AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

2018 Conley Ethics Essay Contest

Background

Established by the John Conley Foundation for Ethics and Philosophy in Medicine, this annual essay contest was administered by the AMA Journal of Ethics since 2004.
Each spring, the AMA Journal of Ethics poses a question in ethics and professionalism as the topic for the contest. Essays are judged on clarity of writing, responsiveness to questions posed in the essay prompt, and applicability to decisions presented in the case. The author of the best essay receives a prize of $5,000. The author of the winning essay is typically contacted within six weeks of the submission deadline and must be willing, if needed, to revise the essays at the request of AMA Journal of Ethics editorial staff in order to have the work published in the journal.
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Eligibility Requirements

Currently enrolled US medical students (MD and DO), resident physicians or fellows are eligible to submit entries. Entries must not have been previously published in print or electronic format and must not have been submitted to any other publication.

Format Requirements

Essays must not exceed 1,500 words, excluding references. Essays must be written by a single author, typed, and double-spaced.

Cover Page Requirements

The first page of the single Word document file must be the cover page, which must include the authorís name, address, telephone number, e-mail address, medical school (and year in medical school) or specialty training program (and year in training program), as well as the word count of the essay (excluding cover page and references), which must be tabulated as follows: In Word, on the Review tab in the Proofing group, click the Word Count icon or use Ctrl+Shift+G. This information must be included on the cover page only; essays including the authorís name on other pages of the essay will not be reviewed.

Submission Requirements

Essays must be submitted as one Word document file attached to an e-mail to Mr. Kelly Shaw. The Word document file name must be the authorís last name only. All materials must be received by 5 PM central time on 25 September 2018, as marked by email time-stamp when received by the AMA. Authors who have waited even until 4:55 PM, for example, to submit materials have occasionally been disappointed, due to transmission delays, so please plan accordingly.

Case

When There’s No One to Whom to Disclose an Error, How Should an Error be Handled?
An 82-year-old man is brought to the Emergency Department with altered mental status, fever, and cough after being found on the street. He cannot be identified and is presumed to be homeless. He is admitted to the ICU for severe pneumonia with developing acute respiratory distress syndrome, and he requires intubation. After his admission, he has a cardiac arrest. In responding to his cardiac arrest, a communication error transpires.
One nurse, who just spoke with another ICU patientís family, conveys verbally to physicians and others on the team that this patientís family agrees to the team not attempting to resuscitate him. Another physician, Dr. K, overhears the nurseís verbal conveyance of this information and assumes (erroneously) that an order not to attempt resuscitation on the 82-year-old patient has just been clarified. So, when the 82-year-old patient suffers cardiac arrest, the team does not attempt to resuscitate him. After 5 minutes, Dr. K learns that the Do Not Attempt Resuscitation (DNAR) message was for a different patient, and though the 82-year-old patient is now hypoxic, Dr. K leads the team in successfully resuscitating him.
Shortly thereafter, however, the 82-year-old patient has another cardiac arrest; again, he is revived with CPR. Dr. K, is concerned that he will have recurrent cardiac arrests secondary to hypoxia. However, nothing is known about his values or preferences, and he continues to have altered mental status. Dr. K believes that he has suffered irreversible brain injury from hypoxia during the first delayed resuscitation attempt. Dr. K feels that even if he were successfully resuscitated following another cardiac arrest, he would have very low quality of life.1,2 Dr. K thinks that it might now be best to change the 82-year-old patientís code status to DNAR. However, Dr. K is concerned, given the erroneous first DNAR and that the patient is unrepresented, that some members of the team might feel compelled to err on the side of providing more aggressive care. Dr. K wonders what to do next.
References
1. Rydvall A, Lynöe N. Withholding and withdrawing lifesustaining treatment: A comparative study of the ethical reasoning of physicians and the general public. Crit Care. 2008;12(1): R13.
2. Courtwright AM, Abrams J, Robinson EM. The role of hospital ethics consultation service in decision-making for unrepresented patients. J Bioeth Inq. 2017;14(2): 241-250.

 

Essay Prompt

In some cases of error, Dr. K might disclose the error to a patientís family members and apologize for the error. In this case, however, since this patient is unrepresented, thereís no disclosure opportunity or chance to express sympathy or contrition. From an ethics standpoint, how could this change this teamsí cliniciansí experiences of having been part of an error that harmed their patient? Should the moral status of an error made in the care of an unrepresented patient be regarded differently than the moral status of an error made in the care of a patient with a surrogate decision-maker? How should the team respond?