This formulation
of the ethics question– you were right. It looks simple,
but it's definitely not easy. It's like any skill. It doesn't develop
overnight. You did very well
with the cases we discussed. You were fabulous. I feel we've accomplished
so much already, but we're still
only on the first step. Yes, but remember,
nobody's asking you to memorize this stuff. You're not cramming
for an exam. Everything we're talking about
is well documented in the materials
you're already using. And believe me,
you'll keep using them.
It took me
a good long while before I didn't have to pull out
the pocket card on every case. That's good to hear. So let's move on to A, which the primer says
stands for: "Assemble relevant
information." And you're absolutely right,
Ms. Whitley. The next step is to go
through a process of data collection
that is more intensive than the preliminary
information step you'll already have done. At this point, you need to go
to as many sources as are available
to you. (Scot)
Yeah, it's like
detective work. You'll want to interview
all the people who are connected
with the case. You want to look
at the medical record. Obviously, the patient should be
consulted if he's able. Exactly.
There is a patient. And even if the patient
cannot be an active participant, you should still visit
the patient. You can get a lot of important
information from that visit, like maybe no one mentioned that
the patient is in restraints. And a really important part
of this process is making sure not to take
everything at face value. Caveat emptor. Benefits of a classical
education, don't you know.
Uh, so if we're not
supposed to take anyone's word for anything– It's not quite
that cut-and-dried. What's important
is that everyone on your team be on the lookout
for subjective language or predictions
and interpretations that are treated
as fact. I spent many years
as a practicing physician, and I know how it can be. We like to think
that our clinical judgments are the same as fact, and they just aren't. Not always. I'-not saying
a word. You'd better not. Everyone can make
the mistake about believing that their perspective
is the only one. And because these cases are so
frequently emotional, you have to be disciplined
about double-checking every piece
of important information. For example,
a physician or a nurse might say that a patient
is coping nicely with pain. But what does that
really mean? The patient's pain
is adequately controlled or the patient is in pain
all the time but doesn't complain
too much? The point is not to let
any labels or conclusions just slip by.
It's easier to do
if you make sure that everyone knows
why you're there and to make it clear
that you're not taking sides. Expectations again. (Danielle)
Exactly. It is also important
to review the ethics knowledge relevant to the case, which some people call
best thinking. Ethics knowledge
might include codes of ethics, ethical standards
and guidelines, consensus statements,
scholarly publications, precedent cases, and applicable
institutional policy and law. Not everyone is a master
of ethics, okay? But the first thing
to aim for is to be a master
of process. That way, you're less likely
to make mistakes as you build expertise
over time. (Danielle)
And recognize
when you need help. Anybody involved in this work
needs help sometimes. You should have access
to experts that you can talk
things over with. It's just too complicated
to go it alone. Well, does it ever happen
during the course of assembling information
that you realize your original ethics question
no longer applies? It happens, and that's one
of your next steps here: to double-check the question
and make sure you have it right.
And if it's not right,
you reformulate it? Exactly. Assuming we have
a valid formulation of the ethics question,
what happens next? (Scot)
At the end of the day, this question
just boils down to gather as much information
as you can and double-check anything
that's really important. (Danielle)
Whenever possible,
get your information firsthand. For example, look at
the advance directive yourself. Don't just go by
what others say it says. (Frank)
Let's move on
to the first S in CASES, which stands for:
"Synthesize the information." You got this big wad
of data. What do you do
with it? You pull it together.
(Frank)
Once you've reviewed
the best thinking, you're ready to begin
the analysis of your case. You've got to be willing
to use different approaches, such as principalism
and casuistry. Well, I'm familiar
with several approaches. I'm most comfortable
with the casuist approach. But I mix in aspects
of several other approaches too. I'm still a novice
to these different approaches. (Frank)
That's okay. No single person
needs to embody every skill necessary
for case consultation. Dr. Burrows' expertise
in ethics analysis is an important
proficiency. And as long as he's
proficient in these areas, his analytic skills
will rub off on the other members
of the team. He can be a mentor
to you. (Scot)
And here we touch again on making sure
you attack the question systematically and logically.
This isn't a debate
where the most passionate person or the best speaker
is going to win by force of personality. It's not like a movie critic
giving a thumbs-up or a thumbs-down either. Everyone participating
has a voice, and every voice
is valid. The different points of view
have to be discussed openly and thoroughly. It's a systematized
examination of a question. One especially important step as you synthesize
the information is to identify the ethically
appropriate decision maker. That is the person
who should make the critical decisions
about the case. Usually the patient
or the surrogate gets to make the decisions. But some decisions are a matter
of professional judgment.
