Local doctors are frequently plagued with ethical questions in their normal everyday work life, such as whether to advise a frail elderly person to have major surgery or simply face the inevitable.

And while that decision can be put in the hands of the patient, what should a doctor do if a sickly elderly person needs a piece of equipment to remain alive that a sickly three-month old baby also needs?

Suppose there's just one of those units on the Island, who should get it? And should the situation be explained to both families?

Questions this tough don't present themselves every day but they do arise. Co-chair of King Edward VII Memorial Hospital's Ethics Board is Dr. Roslyn Bascombe. She said, in celebration of Ethics Week this week, the committee is highlighting ethical decision making for the extremes of life. According to Dr. Bascombe, many of the ethical questions that arise at these times are the same. They can range from informed consent, to the right to resuscitate to advance directives and even bedside manner.

Informed consent

This involves a responsible adult understanding the medical procedure being recommended to them and giving clinicians permission either verbally or in writing, to do it to themselves or to their ward. Only adults can legally consent to treatment in Bermuda. Adults must be at least 18 years old. A 17-year-old girl in labour is not at liberty to say she wants an epidural. Her parent or guardian would have to consent.

Informed consent also includes the patient's right to:

¦ know the purpose and nature of the procedure/course of treatment;

¦ know the risks and uncertainties of the procedure/course of treatment;

¦ be aware of the benefits of the procedure/course of treatment;

¦ be apprised of the possible side effects of treatment;

¦ know that they have the right to stop a procedure/course of treatment once it has begun;

¦ know about any medically acceptable alternatives to the procedure/course of treatment;

¦ and to be aware of the risks in not having the procedure/course of treatment.

Advance directives

As its name suggests, advance directives are plans made in anticipation of possible outcomes. Dr. Bascombe said: "These are written instructions that a person makes, with a witness, which describe what that person would like done to them medically if they are ever in a state where they are alive but cannot speak for themselves.

They are used in situations where the person's quality or quantity of life will not be improved with any further known medical treatment.

In the case of newborns the parents make the decision, unless those parents are underage.

The situation is not as clear-cut for adults.

Advance directives may be made with a lawyer or by filling out a special form available at KEMH and MAWI. But, according to Dr. Bascombe, this does not ensure that the document will be followed should the patient find himself or herself in an unresponsive state.

"They (the clinicians) will try to follow the patient's directives at all times but it is something that has to be weighed between whether the decision they made was done with the full understanding of what the current situation is," she said. "Because, what we've found, and not just us but around the world, is that you get advance directives that have not been revised and, over time, medical advances have been made that may make something potentially reversible. But the advance directive was not updated. So, ultimately, the responsibility lies with he clinician but we encourage that at all times the patient's wishes should be kept paramount," she added.

Bedside manner

Good bedside manner is not a prerequisite for hospital staff at KEMH or MAWI but Dr. Bascombe admitted that there have been cases where local families suffered significant emotional trauma because staff or attending doctors were insensitive.

To address the problem, the ethics committee has arranged lectures but attendance is not mandatory.

A pamphlet with advice on how to break bad news is in the making and the committee hope to release it this week. It will include tips like the importance of having the right people around in terms of family support, choosing the right location to deliver the news – it should be quiet with minimal interruptions and preparing the person for the delivery of the bad news.

Hypothetical ethical issues hospital staff might have to consider, Page 26