Evaluating and Credentialing Ethics Committees

Rosemary Flanigan
October 1, 2009

In the first part of the 1990’s when our ethics committee reached out to encompass all the entities in our Carondelet Health system in KC (2 hospitals, 3 nursing homes, home care, etc.) we busily spread education about ethics in healthcare and how the ethics committee could help.

We were so busy seeking invitations from departments, affiliated groups, nursing homes, that we didn’t bother evaluating—heck! We were doing. And when I hear of the uneasy reliance on process, I remember our “evaluating by quantity” (“We educated x number of groups since last month. . . .”)

I don’t have the answer here—but even if we focus on outcomes, we shall need to qualify the quantification; otherwise, “the operation was a success but the patient died” aphorism will ring true.

Evaluation and credentialing of ethics committees—my two big areas of concern. We’ll persist in the discussion, I hope. THANKS.

Ethics Consultation: what is at stake and for whom?

Rosemary Flanigan
September 18, 2009

The recent issue of Cambridge Quarterly for Healthcare Ethics arrived at home and the entire issue is devoted to reviewing and assessing ethics consultation. One of the articles asks, “Is Consent Necessary for Ethics Consultation?” and it shows that consults may be called for participants other than the patient.

Thus one must ask what is at stake and for whom.

An example given is the cardiologist who is the attending physician for an elderly gentleman for whom he has provided care for over a decade. All along, the patient has insisted that he not end up debilitated and in a nursing home, but here it is, the fifth hospitalization in the past 18 months and the old gentleman is on mechanical ventilation, is in acute renal failure, has a variety of infections and a prolonged altered mental status.

The cardiologist has talked to the family and they have agreed that life support be withdrawn and their father allowed to die. It was at this point that the cardiologist requested an ethics consultation—not for the purpose of reviewing the case or checking the hospital’s DNR policies/terminal weans but whether or not this the “right” time to stop.

If this were your ethics committee, would you invite the family into the consult?

For the patient's good. Complex?

Rosemary Flanigan

September 4, 2009

I sometimes think our ethics committee at Carondelet Health must be one of the most knowledgeable groups in the area—sometimes our self-education takes almost the whole meeting!—but I wish that simultaneously with learning so much, we could be DOING equally much (and maybe we are and I’m just not aware of it).

Back in 1988 the Pellegrino/Thomasma twosome wrote For the Patient’s Good. The Restoration of Beneficence in Health Care, and we are going to discuss the different meaning of the “good” of the patient:

-- The ultimate good (that which constitutes the patient’s ultimate standard for his/her life’s choices, that which has the highest meaning for him/her

--Biomedical good (that which can be achieved by medical interventions

-- The patient’s perception of his/her own good at the particular time and circumstances of the clinical decision and how one prefers to advance one’s own life plan

-- The good of the patient as a human person capable of reasoned choices

The physician is bound to advance each of these four senses of good to the extent possible.

So let’s say the patient dying of cancer who had consistently refused resuscitation now during his/her last hours begs to be put on a respirator because of difficulty in breathing. Here is the place that people might fear their living wills or advance care plans will work against them.

But the physician may order the respirator—in order to make the patient comfortable—without negating the patient’s life plan entirely.

BUT, what if the patient is unable to speak and there is conflict between physician and proxy? Call in the ethics committee!!!! (hopefully, a well-educated one!)

The “patient’s good” is a highly complex concept!!! COMMENTS????

Teach an Integrated Ethics Class

Rosemary Flanigan

August 21, 2009

Thinking back on our years of preparing ethics committees to integrate ethics into every aspect of healthcare delivery in the institution leads me to suggest what Hans Uffelmann proposed years ago:

Sensitize (What’s the Problem?),

Analyze (What are the Facts?),

Synthesize (What ought I/we Do?)

and Actualize (“Can I/we Behave Morally?)

In other words, instill the understanding that there is no “purely factual” element in the entire curriculum! It is all fraught with ethical implications! And much of it is open to argument. (How do you justify placing one value over another? How do you justify proceeding with such obviously risky consequences?)

But over and beyond it all, an integrated ethics class will be successful when the students remember and follow the example of their mentor! She could be a brilliant “presenter” but if her “being a good nurse” doesn’t come across, the endeavor will be easily forgotten.

So constantly raising the ethical threshold by her example will win the day.

"Because that's what we do here..."

Rosemary Flanigan
June 26, 2009

The June 23 Time magazine has an article on healthcare reform (Michael Grunwald’s “How to Cut Health-Care Costs: Less Care, More Data”)which begins with a story about Ezekiel Emanuel, who spoke here in KC two years ago on pandemic policies, and is now near brother Rahm in the Obama White House.