Then comes the discussion
of the options. The ethically justifiable
options. (Frank)
You identify which options
make sense ethically and explain why
others might not. If you're going
to rule out something as not being
ethically justifiable, you have to be able
to back it up based on accepted norms
or standards for ethical practice. You have to show
why it's beyond the bounds of what's accepted. And you try to think
outside the box a little bit. Try to come up with options
that haven't been discussed. And if they get shot down,
so what? It's about examining
the question, not winning the prize by having
the most people agree with you. "Who thinks I'm right?" Not about that. Because, remember,
you're not there to give an answer. You're there to help the ethically appropriate
decision maker understand the range of ethically
justifiable options which they have
in order to make their own decision. (Frank)
Let's say, for example, that a patient is fed exclusively through
a feeding tube because he has a tendency to aspirate his food. The ethics consultant
might raise the question of whether allowing
the patient to eat some foods by mouth
and risk aspiration pneumonia might be an option
that is ethically justifiable because it's consistent with the patient's goals
and preferences.
But if all of this boils down
to only one option, aren't you more or less
dictating their choice? You're not dictating
their choices. You're helping them to navigate
all of the complexities. And if in that work you find that only one option
is ethically justifiable, then they know
how they got there, and they can see it
for themselves. Now, that was
a pretty impressive segue. What? He's right. You did a great job
of summing up the next step of CASES: E for: "Explain
the synthesis." You have to be able to explain
to all the key participants what happened
in the consult process. And you have to be able to
provide educational resources. That's right. Don't take my word for it.
Check for yourself. (Frank)
If you know of an article that would be
especially helpful to them in understanding
the case, it would be good to refer them
to that information. Providing resources
helps educate everyone involved,
including yourselves. (Danielle)
And you don't just have
to explain it to the people involved. You have to be able
to explain it to the future. Translation, please? Document, document,
document. Ah, so anyone
who picks up the chart can understand the case. (Danielle)
Exactly. The consultation
needs to be documented in the patient's
medical record. Unless the consult doesn't
really involve the patient, for instance,
if a health care provider had moral objections
to participating in withdrawing
life-sustaining treatments. In any event, the consultation
needs to be documented in the consultation service's
files. (Danielle)
Exactly. The primer offers
more advice and examples on how to document
a consult. And last but not least,
there's the final S, which stands for: "Support
the consultation process." Your job doesn't end once you've completed
the consult documentation.
That's right. You need to follow up
with the participants to find out what ultimately
happened with the case. And you need to talk
about your own consultation. Talk about
what you did well and what you might
have done better. The integrated
ethics materials include some tools that can
be used for evaluation as well. And if you find something
that could have gone better, you don't get any points
just for recognizing it. You have to adjust
your processes accordingly.
Sometimes
the necessary adjustment isn't within your power. The problem might be
systemic. (Danielle)
That's true. If you find yourself facing the same problem
over and over again– say, the case is involving
withdrawal of a feeding tube– then you might have
a systems problem. It might be
that a process change is required
on a system-wide level. If you think you've identified
a systems issue, don't keep it to yourself. Tell someone:
the preventive ethics team, the ethics committee, whoever's responsible
for handling this stuff. So that's CASES: Clarify the request. Assemble the information. Synthesize the information. Explain the synthesis. And lastly, support
the consultation process. Look, we know
that none of this is news. This isn't the first time
you've heard of this approach. What we want to do is to help
you to implement this technique with the greatest possible
effectiveness. So next we'll be using
what we call the team cams. [imitating movie camera] (Frank)
We'll be setting up
three very small video cameras, one for each of you. And after obtaining
proper consent, those cameras will record
your next consultation. Then we'll review
that video and record our responses
for your future use.
You shouldn't
feel spied on. This isn't Big Brother
or anything. This will be edited
into something that you can study
and work from and even use to train your new
team members when they arrive. The cameras will begin recording
as soon as we leave. You'll do well. Ethics consultation isn't a luxury. It's not an option. It's an absolute necessity
for health care. And to provide it with skill is an act of courage
and compassion.
Health care facilities are– they're places
of physical catastrophe. And in the face
of catastrophe, it's easy for anyone
to lose his way. Each one of you
is a kind of rescue worker. And if someone is lost,
you're right there for them. You're not always
going to know the way yourself, but you're always going to be
the beginning of an answer. You'll always be the reason
that no one is facing their fear
and confusion alone. And it's an honor
to work with you. Well, come on, guys. Let's get out
of their way. [upbeat instrumental music] ♪ ♪ Everybody's looking good. The images are all clear. Yeah, let's see
what their day was like. All right, bye-bye. I've called Nurse Ruiz
and Dr. Burrows. Dr. Ingersoll's conversation
with the patient's wife about the feeding tube doesn't seem
to have gone too well.
