1. Approaches to Social Work Ethical Decision-Making in End-of-Life Care Phase I Steve R. Wilson, Ph.D., LCSW Lisa K. Jennings, Ph.D., LCSW School of Social Work California State University, Long Beach Ethics Across the Curriculum Project May 2011

2. Today’s Session Objectives
Describe the principles that that underlie medical ethics, including: autonomy, beneficence, non-maleficence, justice, dignity, and fidelity.
Apply ethic of confidentiality associated with end-of-life patient concerns to a practice scenario to illustrate ethical principles of dignity and autonomy.

3. NASW Code of Ethics Service Social Justice
Dignity and Worth of the Person
Importance of Human Relationships
Integrity
Competence

4. Core Medical Ethics Autonomy Beneficence Non-Maleficence Justice
The patient’s right to refuse or choose their treatment.
Beneficence
Always acting in the best interest of the patient.
Non-Maleficence
“Above all, do no harm."
Justice
Fairness and equality as to who gets what treatment.
Dignity
Treating the patient, family and practitioner with respect.
Fidelity
Notions of loyalty, commitment, and trust in the relationship.

5. Essence of Social Work
Resolving ethically challenging cases mirrors the problem-solving method which is a hallmark of the social work profession:
Engagement
Data Collection
Assessment
Intervention
Evaluation
Termination
Follow-Up

6. Typical Forms of Ethical Dilemma Resolution

7. Ethics Committees
Social work is represented on 75% of hospital ethics committees.
Only 31% of hospice agencies studied have ethics committees.
Social work is represented on only 53% of these hospice ethics committees.
Csikai, 2004

8. Skill Sets Needed Ethical Assessment Skills Process Skills
Including bioethics, agency policies, professional codes, religious and cultural values.
Process Skills
Effective interaction with key decision-makers. Able to facilitate fair and formal meetings.
Interpersonal Skills
Ability to listen and communicate with respect, support, and empathy for all.

9. Confidentiality & HIPPA
See handout for class discussion vignette

10. Discussion Points Physician-Patient Privilege
Rights of Patent and Surrogate Decision-Makers
Rights of Family Members
What are the medical ethical considerations here?
What are the social work ethical considerations here?

11. Approaches to Social Work Ethical Decision-Making in End of Life Care Phase II Ethics Across the Curriculum Project May 2011

12. Today’s Session Objectives
Describe the multi-step model for collaborative ethical decision-making in end of life care.
Demonstrate the ability to blend social work values and medical ethics to make sound ethical decisions involving patients and their families.
Apply the ethical decision making framework to a patient case in a logical manner, reflecting interdisciplinary collaboration.

13. Review of Phase I components
Medical Ethics
HIPAA Privacy Guidelines
NASW Code of Ethics
Historical Overview
Ethical Challenges in healthcare social work

14. Ethics Training
Are there opportunities for training on ethical decision making?
In your field placement?
Community Seminars?
Seminars by Employer?

15. The Collaborative Ethical Decision-Making Framework

16. The Collaborative Ethical Decision-Making Model
Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation.
Determine issues that present the ethical problem.
Consider alternatives available for implementation, weighing positives and negatives of each.
Consult with professional colleagues and/or experts with knowledge about this or similar situations.
Review alternatives with patient and family and document accordingly.
Implement the best alternative given the circumstances and the environment.
Monitor, evaluate, and document the decision.

17. Step #1
Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation.
Conduct a thorough psychosocial assessment.
Know the facts.

18. Step #2 Determine issues that present the ethical problem.
Clear assessment is key.
Clearly and concisely communicate your presenting problem from your professional assessment.

19. Assessment Information
Medical Indications
Patient Preferences
Quality of Life
Contextual Issues
Morality Issues

20. Step #3
Consider alternatives available for implementation, weighing positives and negatives of each.
We don’t need another well-defined problem.
Consider solutions to present to the ethics team.

21. Step #4
Consult with professional colleagues and/or experts with knowledge about this or similar situations.
No Lone Rangers - Collaboration is key.
Use ethical consultants or committees for problem-solving.
Avoid territoriality and professional rivalry.