The article says, “Ezekiel Emanuel got a memorable introduction to our haphazard health-care system on his first visit to a cancer ward as a medical student. The white coats were ordering a transfusion for a teenage girl, and since shyness does not run in his family. . . .he interrupted to ask why.

Because she had Hodgkin’s disease and her platelets were below 20,000, the team explained.

Emanuel still had questions: Was there evidence for that protocol? Don’t some hospitals wait until 10,000? Why 20,000? Because that’s what we do here, one doc replied.”

“Because that’s what we do here. . . .”

I am reminded of those years I taught undergraduates that to cling stubbornly to the status quo was immoral.

I won’t hastily judge the “immoral” part—but I will question if our healthcare professionals, like banking, insurance, investing professionals, realize that “the unexamined habits of one’s profession are not worth continuing.” (With apologies to Socrates.)

Will the rich resources of reflective ethics committee members be tapped when professionals need to reconsider “that’s what we do here” in the age of reform?

Judging Virtuously

Rosemary Flanigan
April 24, 2009

I am so lucky-I was invited this week to an ethics committee which was reviewing the Baby K case-remember, 1992, the anencephalic baby born in DC; the mother refused to give permission for a DNR order and the baby lived for 2 ½ yrs, going back to the hospital for ventilator support.

There were 7 of us there and an excellent analysis unfolded without a single reference to an ethical principle. The entire discussion hinged on virtue. I have always found that the argument from virtue is the most difficult to make.

Problem # 1: Before one has acquired virtue and is thereby able to judge virtuously by oneself (and thus be one's own ethical standard), one must following the guide of a person already virtuous.

And problem #2: in our culture it is oftentimes difficult to distinguish character traits that are virtues from those which are impressive because of certain contemporary cultural phenomena.

Oh, did I tell you that all 7 of us are female and 6 of them were mothers. I think that fact was important. There was careful weighing of the mother's feelings and desires over against what was best, in their argument, for Baby K.

Sensitive alternatives were proposed aimed towards respect for autonomy, beneficence and justice without those words being mentioned.

Once a Guardian, Always a Guardian

Right? ??

Rosemary Flanigan
April 14, 2009

I told you that last week I had used the recent Hastings Center Report case with my ethics brown bag session. The case involved a fifty-nine-year-old male who was being readmitted to the hospital from a nursing home because he has gangrene of three right toes and both his heels.

He is being told that amputation is necessary: the right leg above the knee and the left heel. What does he say? “Let’s wait it out.” And his family concurs.

Well, of course, the doctors wondered at his capacity, and voila! didn’t they discover that nine years ago, the family chose not to be his legal guardian so he was appointed one. So shouldn’t the team contact the guardian?

Though we have no information about his condition during the intervening years, I was dead set against re-activating the guardian. But 2/3 of the brown baggers took it for granted that the guardian needed to be consulted. They said, “Once you have a guardian, you have a guardian unless the court revokes it.”

But I caught dear Bill Colby on the fly this morning and he said a case can be made either way.

I think my problem is: Those in the majority seemed so implacable; they had found “an answer” in the law, and someone “outside” was going to make a decision about this “waiting” option.

It was an “ethics” brown bag, and I would have hoped that the providers would have talked more to the poor patient to try to understand his “Let’s wait.” But, like so many arguments, if you think you have “the answer,” why bother with all the loosey-goosey in-between matter?

You must have experienced this in YOUR healthcare lives; isn’t it frustrating?? HELP!

Discerning, Deliberating and Deciding

Rosemary Flanigan
April 9, 2009

On April 7 we had over 70 ethics committee members at our training workshop and it was an excellent morning. I thought Terry Rosell did an exceptionally good job (along with John Lantos, Myra, and Bill Colby, of course) leading the discussion of a case at our 8-person tables.

I shall tell you about the case next week, but what Terry made us do is to consciously move together through Discerning (what’s going on? what are the facts?) to Deliberating (what responses are possible?) which in turn led us to Deciding (what are we going to do? and, most interestingly, why have we decided on this?) and finally to Doing (what? when? how?)

It moved the discussion along, towards a goal, within a time frame, and led us to resolution with an ethical basis.

I know, I know, that’s what you do at every ethics committee case consult. But for some reason, I found it refreshing to move together from facts (people love to sit on this step and they can question facts all day!) to possibles to a decision with a reason—and finally, to a plan of action.

