Preventive Ethics

1. Preventive Ethics Beyond the Basics

2. Module 3 Describing Best Ethics Practice

3. Learning Objectives • Define “best ethics practice.” • Identify the steps used to describe a best ethics practice. • Describe best ethics practices for a variety of ethics issues.

4. ISSUES Link STUDY the Issue Diagram the process behind the relevant practice Gather specific data about best practices Gather specific data about current practices Refine the improvement goal to reflect the ethics quality gap

5. Storyboard Progression Advance Directives Issue IDENTIFY an Issue Briefly summarize the issue and the source. • Ethics Issue (who, what, when, how much): Issue: A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. • Source of Issue: The Joint Commission (TJC) survey findings List the (preliminary) improvement goal. Increase assistance to primary care patients who request help with completing an advance directive. • Describe why the issue was selected as a priority by the preventive ethics team. • This ethics issue aligns with strategic goals, is expected to bring significant benefit to patients, and has a high likelihood of success. The IEC agreed with prioritization of this issue and fully supports the team’s addressing this issue.

6. Ethics Quality • Comprises practices throughout an organization that are consistent with widely accepted ethical standards, norms, or expectations for the organization and its staff • Encompasses individual and organizational practices at the level of decisions and actions, systems and processes, and environment and culture

7. Ethics Quality Gap The disparity between current practices and best practices …where “best practices” refers to an ideal practice established on the basis of widely accepted standards, norms, or expectations for the organization and its staff. The difference between what is (right now) vs. what ought to be (ideally speaking)

8. Describing the Ethics Quality Gap: Best Ethics Practice • Identify appropriate sources for ethical standard(s). • Describe ethical standard(s) and exclusions to standard(s). • Draft operational definition of best ethics practice based on ethical standard(s) and specific ethics issue.

9. Common Sources of Ethical Standards • Accreditation standards • Consensus statements, position papers, or white papers from professional societies • Executive directives and other senior management guidance • Organizational policies • Precedents from case law • Professional codes of ethics • Statutes

10. Identifying Source(s) of Ethical Standards • Complete a literature review • Talk to subject matter experts • Consult with ethics consultation service

11. Critically Assessing the Source(s) of the Ethical Standard • Consider how source was developed. • Rigorous development process? • Up to date? • Highly authoritative? • Consider need for 1 vs. multiple sources.

12. Critically Assessing the Source(s) of the Ethical Standard • Conflicting standards or no clear standard descriptions • Ask subject matter experts and ethics consultation for help with difficult cases. • Possibly involve leadership for establishing a standard.

13. Reviewing Source(s) of the Ethical Standard: Use Caution Avoid: • Interpreting standard too narrowly or too broadly • Failing to take into account local considerations • Adopting standard based on common practices Read carefully, interpret cautiously, and then describe.

14. When There Is No Appropriate Ethical Standard • Draft ethical standard for review and approval by leadership based on widely accepted norm.

15. Draft Operational Description of Best Ethics Practice A description of best ethics practice: • Includes word should(what practice shouldoccur) • Includes action that is supposed to happen • Describes who is responsible for action (done by whom) and/or involved in action (applied to whom), if specified DNR orders written by a resident shouldbe signed by the attending physician within 24 hours.

16. Describing Best Ethics Practice

17. Describing Best Ethics PracticeAdvance Directives Issue A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. VHA Handbook 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their request for assistance, withdraw from the Health Care System or who now lack decision-making capacity]. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the health care system (HCS) or who now lack decision-making capacity.

18. Group Activity InstructionsHandouts 3.2 and 3.3 (15 min) Ethics Issue 2 • Identify source(s) of ethical standard; write in column 2 on Handout 3.2. • Look for description of ethical standard in source document(s) in Handout 3.3, and write in column 3. • Consider exclusions; if any, also write in column 3. • Draft description of best ethics practice; write in column 4. • Make sure practice “matches” standard. • Be sure to bracket exclusions.

19. Describing Best Ethics PracticeAdverse Events Issue The quality manager for surgical services found a number of instances where adverse events that caused harm that should have been disclosed to patients or personal representatives were not disclosed. VHA Handbook 1004.08 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in the course of their care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative. [unless patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. Exclusion(s): Patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative.

20. Group Activity InstructionsHandouts 3.2 and 3.3 (20 min) Ethics Issues 3 and 4 • Identify source(s) of ethical standard; write in column 2 on Handout 3.2. • Look for description of ethical standard in source document(s) in Handout 3.3, and write in column 3. • Consider exclusions; if any, also write in column 3. • Draft description of best ethics practice; write in column 4. • Make sure practice “matches” standard. • Be sure to bracket exclusions .

21. Storyboard Progression Advance Directives Issue STUDY the Issue • Gather and summarize information about best ethics practice. • Identify sources for applicable ethical standards. • Draft an operational definition of best ethics practice based on the ethical standard(s) and the specific ethics issue. • Primary care patients who request assistance with completing an advance directive should receive it.

22. Takeaways Describing best ethics practice • Ethics quality gap • Definition of best ethics practice • Sources of ethical standards • Critical assessment of standards, with input from outside expertise and leadership • Exclusions to standards • Describing best ethics practice

23. Module 3 Questions?