Integrated Ethics - Ethics consultation - Responding to ethics conerns in health care - Part 2a of 2

[upbeat instrumental music] ♪ ♪ (male announcer) The IntegratedEthics coaches, three makeover specialists determined to help facilities transform their traditional ethics committees into IntegratedEthics programs: Frank, the Analytic Ace, with years of clinical experience and ethics expertise. Danielle, the Communications Connoisseur, with a background in ethics-related customer service. And Scot, the Process Pro with an eye towards streamlining work processes and procedures. The IntegratedEthics coaches: ready to help you make sure your core functions are functioning. Hello, and welcome back to this two-part course on ethics consultation. In this hour, we will continue to explore the steps of the CASES approach. As you know, ethics consultation is one of the three core functions of IntegratedEthics. The other two functions, preventive ethics and ethical leadership, are covered by other videos in this series. Remember to have those work sheets handy. You'll need them for the activities later on in the video. Last time we saw the IntegratedEthics coaches, Frank, Danielle, and Scot, they were helping Prospect's ethics committee understand the need for procedural consistency in their ethics case consultation process. They also took a look at the first step of the CASES approach. Today they'll explore the rest of the steps as we apply them to a case. So let's rejoin them. So why do they call it Zulu if it's based in Greenwich? Ask the Pentagon. (Frank) Nurse Ruiz, let's hear a little more about that blood transfusion case. Oh, okay, yes. In this case, the patient had GI bleeding. The attending physician felt that a blood transfusion was necessary. So the patient was sedated and intubated, but the wife wouldn't give consent, because she was a Jehovah's Witness. (Burrows) I remember the case. The patient was in ICU. He had been intubated to protect the airway. And the bleeding was quite active. So the first step is what? [together] Clarify the consultation requests. Oh, are they good or what? (Frank) Yes. To clarify the request, you first need to determine if it's appropriate for the ethics consultation service to handle. If it is appropriate, then you determine if it's an ethics case consultation. If it is a case consultation, then you use the CASES approach. Well, the doctor definitely had a question about what was ethically justifiable. Okay, so that means it's appropriate for ethics consultation. But is it an ethics case consultation? Yes, it was an active patient case. Well, that answers that. It's an ethics case consultation, and you should use the CASES approach. Already I'm seeing where I started to go wrong with Dr. Ingersoll. Continuing with the C step, you need to gather information from the requester. Favorite foods, astrological sign. You're a goofball. Hey, I got you sprung from the policy committee. You're a thoughtful goofball. The information you gather can be very basic. Hey, goofball. Moi? Make yourself useful, and take this stuff down. You need the name and contact information of the person doing the requesting. Name and contact info. (Frank) Another piece of info you have to gather is gaining some understanding of the urgency of the request. I guess I didn't do a very good job of that with Dr. Ingersoll either. You also need to clarify the ethics concern from the requestor's perspective. So for this one, it would be the physician wants help with a patient who has active GI bleeding and medical indications for a blood transfusion but whose surrogate decision maker is refusing transfusions for religious reasons. Very nice. Succinct and to the point. Next we need to move on to what's already been done to resolve the concern. Did the physician talk with the wife? And has he truly listened to the other person's perspective? Sometimes something as simple as a five-minute chat where the other person really feels that their concerns are being heard and respected can go a long way towards getting things resolved. And lastly, you need to determine what type of assistance is being sought. Often, the request is vague, like, "Will you help me work this problem out?" So you really need to tease out exactly what they want. Is it a forum for discussion, conflict resolution, policy interpretation, or what? Once you know what's being sought, you're in a position to decide the best way to handle it and who should be involved. Which takes us very neatly into the next phase of the C step, which is to establish realistic expectations. This is a very important element. It has to do with making people understand how the process works and how long it might take. But most importantly, it's vital for them to know what you won't do. Also, it would really help if, when you initiate a consult, you had some sort of printed matter to give them or a website for them to visit which can explain the basics of your function. A lot of people might imagine that you folks are going to come in like referees and decide the issue. But that's not our role. Our job is to help the parties involved to resolve things for themself. Yeah, we're kind of like-- I don't know what-- a lens, maybe. Yeah. We give people a way to see the problem more clearly. That's all accurate and very well said, but I'm sure you know that many of the people who call you don't understand the basic neutrality of your function. [in a Swiss accent] You have to be Switzerland. Yes, but they don't expect that. They expect you to take a side and to settle it accordingly. Sometimes that's why people call in the first place, because they think you're going to side with them. Dr. Rollitz pretty much expected we would say, "You're right; give him the blood." Because you're his colleagues, and he may think you're on his side. And that's part of what's hard about this work. You may be more sympathetic to one side, but you need to distance yourself from your own personal values and be objective. I can see that. So now we move on to the next phase of the clarify step. And this one might be the hardest of all. It's called, formulate the ethics question. (Ruiz) This was in the primer. This is that sentence with the blanks in it. I tried this with Dr. Ingersoll. And your technique here wasn't too bad. I know that this looks simple, but simple does not necessarily mean easy. What we have here is a simple formula that takes some work to fill in correctly. Two different variations on the same basic task. And, please, bear in mind that these formulas aren't here to serve as any kind of question engine. They're just basically rubrics to help clarify your thinking. Or... As you can see, there are a few blanks that need to be filled in. Yeah, but they're big blanks. Okay, which formula should we apply to this situation? The second one, because the doctor already knows he wants to give the blood. Bingo. Now, what about the first blank? What is the uncertainty or conflict about values? Well, isn't it ultimately religion versus science? Or is it standard care versus personal belief? (Maria) No, it's about decision making: the wishes of the wife versus the wishes of the physician to provide the best care. You guys are all thinking way too big. . It's to boil it down to the specifics of the case at hand. None of which you've said just now was wrong exactly, but Scot's correct in calling them too big. None of your suggestions fit this formula. Given what? Try this. Given uncertainty because the wife's refusal is based on her beliefs rather than her husband's, is it ethically justifiable for Dr. Rollitz to order the blood transfusion? I think that's much more to the point. Let's look at another one from your files, the gangrenous foot. Yes, here's a case where we have a patient whose foot is gangrenous. He's able to make his own decisions, but he's refusing to allow amputation, even though the physician feels this is necessary. Can anyone formulate the ethics question? How about: Given the conflict between the physician's obligation to treat his patient and his obligation to perform procedures only with the patient's consent, is it ethically justifiable to amputate the foot? Bravo. [claps] It's exercise time again. Let's see how well you understand the nuances of formulating the ethics question for a given case. On the work sheet labeled Exercise 3, you'll find brief descriptions of several cases. Working together, do your best to formulate the ethics question for each case. You'll have ten minutes to complete this exercise. When the on-screen clock reaches zero, the video will resume.