[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..