Today’s Session Objectives

1. Approaches to Social Work Ethical Decision-Making in End-of-Life CarePhase I Steve R. Wilson, Ph.D., LCSWLisa K. Jennings, Ph.D., LCSWSchool of Social WorkCalifornia State University, Long BeachEthics Across the Curriculum Project May 2011

2. Today’s Session Objectives • Describe the principles that that underlie medical ethics, including: autonomy, beneficence, non-maleficence, justice, dignity, and fidelity. • Apply ethic of confidentiality associated with end-of-life patient concerns to a practice scenario to illustrate ethical principles of dignity and autonomy.

3. NASW Code of Ethics • Service • Social Justice • Dignity and Worth of the Person • Importance of Human Relationships • Integrity • Competence

4. Core Medical Ethics • Autonomy • The patient’s right to refuse or choose their treatment. • Beneficence • Always acting in the best interest of the patient. • Non-Maleficence • “Above all, do no harm." • Justice • Fairness and equality as to who gets what treatment. • Dignity • Treating the patient, family and practitioner with respect. • Fidelity • Notions of loyalty, commitment, and trust in the relationship.

5. Essence of Social Work • Resolving ethically challenging cases mirrors the problem-solving method which is a hallmark of the social work profession: • Engagement • Data Collection • Assessment • Intervention • Evaluation • Termination • Follow-Up

6. Typical Forms of Ethical Dilemma Resolution

7. Ethics Committees • Social work is represented on 75% of hospital ethics committees. • Only 31% of hospice agencies studied have ethics committees. • Social work is represented on only 53% of these hospice ethics committees. Csikai, 2004

8. Skill Sets Needed • Ethical Assessment Skills • Including bioethics, agency policies, professional codes, religious and cultural values. • Process Skills • Effective interaction with key decision-makers. Able to facilitate fair and formal meetings. • Interpersonal Skills • Ability to listen and communicate with respect, support, and empathy for all.

9. Confidentiality & HIPPA • See handout for class discussion vignette

10. Discussion Points • Physician-Patient Privilege • Rights of Patent and Surrogate Decision-Makers • Rights of Family Members • What are the medical ethical considerations here? • What are the social work ethical considerations here?

11. Approaches to Social Work Ethical Decision-Making in End of Life CarePhase II Ethics Across the Curriculum ProjectMay 2011

12. Today’s Session Objectives • Describe the multi-step model for collaborative ethical decision-making in end of life care. • Demonstrate the ability to blend social work values and medical ethics to make sound ethical decisions involving patients and their families. • Apply the ethical decision making framework to a patient case in a logical manner, reflecting interdisciplinary collaboration.

13. Review of Phase I components • Medical Ethics • HIPAA Privacy Guidelines • NASW Code of Ethics • Historical Overview • Ethical Challenges in healthcare social work

14. Ethics Training • Are there opportunities for training on ethical decision making? • In your field placement? • Community Seminars? • Seminars by Employer?

15. The Collaborative Ethical Decision-Making Framework

16. The Collaborative Ethical Decision-Making Model • Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation. • Determine issues that present the ethical problem. • Consider alternatives available for implementation, weighing positives and negatives of each. • Consult with professional colleagues and/or experts with knowledge about this or similar situations. • Review alternatives with patient and family and document accordingly. • Implement the best alternative given the circumstances and the environment. • Monitor, evaluate, and document the decision.

17. Step #1 • Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation. • Conduct a thorough psychosocial assessment. • Know the facts.

18. Step #2 • Determine issues that present the ethical problem. • Clear assessment is key. • Clearly and concisely communicate your presenting problem from your professional assessment.

19. Assessment Information • Medical Indications • Patient Preferences • Quality of Life • Contextual Issues • Morality Issues

20. Step #3 • Consider alternatives available for implementation, weighing positives and negatives of each. • We don’t need another well-defined problem. • Consider solutions to present to the ethics team.

