[upbeat instrumental music] ♪ ♪ Hello, and welcome
to today's course on ethics consultation. In this first of two parts, we'll be exploring the need
for procedural consistency in your ethics case
consultation process. Ethics consultation is one
of the three core functions of IntegratedEthics. The other two functions, ethical leadership
and preventive ethics, are covered by other videos
in this series. Before we go any further, be sure you have
your work sheets handy. You'll need them
for the activities later on in the video. You know, most VA facilities
are committed to improving their mechanisms for handling
health care ethics.
Today's complex
health care environment calls for a more systemic
and pervasive approach. But transitioning
from an ethics committee model to an IntegratedEthics program
can be challenging. And that's
where the IntegratedEthics coaches come in. (male narrator)
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. In today's episode,
the IntegratedEthics coaches will be working
with Prospect VAMC, a typical VA medical center
in Anytown, U.S.A. This is Dr. Mike Burrows,
head of the cancer center over at Prospect VA
Medical Center. He's also chair
of their ethics committee and has been
for the last eight years.
We'll be sitting down
this morning with Dr. Burrows and some other members
of his group. So these folks have been at it
for a while. Seems like they would have
a pretty good handle on where their program
is going. Maybe, Danielle,
but I understand they're still struggling
with how to incorporate an IntegratedEthics
approach. Yeah, and plus,
they all have other jobs and responsibilities
at the hospital. I mean, these
are some busy, busy bees. At least that's
the buzz I hear. So who else
are we seeing today, Frank? This is Maria Ruiz. She's a nurse specialist
for geriatrics and has been
an ethics consultant for the last two years. Bzzzz. And finally, Tina Whitley; she's a licensed
clinical social worker, who works primarily
in surgery.
She's also a founding member
of Prospect's ethics committee. So she's been around
the hive for a while. Why don't you buzz off? Ouch. That really stings. Okay, okay,
our job right now is to help these seasoned
ethics consultants improve and enhance
their consultation process. All right, folks. We'd better get moving. Time to make the honey. You should comb
your hair. You're so sweet. [piano playing
Flight of the Bumblebee] ♪ ♪ Our files indicate
that your ethics program has been around
for a while. (Burrows)
It sure has. I myself have been involved
in the committee for, oh, it's got to be
at least 14 years, the last eight as chair. (Scot)
So are you three the core team
for ethics consultation? Well, that's one of the things
we're trying to figure out. We know that not everyone
on the ethics committee has the proficiency required
for ethics consultation. But at the same time,
we feel that we might need more than just
the three of us.
As far as what
the ideal size team would be, there is no simple answer. No standard formula;
every facility is different. [imitating Groucho Marx]
Take one clinician,
one nurse, one clergyman, stir in medium-size conference
room, season to taste, voilà, instant ethics
consult team. [normally]
No, I don't think so. But I will say this: I think you guys
are in pretty good shape. I mean, you have a nice mix
of backgrounds and skills– What? I can say nice things
sometimes. Oh, and me
without my tape recorder. Okay. Presenting, for your edification
and enlightenment, the knowledge, skills,
and traits necessary for a top-notch ethics
consultation in the center ring. We have the knowledge;
knowledge is power. You got to have knowledge.
If you don't got it,
you got to know where to get it. You got to know your ethics. So what do you got to have? Anyone, someone,
tell me something– this is the part where you
respond back. Yes, you, little lady, front
row, something on your mind? Hm? Oh, oh, how about
clinical literacy? You know, understanding
of medical jargon? Ding ding ding ding, Nurse Ruiz takes an early lead
with 50 points. W-what do you mean,
points? Go away, kid,
you're bothering me. Look, anyone else
want to try to ring the bell? Of course,
you need to be familiar with a broad range
of ethics topics– informed consent,
conflicts of interest, life-sustaining
treatment, and so on. Oh ho ho ho, Dr.
