Saturday Morning in the Clinic

Adecade ago Mark Bliton and Stuart Finder suggested that clinical ethics consultants be "persistently guided" by the question "What do I need to know?"¹ Exploration of this question, they argued, is critical for two reasons. First, it helps consultants to figure out why the ethics consultation was requested in the first place, as well as to understand the details of the situation. Secondly, the conversation it prompts with the primary participants—patient, family, physicians, nurses—is the only way to elicit what they find "troubling and in need of resolution, and therefore what aftermaths they can live with in the light of what is most worthwhile to, and for, them."

Relatively novice at the practice of clinical ethics consultation, we are a junior faculty member tracking toward tenure and a graduate student/ethics fellow training in the practice of ethics consultations and moving toward completion of a dissertation. In addition to our various other medical school obligations, we regularly carry the ethics pager, and when called—usually by a nurse or a resident—we come, oriented each time by this primary question: What do we need to know?

This was our first thought when our pager started beeping around 7:30 on a recent Saturday morning. The surgical resident requesting an ethics consultation needed "ethics help" on the case of Mrs. K, a seventy-one-year-old woman who had been in the surgical intensive care unit for eleven days following treatment for a small bowel obstruction. Throughout her hospital stay, Mrs. K had told various members of her care team that she would "rather die than have a colostomy bag." During the early hours of this Saturday morning, Mrs. K had become septic and unconscious due to the presumed rupture of her small bowel. The resident told us that she required surgery on her previously resected intestine, likely resulting in an ostomy, to save her life. He indicated his desire to respect Mrs. K's stated wishes by not performing the surgery, but he thought he should first consult the ethics service, since failure to operate would result in the patient's death. We agreed to meet him in the ICU as soon as possible and also urged him to contact Mrs. K's husband—and surrogate decision-maker—to update him on his wife's status.

To Consent?

Trained in law and religion and philosophy, neither of us ever feels completely comfortable in the environment of the medical clinic. It is a foreign land, marked by strange, loud noises and permeated by a harried pace. To those untrained in medicine and unfamiliar with the daily contours of such an intense place, this landscape can be disorienting.

We arrived on the scene about an hour after being paged, and we immediately noticed Mr. K's numbed expression as he sat at his wife's bedside, elbows on his knees, his hands propping up his disheveled head. He had arrived in the ICU about thirty minutes before us, and during the intervening time, the attending surgeon had explained the urgency of Mrs. K's compromised status. We were told by the resident who had paged us that the attending surgeon had presented Mr. K with a consent form for his wife's surgery, and that Mr. K had signed it. As we attempted to get our bearings, preparations for Mrs. K's surgery were already underway.

During our earlier conversation with the surgical resident, he had been clear about his understanding of Mrs. K's unequivocal desire to decline any surgery that would result in an ostomy. The preparation for surgery thus struck us as odd, so we approached Mr. K to learn more about the decision he had just made on his wife's behalf. He said quite plainly that he knew his wife would be "mad" at him once she awoke from surgery, and in fact, he believed that upon waking she would immediately "rip the bag off " herself. Married for fifty-seven years, he knew his wife's wishes, but he said the surgeon had told him that colostomies are sometimes reversible...