With innovations in medicine, ethicists are consulted on cases without sufficient clinical knowledge or ethical precedent to call upon. Under pressure from a distraught care team, the ethicist in this case tries to justify a unilateral withdrawal of an advanced form of cardiac life support – VA-ECMO. She shares how her sense of obligation to relieve the team’s moral distress blinded her from appreciating that the patient was not "really, most sincerely dead." In consultation with the hospital’s legal counsel, the ethicist agreed that the patient did not meet strict criteria under the definition of death by circulatory criteria/cardiac death.

The patient’s family, in shock by his rapid decline following a complicated aortic dissection repair, were holding out for a miracle. Because they could see the ECMO machine pumping blood throughout his body, they struggled to believe he would never recover. The ethicist used a different strategy to resolve the conflict: She coached the team to present the medical facts in lay-person’s terms, using a commonly recognized sign of cardiac death, the flat-line. The family then accepted that patient’s native organ was gone. Since he was not a candidate for transplant, they agreed to disconnect the ECMO machine.

We describe our personal and professional struggles with an organizational ethics consultation involving thoracoabdominal normothermic regional perfusion (TA-NRP), an organ procurement technique used after circulatory death. We ultimately concluded that TA-NRP is ethically permissible (with caveats), yet we are haunted. Our advice was taken seriously, but was it the right advice? Our recommendations might have let us off the hook.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author describes a case wherein surgical instruments were reused after a prion disease case at a time when the protocol would have been to discard them. Given that there are no interventions available for this prion disease questions arose regarding disclosure, in particular when it would be required and who would be in a position to provide that disclosure.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author describes an 83-year-old woman with dementia who sustained jaw and other minor fractures post motor vehicle accident. A DNR order was written by the trauma surgeon upon her arrival. Her attending still decided to put her on oxygen (nasal cannula) because she was struggling to breathe and jaw surgery was planned. The patient’s daughter supported comfort care based on substituted judgment, but nurses were skeptical of her motives. A nurse refused a physician’s order to discontinue oxygen and begin comfort care and the author was called again. The author reflects on the responsibility of ethics consultants in patient outcomes, self-doubt, and the case’s unsettling impact on the author.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the, the author reflects on change in practice in end-of-life care and ethics consultation since the publication of the first edition. As society becomes increasingly diverse, it is important that clinical ethicists recognize that principlism and Western concepts of ethics do not serve all of the needs of the diverse populations and communities that seek care. These cases encourage us and others to stop, pause, and be curious. More often than not, we have time to foster dialogue, thoughtfully explore the consequences of potential pathways of our actions and give respect to the weightiness of death.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author reviews chapters from Volume 1 that describe ethics consultations in the perinatal and neonatal patient population. Enduring lessons from these cases include pausing before making recommendations, the value of trust and the importance of emotional intelligence and genuine self-reflection. It includes a brief discussion of how these consultations might be different today and offers suggestions for how clinical ethicists should manage the impact of the affective components of doing ethics consultation.

The chapters in this Part VII of Complex Ethics Consultations: Cases that Haunt Us are a powerful reminder that healthcare ethics consultation does not involve clinical ethics consultation alone. Organizational ethics issues can also weigh heavily on healthcare providers causing deep moral distress. The four chapters in this section reinforce enduring themes, but time and experience allow a reexamination. The first theme is the lesson of truth-telling, error disclosure, and organizational responsibility. The second is the importance of transparency in organizational decision making along with the importance of communication and coordination of care. These themes are explored in the part they played in real cases, looking at the lessons they teach; current dilemmas; the role of diversity, equity, and inclusion; and finally, the meanings for future practices. As the field of ethics consultation progresses, so too will moral distress and the need for the profession to protect its practitioners, as well as the ethicists to emotionally protect themselves. The successful future practice of ethics consultation depends on it.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author addresses the unassailable, sometimes unmentionable, common thread of deep-seated values and cultural or religious beliefs that serve as a core set of values that can define and certainly do surround us. In bioethics consultations, the process often serves as a deep dive into what is deeply embedded at the center of our behaviors, uncovering cultural, religious, or even family-held norms that underlie our individual sense of place and identity in the world around us. As ill health and disease destroy patients’ sense of autonomy and self-reliance, our core values become more apparent, and we cling more to them in efforts to exercise our will. This fact alone makes the reflection of these core values essential within ethics consultation process because they are defining for many of us. The commentary takes a deep dive into the chapter’s four haunting ethics cases centered around culture and religion and the ethical challenges that they reflect.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the authors describe a 70-year-old man who is refusing all options available to him and expresses faith that his suffering must have some meaning since it was "God’s will." The team struggled with apparently inconsistent patient expressions of turning down surgery but insisting on attempted resuscitation. The case additionally highlights the uncertainty involved in medical decision making.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author reviews four pediatrics cases, emphasizing the importance of honoring parental authority and encouraging greater investment in education to reduce bias and injustices in the clinical setting. Social and cultural identities and circumstances should be treated with more care and respect in the clinical realm, so that curiosity and empathy are front and center. The author specifies how equity and inclusion could have been enhanced in each case and provides a direction for future clinical ethics practice.

