What?
What's wrong? I think we just saw
a drive-through consult. Yes, or what we sometimes
refer to as a curbside consult. To put it bluntly,
a curbside approach is not appropriate
for a consultation on an active patient case. Actually, you did
several things well: your early decision
to not rush, your formulation
of the ethics question. There were moments
where you did just fine. But? Others,
not so much. My primary concern
was with the way you gathered information. Or didn't. (Frank)
You took what Dr. Ingersoll
said at face value, and it was pretty clear that she was hoping
for a specific answer. I know you wanted
to help her. But you only heard one side of the story. (Scot)
Actually, this whole episode illustrates the point
that I was trying to make before we were–
ahem–interrupted.
If you have consistency
of procedures, your life gets much easier. And you're less likely
to make mistakes. Plus, new team members
are easier to train. And it's easier on you too, because you don't have
to make it up as you go along and wonder whether you made
the right choices. I guess that's
what we've been doing. (Scot)
Well, one day
you're going to retire or win the lotto
or whatever. I mean, do you want the new
people coming in to be told, "We don't really do things here
the same way every day. You're just
going to have to feel it"? I think we get the point. So what do you recommend? What should we do
to make sure that our response
is consistent? I am so glad you asked. (Danielle)
You have too much free time. I know you've seen
this acronym in the primer. C-A-S-E-S;
each letter stands for a step
in the consultation process. The first letter, C,
stands for clarify, as in clarify
the consultation request.
Make sure you know what
the requestor is asking for. And make sure
that it's really appropriate for an ethics consultation. Hang on.
What do you mean by appropriate? (Danielle)
You have to make sure that the requestor wants help
resolving an ethics concern. Somebody may have
a legal question or an allegation
of misconduct or just
a general complaint. But these aren't what we mean
by ethics concerns. What we're looking for
is uncertainty or conflict about values.
Among requests
that are appropriate for the ethics
consultation service, you have to determine
whether it's appropriate for case consultation. Remember,
an ethics case consultation is an ethics consultation
on an active patient case. (Scot)
You might get asked a question
about a hypothetical case or a case that occurred
in the past, or you might get asked
a question about a policy. Now, these might
all be good questions for your team to handle, but the CASES approach
is designed especially
for case consults.
When you're asked to help
with an active patient case, think C-A-S-E-S, cases,
kh-ah-ss-eh-ss, cases. Scot, that is a lovely sign, but could you go put it
somewhere else? Sure. I think this
would be a good time for us to take a look
at those consult records we asked you to bring. What's the matter? Show him the box. [together]
Ooh. Now, before
you say anything, we know we need
a better filing system. Or a box of matches,
either way. What? Procedural consistency should also apply
to documentation– the documents
your processes generate and the way those documents
are managed. But that's for later. For now,
let's just sort through and find something we can use
to help demonstrate the CASES approach. Uh, let me see
what I can… Okay. Oh, here's one. Um, Mr. Cul–
hang on. Is it okay for us
to use names? That's a very heads-up
ethics question. Absolutely; and yes,
we will be discussing identifiable
health information. We are here
in an official training and quality improvement
capacity. And we're in compliance
with all the rules. We have a business associate
agreement and all that.
But try to stick to the minimum
information we all need to have. Okay, this is Mr. C. Uh, he was your case,
remember? Permanent resident? Oh, yeah, I remember. He kept saying that
since he was a veteran, he was entitled to stay
as long as he wanted. Mm, did he even do windows? (Burrows)
Oh, boy, remember the family where the wife was refusing
a blood transfusion for religious reasons? Jehovah's Witness,
I think it was. (Whitley)
Oh, I remember this one. They wanted me to tell
a critically ill patient about the death
of his sister. We found out about it while we
were prepping him for surgery.
This one was a lab technician
complaining that a coworker
was falsifying the time card. (Scot)
Need it. Need it; got it;
got it; need it; got it– ooh, I'm not
messing anything up, am I? Uh, patient's mother
thinks the food is unhealthy. Patient's sister wants
the televisions turned on. Chinese restaurant
wants you to pay your tab. Look, I said we know
it needs cleaning up.
It's not a question
of organization, although I will admit that
that's an issue. Third floor coffee machine
needs to be fixed. Nurse Ratched needs
the weekend off for a face-lift. I'm surprised no one turned
their car in for detailing. They get it. You're saying
that these are requests that should not have been
handled by our team? Hey, she really does get it. Of course, not every case
you mentioned was wrong for the team. But it sounds like
some of them should have ended
with the initial phone call. Others could have been reframed
to focus on the ethics question. Which is the first step that we're asking you
to standardize so that everybody
who calls the team will have
the same experience– when it comes
to the first call, I mean. Clarify
the consultation request– C for clarify. We should've referred some
of these requests elsewhere. Yes, some of them are in purview
of other departments– compliance or social work
or even chaplaincy. But we don't want
to send people away, do we? We want people to know we're
here and to use our services.
Look, I know
you want to help, and that's why you're
in this line of work. But the bottom line is,
the ethics consultation service doesn't have time
to do everything. And you are making
a positive contribution by directing them
to the people who are in a better position
to help them. Precisely. Now that we've discussed
the elements of a consultation request that make it appropriate
for case consultation, we'd like to do
another exercise. On the work sheet
labeled Exercise 2, you'll find synopses
of several requests. Discuss which of these requests
would be appropriate for the ethics
consultation function. Make sure you consider
the reasons why the request might
or might not be appropriate. As before, we'll take
ten minutes for this, and when the on-screen counter
hits zero, we'll return to the video. (Frank)
You folks are making
our job pretty easy. How about we grab some lunch and then we'll keep moving
through the CASES approach. We've still got
a lot to cover because clarifying
the consultation request is only the beginning. But no wisecracks
about the hospital food. What'd I say? What did I say? (Danielle)
Boy, she put you in your place. This concludes part one
of ethics consultation.
In part two,
the IntegratedEthics coaches will continue familiarizing
the hospital's team with the CASES approach, and we'll watch the team
take on their first consultation with their newfound skills. See you soon..