Performing Ethics Consultation: Facilitation or Recommendation?

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Performing Ethics ConsultationFacilitation or
Recommendation?

• Anita J. Tarzian, PhD, RN
• [phone]
• atarzian_at_law.umaryland.edu

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Ethics consultation precursors

• Landmark legal cases
• Presidents commission
• Baby Doe regulations
• JCAHO (Joint Commission)

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Karen Ann Quinlan (1976)

• Should the responsible attending physicians
  conclude that there is no reasonable possibility
  of Karen's ever emerging from her present
  comatose condition to a cognitive, sapient state
  and that the life-support to Karen should be
  discontinued, they shall consult with the
  hospital "Ethics Committee or like body of the
  institution in which Karen is then hospitalized.
  
• -Justice Hughes

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Presidents Commission for the Study of Ethical
Problems in Medicine Biomedical and Behavioral
Research

• Health care institutions should explore and
  evaluate various administrative arrangements
  for review and consultation, such as ethics
  committees, particularly for decisions that have
  life or death consequences. (1983)

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DHHS Baby Doe Regulations (1985)

• Strongly encouraged hospitals caring for newborns
  to establish Infant Care Review Committees
• Committees were to review cases where the
  withholding of LST for a newborn was being
  considered

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JCAHO (1995)

• Included in its standards for accreditation of
  both acute care and long term care facilities
  that they establish a mechanism for resolving
  ethical dilemmas in the institution

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Functions of ethics committees

• Policy development/review
• Education
• Consultation

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Core Competencies 2nd Ed.
bioethics

• Scope definition of ethics consultation

healthcare ethics
ethics consultation
Consults involving active patient
All other consults
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Professional organizations

• ?

• ? merged 1997

• Society for Health and Human Values (1970)
• Society for Bioethics Consultation (1986)
• American Association for Bioethics (1994)

• American Society for Bioethics Humanities
  (1998)

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Professional v. Self-taught
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Reasons for voluntary guidelines

• Lack of data surrounding the current state of
  ethics consultation
• What is special expertise?
• Lack of available outcomes data
• Voluntary guidelines are sensitive to the wide
  diversity of institutional settings where
  consultation takes place
• Voluntary guidelines can encourage gradual change
  and stimulate public discussion

ASBH (1998)
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What are the goals of health care ethics
consultation?

• To improve the provision of health care and its
  outcome through the identification, analysis and
  resolution of ethical issues as they emerge in
  clinical cases in health care institutions.

ASBHs Core Competencies for Health Care Ethics
Consultation (1998)
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General goal more likely to be achieved if
consultation accomplishes intermediary goals of
helping to

• Identify and analyze the nature of the value
  uncertainty or conflict that underlies the
  consultation
• Facilitate resolution of conflicts in a
  respectful atmosphere with attention to the
  interests, rights, and responsibilities of those
  involved.

ASBHs Core Competencies for Health Care Ethics
Consultation (1998)
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Successful health care ethics consultation will
also serve the goal of helping to

• Inform institutional efforts at policy
  development, quality improvement, appropriate
  utilization of resources by identifying causes of
  ethical problems promoting practices consistent
  with ethical norms and standards.
• Assist individuals in handling current future
  ethical problems by providing education in health
  care ethics.

