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Professionalism, Ethics and the Late Pediatric Patient: 
How Can We Balance Compassion and Efficiency?

Pediatric clinics in a setting marked by poverty, social disruption, and chronic illness are tough management puzzles.  One ever-present and never-simple problem is the late patient.  How can care providers, clinic management, front desk staff and the patients themselves work together to find a balance between efficiency and honest, compassionate accommodation of the real world difficulties our patients experience?
The ethics issues that arise include concerns such as balancing the competing interests of patients – specifically the late patient who needs care and the on-time patient,  promoting fairness while recognizing that all families are not the same, respecting the needs and experience of the clinic staff while protecting the well-being of sick children and making sure not to punish children for their parent’s errors.
This discussion will include a panel of stakeholders in the clinic – providers, managers and front desk staff.

Tuesday, February 16, 2016
12:00pm - 1:15pm
Location: Johns Hopkins Hospital
Sheik Zayed Tower

Zayed 2117 (Arcade)
Lunch will be provided
Click here for a full list of upcoming Ethics for Lunch: Case Presentations and Discussions

Summary of our previous Ethics for Lunch:
"Is it Ethically Permissible to Unilaterally Declare CPR a Medically Ineffective Treatment?"

Presented January 19, 2016 / Video Available Online

Panelists: Mark T. Hughes, Cynda Hylton Rushton,Thomas Y. (Ty) Crowe, Margaret Garrett, and Helen Michalisko

The last Ethics for Lunch explored the issue of whether the healthcare team can invoke the policy on medically ineffective treatment for cardiopulmonary resuscitation (CPR) in a critically ill, incapacitated patient who had previously expressed the desire for life-sustaining treatments and whose family continued to support this approach. Here are key points to consider in these cases:

1. The Do Not (Attempt to) Resuscitate Order (DNR) is a set of orders resulting from discussions with the patient or surrogate and approved by the attending physician that specifically describes the protocols or modalities that will be provided, limited, or withheld in the event of cardiopulmonary arrest. The Johns Hopkins Hospital policy on DNR orders can be found at (PAT005) Do Not Resuscitate Orders.

2. Generally speaking, if the goals of care in a particular case cannot be attained, then the therapy can be considered ineffective. This determination includes both objective and subjective data. According to the Annotated Code of Maryland, medically ineffective treatment legally means that “to a reasonable degree of medical certainty, a medical procedure will not: (1) Prevent or reduce the deterioration of the health of the individual; or (2) prevent the impending death of an individual.” A physicians is not legally obligated to provide medically ineffective treatment. The Johns Hopkins Hospital policy on Futile or Medically Ineffective Treatment can be found at (MEL004) Futile or Medically Ineffective Treatment.

3. The decision to withhold CPR should occur after a discussion of the goals of care with the patient or appropriate surrogate taking into account the patient’s values and preferences and the medical team’s recommendation regarding resuscitation based on the patient’s prognosis. As part of this process, it is important to find out what the patient and family are hopeful for and what their expectations are. The team should take time to understand the patient and family perspective. The team should not just “talk to” the family but should also listen to the family. This is one of the roles of the ethics consultants.

4. Context matters in determining how to resolve cases in which there is ethical conflict or concern. Clinicians should incorporate cultural competency and humility into their deliberations with patients and families in order to deliver patient and family centered care. Many families approach end-of-life decisions through the lens of their faith – the health care team should make a referral to a chaplain who can support this conversation.

5. It is important to understand how individuals and families function within systems and in the community, as well as role responsibilities and dynamics within the family system. The team should understand what their support networks are, if any, and recognize the emotions associated with these situations as they often involve feelings of fear, uncertainty, loss, and anticipatory grief.

6. The team should strive to reach consensus amongst its members in providing recommendation to the patient and family. Family members may latch on to a specific comment by one team member.

7. Team members should recognize their own stress or moral distress in caring for these patients and seek out support as necessary. The hierarchical nature of the professional and academic environment may create vulnerabilities impacting one’s ability to speak openly about his or her opinions on the care of the patient. Clinicians who build moral resilience can help reduce the chances of burnout. Resources such as the Resiliency In Stressful Events (R.I.S.E.) team or debriefing sessions facilitated by ethics consultants may be useful.


