1. Understanding the Method Behind the Madness: An Exploration of Methodologies Designed to Improve the Quality of Clinical Ethics Consultation Mark Repenshek, PhD Healthcare Ethicist Columbia St. Mary’s Mrepensh@columbia-stmarys.org Mark Repenshek, PhD Healthcare Ethicist Columbia St. Mary’s Mrepensh@columbia-stmarys.org

2. Context for Ethics Consultation Columbia St. Mary’s Health System –Four Acute Care Hospitals ~922 beds –64 physician clinics with ~360 employed physicians –FY 2009: 404,637 outpatient visits; 68,396 ED visits; 3430 births –Ethics Consultation Service: Two Medical Staff Ethics Committees One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model –Ethics Consultation for Database: 352 consults from January 2003 through December 2009 Cases: –Identified ethical reason for consultation –Identified discipline requesting –CSM Ethics consultation service engaged –Ethics consultation documented –Ethics recommendations made to case Columbia St. Mary’s Health System –Four Acute Care Hospitals ~922 beds –64 physician clinics with ~360 employed physicians –FY 2009: 404,637 outpatient visits; 68,396 ED visits; 3430 births –Ethics Consultation Service: Two Medical Staff Ethics Committees One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model –Ethics Consultation for Database: 352 consults from January 2003 through December 2009 Cases: –Identified ethical reason for consultation –Identified discipline requesting –CSM Ethics consultation service engaged –Ethics consultation documented –Ethics recommendations made to case

3. Previous Conclusions about Ethics Consultation

4. Clinical Consultation Changing Organizational Practice? Ethics Tracker Database –August 2006-October 2006 –3 consults related to Intra/peri-operative Code Status MD Association Guidelines – American College of Surgeons: ST-19 Statement on Advance Directive by Patients: “Do Not Resuscitate” in the Operating Room – American Society of Anesthesiologists: Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders Goal: Initiate opportunity within existing pre-procedure processes for MD to address with patient or designated surrogate(s) existing directives to limit the use of resuscitation procedures –Dept of Surgery follow-up re: Ethics Case Consultations –Grand Rounds follow-up with CME Accountabilities for CIP Ethics Tracker Database –August 2006-October 2006 –3 consults related to Intra/peri-operative Code Status MD Association Guidelines – American College of Surgeons: ST-19 Statement on Advance Directive by Patients: “Do Not Resuscitate” in the Operating Room – American Society of Anesthesiologists: Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders Goal: Initiate opportunity within existing pre-procedure processes for MD to address with patient or designated surrogate(s) existing directives to limit the use of resuscitation procedures –Dept of Surgery follow-up re: Ethics Case Consultations –Grand Rounds follow-up with CME Accountabilities for CIP

5. Clinical Consultation Changing Organizational Practice Medical Staff Pre- Procedure Checklist Adopted: Dept Anesthesiology Dept Surgery Dept Orthopedic Surgery Dept of Medicine (Exec Council)

6. New Model to Measure Patient/Organization Impact

7. Ethics Consultation Model Ethics Consultation Service: Two Medical Staff Ethics Committees One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model Ad Hoc Consultation Model/Advisement Advisement: Requests include, but not limited to, questions concerning interpretation of the Ethical and Religious Directives for Catholic Healthcare Services, 5th ed., elaboration on CSM Ethics Policies, or matters of mere procedural clarification. Ad Hoc Consultation: required for all consults that are not advisory in nature. Ethics Consultation Service: Two Medical Staff Ethics Committees One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model Ad Hoc Consultation Model/Advisement Advisement: Requests include, but not limited to, questions concerning interpretation of the Ethical and Religious Directives for Catholic Healthcare Services, 5th ed., elaboration on CSM Ethics Policies, or matters of mere procedural clarification. Ad Hoc Consultation: required for all consults that are not advisory in nature.