B roars
into the lead with 100 points. How come he got 100? (Whitley)
There's a long list of things you need to know about. It's all in the ethics
consultation primer. (Scot)
Oh, and Ms. Whitley out of nowhere
roars into the lead. She's right, folks. It's in the primer. You should've all read
the primer by now? Okay, now, you may
be asking yourself, "Is it worth all this effort
for that knowledge?" Well, let me tell you, neighbors and friends,
ladies and gentlemen, it's an effort
that pays you back. Because
without this knowledge, it will turn a seemingly
"normal" consultation into the kind of monster
that could ruin you, your patient,
and your whole program. (Ruiz)
Um, is it always like this
around you guys? Ah, the fun never stops.
Ha-cha-cha-cha. I think we all take the need
for ethics knowledge seriously. But it's not as simple as
just checking it off some list. You can't just go
to the knowledge mart and pick up two bags
of bioethics concepts. I like you. Developing your ethics knowledge
is a never-ending pursuit. You need to continually
re-educate yourself– attend conferences,
read journals. And don't forget
that ethics expertise is about more
than just knowledge. You also need to develop
certain skills. Analytical skills. Communication skills. The ability to facilitate
and foster dialogue. (Danielle)
The ability to identify
ethically justifiable options. (Scot)
Critical thinking. Listening well. And consensus
building. The skills you need
are all outlined in the primer along with the traits that
make these skills achievable. (Danielle)
Like patience. And tolerance. And humility. She's got loads
to be humble about. (Frank)
We'll be moving on in just a moment. I'd like you folks
to show us around the facility a bit,
if you don't mind.
But first,
we always have to ask, what would you say
is the single largest obstacle between
your current situation and a first-rate
ethics consultation service? Staffing. Manpower. Time. Our administration is very
supportive of the idea of ethics consultation. (Burrows)
But in actual practice, it tends to be treated
more like a collateral duty than a primary function. It's something
we have to make time for. (Frank)
I hope that's all
going to change soon. It's one of the things
we address in our session
on ethical leadership. In the meantime, there
may be some things you can do.
How has your supervisor
handled the situation of having to "make time"? Well, I haven't really
pushed it. I mean, I've said
generic things like, "Wow, the consultation
service seems busy." But it doesn't seem like
she's gotten the hint. This is Jeanne Yancy
you're talking about. I know you probably
already know this, but for the record,
hinting isn't the same thing
as communicating.
I know, it's just that
I don't want to seem– (Scot)
You just don't want
to complain. Oh, I love this woman. Oh, please, please,
can I take this one? Look, look, I can fix it;
I'll be very persuasive. Scot– I'll be good;
I'll be good. Jeanne Yancy, you said? Yes. Up, up, and away! [trumpet fanfare] It's going
to be interesting. Maybe you could
show us around. Certainly. (Frank)
One of the first things
I'd like to address is access to your
consultation service. It's important for staff,
patients, and families to know what the ethics consultation
service is there for.
Excuse me. If you had
an ethics question related to one
of your patients, what would you do? The patient number
for ethics consultation is right there
on the board. It is;
look. "Have an ethics
question?" Page the beeper. (Danielle)
That's great. Let me try something else. Oh, excuse me. Can you tell us
when it's appropriate to request
a ethics consultation? Sure, it's basically anytime
you have uncertainty or conflict about
the right thing to do. We get literature
on it every year. Plus, I think
there's something about it in the employee orientation,
if you remember. If you have any questions,
just contact your supervisor, or else call the ethics
consult service. Excuse me, please. I got to start working out. Well, it certainly seems your service
is well-publicized. Are the patients as aware
of all this as the staff? They get a brochure
about our service when they're admitted. And that same brochure
is available in most of the reading rooms
and at every nurse's station. And there's an ethics link
on Prospect's home page.
