patient documented in the
medical record. The following order of priority for
determining surrogate decision-maker is to be followed:

1) Guardian 2) Spouse

3) Adult Son or Daughter 4) Parent

5) Adult Sibling

7) Close Friend

6) Adult Grandchild 8) Guardian of the Estate.

• d. Attending physician shall discuss treatment decisions with surrogate decision-maker, using the following standards for decision making:

• 1) If there are multiple surrogates at the same priority level, they have a responsibility to reach a consensus. The attending physician may choose to follow the wishes of the majority.

• The surrogate(s) should be advised to make a decision that conforms as closely as possible to what the patient would want, take into account patient's beliefs and values and weigh as the patient would have weighed, benefits of treatments against burdens imposed.

• 3) The surrogate must express the treatment decision to the attending physician and one adult witness. Adult witness must sign medical record along with the attending physician.

• Attending physician shall inform the patient that it has been determined that the patient lacks decisional capacity and that a surrogate decision maker will be making life- sustaining treatment decisions on behalf of the patient. Moreover, the patient shall be informed of the identity of the decision-maker and any decisions made by that surrogate. If the person identified as the surrogate decision-maker is not a court appointed guardian and the patient objects to the statutory surrogate decision-maker or any decision made by the surrogate, then the provisions of this act shall not apply.

• f. Attending physician who because of personal beliefs or views or his or her conscience is unable to comply with the terms of a decision to forgo life-sustaining treatment shall then assist the patient or surrogate in effectuating the timely transfer of the patient to another healthcare provider and/or facility willing to comply with the wishes of the patient or the surrogate.

 

To ensure compliance with the above requirements, attending physician shall complete Healthcare Surrogate Act Physician Certification form and place in front of medical record. This form does not supplant the need for detailed progress notes.

• • 3. If a decision is made to forgo some or all treatment, the attending physician shall complete a Limitation of Treatment order form to facilitate communication among treatment team members. Any specific orders related to treatment limitation are to be written on this form. This Limitation of Treatment order form must be signed by the attending physician or authorized resident (after consulting with the attending physician) and placed in the front of the patient's medical record. The attending physician must countersign verbal orders to authorized resident within 24 hours of issuance of the orders.

If treatment limitation is not documented, as set forth in this policy, the presumption is that life-sustaining interventions, including cardiopulmonary resuscitation, are to be provided.

If treatment limitation calls for removal of ventilator, the attending physician or his/her designated physician, after consultation with the attending physician, must be present at the time of the removal. Attending physician, together with other healthcare personnel, should assist in arranging for emotional, physical and spiritual support for surrogate and family members.

Following limitation or withdrawal of life support therapy, attending physician, together with healthcare personnel, will design a supportive care plan to ensure patient's comfort, pain control and dignity.

Attending physician, who for any reason, cannot comply with the terms of a decision to forgo life-sustaining treatment shall notify the Administrator On-Call, then provide for a timely transfer of the patient to another physician and/or facility willing to comply with the wishes of the patient or the surrogate.

In the event of questions or disagreement among either patient, family, surrogate or healthcare team members about the appropriateness of the management of patient or treatment decisions, consultation should be obtained from the hospital Ethics Committee by contacting the Ethics Chair or the President of the Medical and Scientific Staff Faculty to assist in resolving the issue.

The attending physician formally determines that the patient lacks decisional capacity to participate in health care decisions. A second medical opinion corroborates this determination. The attending documents this assessment in the patient's chart.

The attending physician or designee documents in the chart any and every attempt to identify an appropriate surrogate decision- maker for each patient.

If there is consensus among members of the health care team regarding the decision to withhold or withdraw life-sustaining treatment, the attending physician may write such orders and documents such consensus in the patient's chart. The attending physician should include:

a) documentation of the medical rational

• available treatments are medically futile;

• the patient is permanently unconscious

• the patient has an incurable or irreversible condition :the patient is terminally ill such that treatments will only serve to prolong the dying process; or there are indications that life-sustaining treatments conflict with the patient's wishes and/or values;

• b) clarification of the plan of care (i.e. palliation) with other involved members of the health care team.

 

• 4. If physicians or other members of the health care team identify issues of concern regarding end-of-life decisions, a formal ethics discussion of the case may be arranged by contacting the Chair of the Ethics Committee. Elective medical decisions (e.g. placement of feeding tube, discontinuation of ventilator) should be delayed until the ethics discussion has occurred.