Within our reflection on authenticity, I am glad Brian reminded us of Rebecca Dresser’s “Another Voice” at the start of the issue: if respect for a person’s authenticity is the ground of our respect for that person’s advance directive, might we not have good reasons sometimes to override specific requests stated in the AD??

Why? Because they don’t jibe with who the person really is.

Hmmmmmmmm.

Ethics Committees and Blood Transfusions II

Rosemary Flanigan
April 7, 2009

Thanks to all of you who ruminated on the suggestion that ethics committees review orders for over 7 units of blood!! Those would have to be very special ethics committees and supported by a very special medical staff!!

John Carney said 2/3 of patients who didn’t want CPR, for example, “want other measures of life-sustaining treatments.”

So the question is, “How does the hospital respond in such cases?” And I would answer, “However the patient decides”—on the POLST or TPOPP forms where they list the “other measures” they want. Of course, this demands an institutional commitment and a medical staff commitment.

BUT it certainly calls for a literate, thoughtful patient-body!!!! And isn’t that what so many of us have been about these many years?

And not just us—but our surrogates as well.

Blood Transfusions & Ethics Committees

Rosemary Flanigan
April 3, 2009

Dr. Robert Potter, who was on the staff of the Center for 10 years and is back for a visit, told us that in Portland, OR where he is retired and working with the ethics center there, it is a policy of the hospital that patients who receive 7 blood transfusions must have their cases reviewed by the ethics committee.

That fact says several things to me:

1) the respect with which the ethics committee is held by the medical staff and administration

2) the realization that 7 blood transfusions raises distributive justice concerns

3) the track record of the committee in handling both clinical and ethical aspects of this fact

Our ethics committee at Carondelet Health is not alerted, though a medical staff committee of some kind must be.

Did any of you ever hear of an ethics committee so employed??????

THANKS.

DNR Best Practices?

Rosemary Flanigan
April 1, 2009

Remember my telling you about the patient with terminal renal cell carcinoma who is incompetent, has had a guardian appointed, and the team of 7 physicians caring for him thought it appropriate to have a Do Not Resuscitate Order.

I heard this morning that he has it!!! The ethics committee, after discussing “at length the various legal, moral, and ethical reasons both for and against instituting a DNR when the patient no longer possesses the decisional capacity to decide for himself,” concluded that the 2 physician specialists would co-sign the DNR and that the team leader would write a treatment plan to be shared with unit staff regarding what measures would or would not be taken in the event of a medical emergency.

Personally, I think that was a defensible outcome; I assume that the guardian agreed. Amazingly, during the course of all this, they were able to find family members whom he had not seen in 5 years and who were satisfied with the DNR and the treatment plan.

My peek into the future of healthcare reform tells me that there will be more DNR orders initiated and encouraged by physicians along with patient/family proposals. What my “peek” doesn’t tell me if whether or not there will be some “best practice” guidelines that will simply mandate a DNR order, regardless of physician OR patient OR family concurrence.

What do you think?

Cambridge Quarterly and Ethics Committees

Rosemary Flanigan
March 16, 2009

I let my subscription of Cambridge Quarterly expire, and just renewed it. I have long treasured CQ because it targeted ethics committees—and still does, I guess, though I have found this current issue rather thin.

The main section features revisiting vulnerability. The lead article defines it as “To be vulnerable means to face a significant probability of incurring an identifiable harm while substantially lacking ability and/or means to protect oneself,” and then goes on with articles about different kinds of vulnerability and different sites (research sites, especially) where different groups are especially vulnerable.

Yes.

But it was an article by a trio of Australian women discussing “Developing ‘Ethical Mindfulness’ in Continuing Professional Development in Healthcare” that I especially enjoyed—it’s the issue of ongoing education in one’s competence to recognize an ethical moment and to analyze it.

That sums up the 25 year history of the Center’s work—but the women’s approach is especially through the use of narratives. Still, it is not enough to do a superb job of educating well if the receivers of all that good learning do not practice what they’ve learned.

Nothing new there, but it’s good to be reminded.

Ethics Committees and Pain Policy

Is there a fit?

Rosemary Flanigan
March 6, 2009

All of you who are members of the Center for Practical Bioethics have received our latest publication, a policy brief entitled "Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice."

Long title but a join effort of the Federation of State Medical Boards, the National Association of Attorneys General and the Center.

As research leading up to the report indicated, fewer than 0.1% of practicing physicians were charged between 1998-2006 with criminal and/or administrative offenses related to prescribing opioid analgesics (Pain Medicine. 2008:9(6) 737-47).

Contrast that figure with the Journal of American Medical Association conclusion that 40% of the 2.2 million nursing home residents in this country who live with "moderate" to "excruciating" pain daily (JAMA. 2001: 285(16): 208l).