The three of us
are going to meet in Dr. Burrows' office
right now and hope we can find some way
to patch things up before the wife
gets even more upset. We're going
to Dr. Burrows' office. Turns out this case is a long way
from being settled. Ooh, somebody's
in trouble. Okay, let me
fill you all in. So that's the size
of it. I kept things
too informal, and Dr. Ingersoll
went back to the patient's wife feeling as though
she had received a verdict
from on high, especially because
that's what she wanted to hear. And the wife
went through the roof. How bad is it? Well, she's talking
lawsuits, and she's going to go
to the TV station. She was outraged. What do we do? Well, I have a call in
to the facility director to give him a heads-up
just in case 60 Minutes shows up
at the front desk. But what I'd really like
to try to do is find a way
to resolve this conflict.
And I'm going to need
as much help from the both of you
as I can get. That's great. We'll try to get a copy of the patient's
advance directive right away. In the meantime,
if you could hit the literature, try to gather
the relevant ethics knowledge, anything with a conflict between a surrogate
and an advance directive. Sure. And I want to try
and gather as much clinical data
as I can to try to build
a more complete picture of the patient's
condition. Assembling
the information. Getting the facts.
Excellent. Maria, start
by calling the wife. It's crucial we understand
her perspective of things.
I'd call her myself, but I am worried
that she'd be too angry to want to discuss anything. (Maria)
Okay, I'll take care of that. I think we can salvage
this one. Let's get busy. Okay. Yes, uh-huh,
we–yes. We understand completely,
ma'am. That's why we want to do
everything we can to make sure that
your husband's wishes are fully respected. Oh, she's good. Keep it on the patient,
not on the conflict. Mm-hmm. (Frank)
This is very good. Tracking down
the ethics knowledge using both print
and internet media. And what is your analysis
of the patient's condition? Well, there are
a variety of problems. But, basically, he's dying
of his osteomyelitis. And from what I understand,
it's essentially untreatable. And there was something
about a sister and– Right, the sister said that
he signed an advance directive, but I've actually
never seen it. Mm-hmm, oh, I agree with you
100%, ma'am. And that's why I think we need
to talk about this further.
Well, of course
sisters matter. We'd really appreciate it. Oh, and, please,
this is very important. Be sure you bring that copy
of your brother's living will. Okay? Thank you. I know it's not published yet,
Linda. I'm not going to show it
to anyone. I just want to see what
you have to say on the subject. Part of my job is to assemble the best current thinking
on the issue, and you're my best source
for that. Can you send it
as an attachment? Thanks.
I owe you one. Hi, Hal. Listen, you were
the ID specialist who looked at Mr. Johnson,
right? This footage was shot
while Dr. Burrows was looking
for another opinion about whether the patient
was truly dying from the infection or not. This is
right on the money. Yeah, I need
a little clarification on your prognosis
for the osteomyelitis. Do you think
you could walk me through your assessment of things? Mr. Johnson,
I'm Dr.
Burrows. I'd like to speak to you
for a few minutes. No substitute
for seeing the patient yourself. Ms. Whitley had the idea that the patient's
primary care physician might be able
to shed some light on the patient's wishes. She's really covering
all the bases. This is Tina Whitley. I'm doing an ethics consult
on Mr. Everett Johnson. Right, that's the one. Now, you're his
primary care doctor, right? Great, I have a couple
of questions. Have you, by any chance,
talked to Mr. Johnson about his wishes
for end-of-life care? So it's decided,
then. I'll go ahead
and set up the formal meeting. I'll be there. (Burrows)
Now, we're not here
to make a decision or to provide a single
final answer. My team's function
is to help people work through
a difficult decision by listening
to what everyone thinks and then helping them
to understand the range of options.
(Danielle)
Nicely put. [Burrows over TV]
Now, Mrs. Johnson, since you're here
not only as the patient's wife but also as the designated
health care agent, why don't you try
to give us your impression of where things stand? Where things stand
is that you people want to remove
my husband's feeding tube, and I don't understand why. I assure you
that everyone here has your husband's interest
in mind. But first, let's try to be sure
we understand his wishes. Now, your sister-in-law
brought in a copy of this living will
that he made. Have you ever
seen this before? [scoffs]
No. All I can figure is,
he must have done it years ago without ever telling me. You people must understand. You know how it is
when you're young.
