SWNDHA Clinical Ethics Workshop - Christy Simpson and Jeff Kirby November 26, 2003

Clinical Ethics Workshop
       SWNDHA

Christy Simpson and Jeff Kirby
      November 26, 2003

Overview

• Outline of workshop
• General discussion about ethics and
  SWNDHA
• Focusing on ethics education
• Focusing on clinical ethics consultation
• Looking ahead

What is your vision
 for (clinical) ethics
in this health region?

What are some of the
key features of SWNDHA
       that relate to
  this vision of ethics?

Ethics across the spectrum…

• Ethics as identity and ethics as tools

• Range of activities and approaches:

      Education…Consultation...Policy
           Formal……Informal
 Structured…Less structured…Unstructured
           Clinical……Organizational

Ethics involves…

• Thinking about values

• What are values?

  “Things we think are important for
       their own sake.” (Jiwani 2001)

Ethics involves…

Three ways values can influence what we do:

     1. Values frame the issue/problem.

     2. Values supply alternatives.

     3. Values direct judgments.

Ethics Education

• What have you tried or are doing?

• Any lessons learned?

Ethics Education
“Big Picture”
 Focus on:
     Ø Issues of relevance
     Ø Mixed approaches
     Ø Blend of theory and practice
     Ø Recognition and connection to
        experience
     Ø Link to vision for ethics
     Ø Target variety of groups

Ethics Education
“Small Picture”
 Focus on:
     Ø Pick one or two things and do them
        well
     Ø Expect momentum to build slowly
     Ø Start at beginning – what is ethics?
     Ø Start with common topics/issues
     Ø Determine who to do education with
        first

Clinical Ethics Consultation

Setting the stage for this discussion:

• Terminology
• Approaches

Why do we (want to) do
clinical ethics consultation?

Possible goals of clinical ethics
     consultation include…

• Facilitation of communication among
  involved parties

• Ethics-based analysis and recommendations

• Ethics education of institutional staff

• Building of ethics awareness and sensitivity

What are common barriers
       for clinical
  ethics consultation?

Barriers include…
• Minimal awareness of availability of service
• Lack of understanding of CEC process
• Uncertainty and/or lack of trust in process
• Unsure as to whether process will be helpful
• Time required is too great (by health care
  providers and/or committee members)
• Lack of institutional support
• Concern about competency or expertise

Key factors influencing choice
      of goals include…
• Expectations of your health care
  organization

• Availability of health care ethics expertise

• Availability of other sustainable resources:
  people, time & finances

How does being in a rural and
community context influence or
    shape clinical ethics
       consultation?

“Ethic of Familiarity”
• Different sense of community
  • Shared future – impact of decisions
  • Perceptions of good care discussed
  • Trust built in relation to role in community

• “Who knows what” – different information
   boundaries
  • Confidentiality and privacy
  • Complainer or team player?

“Ethic of Familiarity”
• Relationship, role, and boundary concerns

• Decisions both easier and more difficult

• Potentially greater impact of cultural
  understandings

• Potentially different understanding of what
  health and/or health care is and should be

Upshot?

• Value of ethical reflection and deliberation
  is still relevant

• Still accountable for gathering all facts,
  following a good process, considering
  options, and evaluating what happens

• Contribution to building a moral community
  still possible

What are different approaches
to clinical ethics consultation?

Ethics Consultation Models

• Single clinical ethics consultant
• By committee
• Small team approach
• Ethics mentors/influentials

Clinical Ethics Consultant
                 Advantages

• Solitary individual with advanced core
  competencies
• Consultations usually easier to arrange in a
  timely fashion
• Well suited to ‘bedside’ consultation

Clinical Ethics Consultant
                  Disadvantages

• Looks authoritarian/paternal with
  consultant positioned as primary moral
  decision-maker

• Sends wrong institutional message that
  ethics, value clarification, etc. are only for
  ‘experts’

• Cost of hiring health care ethicist full time

By Committee
               Advantages

• Diverse, multidisciplinary perspectives
  brought to process

• Opportunity for ethics education of
  committee members

• Diffusion of responsibility for
  recommendations

By Committee
               Disadvantages
• Logistical difficulties getting committee
  together in timely fashion
• Costly in terms of time spent by committee
  members away from their primary
  responsibilities
• Potential greater emotional cost to involved
  parties (larger audience including, for
  providers, their peers) and greater risk of
  confidentiality breaches than other models

• Not well suited to ‘bedside’ consultation

Small team approach
                Advantages

• Less authoritative looking than single
  consultant
• Consultations easier and faster to arrange
  than with whole committee
• Team members can collectively provide
  necessary core competencies

Small team approach
               Disadvantages

• Requires roster of interested/competent
  individuals (usually committee members)
• Less diversity of input than with full
  committee
• Possibly slower process than with single
  consultant model

Ethics mentors/influentials
• Less formal approach

• Focus is on identifying and providing ethics
  education/training for key persons in
  different locations throughout health region

• Function as form of ‘local’ support and
  leadership with respect to ethics

• ‘First response’ to ethics concerns

Ethics Mentors/Influentials
                 Advantages

• Develop network of mentors

• Visible commitment and awareness of ethics

• Over time, more persons with ethics training

• Potential decreased burden on clinical ethics
  consultation process and ethics committee
  members

Ethics Mentors/Influentials
                Disadvantages
• Initial, higher demands for ethics education
  and training

• Difficulty of maintaining contact between
  mentors

• Possible high rate of turn-over

• Questions about replacements

• Difficult to evaluate

What skills, knowledge, etc.
 are important for ethics
      consultation?

