ETHICS ON CALL: The role of Bioethicists in health care - PowerPoint PPT Presentation

ETHICS ON CALL: The role of Bioethicists in health care organizations January 2014

HELLO, MY NAME IS…  Michelle Allain, MSc. Bioethicist

The Runaway Streetcar: Part 1  A runaway streetcar is hurtling towards five people.  They will all be killed…  Unless you throw a switch that will steer the trolley onto a sidewalk, where it will kill just one person instead of five.  Should you throw the switch? 3

The Runaway Streetcar: Part 2  Now consider a variation…  As before, the streetcar threatens to kill five people.  This time you are standing next to a large stranger on an overpass that arches over the tracks.  Because you are small but agile, the only way to save the five is to push the stranger off the bridge onto the tracks below;  It is certain that the stranger will die, but his body will stop the streetcar, saving the five others.  Should you push the stranger to his death? 4

(BIO)ETHICS? Goal of the ethics program: Support the improvement of patient care by assisting patients, families, staff, physicians & volunteers resolve ethical issues.

Ethics in the Media…

Top 10 Health Care Ethics Challenges Facing the Public: Views of Toronto Bioethicists (Breslin, 2005) Disagreement between patients/families and health care professionals 1. about treatment decisions Waiting lists 2. Access to needed health care resources for the aged, chronically ill and 3. mentally ill Shortage of family physicians or primary care teams in both rural and 4. urban settings Medical error 5. Withholding/withdrawing life sustaining treatment in the context of 6. terminal or serious illness Achieving informed consent 7. Ethical issues related to subject participation in research 8. Substitute decision-making 9. The ethics of surgical innovation and incorporating new technologies for 10. patient care

Ethical Decision-Making in Healthcare… It’s complex!  Federal, provincial & local laws & regulations  Professional values & codes of ethics  Organizational policies, procedures & values  Societal expectations & demands  Individual values & beliefs  Patient  Family  Colleagues

Comprehensive Ethics Program Consultation Education Bioethics Organizational Ethics Support Program Expertise Policy Review & Research Development

Who & How Bioethicists Help  Who: Anyone can call or email the bioethicist to request support  Patients, families, SDM(s) or can ask a staff to do so on their behalf.  Staff  Volunteers Confidential consultation available  How:  Consultation (confidential)  Debriefings One on One  Mediation Group  Education  Policy review/development

Domains of Practice Education  Purpose: Education  Build ethics capacity & awareness across the organization Bioethicist  Value of building ethics capacity:  Trust & organizational moral climate  Healthcare human resource retention  Client/caregiver experience  Staff quality of work life  Quality of care  Accreditation Canada

Domains of Practice Education How do I know when I’m facing an ethical issue?  Discomfort or uncertainty about the ‘right’ thing to do – could vs. should  Complex decisions that involved multiple stakeholders, perspectives, or interests  Disagreement about what is ‘right’  Competing values (e.g.: telling the whole truth vs. preserving confidentiality)  Knowing the ‘right’ thing to do in a situation, but encountering organizational or personal barriers.  Lingering distress as a result of unresolved ethical issues

Domains of Practice Education What is the Ethical Decision-Making  Framework? An analytic tool designed to help individuals  work through & address ethical issues in client care. When should I use it?  Use the tool as ethical issues or questions arise.  The tool can be used at any point during the decision process, although the earlier the better. Common triggers include:  Uncertainty about the ‘right’ course of action  Differences in values  Complex decision that involves multiple  stakeholders etc.. Who should use the tool?  Anyone can use the tool. It may be especially  helpful for: clinicians, health care teams, clients/families, administrators etc… How do I use the tool? 

Domains of Practice Education

Domains of Practice Research  Purpose: Education Ethical review of research proposals & a) protocols  Research Ethics Board (REB) Bioethics Advancement of health care through b) Program research on ethical issues  Example: Research A)

Domains of Practice Research Example: B)

Domains of Practice Policy Review & Development  Purpose: Education  Ensure organizational policies & guidelines meet ethical Bioethics Program requirements.  Examples: Policy Review & Research  End of Life Development  Confidentiality  Conflict of interest

Domains of Practice Consultation  Clinical Consultation Education  “…improve the process & outcome of care by helping clinicians to identify, analyze & Bioethics resolve ethical problems that Program arise in specific clinical cases” (Source: Agich, 1996: 125, Cited in Gordon 2007:27.) Example: Policy Review & Research Development

Domains of Practice Effect of Ethics Consultations on Nonbeneficial Consultation Life-Sustaining Treatments in the Intensive Care Setting: A randomized controlled trial Schneiderman et. al., 2003  Clinical Purpose:  “…improve the process & Investigate if consultations in the ICU reduce the  outcome of care by helping use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital clinicians to identify, analyze & Bioethics discharge resolve ethical problems that Program Investigate the reactions of HCPs & arise in specific clinical cases”  patients/SDMs (Source: Agich, 1996: 125, Cited in Gordon 2007:27.) Results: Example: Policy Review & Research Usual-care groups showed no difference in  mortality Development Ethics consultations were associated with reduced  hospital & ICU days & life sustaining treatments 87% of physicians, nurses and  patients/surrogates found ethics consultations in the ICU were helpful in addressing treatment conflicts

Domains of Practice Consultation  Clinical Consultation Education  “…improve the process & outcome of care by helping clinicians to identify, analyze & Bioethics resolve ethical problems that Program arise in specific clinical cases” (Source: Agich, 1996: 125, Cited in Gordon 2007:27.) Example: Policy Review & Research Development

Domains of Practice Consultation  Clinical Consultation Education  “…improve the process & outcome of care by helping clinicians to identify, analyze & Bioethics resolve ethical problems that Program arise in specific clinical cases” (Source: Agich, 1996: 125, Cited in Gordon 2007:27.) Example: Policy Review & Research Development

Domains of Practice Consultation  Organizational Consultation Education  The systems-level prevention/ management of ethical issues that affect the management of Bioethics the organizational &/or patient Program care.  Importance of Organizational Ethics: Policy Review & Research Organizational issues are inherently Development • value driven Organizations have a mandate to uphold • institutional mission/vision/values Breadth of impact • Public accountability •

“ Organizational ethics calls on health care managers & board members to: • Champion the organization’s efforts to define its core values and mission, • Identify areas in which important values come into conflict, • Seek the best possible resolution of these conflicts and, • Manage its own performance to ensure that it acts in accord with espoused values” (Gibson, 2007, Healthcare Management Forum, p. 34)

COMMON ORGANIZATIONAL ETHICS CHALLENGES (Gibson, 2007) Resource allocation • Business development • Charitable fundraising • Access to care • Workplace ethics • Relationships with vendors • Conflict of interest • Relationships with other providers in the community •

Domains of Practice Consultation  Organizational Consultation Education  The systems-level prevention/ management of ethical issues that affect the management of Bioethics the organizational &/or patient Program care. Example: Policy Review & Research Development

APPROACHING ORGANIZATIONAL ETHICS IN PRACTICE… 1. Organizational ethics depends on leadership 2. The mission, vision & values of an organization should be the foundation for all decisions & actions 3. Ethical guidelines, policies & decision-making frameworks should be in place 4. Processes should ensure ethical decision-making processes & mechanisms make use of these tools, promoting an open & transparent organizational culture 5. Evaluation should be ongoing (Gibson, 2007, Healthcare Management Forum)