 

If any involved staff disagree with the consensus of the formal ethics discussion, they should be encouraged and supported to take steps to remove themselves from the care of the patient. In all situations continuity of patient care will be assured. (See Hospital Policy C-20)

If it is not possible to resolve the issue through institutional processes, the matter will be referred to the hospital's legal counsel for possible court intervention.

Decisions to forgo life-sustaining treatments for infants and minors are compounded in their difficulty by the fact that these patients have never exercised decisional capacity or expressed their values and preferences regarding medical treatments. While many of the principles and procedures outlined in B-52 apply in these cases, the following procedures are recommended:

INFANTS

• 1. The normal context of decisions to forgo treatment is the physician-parent relationship.

• 2. The best interests of the infant normally include such factors as relief of suffering, preservation and restoration of bodily functions, anticipated quality and extent of life sustained, and the impact of the decision on the patient's family.

• 3. In emergency situations, medical treatment, including lifesustaining therapies, should be provided to the infant.

Treatments proving to be futile may be discontinued.

• 5. When life-sustaining treatments are forgone or withdrawn from infants, infants should receive humane and dignified comfort care (warmth, food and fluids to the extent that they can be received).

6.Parents should act as surrogate decision-makers in treatment
decisions, unless:
a. they are incompetent;
b. they have unresolvable disagreement between them; or
c. their decision is clearly against the best interest of the
infant, in the attending physician's opinion.

Emotional and spiritual support should be offered to parents.

8. open communications amongst physicians, parents, and involved members of health care team is essential. Active involvement ana consensus among all professional caregivers is the preferred method of decision-making regarding treatment.

• 9. Should disagreements or conflicts about treatment arise between the healthcare team and the parents, the physician should try to resolve the disagreement, utilizing hospital resources, care conferences and ethics consultations as appropriate.

• 1. Minors should be included in decision-making to the extent of their capacity to understand the situation. The attending physician is responsible for assessing the decisional capacity. Minors should receive answers to their questions in understandable and helpful ways. Minors over the age of fourteen ordinarily are capable of making their own decisions about treatment; however, the legal responsibility for deciding care resides with the parents until they are 18 years of age. Emancipated minors (i.e. those 16 but less than 18 years of age who are living alone and financially independent or pregnant) have the right of informed consent.

• 2. In emergency situations, life-sustaining treatments should be provided. Evaluation of futility, benefits vs. burdens of treatment, etc., may be made at the earliest appropriate time.

Active involvement and consensus among all professional caregivers is the preferred method of decision-making regarding treatment.

• 4. Emotional and spiritual support should be made available to parents and other family members.

• 5. Discussion, documentation, and conflict management procedures described in B-53 apply.

• 6. The attending physician and Mercy Hospital may take steps to arrange for legal guardianship of patients without parents or legal guardians.

Physician's Orders

Resuscitation/Limitation Of Treatment Mercy Hospital and Medical Center Stevenson Expressway at King Drive Chicago, Illinois 60616-2477

Note that identifying resuscitation status does not exclude any or all specific measures listed under Limitation of Treatment. Appropriate lines in both categories I & II should be checked.

1. LIMITATION OF TREATMENT PRIO R TO/PENDING CARDIO OR PULMONARY ARI

Limitation of treatment consistent with patient management goals now includes:

• No Card ioversion/Defibri I I ation

• No Vasopressor/Inotropic Agents

• No Increase in Vasopressors

• No Intubation/Mechanical Ventilation

• No Electrolyte or Acid/Base Corrective Measures

• No Hyperalimentation by Central Venous Access

• No Alimentation via Insertion of Gastrostomy or Feeding Tube

 

• No Antiarrhythmics

• No Transfer to ICU

• No Blood/Blood Prod

• No Blood Drawing

• No Dialysis

• No Antibiotics

• No Intravenous Hyd

• Other

Comfort care is ONLY goal. In general, this implies that none of the above will be initiated.

11. RESUSCITATION STATUS IN THE EVENT OF CARDIO OR PULMONARY ARREST

• Do Not Resuscitate - DO NOT initiate external cardiac massage, emergency life support medications, artificial ventilation or deribrillation.