ASBHs Core Competencies for Health Care Ethics
Consultation (1998)
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Table 1 Skills for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 1 Skills for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 1 Skills for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 1 Skills for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998)
Skill Area 1 ALL IN CONSULT ALL HEC
Identify nature of value uncertainty/conflict underlying need for EC A B B
Analyze value uncertainty/conflict A B B
Facilitate formal informal meetings A B B
Build moral consensus A B B
Utilize institutional structures resources to facilitate implementation of chosen option B NR NR
Document consults elicit feedback regarding process of consultation so process can be evaluated B NR NR
Listen well communicate interest, respect, support, empathy A B B
Educate involved parties regarding ethical dimensions of case B NR NR
Elicit moral views of involved parties A B B
Represent views of involved parties to others A B B
Enable involved parties to communicate effectively be heard A B B
Recognize attend to various relational barriers to communication B B B
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Table 2 Knowledge for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 2 Knowledge for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 2 Knowledge for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998) Table 2 Knowledge for Ethics Consultation (ASBH Core Competencies for Health Care Ethics Consultation, 1998)
Knowledge Area 1 ALL AC
Moral reasoning ethical theory r/t ethics consultation A B NR
Bioethical issues/concepts that typically emerge in ethics consultation A B NR
Health care systems r/t ethics consultation B B NR
Clinical context r/t ethics consultation B B NR
Health care institution in which the consultants work, as it r/t ethics consultation B B NR
Local health care institutions policies relevant for ethics consultation B B NR
Beliefs perspectives of patient staff population where one does ethics consultation B B NR
Relevant codes of ethics, professional conduct guidelines of accrediting organizations as they relate to ethics consultation B NR NR
Health law relevant to ethics consultation B B NR
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Adoption by bioethics programs
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Characteristics of consultants
consultsMARYLAND, 1997

• 27 HECs had trained philosopher/bioethicist
• 2/3 had written criteria for who could perform EC
• HEC membership (20)
• Hospital employee (14)
• Time on ethics committee (11)
• Training/apprentice (11)
• Bioethics education (9)
• 24 had performed no consults in 97
• Mean 5, median/mode 3 consults in 97
• 62 had no formal bioethics education
• 82 had not attended a bioethics insx in 97

Hoffmann, D.E., Tarzian, A.J. ONeil, A.
(2000). Are Ethics Committee Members Competent to
Consult? JLME, 28, 30-40.
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Characteristics of consultants consultsU.S.
HOSPITALS, 1999

• 81 had an ethics consult service
• Median ethics consults 3/yr (range 0-300)
• 22 had performed no consults prior year
• 90 had performed lt 25 consults prior year
• 29,000 persons ? 314,000 consult hours
• 5 ECs completed BE fellowship/graduate program
• 41 had formal, direct supervision
• 45 learned independently
• 72 documented consult in medical record
• 28 had formally evaluated consults

Fox, E., Myers, S., Pearlman, R.A. (2007).
Ethics consultation in United States Hospitals A
National Survey. AJOB, 7(2), 1-14.
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Media Scrutiny
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State laws

• Thaddeus Mason Pope, Legal Briefing Healthcare
  Ethics Committees, The Journal of Clinical
  Ethics 22, no. 1 (Spring 2011) 74-93.
• http//www.thaddeuspope.com/images/Pope_-_JCE_22_1
  _HEC_FINAL.pdf

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Professionalization of Ethics ConsultantsASBH

• Development of a Code of Ethics
• ACES survey
• Core Competencies Update Task Force
• ASBH Clinical Ethics Consultation Affinity Group
  (CECAG)
• ASBH Clinical Ethics Consultation Affairs (CECA)
  Standing Committee
• Exploring certification/accreditation
• Code of Ethics

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Other initiatives

• Montefiores Working Group
• Hospital credentialing/privileging
• Demonstrate competence via chart note?
• Canadas PHEEP
• Practicing Healthcare Ethicists Exploring
  Professionalization)
• http//www.bioethics.ca/pheep.html

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Chidwick, et al. (2010). Exploring a Model Role
Description for Ethicists. HEC Forum, 22,
31-40.
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Integrated Ethics

• Catholic Healthcare
• Ethics champion programs
• VAs IntegratedEthics
• http//www.ethics.va.gov/integratedethics/
• University of Toronto Hub Spokes model
• MacRae, S. et al. (2005). Clinical bioethics
  integration, sustainability, and accountability
  the Hub and Spokes Strategy. J. Med.Ethics, 31
  256-261.
• Kaiser Permanente

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Core Competencies (2nd Ed)
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Domains of Ethics Concerns Questions

• Ethics Domains

• Examples of Questions

• Shared decision making with patients
• Ethical practices in end-of-life care
• Ethical practices at the beginning of life

• When should a patient with intellectual
  disability be allowed to consent?
• Who should be authorized to make decisions on
  behalf of this incapacitated patient?
• Should CPR attempts be withheld without
  permission?
• Is stopping enteral feedings for a patient
  ethically justified?
• Is comfort care alone an option for an ELBW
  premature infant?