22. Step #5
Review alternatives with patient and family and document accordingly.
Congruent with hospice philosophy and social work ethics.
Communication is vital to maintaining healthy professional relationships with patients and families.
Honor the dignity of autonomy.

23. Step #6
Implement the “best” (most functional) alternative given the circumstances and the environment.
Based on input from professionals and family, and with respect for medical and social work ethical principles, introduce the alternative that is the most viable given the circumstances.
Leave your own values, opinions, and judgments at the door.
Implementation plans are subject to change at any time, without notice.

24. Step #7 Monitor, evaluate, and document the decision.
Document, document, document.
Monitor for new dilemmas, while moving forward on other day-to-day matters.
Debrief – Engage in a Retrospective Review

25. Case Example #1 (see handout)
“Shiela”
59-year old African American female
History of Depression
Family wants aggressive care
Patient wants palliative/hospice care
Husband invalidates Shiela’s health-related wishes
Case will be presented by instructor. Each step of the model will be presented to the students with examples of how to apply to this case.

26. Session Wrap-up Review of today’s topics Assign case(s) for homework
Suggested reading to prepare for Phase III

27. Module Objectives
Build upon knowledge from Phase I and Phase II to practice Ethical Decision-Making as Team Leaders.
Apply an ethical decision making framework to a patient cases in a logical manner, reflecting interdisciplinary collaboration.
Discuss the ethical leadership role in complex end-of-life care cases.

28. Approaches to Social Work Ethical Decision-Making in End of Life Care Phase III Ethics Across the Curriculum Project May 2011

29. Review of Modules I and II

30. NASW Code of Ethics Service Social Justice
Dignity and Worth of the Person
Importance of Human Relationships
Integrity
Competence

31. Core Medical Ethics Autonomy Beneficence Non-Maleficence Justice
The patient’s right to refuse or choose their treatment.
Beneficence
Always acting in the best interest of the patient.
Non-Maleficence
“Above all, do no harm."
Justice
Fairness and equality as to who gets what treatment.
Dignity
Treating the patient, family and practitioner with respect.
Fidelity
Notions of loyalty, commitment, and trust in the relationship.

32. The Collaborative Ethical Decision-Making Framework

33. The Collaborative Ethical Decision-Making Model
Assess situation completely from a social work perspective examining the clinical, physical, legal, cultural, and systemic issues facing the situation.
Determine issues that present the ethical problem.
Consider alternatives available for implementation, weighing positives and negatives of each.
Consult with professional colleagues and/or experts with knowledge about this or similar situations.
Review alternatives with patient and family and document accordingly.
Implement the best alternative given the circumstances and the environment.
Monitor, evaluate, and document the decision.

34. Case Example #2 Graciela and Marco
Students will be split into small groups to work on this case. The case handout is included in the instructor notes for Phase III. This particular case focuses on a couple who both have medical conditions and interaction with their adult daughter.

35. Case # 2 Discussion Prompts
How does cultural competence in health care enter into the ethical decision making process?
In what ways can the discussion about hospice from the social worker and the medical team address the following?
Exploring both the disease and the illness experience
Understanding the whole person
Being realistic about the prognosis

36. Case Example #3
Ronald
This case involves an 80 year old man who lives with his wife in an assisted living facility.

37. Case #3 Discussion Prompts
What ethical dilemmas are present in this case?
Had depression rendered him incapable of making a legitimate life-and-death decision?
Is Ronald able to give consent?
What are appropriate steps for the social worker to take?

38. Debriefing & Ethics Module Wrap-up

39. OK…Now Let’s Hear From You…
Let’s walk through some examples from your experience in hospice agencies and field settings.
Examples from your agency?
How can a model like this work at your hospice with social work as the lead?

40. Discussion Prompts Reflective Evaluation
What are the major challenges of ethical situations in end-of-life care?
How can social workers manage complex cases?
How can social workers take on a larger leadership role in medical ethics teams and committees?

41. Continuing Education
Develop a personal plan for continued ethics training and development.
Develop a professional network of colleagues to discuss ethical dilemmas and possible solutions.

42. Thank you for your participation!
Ethics Across the Curriculum Project
May 2011