8. Ethics Consultation Intake: Requestor Info

9. Ethics Consultation Intake: Ethics Quality Info

10. Clinical Ethics Consultation: Columbia St. Mary’s Health System Ethics Consultation implemented the ASBH Process for Ethics Consultation in 2003 The Report of the ASBH. Core Competencies for Health Care Ethics Consultation. 1998, section 1.2 Appropriate competencies added re: Skills for Ethics Consultation relative to the Ethical and Religious Directives for Catholic Healthcare Services The Report of the ASBH. Core Competencies for Health Care Ethics Consultation. 1998, section 2.2 Ascension Health Core Competencies for Ethics Consultation in Catholic Health Care, see: https://www.ascensionhealth.org/ethics/affiliates/main.asp Ethics Consultation implemented the ASBH Process for Ethics Consultation in 2003 The Report of the ASBH. Core Competencies for Health Care Ethics Consultation. 1998, section 1.2 Appropriate competencies added re: Skills for Ethics Consultation relative to the Ethical and Religious Directives for Catholic Healthcare Services The Report of the ASBH. Core Competencies for Health Care Ethics Consultation. 1998, section 2.2 Ascension Health Core Competencies for Ethics Consultation in Catholic Health Care, see: https://www.ascensionhealth.org/ethics/affiliates/main.asp

11. Clinical Ethics Consultation: Columbia St. Mary’s Health System CSM Ethics Consultation for Database: –352; January 2003 - December 2009 No. of Consults/Literature: 255; Swetz, et al. Mayo Clinic Proceedings 2007; 82(6): 686-691. 150; Schenkenberg. HEC Forum 1997; 9;147-158. 104; La Puma, et al. JAMA 1988;260: 808-811. 31; Forde & Vandvik. J Med Ethics. 2005; 31:73-77. 39; Waisel, et al. Mil Med 2000; 165:528- 532. CSM Ethics Consultation for Database: –352; January 2003 - December 2009 No. of Consults/Literature: 255; Swetz, et al. Mayo Clinic Proceedings 2007; 82(6): 686-691. 150; Schenkenberg. HEC Forum 1997; 9;147-158. 104; La Puma, et al. JAMA 1988;260: 808-811. 31; Forde & Vandvik. J Med Ethics. 2005; 31:73-77. 39; Waisel, et al. Mil Med 2000; 165:528- 532.

12. Clinical Ethics Consultation: Columbia St. Mary’s Health System/ per Month Group A; n=169 Group B; n=151 2008 Implementation of Standardized Methodology for Clinical Consultation

13. Hypothesis No.1: Increasing the Integration of the clinical ethics program will bring consultation closer to admission

15. Hypothesis No.2: As ethics consultation occurs closer to admission, consultation will be more advisory than conflict resolution

17. Hypothesis No.3: An integrated clinical ethics program creates opportunities for demonstrable organizational/clinical change in practice Assumptions: –Identified ethical reason for consultation –Identified discipline requesting –CSM Ethics consultation service engaged –Ethics consultation documented –Ethics recommendations made to case Inclusion Criteria: Acuity of patient population: ICU Complexity of patient population: 2 hospitalizations within past six months for same primary DRG Exclusion Criteria: No retrospective reviews--level of consult request Assumptions: –Identified ethical reason for consultation –Identified discipline requesting –CSM Ethics consultation service engaged –Ethics consultation documented –Ethics recommendations made to case Inclusion Criteria: Acuity of patient population: ICU Complexity of patient population: 2 hospitalizations within past six months for same primary DRG Exclusion Criteria: No retrospective reviews--level of consult request

18. Hypothesis No.3: An integrated clinical ethics program creates opportunities for demonstrable organizational/clinical change in practice Methodology: Deviation on LOS: Expected vs. Actual Methodology: Deviation on LOS: Expected vs. Actual

19. Hypothesis No.3: An integrated clinical ethics program creates opportunities for demonstrable organizational/clinical change in practice

20. 2008 Implementation of Standardized Methodology for Clinical Consultation Recall:

21. Hypothesis No.3: An integrated clinical ethics program creates opportunities for demonstrable organizational/clinical change in practice Hypothesis No.3 Measure: PCL approaching 0 (zero) p = 0.14, but process continues to improve Deviation expected/actual for all ICU stays with Ethics consultation Cohort A/Cohort B--CH ICU Model Intensivist: MD/MA Bioethics

22. Conclusions Ethics consultation can be measured both in process and impact--No free pass on quality measures; Conversation has and must continue to move from whether to measure to how to measure; Rigorous debate on whether these methodologies are on target in terms of capturing process/impact of ethics consultation; Implement methodologies or adaptations thereof to larger sample sets (i.e., VHA, Ascension, etc.) to test the validity with larger n. Ethics consultation can be measured both in process and impact--No free pass on quality measures; Conversation has and must continue to move from whether to measure to how to measure; Rigorous debate on whether these methodologies are on target in terms of capturing process/impact of ethics consultation; Implement methodologies or adaptations thereof to larger sample sets (i.e., VHA, Ascension, etc.) to test the validity with larger n.