This decision was based on:

• Verbal Directives of Patient - Living Will Power of Attorney Legal Gua

- Directives of Surrogate - Date of Discussion

- Other (Please Specify):

Physician Completing Form

Attending Physician's Signature

Date

Date

If there are multiple changes required, based on the patient's improvements, please complete another Physician's Orders kesuscitation/Limitation of Treatment Form.

FORM NO. 05.48-07193-1 REORDER NO. 04169



Advance Directive is it Written document which (it) gives instructions to health care provider its to tile patient's wishes or (b) designates another person (surrogate) Io make health care decisions (in' behalf' of the patient if the patient loses decision-making capacity or cc) both.

Artificial Nutrition and Hydration means supplying food and water through a conduit. such as a tube or intravenous line. where the recipient is not required to chew or swallow voluntarily . including but not limited to, nasogastric tube,,. Last rostoni ies, jejunostonlies. and intravenous infusions. Artificial nutrition and hydration does not includeassisteJ feeding. such as spoon or bottle feeding.

Benefit/Burden means it treatment would be considered morally obligatory when tile benefits hoped for or obtained are proportionate to the burdens. A treatment is not morally obligatory (thOL14111 it may still be employed) if it is of' little or no benefit or if the burdens outweigh the benefits. Burdens may be physical, psychological. social, spiritual financial and are normally judged in relation to the total well-being of the patient. Both the benefits and burdens are determined from the patient's perspective.

Comfort Care means patient management in those instances when the primary goal is to maximize the patient*s comfort as he/she is dying. Certain obligatory procedures will be provided that include but are not limited to airway maintenance. oxygen by face mask or nasal catheter, food and drink by mouth if tolerated. medication and treatment for pain, maintenance of body warmth, bodily re positioning, bodily cleanliness (including oral and eye care). verbaly and tactile communication, and psycho-spiritual care.

Decisional Capacity means the ability to understand and appreciate the nature and consequences of' a decision regarding foregoing life-sustaininty treatment and the ability to reach and communicate an informed decision in the matter its determined by the attending physician. A diagnosis of mental illness or mental retardation in and of itself. does not mean that the patient lacks decisional capacity. Lack of' decisional capacity must be documented in the patient's medical record by the attending physician and one other concurring licensed physician.

Forego Life-Sustaining Treatment means to withhold. withdraw, or terminate all or my portion of' life-sustaining treatment with knowledge that (he patient's death is likely to result.

 

Hierarchy of Surrogate Decision Makers means that the following order of' priority is to be followed in making treatment decisions when indicated: 1) Guardian 2) Spouse 3) Adult Son or Daughter 4) Parent 5) Adult Sibling 6) Adult Grandchild 7) Close Friend 8) Guardian of' Estate,

Non-Beneficial Treatment any therapy which does little or nothing to promote the patient's overall well-being. A treatment which produces its intended physiological effect may still be considered non-beneficial to the overall good of' tile patient.

Life-Sustaining Treatment means any medical treatment, procedure, or intervention that. in the judgement of' the attending physician. when applied to it patient with a qualifying condition. would not be effective to remove the qualifying condition or would serve only to prolong the dying process. Those procedures can include, but are not limited to. assisted ventilation. renal dialysis, surgical procedures. blood transfusions. and the administration of antibiotics. and artificial nutrition and hydration. I

Limited Treatment occurs when all efforts to reverse or abate the disease process are no longer medically appropriaie and are not desired by the patient/surrocoate. AFgressive treatment ceases and. subsequently. a decision is made ahOLI( which therapies to continue in order to maintain the patient's survival as optimally as possible.

Qualifying Condition means the existence of'one or more of the following conditions in a patient documented in the patient's medical record by the attending physician and by one other concurring licensed physician:

i ) Terminal condition means an illness or injury for which there is no reasonable prospect of cure or recovery, death is imminent. and the application of life-sustaining treatment would only prolong the dying process.

2) Permanent Unconsciousness means a condition that. to a high degree of medical certainty will last permanently. without improvement. in which thought. sensation. purposeful action. social interaction and awareness of' self' and environment are absent. and for which initiating or continuing life-sustaining treatment. in light of the patient's medical condition. provide only minimal benefit.

