Ethics committees and decisions to limit care. The experience at the Massachusetts General Hospital

Abstract

Decisions to limit care for terminally ill patients present a number of ethical and legal issues. For the past 13 years, the Optimum Care Committee (OCC) of the Massachusetts General Hospital, Boston, has provided advice for physicians faced with such issues. I have reviewed the experience of the committee with the 73 cases on which it provided consultation from 1974 through 1986. In addition, I have compared these cases with those of all 113 patients at the Massachusetts General Hospital who were accorded do-not-resuscitate status without OCC input during a three-month period and found that the two groups differed significantly on a number of clinical variables. I have also found that the OCC cases fall into six categories, each of which presents different ethical and legal issues. In addition, the use of the OCC within the hospital is increasing especially with regard to certain categories of cases. The committee has dealt with controversial issues in a consistent and ethically forthright manner, but legal and moral questions remain. More discussion of the role of ethics committees in withdrawal-of-care cases is needed.

KIE: In this study of ethics committee functioning, the medical records of every consultation completed in the years 1974-1986 by Massachusetts General Hospital's Optimum Care Committee (OCC) were reviewed. These 73 cases were then compared with the records of 113 patients who were coded do-not-resuscitate (DNR) at Massachusetts General in 1986-1987 without consultation by the OCC. The 73 OCC consultations, five of which are presented here, were classified by Brennan into six broad categories on the basis of the decision made by the committee and the attending physician. Many of these cases involved incompetent patients. Brennan comments that consultation with the OCC is increasing, and that the committee has consistently applied ethical principles, particularly the concept of beneficence, to difficult and sometimes controversial cases.