Meghan D'Angelo RN, MSN, CPN
Assistant Nurse Manager, Rubenstein Child Health Building
Margaret Moon, MD, MPH
Associate Professor of Pediatrics, Associate VIce-Chair for Professional Practice, Johns Hopkins Children's Center Freeman Family Scholar in Clinical Ethics, Johns Hopkins Berman Institute of Bioethics
Sharon Pearson
Lead Patient Service Coordinator Harriet Lane Primary Care Clinic
Barry Solomon, MD, MPH
Assistant Dean for Student Affairs Associate Professor of Pediatrics Medical Director, Harriet Lane Clinic Division of General Pediatrics & Adolescent Medicine

The Johns Hopkins Hospital Ethics Committee and 
Consultation Service

Cynda Rushton, RN, PhD, Co-Chair
Mark T. Hughes, MD, MA, Co-Chair

Janyne Althaus, MD
Zackary Berger, MD, PhD
Lynn Billing, RN
Renee Boss, MD
Andrew Cameron, MD
Michael Clark, MD
William Conley, MD
Ty Crowe, MDiv
Marina Dackman, RN
Lee Daugherty, MD, MPH
Shirley Davis
Daniel Finkelstein, MD, MA
Margaret Garrett, BSN, MED, JD
Chris Grybauskas, MD
J. Alex Haller, Jr., MD
Jane E. Hill, MPH
Joan Kub, RN, PhD
Melissa Kurtz, MSN, MA, RN
Sharon Mears, MS, Secretary
Helen Michalisko, MSW, LCSW-C
Redonda Miller, MD
Etan Mintz
Margaret Moon, MD, MPH
Jacek Mostwin, MD, DPhil
Marie T Nolan, PhD, RN
Matt Norvell, MDiv
Sharon Owens, ACNP-BS, PhD
Timothy M Pawlik, MD, MPH
John VPR Ponnala, MA, BD
Kevin Riggs, MD
Jack Schwartz, JD
Tsvi Schur, DCPC
Caryl Siems
Thomas Smith, MD
Robert D Stevens, MD, PhD
Krista Stranz, MSW, LGSW-C
Lode J Swinnen, MD
Peter B. Terry, MD, MA
Alison Turnbull, DVM, MPH, PhD
Janice Wallop, MSN, ACNP-BC
Susan Ziegfeld, PhD, ACNP


Johns Hopkins Berman Institute of Bioethics

Joseph Ali, JD
Mary Catherine Beach, MD, MPH
Zackary Berger, MD, PhD
Betty Black, PhD
Hilary Bok, PhD
Renee Boss, MD
Joseph Carrese, MD, MPH
Matthew DeCamp, MD, PhD
Ruth Faden, PhD, MPH, Director
Jessica Fanzo, PhD
Daniel Finkelstein, MD, MA
Thomas Finucane, MD
Gail Geller, ScD, MHS
Carlton Haywood, Jr, PhD, MA
Leslie Meltzer Henry, JD, MSc
Mark T. Hughes, MD, MA
Adnan Hyder, MD, PhD, MPH
Gail Javitt, JD, MPH
Jeffrey Kahn, PhD, MPH
Nancy Kass, ScD
Michelle Lewis, MD, JD
Debra Mathews, PhD, MA
Maria Merritt, PhD
Margaret Moon, MD, MPH
Marie Nolan, PhD, MPH
Peter V. Rabins, MD, MPH
Travis N. Reider, PhD
Alan Regenberg, MBE
Joanne Rodgers, MS
Karen Rothenberg, JD, MPA
Leonard Rubenstein, JD
Cynda Rushton, RN, PhD
Brendan Saloner, PhD
Andrew Siegel, JD, PhD
Jeremy Sugarman, MD, MPH, MA
Holly Taylor, PhD, MPH
Peter Terry, MD, MS
Yoram Unguru, MD, MA, MS


Follow this link for a full list of upcoming
Ethics for Lunch:
Case Presentations
and Discussions
Johns Hopkins Berman Institute of Bioethics

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