21. Step #4 • Consult with professional colleagues and/or experts with knowledge about this or similar situations. • No Lone Rangers - Collaboration is key. • Use ethical consultants or committees for problem-solving. • Avoid territoriality and professional rivalry.

22. Step #5 • Review alternatives with patient and family and document accordingly. • Congruent with hospice philosophy and social work ethics. • Communication is vital to maintaining healthy professional relationships with patients and families. • Honor the dignity of autonomy.

23. Step #6 • Implement the “best” (most functional) alternative given the circumstances and the environment. • Based on input from professionals and family, and with respect for medical and social work ethical principles, introduce the alternative that is the most viable given the circumstances. • Leave your own values, opinions, and judgments at the door. • Implementation plans are subject to change at any time, without notice.

24. Step #7 • Monitor, evaluate, and document the decision. • Document, document, document. • Monitor for new dilemmas, while moving forward on other day-to-day matters. • Debrief – Engage in a Retrospective Review

25. Case Example #1 (see handout) • “Shiela” • 59-year old African American female • History of Depression • Family wants aggressive care • Patient wants palliative/hospice care • Husband invalidates Shiela’s health-related wishes

26. Session Wrap-up • Review of today’s topics • Assign case(s) for homework • Suggested reading to prepare for Phase III

27. Module Objectives • Build upon knowledge from Phase I and Phase II to practice Ethical Decision-Making as Team Leaders. • Apply an ethical decision making framework to a patient cases in a logical manner, reflecting interdisciplinary collaboration. • Discuss the ethical leadership role in complex end-of-life care cases.

28. Approaches to Social Work Ethical Decision-Making in End of Life CarePhase III Ethics Across the Curriculum ProjectMay 2011

29. Review of Modules I and II

30. NASW Code of Ethics • Service • Social Justice • Dignity and Worth of the Person • Importance of Human Relationships • Integrity • Competence

31. Core Medical Ethics • Autonomy • The patient’s right to refuse or choose their treatment. • Beneficence • Always acting in the best interest of the patient. • Non-Maleficence • “Above all, do no harm." • Justice • Fairness and equality as to who gets what treatment. • Dignity • Treating the patient, family and practitioner with respect. • Fidelity • Notions of loyalty, commitment, and trust in the relationship.

32. The Collaborative Ethical Decision-Making Framework

33. The Collaborative Ethical Decision-Making Model • Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation. • Determine issues that present the ethical problem. • Consider alternatives available for implementation, weighing positives and negatives of each. • Consult with professional colleagues and/or experts with knowledge about this or similar situations. • Review alternatives with patient and family and document accordingly. • Implement the best alternative given the circumstances and the environment. • Monitor, evaluate, and document the decision.

34. Case Example #2 Graciela and Marco

35. Case # 2 Discussion Prompts • How does cultural competence in health care enter into the ethical decision making process? • In what ways can the discussion about hospice from the social worker and the medical team address the following? • Exploring both the disease and the illness experience • Understanding the whole person • Being realistic about the prognosis

36. Case Example #3 Ronald

37. Case #3 Discussion Prompts • What ethical dilemmas are present in this case? • Had depression rendered him incapable of making a legitimate life-and-death decision? • Is Ronald able to give consent? • What are appropriate steps for the social worker to take?

38. Debriefing & Ethics Module Wrap-up

39. OK…Now Let’s Hear From You… • Let’s walk through some examples from your experience in hospice agencies and field settings. • Examples from your agency? • How can a model like this work at your hospice with social work as the lead?

40. Discussion Prompts • Reflective Evaluation • What are the major challenges of ethical situations in end-of-life care? • How can social workers manage complex cases? • How can social workers take on a larger leadership role in medical ethics teams and committees?

41. Continuing Education • Develop a personal plan for continued ethics training and development. • Develop a professional network of colleagues to discuss ethical dilemmas and possible solutions.

42. Thank you for your participation! Ethics Across the Curriculum Project May 2011