You're proud,
and you're bulletproof, and you would never want
some machine feeding you. But then you get older. And even little things
become terribly precious. I'm telling you all
this is not his time, not yet. (Maria)
Okay. Just so that we're clear, you're saying
that you do not believe that the living will tells us
what your husband would say if he were able
to talk to us right now? That's right. It's important to remember that a lot can change
in six years. But six years ago, he signed this language. "If I should have
an incurable "or irreversible condition
that will cause my death, "it is my desire
that my life "not be artificially prolonged
by administration of life-sustaining
procedures." That's why I thought
it was so important. I'm not trying to be
an evil witch here or anything. But when I read that,
my brother didn't want to suffer or be hooked up
to a bunch of machines or tubes
keeping him alive. I don't want anyone to feel
trapped by a piece of paper, but I have to say the language
sounds awfully straightforward.
It might seem straightforward
on the face of it, but studies have shown
that health professionals vary widely
in their interpretation of advance directives. And often,
they're not as useful to the decision makers
as we would like them to be. (Scot)
Ooh, very good. This is what review
of the best thinking can do for you. Isn't the advance directive
itself the decision maker? No, not exactly. Mrs. Johnson
is the official surrogate. And as such, it's her job
to try and act according
to her husband's wishes. The advance directive
is simply a piece of evidence about those wishes. But isn't it
a pretty powerful piece? Generally, yes,
but not as much so if his condition is unclear. And there may be
some ambiguity here.
The staff here
reached the conclusion that his infection
is terminal. But the infectious disease
specialist said he may continue with his
osteomyelitis for some time. He may even recover. (woman)
That's very– Okay, I'm surprised, because that's
not what I understood. I must say I– I don't entirely agree. We have to remember
that our role here is to identify
the areas of ambiguity and try to work
our way through it so Mrs.
Johnson has
the clearest sense of her husband's wishes
and her options. Shouldn't we talk
about the information Tina Whitley got
from his primary care physician? Yes, certainly. Apparently,
about 18 months ago, Mr. Johnson told his doctor that he used to have
an advance directive, but he tore it up. He was afraid
that the doctors would let him die
before his time. Exactly. (Burrows)
There are several
areas of ambiguity. First of all, there's
the question of prognosis, about which we have
conflicting opinions. And then there's the question of whether the six-year-old
advance directive reflects the patient's
present-day wishes. The VA policy states
that a patient may revoke
their advance directive at any time simply by stating
their intent to do so.
Such a statement was noted by Mr. Johnson's
primary care physician. So how do we
resolve this? We don't resolve anything. Mrs. Johnson is the appropriate
decision maker. This meeting is happening
to clarify the range of options
that are ethically justifiable. We're here
to help Mrs. Johnson. (Frank)
That's very good work. Very strong, keeping
everybody's expectations exactly where
they need to be. Mrs. Johnson,
in that role, it's your duty to represent
what your husband would tell us if he were able to. Do you believe you're able
to perform that function? I do, yes. I-I know him
better than anyone. Let's try to clarify
the goals of care.
Mrs. Johnson,
if he could tell us himself, what do you believe
would be his hopes for the near future? What would he like
to see happen? A magical cure isn't
one of the choices, is it? Well, I think he'd want
to be comfortable and hope to get well enough
that he can move out of here and maybe into the nursing home
that's close to our house so that our son
and I and Rebecca would be able
to visit him. (Maria)
You mentioned comfortable. What would be his hopes
when it comes to comfort, pain management, and so on? Well, he's a tough old dog.
I'll tell you that. What I call pain
he calls pesky. He seems okay
on the pain meds he's getting. Well, what if he took
a turn for the worse? What if he struggles
with his breathing again? Oh, I don't think
he'd want to go back on that ventilator. He'd say at that point,
"That's it." Or if he could no longer
interact with or recognize us, he would not want
to be kept alive.
(Maria)
At that point, his goals of care
would change? (Burrows)
And now that we understand
what he would want, I assure you
that we'll do everything we can to try to achieve
his goals. I want to thank everyone
for all their hard work. Very well done,
folks. Very well done. Yeah, I think Dr. Burrows is feeling pretty relieved
right about now. He felt he'd really
screwed that one up. It's like medicine itself. Ethics consultation is an art,
not an exact science.
And, like medicine, it becomes
more natural with practice. Oh, I had a message
from Nurse Ruiz. She said, "Don't worry. "We didn't forget
the E or the S of CASES. "We provided
a review article "about interpreting
advance directives, "and we documented everything
in the patient's medical record "and in our case files. "We're doing all of our
follow-up communications. "And as soon
as we get your tapes, "we'll start evaluating and adjusting." I couldn't be
more impressed. Second the motion. I'd like
to toast them all for a job well done. Hear, hear. Hear, hear. [upbeat instrumental music] ♪ ♪.