Ethics corner: cases from the Hebrew Rehabilitation Center for aged-friends.

This article begins a new six-part series in the Journal of the American Medical Directors Association devoted to medical ethics. Each issue, a case will be presented from the Ethics committee at the Hebrew Rehabilitation Center for Aged (HRCA) in Boston, Massachusetts. Following a description of the case and a discussion of the ethical issues that the case raises, Dr. Steven Levenson will discuss the implications for medical directors. Founded in 1905 as the Jewish Ladies Home for Aged, HRCA is now a 725-bed long-term care facility in Boston, Massachusetts. There is a 20-bed skilled nursing unit, with permanent residents occupying the remaining beds. The main campus also houses an outpatient clinic and adult day health program. The mean age of the inpatient population is 89 years old and the average length of stay for a permanent resident is 4 years. Medical care is provided by a closed medical staff. The HRCA is a major teaching site for the Harvard Geriatrics Fellowship Program and is home to the Research and Training Institute, whose members conduct clinical and social science research. The 12-member ethics committee is composed of representatives from psychiatry, geriatric medicine, social services, nursing, hospital administration, dietary, and the therapies (eg, physical therapy, occupational therapy, recreation, creative arts). There is also a community representative. Training and experience of ethics committee members varies from member to member, and members are encouraged to read the medical ethics literature and attend relevant educational programs. Consult requests are referred to the ethics committee chairperson, who assigns the consult to two committee members. Any staff member at HRCA may request an ethics consult to address an ethical dilemma in the care of a resident. The ethics committee consultants’ findings are discussed with the requesting party, and a report is placed in the resident’s medical record. The ethics committee meets monthly, at which time the month’s consults are discussed. A journal article is distributed at each meeting for discussion the following month. Other activities of the ethics committee have included participation in staff education programs, quality assurance initiatives in areas such as documentation of advance directives, and development of institutional policies relating to areas such as the withdrawal and withholding of treatment.