In this chapter of Complex Ethics Consultations: Cases that Haunt is, the author describes the request of a middle-aged patient with COPD for terminal ventilator withdrawal. The consult occurred soon after the author began working at a Catholic hospital. The patient’s husband objected to withdrawal, despite the fact that the patient had reasonable capacity and could mouth or write. The attending physician said he would not withdraw treatment if "there was disagreement" in the family. Upon questioning, the patient reiterated her wishes and said the team should not abide by his wishes and did not want him involved in the decision if he was objecting to her request. A week later, still on the ventilator, she declined SNF placement and her distraught husband wanted transfer. Suspicions about her husband gained traction on the unit. The author offers advice and insights for new ethics consultants. She was haunted by her inexperience, her doubt whether she was assertive enough, the narrative around her husband’s suitability as a surrogate, and some of the staff’s admonition that the consultant did sufficiently advocate for the patient.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author describes a 14-year-old girl who presents with an ectopic pregnancy. She and her family are immigrants and although the girl speaks English, many of her family members do not. She fears her family would be disgraced if the news of her pregnancy is discovered and adamantly declines suggestions to enlist her mother. The author was asked about the permissible bounds to deceive the patient’s mother in order to protect the adolescent’s confidentiality. The patient might need help with the medication and clinical follow-up. The mother was told they were treating the patient’s pain, but she doubted the team’s veracity. The author reflects on balancing truth-telling, adolescent autonomy, and respecting cultural values.

This chapter of Complex Ethics Consultations: Cases that Haunt Us delineates how to use the book to educate ethics committees, ethics consultants, and bioethics students at all stages of study. Detailed educational activities are outlined for ready use by teachers, students, clinicians, and ethicists. The chapter identifies cases in the book with similar themes, proving invaluable case-based educational material.

In this case of Complex Ethics Consultations: Cases that Haunt Us, the author recounts an ethics consultation involving a 70-year-old Roman Catholic nun in the cardiac ICU after emergency bypass and mitral valve replacement. As difficult postoperative complications began to resolve, including her respiratory function, the patient indicated that she wanted all treatments stopped, but in the past she had accepted treatments after initial reluctance. She pointed to her trach, saying she wanted it to be removed. Upon questioning by the ethics consultant, her discomfort was with the tube, not the ventilator per se. Reducing the diameter of the trach tube eased her comfort and she consented to a two-day trial. She was subsequently weaned from the vent. The author reflects on professional boundaries in ethics consultations and the risk that ethics consultants can inadvertently become stewards of the "culture of death" when they make premature assumptions.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the authors describe a baby born at 25 weeks gestational age (at a time when survival at that stage was tenuous) to an adolescent mother. The fragile preemie developed necrotizing enterocolitis that was so extensive that definitive surgical resection was impossible. With no definitive treatment and inevitable suffering without it, the recommendation to shift to comfort care was declined and ethics consultants helped to negotiate the conflict.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author describes a 24-year-old woman who was comatose with a devastating neurological injury after suffering a cardiac arrest soon after receiving chemotherapy for acute myelogenous leukemia. The treating team recommended discontinuing ICU level care and shifting to comfort care. The patient’s mother declined, saying this course of action did not align with the patient’s and her Islamic faith and requesting transfer, which was impossible due to the patient’s medical instability. The author reflects on the culture of adult medicine, in contrast to her pediatric practice. She is haunted because she worries she did a good job as an ethics consultant but was lacking as a physician. This case raises the complexities of the dual role some consultants play as clinicians and ethics consultants.

Clinical ethics consultations can be haunting. Ethics consultants have few opportunities to reflect on the affective impact of their work. This book offers detailed cases, confessions, reflections, regrets, and triumphs experienced by ethics consultants. The authors bravely share what haunts them about the complex and demanding work of ethics consultation. Consultants experience moral distress but it’s rarely discussed. Our values are woven into the consultation. We’re not always sure if this is for better or worse. One poignant case may haunt us for our entire career. The second edition of the book includes the cases written by original authors regarding neonatology, pediatrics, palliative care, psychiatry, religious and cultural values, clinical innovation, professionalism, and organizational ethics. The book includes educational activities for ethics committees, consultants, and students at all levels of study. In the second edition, new authors reflect on clinical ethics practice, highlight how our practices have changed, and reflect on equity and diversity dimensions of patient care and ethics consultations.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the authors review the ethical challenges from a Canadian context when patients in acute care settings have no skilled nursing facility to which they can be discharged. They explore the policy challenges and the real impact on patient’s lives. This case highlights how individual ethics consultants can help institutions review and revise policies.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the authors reflect on the case of a term newborn with cardiac, respiratory, skeletal, and renal anomalies. His prognosis was unclear. Just as his respiratory status begins to improve, the baby’s parents request discontinuation of mechanical ventilation, believing he faced an inevitable, protracted death. The covering NICU team requests an ethics consultation. The consultant supports the parent’s decision and the baby died in his parent’s arms. When the NICU team returns, they express great concern, believing that terminal withdrawal at this point should have been discouraged, leaving the authors haunted by the consultation.

In this chapter of Complex Ethics Consultations: Cases that Haunt Us, the author explores the complexities of maternal–fetal surgery when it was in its infancy. When spina bifida was detected at 18 weeks gestational age, the patient and her partner chose not to terminate the pregnancy. The ethics consultant explored emotional, ethical, medical, and social issues that impact her decision, including the risk of losing the pregnancy because of the surgical intervention. She lost the baby and the ethics consultant is struck by the patient’s tenderness in the midst of great loss. He digs deeply into the fragility of being human and the preciousness of sharing these experiences with patients and their families.