Ethics Committee Structures & Decision Making Models Philip Boyle, Ph.D. Vice President, Ethics

Goals for today’s conversation House keeping & review of course Expectations Moral Ecology of Continuing Care Different ethics mechanisms –The Next Generation Nature of ethics Evaluation of ethics functioning Nature of ethical decision making

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The Moral Ecology The residents/clients Impaired sensory, cognitive, & functional Limit autonomy –Subtle clotting and vulnerability More woman, limited means, power differential & vulnerable positions Stigma: age as disability—unable or less than capacitated

The Moral Ecology Family informal caregivers Mainly woman Need family to cooperate Family feelings about resident in LTC –Relief –Guilt Family feelings about home care –Exhaustion & frustration

The Moral Ecology The staff—different professional training Not as skilled Up to 70% nurses aids Professional boundaries unclear –Less supervision & mentoring in the field –Becoming intimate with the resident Self disclosure, prying, identifying with resident, accepting or giving gifts Coercion— behavioral limits

The Moral Ecology Public perception of long-term care Happy to be outside LTC Sad about residents in LTC Feel guilty to place family member –Don’t ever put me away in a home –Let me die before you put me there By 80 2-out-of-3 in some form of assisted living. An issue we would rather ignore

The Moral Ecology The setting LTCs & quasi-institution Routines – Efficiency dictates people rise, eat, bath, and have fun –Routines foster patterns that go unnoticed Institutions tend to be noisy Home-- issues about negotiating personal territory

The Moral Ecology Externalities: law, regulators, dept of aging Long-term care more adversarial Regulations focus on the quality & safety Regulation often misinterpreted by outside inspectors and breed a more restrictive and severe interpretations of standards to ensure safety

Focus of concern Caring Dignity Flourishing

Conclusions Ethics of everyday living Attention to particularities Focus: caring, listening, respecting… Need separate mechanisms

Case of Mrs. White 82 year old Found unconscious at home Placed on vent 3 days later awake Take me off vent, I want coffee Listen to my son MD refuses Ethics consultation provide info on state law

Nature of ethics consultation? How would you describe the actions? –Recommending? –Consultation? –Mandating? What do these verbs connote? Are any antithetical to the nature of ethics? What is the authority of the EC?

Nature of ethics Goal: –Compliance –Ethics is good business/practice –Doing good, avoid evil –Human flourishing Facilitating the decision maker to make a good decision

Ethics Mechanisms: Before and After Before—in the beginning Largely grass roots Not hard wired to administration Focused on patients’ rights Philosophical discussion of hard cases Dispute resolution forums

Process Scope of jurisdiction and authority What authority do they have? –What is the authority of the education? –What is the authority of the consultation? –What is there authority on policy review? Are there any functions that the committee will never accept? Could some other existent committee better handle this request? Are we duplicating functions? Who calls the committee into being? To whom does the committee report? The nature of ethics committees—“safe place for unsafe ideas” –Confidentiality –Functional consensus

Functions Education –Will only certain groups be targeted? –What formats will be best for the various groups? –What is the expected outcome for education? Changed behavior? Provision of guidelines? Standards of practice? –In a pluralistic society, where there is little agreement on ethical issues, what information can be presented? –How does education avoid appearance of mandating?

Functions Policy –Should the policy come from the ethics committee or from another group? –Should the committee merely review policy, or help develop it? What is the extent of the authority given to the committee in policy making? What are the pros and cons?

Functions Case consultation –At what point in an ethics committee's functioning should it provide case consultation? –Should it provide prospective and retrospective consultation? –Should the consultation be binding? What if the entire committee agrees but the person asking for the consultation disagrees? –Who can ask for a consultation? –Who decides whether the consultation comes before the committee? –Should there be an ad hoc subcommittee on call to consider ethical problems that arise? Should the subcommittee follow standard pattern of consultation? –Shall the consultations be noted in the chart?

Functions Advocacy –To what extent should community education efforts advocate one position or another? –Should the committee become involved with political advocacy for the passage of a bill?

Who should have access to the ethics committee? –Physicians only? –Nurses after they have exhausted existing channels? –All staff? –Patients? Family? –Community members?

How will people know about the committee and access it? –Through the chairperson only? –Through any member of the committee? –Through department heads? –By request of physicians or administration, or merely by asking to be put on the agenda?

Priorities Priorities: What substantive issues are most important to the institution? Long range planning How broad shall the committee cast its nets? –Should it consider social issues i.e., rationing? –Should the committee consider business ethics? How much time will be allotted to diversions from designated goals to talk about issues such as procedure? What are our priority functions? What are our priority substantive issues? What is our 1 and 3 year plan? How will and when will we evaluate them?

After Ethics Mechanisms: The Next Generation Integrating Healthcare Ethics into Healthcare Operations Holding Ethics Mechanisms Accountable Ethics Mechanisms: Going from Good to Great Ethics as Mission Reflection: A Spirituality at Work

Notable successes Self education First responders Ethics Champions Safe-place for unsafe ideas Identifiable institutional response Participative & collaborative

Notable failures? Limited to clinical ethics Lack of demonstrable value/effectiveness Good intentions = value Stuck on hard cases Doing ethics = talking about ethics Volunteers = amateurs Consistency in action Dispute resolution forums with no power or training in arbitration

How can we respond to the record? Improving? Refining? –New slant on consultations e.g., organizational ethics? –Enhance policy development for management tool? –New pedagogy to shape professionals or new sexy topics e.g., face transplants?