3) Incurable or Irreversible Condition means an illness or injury for which there is no reasonable prospect of cure or recovery. that ultimately will cause the patient's death even if life-sustaining treatment is initiated or continued. that imposes severe pain or otherwise imposes an inhumane burden on the patient, and for which initiating or continuing life-sustainino treatment. in light of the patient's medical condition. provides only minimal medical benifits

Administrative

Health Care Surrogate Act Physician Certification

-Merrcy Hospital and Medical Center
Stevenson Expressway at King Drive
Chicago, Illinois 60616-2477

THE ILLINOIS HEALTHCARE SURROGATE ACT REQUIRES THIS INFORMATION

• TO BE CERTIFIED BY PHYSICIAN

Name of Patient

Room Number

1.0 After personal examination, determination has been made that the above patient:
a. Lacks Decisional Capacity and,
b. Has one or more of the following conditions:
El Terminal
El Permanent Unconsciousness
El Incurable or Irreversible Condition

Explanation

Attending Physician

Concurring Physician

2. Determination of surrogate decision maker has been made.

Name

Address

3. El

Date

Date

Telephone

Relationship

Discussion between attending physician and surrogate decision maker, as well as decision expressed by surrogate as to foregoing life-sustaining treatment for above patient, has occurred and was witnessed.

Substance of Decision

Attending Physician

Witness

Date

Date

El In Person

El Phone Conversation

El Written Authorization

• 4. El Patient was informed and did not object to the above determinations, the identity of the surrogate . decision maker and the decision whether to forego life-sustaining treatment.

FORM NO. 02.87-05!92-1 REORDER NO. 04249

Life-Sustaining Treatment means any medical treatment, procedure, or intervention that, in the judgement of the attending physician, when applied to a patient with a qualifying condition, would not be effective to remove the qualifying condition or would serve only to prolong the. dying process. Those procedures can include, but are not limited to, assisted ventilation, renal dialysis,- surgical procedures, blood transfusions, and the administration of drugs, antibiotics, and artificial nutrition and hydration.

Forego Life-Sustaining Treatment means to withhold, withdraw, or terminate all or any portion of lifesustaining treatment with knowledge that the patient's death is likely to result.

Qualifying Condition means the existence of one or more of the following conditions in a patient documented in the patient's medical record by the attending physician and by one other concurring licensed physician:

• 1) Terminal Condition means an illness or injury for which there is no reasonable prospect of cure or recovery, death is imminent, and the application of life-sustaining treatment would only prolong the dying process.

• 2) Permanent Unconsciousness means a condition that, to a high degree. of medical certainty will last permanently, without improvement, in which thought, sensation, purposeful action, social interaction and awareness of self and environment are absent, and for which initiating or continuing life-sustaining treatment, in light of the patient's medical condition, provide only minimal benefit.

• 3) Incurable or Irreversible Condition means an illness or injury for which there is no reasonable prospect of cure or recovery, that ultimately will cause the patient's death even if life-sustaining treatment is initiated or continued, that imposes severe pain or otherwise imposes an inhumane burden on the patient, and for which initiating or continuing life-sustaining treatment, in light of the patient's medical condition, provides only minimal medical benefit.

Decisional Capacity means the ability to understand and appreciate the nature and consequences of a decision regarding foregoing life-sustaining treatment and the ability to reach and communicate an informed decision in the matter as determined by the attending physician. A diagnosis of mental illness or mental retardation in and of itself, does not mean that the patient lacks decisional capacity. Lack of decisional capacity must be documented in the patient's medical record by the attending physician and one other concurring licensed physician.

Surrogate Decision-Maker means an adult individual or individuals who have decisional capacity, are available upon reasonable inquiry, are willing to make decisions regarding the foregoing of life-sustaining treatment on behalf of a patient who lacks decisional capacity and is diagnosed as suffering from a qualifying condition, and are identifed by the attending physician in accordance with the provisions of this Act as the person or persons who are to make those decisions in accordance with the provisions of this Act.

 

Hierarchy of Surrogate Decision-Makers means that the following order of priority is to be followed in making life- sustaining treatment decisions when indicated: 1) Guardian 2) Spouse 3) Adult Son or Daughter 4) Parent 5) Adult Sibling 6) Adult Grandchild 7) Close Friend 8) Guardian of the Estate.

 

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1. GENERAL
It is the policy of Mercy Hospital and Medical Center to assist patients, families and healthcare professionals in the
exercise of their rights in making decisions regarding medical treatments.

1. PURPOSE
The purpose of this policy is to provide a mechanism for addressing conflicts or ethical concerns in decision-making,
should they arise.