Core Competencies for
           Health Care
       Ethics Consultation

• Recommendations of the American Society
        for Bioethics & Humanities
      - May, 1998 Task Force Report

Core Ethics Competencies
• Skills – basic and advanced
  • Ethical assessment
  • Process
  • Interpersonal

• Knowledge - basic and advanced (brought
  or available)
  • Nine core areas

Character Traits/Qualities
         Associated with
     Successful Consultations
•   Tolerance & compassion
•   Patience
•   Integrity
•   Honesty & forthrightness
•   Courage
•   Self-knowledge
•   Prudence & humility

What are the different steps of
    ethics consultation?

Ethics Consultation Process
• Access
• Intake
• Notification
• Deliberation
• Documentation
• Debriefing
• Evaluation

Process: Access

• Who gets to use the service?
  • Patients, family, friends, health care providers
• Awareness
  • Let people know about service – website,
    newsletter, pamphlet
• Contact information
  • Dedicated phone line, timeframe for response

Process: Intake
• Screening – is this an ethics consult?
• Gather information
   • Develop standard form/approach
• Identify the issue(s)
• Prepare people for the process and their
  roles in the process
   • Identify who should participate
   • Suggestions for how to participate
• Prepare the ethics team – who will be in this
  role and what is expected of them

Process: Notification
• Typically the patient and the attending
  physician are informed that an ethics
  consultation has been requested (if not the
  initiators)
• Permission from the patient and the
  attending is not required for the ethics
  consultation to proceed
• Other relevant parties are notified as well

Process: Deliberation
• Opening statement (ritual)
   • Introductions
   • Objectives or goals of process
   • ‘Ground’ rules (already explained in intake)
• Possible roles for ethics consultants
   • Facilitator – everyone gets a chance to talk
   • Recorder – maintain a summary of issues
     discussed and any recommendations reached
   • ‘Expert’ – ethics tools employed

Process: Deliberation
• Focus on the process
  • Attention to ‘construction’ of optimal, inclusive
    ‘moral space’ for reflection & deliberation
  • Focus on engaged participation
  • Emphasis on bringing diverse, individual,
    vocational & life experiences & perspectives
  • Ensure communities of meaning (for patient)
    are included, if appropriate
  • Be prepared to sum up, repeat, and check what
    points people are making – help make best case

Process: Deliberation
• Focus on the process
  • Attention to who gets to speak first
     Ø Person requesting the consult?
     Ø Beware of heavy emphasis on medical
       information
  • Be prepared for conflict, emotional responses
  • Draw on what learned during the intake process
  • Work on clarifying the issue(s) and what the
    ethical features are
  • Discuss courses of action/inaction and their
    ethical aspects

Process: Deliberation
• Wrap-up
  • Recorder sums up discussion and any
    recommendations arrived at by the group
  • Asks for agreement on this record (becomes
    part of documentation)
  • Formal thank you for participants
  • Offer of additional support extended, if
    appropriate

Process: Documentation
• Record of presenting issue and any
  additional issues discussed
• Record of recommendations and/or
  consensus reached
• Maintain for consultation service
• Place on patient’s chart?
  • Many places do indicate an ethics consultation
    took place, the issues discussed, and any
    recommendations – but is a contentious issue

Process: Debriefing
• Important for ethics consultants to discuss
  how the process went, what could be done
  better next time, what worked, etc.
• Focus on the process, not necessarily
  content
• Share learning with other members of ethics
  committee or ethics consultants
• Identify any learning issues

Process: Evaluation

• By participants in consultation
  • Immediately after/3-6 months later
  • Survey or phone call

• Option of tape-recording consultation
  • For further evaluation of process, learning for
    ethics consultants

Some ‘tools’
Ethical decision-making frameworks:

• “A Method for Ethical Deliberation: RICE”
   by Andrea Frolic

• “A Framework for Ethical Problem-solving”
   by Françoise Baylis

‘Operating Assumptions’
•   Decision-making by consensus
•   Responsibility
•   Respect
•   Cooperation
•   Self-discipline
•   Struggle
              (Women’s Encampment for a Future of Peace and Justice,
                  Seneca Army Depot, NY, Resource Handbook, 42.)

Taking a look at an ethics
     consultation…

Looking ahead…

       • How will we move
         forward with
         respect to ethics
         education and
         clinical ethics
         consultation?