Experience/ History Disillusionment Are ECs making a demonstrable difference in pt care? –Quasi-legal protection of pt rights Operating dispute resolution forums with little power of training in arbitration

How can we respond to the record? The Next Generation Proactive agent of system change –Better integrated –Upstream –Improved Pt care –Adds value & contributes to quality Integrated Mission Reflection

What does this mean practically? Mission & Vision May be articulated, often not Source of conflict Clear mission & vision Catalyst & facilitator for systemic change Not principle vehicle for change

What does this mean functionally? Ethics Resource Service (ERS) –Clinical Consultation Group –Facilitates Cases –Educational Forums Healthcare Ethics Committee (HEC) –Integrates ethics into quality –Operationally minded –Measures outcomes, hold accountable

Membership Selecting qualified members, not location Core education Trained in conflict resolution Escape appearance of volunteers Long-range training

Modes & Methods of Operation Focus is operations, not philosophical discourse Skill-set: operational accomplishment –How to get things done –How to bring about change –How to facilitate org development

Ethics Resource Service 1. Provide competent informational & decision- making support –Consultation mechanism –Core knowledge –Dispute resolution 2. Advise HEC on recurring issues Systemic/structural solutions

Total Quality Improvement Operationally Integrating Ethics Trending Values-based Decision-making Process Indicators/Trigger Mechanisms Committee self-evaluation

Why use it? Consistent evidence of supporting Mission Evidence of Participation and Respect for Persons Evidence that the Spirit has guided Checks & Balances Fosters habit of moral reasoning

When to use it? Formally Decision that affect significant interests and populations Opening Closing Services Significant HR issues Development of Strategic management tools Informally—all moral decisions

Phase I: Preparation Number of persons/groups impacted –Does it affect a department or the institution? Duration of the impact –Does the impact last a few years or the span of the ministry? Depth or weight of impact – Does the question affect the entire ministry or a portion of it? Closeness to Core Values –Does the question directly jeopardize a value? Degree of complexity Past commitments –Does the question positively or negatively affect past commitments? Relationship to strategic direction

Whose interests are affected? Based on the nature of the issue, what other individuals or groups need to be part of the process? What is the nature and frequency of the connection between the groups and the question? What departments will be affected? What departments might have insight? What other entities will be affected by the decision? Who would have insights to the Mission and tradition as it applies to this decision?

Phase II: Decision Making 1.Pray, reflect, identify question, and clarify authority of decision-making group. Prayer and reflection are necessary because the group believes that it is God’s spirit that is guiding and perfecting the many decision-making talents brought to the table. A spirit of prayerful reflection centers the group on the fact that they are continuing the healing, transforming ministry of Jesus. Identification of the question is essential because each decision maker will perceive and state the question differently. If the question is inaccurately identified at the outset of decision making, or not agreed upon, then the ensuing process will be counterproductive. The decision-making group should be clear about its scope of authority. Do they have the ultimate decision-making authority, or are they a consultative group that provides information to the ultimate decision maker(s)?

Phase II: Decision Making 2. Determine primary and secondary communities of concern and their interests. While there may be a large community of concern, not everyone in that community has the same interests. The decision-making group should assess the manner and degree to which a sub-community will be affected positively and/or negatively. The decision-making group should consider how those who are poor and vulnerable will be affected by the decision.

Phase II: Decision Making 4. Identify key moral commitments and values, as well as conflicts among them. Identify the question in terms of trade-offs between one or more values. For example, consider your decision in terms of human dignity and identify the dignity trade-offs in the various options that you are weighing. Identify the major consequences of this dignity trade- off in terms of individuals and groups; in terms of long- and short-term burdens and benefits; or in terms of money, morale and relationships, etc.

Phase II: Decision Making 5. Establish priorities among commitments and values. The moral commitments and values that deserve priority will flow from consideration of strategic goals/objectives, core values, historical commitments, the broader religious tradition, and special circumstances. List each priority and provide the rationale for why it is a priority.

Phase II: Decision Making 6. Develop options that support the priorities. Identify options that promote the moral commitments and values deserving priority. Examine carefully the major options and evaluate the positive and negative consequences of these options on the identified priorities. Consider not only the burdens and benefits of the preferred option but all of the options. Do any of the options preserve and protect a majority of the identified priorities?

Phase II: Decision Making 7. In silence reflect and then listen to viewpoints. To ensure that the Spirit has guided the discussion and to promote the voice of any reservations or opposition, a quiet time of reflection should be offered during which group members consider the discussion in light of the faith tradition and personal conviction. Consider the following reflective questions: –Have I listened to the facts and appreciated the viewpoints of others? –Have I opened myself to the workings of the Spirit? –Have I sought the good of the entire ministry and then the particular good of others? Has input been elicited from all decision makers?

Phase II: Decision Making 8. Gain consensus on decision. Invite all members to express which option should be pursued and why. Discussion should be held until every member has had an opportunity to voice an opinion. At the conclusion of the participatory decision making, estimate if a consensus exists, and if not, identify the points of disagreement and allow for additional conversation for clarification. If a consensus is reached, identify the values that will suffer because of the choice. Discuss how to mitigate the harms.

Phase III: Follow Through Assign accountabilities to specific persons for each component to be realized. Build a plan for monitoring and reporting with measurable outcomes. Build a communication plan for community of concern with key messages and methods. Build a plan that connects to the larger meaning and purpose.

Conclusions One needs to first clarify the nature of ethics Then focus on the nature of facilitation –Core knowledge –Competencies for facilitation Proper use of values-based decision making