I wondered about the atmosphere concerning adequate pain management at the hospitals in which most of you serve--and I thought that our ethics committees could do a remarkable job of education within those hospitals concerning the strategies suggested to reduce diversion and to encourage physicians to prescribe what is best for their patients without fear.

Anybody have a comment??????

Links:

New policy brief aims for balance in pain investigations

Law enforcement, medical and bioethics communities come together in search of “strategies” to balance competing interests

A new policy brief suggests several key strategies to aid law enforcement faced with the complicated case of a doctor suspected of illegal conduct related to prescription drugs. The document is a key step in the Center’s Balanced Pain Policy Initiative.

Links:

News Release, February 19, 2009

Podcast, The Bioethics Channel, with Bill Colby

Balance, Uniformity and Fairness policy brief

Ethical Analysis of Healthcare Reform

Rosemary Flanigan
February 25, 2009

Wheee! This has been a busy week—I’ve been talking to groups about the Center and each time I become inordinately proud (even though it’s Ash Wednesday) of the Center’s accomplishments over these past 25 years.

Somebody gave me the title, “Ethics Working for You”, and I have used it shamelessly. Because ethics can really “work” in the healthcare setting.

HOWEVER, in the President’s talk last night I didn’t hear “immigration” though I did hear over and over “healthcare reform” so I am predicting our ethics committees and centers will be “on the point” for discussions of different plans.

Meanwhile, our care for the poor will go on, unabated and unreimbursed! I always knew I was living in the Golden Age of Medicare and I predicted such goldenness would dim before I die—as it needs to do.

The need for ethical analysis all along the spectrum calls us to a renewal of our education out-thrust. I hope we’re up to the task. Any ideas for such an effort?????

Observing Martin Luther King Day

Rosemary Flanigan
January 19, 2009

Happy Martin Luther King, Jr Day to all. We just had a program at the Center—and didn’t 86 people show up!! I think people want to celebrate together.

First, I thank Francie for her MOST THOUGHTFUL organizational ethics issue from the perspective of an emergency department doctor. Questions like these MUST be addressed!!

How do the rest of you handle continued care for the un/underinsured?? I know that the Center, under Terry Rosell's leadership, has developed a service in the Kansas City area in which specialists sign up to see a certain number of such patients on a pro bono basis—but that is charity trumping justice. It need not be that way.

AND, just to use one e-mail, a friend at the Consortium gave me “Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers” from the 2008:149:861-868 issue of Annals of Internal Medicine. This is a great article for ethics committee education—excellent real arguments when the physician says, “I can’t tell she’s dying; it will destroy her hope.”
MARVELOUS!

Happy day!

Practicing on the newly dead

Rosemary Flanigan
December 11, 2008

When we “argue” (discuss?) at an ethics consult, we find ourselves sometimes arguing about erroneous conscience decisions, I think.

FOR EXAMPLE, let’s say as an intern, a physician may have practiced intubation on a newly dead patient without family consent. Years later, in retrospect, the physician may have arrived at the judgment that this was wrong to do and that he/she will teach medical students not to do it.

AH HA!!! So medicine needs to be practiced, and this particular procedure probably needs a lot of practice. What would lead the physician to see that such “practicing” was not a good thing?

What about the physician who doesn’t need to practice anymore—but still sees that practicing on the newly dead is better than not practicing at all so he/she does not teach medical students to avoid doing so?

Would you argue with this physician?

To share your comments, click here.

Substituted Judgment and the Limits of Autonomy

Rosemary Flanigan
Program Associate
Center for Practical Bioethics

Our own John Lantos co-authored an article in the 2008 Journal of General Internal Medicine (23(9):1514-7) entitled Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making.

The authors make an interesting point: that there is "a compelling argument against substituted judgment. . .based on empirical evidence," and alternative models do a better job of respecting the patient as a person.

(I'm sure you know the arguments against: patients change their minds over time; predictions by surrogates are correct about 68% of the time; research shows that patients themselves do not want decisions made on their behalf to be based solely on their prior statements (!)

So what models to use?

1)Best-interest standards based on community norms (but that is unwieldy. Think of the time it would take to reach those "norms" and, once reached, how do we know they apply to "this" patient?)
2) The patient's life story: respect for persons approach. Here, decisions are not made by trying to predict the actual choices that an incapacitated loved one would have made; instead, decision-makers consider the individual's interests and values in the context of the current situation.

It is an interesting paper. Perhaps ethics committees could consider how surrogate decision making occurs in institutions.

Has anyone done so recently?