I. CONFLICT IN TREATMENT DECISIONS
A. Conflicts between patient and patient's family or among family members:

• 1 . Efforts should be made to settle the conflict within the family.

 

• 2. Resources within the hospital should be identified to facilitate resolution of conflict. Among those who may be helpful are physicians, nurses, social workers, chaplains, patient representatives, administration and the Medical Ethics Committee.

 

• 3. In those instances when the patient possesses decision making capacity, in accordance with legal and ethical standards, the patient's preferences should always be honored, and will be followed when the patient refuses medical tests or therapies.

• 4. In those instances when the patient lacks decision making capacity:

• a) If there is an advance directive, the patient's written instructions regarding limitation of medical

• therapies should be followed.

• b) If there is no advance directive, the Illinois Healthcare Surrogate Act (9/26/91) determines that the treatment

• decision is to be made by an appropriate surrogate, providing the surrogate is representing the patient's wishes,

• or if the wishes are unknown, is deciding in the patient's best interest. The established hierarchy for

• determining surrogacy is as follows: 1) Guardian 2) Spouse 3) Adult Son or Daughter 4) Parent 5) Adult

• Brother or Sister 6) Adult Grandchild 7) Close Friend 8) Guardian of the Estate.

• 5. If conflict regarding medical tests or therapies persists after ethics consultation has been offered, appropriate legal counsel may be sought by the parties involved.

B. Conflicts between the patient or patient's surrogate and healthcare professionals or Mercy Hospital and

Medical Center:

• 1. If the attending physician and patient or patient's surrogate disagree as to the course of treatment, if the patient or surrogate make requests for medically contraindicated treatments or that violate the values of the hospital, or if other ethical concerns regarding care of the patient arise, consultation with the Medical Ethics Committee is encouraged.

2. If after appropriate consultations, there is still disagreement, or the attending physician conscientiously objects t patient's/surrogate's decision, attending physician will notify the Administrator On-Call and then shall assist the patient or surrogate in effectuating the timely transfer of the patient to another health care provider who is willing to comply with the wishes of the patient or the surrogate or to another fi~lity designated by the patient or the surrogate (see Administrative Policy B-8).

If the policies of Mercy Hospital and Medical Center preclude compliance with a treatment decision, the hospital shall take all reasonable steps to assist the patient or surrogate in effectuating the timely transfer of the patient to a facility in which the decision can be carried out. (see Administrative Policy B-43)

IV. EMERGENCY INTERVENTION FOR NON-COMPETENT PATIENTS WITHOUT SURROGATE DECISIONMAKER

• In emergency situations when a patient lacks decisional capacity and no family /surrogate decision-maker can be found, and after all reasonable attempts to determine such availability have been exhausted and documented, the attending physician has authority to make medical decisions/interventions without any court intervention. In such instances Administrative notification/consent would be required.

The following Probate Division Statute defines such an emergency situation in this way:

• A medical or dental emergency exists when delay for the purpose of obtaining consent would endanger the life or adversely and substantially affect the health of a recipient of services. (Mental Health Code: Chapter 91-172, Sec. 2-111)

V. PURPOSE AND PROCEDURE FOR UTILIZING ET141CS CONSULTATION

• A. One purpose of the Medical Ethics Committee is to serve as a resource to make available specialized training, understanding and experience within the hospital setting for patients, families, and staff. The purpose of ethics consultations is to provide a forum in which the Ethics consultant or members of the Ethics Committee are called upon to help facilitate communication between involved parties and to help patients, family, healthcare professionals and others to surface, identify, understand and respond to a broad range of ethical concerns in the light of applicable ethical and legal standards, and with respectful consideration of cultural and religious factors that may apply.

B. Patients, family or health care professionals with concerns and questions should be directed to the Medical Ethics Chair who will confer with the appropriate parties involved and gather the necessary facts in order to determine appropriate actions. These actions may include:
1. Providing or obtaining information to resolve the concern or questions.

2. Arranging a Patient Care Conference, involving appropriate healthcare personnel which may include: Attending Physician, Resident Physician, Nursing, Social Work, Chaplaincy, Patient Representative, Administration, Ethics Consultant, Members of the Ethics Committee. If deemed advisable, family members, surrogate or legal guardian may also be invited.

C. The Medical Ethics Committee reviews all completed Ethics consultations at its regular meetings, taking care to protect patient's privacy and confidentiality in its discussions and records.