Core Competencies for Health Care Ethics
Consultation (2011). 2nd Ed. Glenview, IL ASBH.
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Domains of Ethics Concerns Questions

• Ethics Domains

• Examples of Questions

• Patient privacy confidentiality
• Ethical practices in resource allocation

• Should a woman be allowed to keep her sons HIV
  status secret from the childs father?
• Should a physician seek permission from a
  patient before using the patients case for
  teaching?
• How should ICU beds be triaged?
• Is bedside rationing ethically justifiable?

Core Competencies for Health Care Ethics
Consultation (2011).
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Domains of Ethics Concerns Questions

• Domains

• Questions

• Ethical practices in the everyday workplace
• Professionalism in patient care

• What should be done about a verbally abusive
  surgeon?
• When is it ethically justifiable for a nurse
  refuse to implement an order he/she finds morally
  objectionable?
• What gifts from pharmaceutical companies to
  health care providers, if any, are ethically
  acceptable?
• When are overlapping professional-personal
  relationships inappropriate?

Core Competencies for Health Care Ethics
Consultation (2011).
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Core Competencies 2nd Ed.

• Change to case vs. non-case instead of case
  vs. organizational ethics
• Integrating ethics within institution

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Core Competencies 2nd Ed.

• Clarify facilitation approach
• Case dictates skills needed
• Examples mediation, sharing ethics expertise
• What about recommendation?

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CASE STUDY

• 68 year old man with multiple co-morbidities
  being treated in ICU after suffering severe
  hemorrhagic stroke
• No surgical options available
• Doctors consider his condition to be terminal
• Currently on ventilator, receiving continuous
  dialysis, with full code status no advance
  directive
• 89 year old father, at times forgetful, accuses
  physicians of wanting to kill his son believes
  his son can pull through
• Patient has lived with father for past several
  years 2 sisters (not close to patient) claim he
  would not want to be kept alive on machines
• Ethics consultation request Who is appropriate
  decision-maker?

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Core Competencies 2nd Ed.

• Process standards identified
• Policy
• Access
• Known available to patients/families/staff
• Hours of access turn-around time
• Logistics of making request
• Process
• Who does intake?
• How is request clarified?
• Who responds?
• How is it decided if formal meeting required?
• Who is invited? Who is notified?
• Are roles of staff in consults clarified?

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Core Competencies 2nd Ed.

• Documentation
• What records are kept for consult
  service/committee?
• What is recorded in medical record?
• Does documentation include ethical analysis?
• Evaluation/Quality improvement
• How is consult evaluated and improved?
• How are outcomes measured?

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Core Competencies 2nd Ed.

• Recognize necessity of QI knowledge/skills

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Core Competencies 2nd Ed.

• Recognize emerging trends
• Importance of role definition for consultants
• Overlap with palliative care
• Remote consults/rural ethics

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Core Competencies 2nd Ed.Professional Ethics

• 1998 CC
• Disclosure or recusal if personal or professional
  relationship could lead to bias
• Never serve on cases in which EC has clinical
  and/or administrative responsibility
• Never exploit persons served by using ECs
  position of power
• Manage conflicts of interest

• CC Revision
• Confidentiality
• E-mail
• Teaching cases
• Public statements
• Conflicts of obligation
• Scope of righting wrongs

Check ASBH website for Code of Ethics
updates! www.asbh.org
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Ongoing discussion

• How do ethics consultants bring most value?
• Are there different expectations for volunteer
  versus paid HCE consultants?
• Incentive to use paid staff (more consults at
  expense of staff ethics proficiency? Or
  win-win?)