|A newsletter for research & medical education||March 2014|
The "Least Worse" Option
Clinical Ethicist Peter DePergola on Making the Hard Choices
Growing up, Peter DePergola often did his homework in a small room off the Baystate ICU where his mom was manager. He remembers seeing the excruciating decisions that were being made involving some very sick people. And he wondered, "How do people figure out what the right thing to do is?"
Twenty years later, with degrees in liberal arts, theology and philosophy, ethics, and healthcare ethics, Mr. DePergola MTS, PhD(st), is now at BMC as clinical ethicist in the Division of Academic Affairs, and Lecturer in Biomedical Ethics in the Department of Medicine at Tufts University School of Medicine.
He says that fully 60% of his ethics consultations are life and death situations. Others involve such serious issues as, questions regarding medical futility, mediation in family-clinician meetings, and clarifying moral obligations in relation to goals of care.
But he stresses that any time someone is in a situation where there are conflicting values, and they just don't feel right with what is going on, they can contact him by searching for "ethics" in Web Paging on eWorkplace. "My pager is on 24 hours a day, 7 days a week," he says. "Nothing is too small."
Ethics is Not Just a List of Rules
People might think of ethics as strictly following a set of rules. But DePergola doesn't bring a rule book and say, "You’ve violated this" and "You can’t do that."
Instead, he sees his role as helping to advance a communication process that has stalemated. He ensures that the voices of the patient and family are heard, and that clinicians feel supported to make the right decision. He reassures clinicians that they are never made to do something they are truly opposed to.
What’s Possible, What’s Permissible, What’s Prudent
According to DePergola, the situation being faced during an ethics consult is usually how to make a choice between two poor options. Typically he meets with each party separately, and then gets everyone together to brainstorm a way to bridge the gap in a way that honors the values of the patient and family and the moral and professional responsibilities of clinicians. "Science tells us what is possible, the law tells us what is permissable, and ethics discerns what is prudent in light of the two."
He says he's never been part of a clinical ethics consultation that has not facilitated the conversation and moved it forward. "If we define success as helping to clarify the goals of care, examine two bad choices, eliminate the poorest choice, and settle on the least worse choice, then we are quite successful."
It’s Not All About Hot Topics Like Stem Cell Research
Another of DePergola’s roles is to provide ethics education to all clinicians at Baystate, addressing the pressing ethical issues that Baystate clinicians are actually struggling with as opposed to controversial topics that are merely interesting.
One way he identifies these issues is by implementing a clinical ethics coding system that identifies repetitive patterns in a unit's consultation requests. For example, in one recent month the PICU requested clinical ethics consultation four times, of which three had do with the moral intricacies of treating patients who attempted suicide.
He can then tailor-make in-services to remedy the specific issues that have arisen in that unit. "Through this process of identification, research, evaluation, and education, I can provide clinicians with the moral tools necessary to maximize patient care," he says.
Starting March 26 2014, he will be offering a course for clinicians and non-clinicians that explores controversial moral issues that arise in contemporary medical practices. (See sidebar)
Mr. DePergola also chairs the Conflict of Interest and Conflict of Commitment Committee and updates Baystate policy to remain current with contemporary bioethics literature.
"The hope,” he says, is that “the conversation about the right and the good at Baystate can become more robust and thorough."