Performing Ethics Consultation: Facilitation or Recommendation?

1. Performing Ethics Consultation:Facilitation or Recommendation? Anita J. Tarzian, PhD, RN (410) 706-1126 atarzian@law.umaryland.edu

2. Ethics consultation precursors • Landmark legal cases • President’s commission • Baby Doe regulations • JCAHO (Joint Commission)

3. “…[S]hould 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 Karen Ann Quinlan (1976)

4. President’s 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)

5. 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

6. 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

7. Functions of ethics committees • Policy development/review • Education • Consultation

8. Core Competencies 2nd Ed. bioethics • Scope & definition of “ethics consultation” healthcare ethics ethics consultation Consults involving “active patient” All other consults

9. Professional organizations   merged 1997 American Society for Bioethics & Humanities (1998) • Society for Health and Human Values (1970) • Society for Bioethics Consultation (1986) • American Association for Bioethics (1994)

10. Professional v. Self-taught

11. 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)

12. 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. ASBH’s Core Competencies for Health Care Ethics Consultation (1998)

13. 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. ASBH’s Core Competencies for Health Care Ethics Consultation (1998)

14. 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. ASBH’s Core Competencies for Health Care Ethics Consultation (1998)

17. Adoption by bioethics programs…

18. 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. & O’Neil, A. (2000). Are Ethics Committee Members Competent to Consult? JLME, 28, 30-40.

19. 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 < 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.

20. Media Scrutiny

21. 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

22. 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

23. Other initiatives … • Montefiore’s Working Group • Hospital credentialing/privileging • Demonstrate competence via chart note? • Canada’s PHEEP • Practicing Healthcare Ethicists Exploring Professionalization) • http://www.bioethics.ca/pheep.html

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

25. Integrated Ethics • Catholic Healthcare • Ethics champion programs • VA’s 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

26. Core Competencies … (2nd Ed)

27. Domains of Ethics Concerns & Questions Ethics Domains Examples of Questions 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? • Shared decision making with patients • Ethical practices in end-of-life care • Ethical practices at the beginning of life Core Competencies for Health Care Ethics Consultation (2011). 2nd Ed. Glenview, IL: ASBH.

28. Domains of Ethics Concerns & Questions Ethics Domains Examples of Questions Should a woman be allowed to keep her son’s HIV+ status secret from the child’s father? Should a physician seek permission from a patient before using the patient’s case for teaching? How should ICU beds be triaged? Is bedside rationing ethically justifiable? • Patient privacy & confidentiality • Ethical practices in resource allocation Core Competencies for Health Care Ethics Consultation (2011).

29. Domains of Ethics Concerns & Questions Domains Questions 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? • Ethical practices in the everyday workplace • Professionalism in patient care Core Competencies for Health Care Ethics Consultation (2011).

30. Core Competencies 2nd Ed. • Change to “case” vs. “non-case” instead of “case” vs. “organizational ethics” • Integrating ethics within institution

31. Core Competencies 2nd Ed. • Clarify “facilitation approach” • Case dictates skills needed • Examples: mediation, sharing ethics expertise • What about “recommendation”?

32. 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?

33. 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? …

34. 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?

35. Core Competencies 2nd Ed. • Recognize necessity of QI knowledge/skills

36. Core Competencies 2nd Ed. • Recognize emerging trends • Importance of role definition for consultants • Overlap with palliative care • Remote consults/rural ethics

37. 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 EC’s position of power Manage conflicts of interest CC Revision Confidentiality E-mail Teaching cases… Public statements Conflicts of obligation Scope of righting wrongs Core Competencies 2nd Ed.Professional Ethics Check ASBH website for Code of Ethics updates! www.asbh.org

38. 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”?)