You guys are good. I wonder what's
going on upstairs. I'm on my way
to talk with Jeanne Yancy and find out why poor Maria Ruiz
doesn't feel like her work on ethics consultation
is valued. And since this is a federal
government job, I'm going to go into G-man mode
just for a minute. It's going to be
real Joe Friday type stuff. Jeanne Yancy? Yes. Ms. Yancy, I'm here
in an official capacity, and it's imperative
that I talk with you. I don't– It'll save
a lot of troubles later on if you just
follow me, please, ma'am. You know,
I really don't– [whispering]
Is she following me? Oh, thank goodness. Sir, you could
wait a moment, please? It'll only be a minute,
ma'am.
Sir, I really–
what is your name? You can call me Scot. And I need to know
why you're here, Scot. I'm doing a friend a favor. And actually, I'm doing you
a favor too, in the long run. Now, do you recognize
this desk? (Yancy)
Of course I do;
it's Maria's, Nurse Ruiz. That's very good;
now, tell me what you see. I don't understand
what you're asking. And I am going
to have to ask– I'll tell you what I see.
I see files that need
to be filed; I see– [sniffs] Beef surprise. I see stacks and stacks
of policies, and–what am I missing? I'm missing something;
what am I– Ah, patients. Nurse Ruiz provides care,
doesn't she? Of course she does. Now, will you really– You look fabulous,
by the way. Can I ask you something? Do you think
this hospital values the work
that Nurse Ruiz does on the ethics
consultation service? We value that work
as highly as we do all the other aspects
of patient care. Then why aren't
her ethics responsibilities made explicit
in her performance plan? I really
haven't considered. Couldn't you buy her
a little more time if you took off
the nursing policy committee? I guess. You see,
here's the thing. Nurse Ruiz, she doesn't
want to complain or anything. So she's never told you how overwhelming
all this stuff is.
And, believe me,
we're going to be teaching her how to speak up
and how to express her concerns, because we know
it's not fair to you to turn into a mind reader
or anything. But in the meantime,
anything you can do to let her know that you value
her ethics responsibility, that you want her
to have the time to do it, would be
absolutely terrific. Don't you think? I guess. You are just too great. I am serious;
she's gonna be thrilled. Don't be a stranger. (Frank)
May I ask what happens
when someone pages the ethics
consultation service? (Burrows)
Well, that all depends. On what? Well, for one thing,
it depends on who's wearing the pager
that day. Ahh, it depends. (Danielle)
Exactly. It's not that complicated. I get the page,
I call the other two, and we get
to the bedside ASAP. I try to get a little
preliminary information from the caller first, or I might review
the patient's history myself before I call
the other two. (Burrows)
Exactly; it depends
on circumstances. Sometimes I'll see
the patient first myself to see what's what,
but I mean, it depends
on how much time I have.
[coughing]
Problem. I beg your pardon? (Danielle)
You need to be consistent with your
initial response. And the first step
of that response should be to clarify
the consultation request so that you can
come up with your game plan, including which members
of the team that you want to involve. Based on the complexity
of the case, the subject matter,
the nature of the request, not on how much time you
happen to have at that moment. No matter which one of you
gets the page, this needs to be
your initial step. What we're saying is, for ethics consultation
to work best, you have to have
procedural consistency. Both you
and the people you serve have to know exactly
what to expect at every phase. [beeping] Uh, Jill Ingersoll
just sent me a page. She has
an ethics question. You mind
if I step out a minute? Actually, why don't you call her
on the speakerphone? That way, we'll
be able to follow along and talk about it later.
All right. Extension 321. [phone rings] Jill Ingersoll. Hi, Jill, this is Mike Burrows
returning your page. Your call came
at a really good time. We have the whole
consult team here doing a little training. I have you on the speakerphone;
is that okay? Sure. (Burrows)
What's going on? I've got this patient
with a living will that says he doesn't want
his life prolonged. It also names his wife as
the durable power of attorney. She thinks
it's too early to give up and wants to do everything. I want to honor
the patient's wishes and remove
the feeding tube. I can do that, right? Well, it sounds
a little too complicated to give a quick
yes-no answer. Can you back up a minute and give me some more
specifics on the case? Sure, the patient
is Everett Johnson; he's 75. He's had multiple strokes,
and he has a feeding tube.
