Ethics Committees Flashcards
“traditional” medical ethics
Physician centric
Professional and Virtue ethics (Hippocratic Oath)
“Good of the patient”
Paternalistic
-Physician gave orders
-“Good” patients were compliant
-Nurses and others were obedient & supportive
emergence of emphasis on patient and “clinical ethics”
Emergence of “Patient Rights”
-Autonomy
Concept of informed consent
-Right to refuse treatment
Change in nursing and other providers’ ethics
-From loyalty to physician to patient advocate
“clinical” ethics
“…the identification, analysis, and resolution of moral problems that arise in the care of a particular patient.”1
Care of patients is an ethical activity, and includes:
- Personal ethics (of patient and families)
- Ethics of other professionals (other providers, nurses, social workers, clergy,…)
- Essential to include ethics, beliefs and concerns of patients and families.
- Requires openness, mutual respect, sustained dialogue.
- Distinguish between “disease” (pathophysiology) and “illness” (experience of the parson patient
1976 - Karen Quinlan
In a ruling by New Jersey Supreme Court responding to a request by her parents to take her off a respirator the court designated a role for a hospital ethics committee.
1983 - president’s comission
President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research encouraged creation of hospital ethics committees in its report, “Deciding to Forego Life-Sustaining Treatment”
1984 - baby doe rules
In its 1984 Baby Doe rules, the federal government recommended establishment
of infant care review committees, which promoted the growth of hospital ethics
committees
-baby with down syndrome whose parents declined surgery to fix esophageal atresia with tracheoesophageal fistula, leading to the baby’s death
1992 - JCAHO
Joint Commission on Accreditation of Healthcare Organizations required establishment of a mechanism to provide “…education to caregivers and patients on ethical issues in health care…”
1986 - American Hospital Association
“Handbook for Hospital Ethics Committees”
Three primary functions:
1. educating medical staff, hospital staff, and patients and community
2. developing institutional policies and guidelines concerning bioethical issues
3. consulting and reviewing cases
ethics committees roles
- review of treatment decisions made on behalf of incompetent, terminally ill patients;
- review of medical decisions having ethical implications with the option, in cases of disagreement, to refer cases to a court with proper jurisdiction;
- provision of social, psychological, spiritual, or other counseling for patients, family members, physicians, or other hospital staff;
- Establishing guidelines regarding treatment or other medical decisions;
- Sponsoring or conducting educational programs to inform all concerned, including the public, about ethical problems in medicine.
Most committees attempt to establish a broad based, multidisciplinary approach and include:
physicians, nurses, other allied health providers, social workers, clergy, and academic ethicists from philosophy or the social sciences.
Types of ethics consultations
Case consultations – an active clinical case
(includes interaction with the patient (or surrogate) and documentation in the health record)
Non-case consultations - answering questions about ethics topics, interpreting policy, reviewing documents, providing ethical analysis of organizational questions, and responding to hypothetical or historical questions.
types of ethics committees
Individual Experts
Small Teams
Full Committees
essential components of an ethics consultative process
-What are the facts?
-What is the ethical dilemma?
Which values are in question or conflict?
-Who is involved or affected (stakeholders)?
-What are the possible options?
-What is the best option?
-Feedback and evaluation of the process.
gathering facts
- Medical problems / clinical facts
- Treatments and actions taken
- Goals of treatment, patient preferences
- Competence, surrogates
- Benefits, risks, understanding and consent
- Quality of life issues
- Conflicts of interest, family, professional issues
- Confidentiality
- Issues of justice, fairness, institutional, public
- Financial, legal, religious, other
facts: inclusion of all involved
- Patient
- Personnel involved in care
- Family
- Communities of care
facts: social and economic factors
- Costs: human, economic, financial, resource, social
- Who will pay these costs?
- How will these costs be paid?
facts: quality of life
Patient’s perspective
4 Boxes prompts
clarify ethical dilemma and issues
- Dilemmas
- Ethical principles, values at conflict
- Differing opinions regarding consequences of various options
defining the ethical dilemma
- How does the person requesting
consultation frame the problem? - What do they find particularly troubling?
- How do their values, beliefs, faith &
intellectual commitments shape their
understanding of & response to the
dilemma?
ethical issues and values
Review all ethical issues and values that are relevant or come up in the discussion.
Include all participants viewpoints.
identify stakeholders
Identify all stakeholders
Patient
Family, friends, communities
Providers, clinical team
Others (payers, institutions)
consider management options
All options considered
Ethical rationale for each
final recommendations
Best option
Note disagreements, minority / majority opinions
recommendations need to include legal aspects
Note relevant laws and regulations
(after consideration of ethical issues)
Consider previous cases.
recommendations - documentation
- Names of all on Committee
- The stated ethical concern
- List of stakeholders
- Summary of case
- Summary of ethical issues considered, with possible courses of action
- List options considered
- Final recommendations, with ethical rationale
follow up
- feedback
- evaluation of process and outcomes
