Ethics Committees in Nursing Homes: Applying the Hospital Experience
The need to develop effective methods for addressing ethical issues in clinical care is even greater in nursing homes than acute care hospitals. Institutionalization in itself raises a basic concern about the privacy and self-determination of long-term care patients. This is heightened by the fact that although 50-70 percent of these residents suffer some impairment of their decisional capacity, many lack legal guardians or involved family members to serve as surrogate decisionmakers.  Lack of clarity about the role of aggressive treatment, the comparative frequency with which decisions about the use of potentially life-sustaining treatment must be made, and the minimal presence of physicians in daily care in nursing homes increase the need to create institutional means to respond to the ethical dimensions of patient care in these facilities.
Ethics committees, although still rare, are being formed with growing frequency in nursing homes.  Discussion of the role and composition of these committees in the literature is based largely on experience in the acute care setting. Ethics committees in hospitals recommend institutional policies, educate participants in the decisionmaking process, consult about ethical dilemmas in individual cases, and provide emotional support for professionals who confront ethical dilemmas in patient care. While both hospitals and long-term care facilities benefit from the policy development function of ethics committees, the relative importance of the remaining functions of ethics committees differs for each. The unique ethical issues that arise in long-term care suggest that a cautious approach should be taken to applying the lessons of the hospital experience to the nursing home when developing ethics committees.
There should be a more limited need for ethics committees to review individual cases in nursing homes, since the trajectories of illness there tend to follow a more predictable course and can be more readily foreseen and planned for by residents and staff. Efforts to identify patient preferences can be initiated on admission or in the early months of placement before a crisis erupts. When patients are cognitively impaired at the time of placement, appropriate policies for identifying surrogate decisionmakers can also minimize the need for crisis-based committee review.
The high rate of staff turnover in long-term care facilities, in contrast with the greater stability of primary caregivers in the acute care setting, dictates the need for continual emphasis on education in clinical ethics in nursing homes. The educational role of ethics committees, consequently, seems even more important in nursing homes than in hospitals.
The function of providing emotional support to professionals also takes on greater significance in the nursing home context. The close relationships that can develop between nursing staff and patients make the emotional impact of ethical conflict even greater in this setting. Further, the frequency with which questions about life-extending care are faced by nursing staff, and the greater involvement of staff in the reactions of families to difficult decisions, make the need to provide emotional support especially pressing in long-term care.
The composition of ethics committees in nursing homes should also be somewhat different from that in hospitals. The former should have a substantial number of nursing staff, as well as patients or their representatives. The need for greater nursing representation on committees in long-term care facilities stems from three factors: (1) the more central role of nursing staff in directing patient care; (2) the greater knowledge nurses develop about patients, especially about the values and treatment preferences expressed earlier by patients who have become cognitively impaired; and (3) the greater burden of responsibility nursing staff often bear in meeting facility policies about end-of-life care decisions. …