He has grade 4 pressure ulcers
and chronic osteomyelitis that has not responded
to antibiotics. He's been in and out
of ICU with sepsis and has been on the ventilator
several times for his COPD. We've been trying
to get him stabilized long enough to move him
into a nursing home, but it's been one thing
after another. His wife says do everything, so that's
what we've been doing. And then yesterday
out of the blue, his sister shows up
with this living will that says he doesn't want
to be tube fed. And it also names his wife as the durable power
of attorney for health care. And it says specifically that his wife
needs to follow his wishes as stated
in the living will.
So I think
it's pretty straightforward. It sounds pretty
straightforward, but let's clear up
a couple of things just so we know for sure
what we're dealing with. Shoot. Is it a VA living will? Yes, it's our
standard form. And the power of attorney
is our form too? Yes. Signature's there
and everything? Absolutely;
two witnesses, everything seems right
by the book. And it says specifically that
he doesn't want a feeding tube? No life-sustaining
procedures of any kind. Okay, next,
what is the patient's prognosis? Really poor; he's been going
steadily downhill. The way things are going,
I seriously doubt he'll survive
another trip to the ICU. Why does he have
a feeding tube? Is he eating
anything at all? No, he's NPO;
recurrent aspiration pneumonia. Practically
everything he eats goes straight
to his lungs. So there's no way
he could be fed orally? No way. And you're sure he lacks
decision-making capacity? He doesn't talk at all. Well, can he communicate
nonverbally? Intermittently. He's pretty out of it
most of the time.
Has he had a formal assessment
of decision-making capacity? I think so. I'll check. You should be sure that that's adequately documented
in the chart, especially if you're thinking
of withdrawing the life-sustaining
treatment. Good point;
you're right. I'll do that. Okay, let me summarize here by formulating
the ethics question. Should you remove
the feeding tube over the objections
of the surrogate based on the patient's
clear advance directive? That's exactly
my problem. Now, what about the wife? Have you talked
to her about this? Not yet; I thought
I should talk to you first. What I want to tell her
is that we need to follow the patient's
advance directive. He said no feeding tube, so there's really no choice. Isn't that our policy? Right; VA policy states
that the surrogate must follow the patient's wishes
as far as they're known.
It's a matter
of patient autonomy. The patient still gets
to make his own decisions even after he's lost
decision-making capacity. See, that's what I thought. Tell you what, Mike, I'm going
to talk to her, see how it goes. I'm hoping I can get her
to go along with it. It would sure
make things easier. It definitely would.
These conversations
can get a little dicey. Do you want me involved? I don't think so. I'm going to do
what we talked about before. You know, make sure
we stay focused on what the patient
would want us to do. Sounds good. One more question. Anybody on the team
have a problem with the feeding tube
withdrawal in this case? No, everyone agrees we should
go with the advance directive. I don't anticipate
any problems on that front. And the patient's sister, she wants the feeding tube
withdrawn? Definitely. Given the conflict
in the family, you should probably
involve legal counsel. I've already got
a call into them. [beeping] Hey, listen, I've got to run. Someone's paging me. Okay, then; let me know
what happens, will you? You bet;
hey, do me a favor. Would you do a consult note
for the chart? Yeah… Yes. Great; talk to you. Well, sorry about that. I guess it was pretty much
a false alarm.
What? What's wrong? Is there anything wrong? What did you see
that went right? What did you see that you
would have done differently? Let's pause for ten minutes to analyze
this telephone conversation between Dr. Ingersoll
and Dr. Burrows. Use the work sheet
labeled Exercise 1. There's a transcript
of the telephone conversation and a few questions
for you to discuss. When the clock
on screen reaches zero, we'll come back
to the action.