Monday, August 10, 2015

Strengthening Hospital Ethics Committees

The first hospital ethics committees in the nation were established in the 1970s, and the primary catalyst for their growth was the 1976 Karen Quinlan case. As the case was argued, the judge, who had read an article about ethics committees in the Baylor Law Review, remarked that cases like this belong before ethics committees rather than courts.

In 1992, the Joint Commission – then the Joint Commission for the Accreditation of Healthcare Organizations – mandated that hospitals establish a clinical ethics “mechanism.” For more than two decades, this guidance has allowed hospitals to craft widely varied responses. A facility may or may not have a standing ethics committee. The committee may or may not meet regularly. Its members may or may not have training in thinking through issues ethically.

The three primary functions of ethics committees, as identified by the American Hospital Association in 1986, are to:
• Educate themselves to “do ethics”
• Develop and review hospital policies
• Consult on complex cases arising in the hospital

Center for Practical Bioethics’ Efforts

In 1986, in response to numerous ethics committee members seeking opportunities to learn from each other, the Center for Practical Bioethics, which counseled both sides of the Cruzan case, convened the Kansas City Regional Hospital Ethics Committee Consortium, This is the oldest continuously operating Consortium of its kind in the nation.

In a project entitled “Organizational Ethics: Beyond Compliance,” Center staff traveled to cities across the country to present new standards for patients’ rights and organizational ethics, after collaborating with the Joint Commission in 1993 to promulgate them.

The Center has trained more than 200 hospital ethics committees across the country. Today, as a benefit of Center membership, Center staff members serve on the ethics committees of several hospitals in the Kansas City metro area. Many of these committees have made significant strides in strengthening their individual approaches to meeting the requirement for an “ethics mechanism, ” as illustrated by activities at Shawnee Mission Health, Liberty Hospital and North Kansas City Hospital.

Consultation Team Model

For many years, the ethics committee at Shawnee Mission Health (SMH) in Shawnee Mission, Kansas – one of the oldest ethics committees in the Kansas City area – met monthly at 7:30 am. On average, 20 of the committee’s approximately 30 members, including the hospital CEO and CFO, would attend. From time to time along with the committee members, clinicians and allied health practitioners would gather in response to a request for a formal “ethics consultation.” This “call” could result in a rather large group for an ethics consultation, and while the expertise was appreciated, the committee realized that family members and friends could find the process overwhelming. SMH envisioned a process that would be more intentionally responsive to its commitment to person-centered care and shared-decision making.

In Spring 2014, SMH asked Sandy Silva, vice president of education at the Center, and Mark Stoddart, the health system’s administrative director of spiritual wellness, to serve as committee co-chairs and encouraged them to explore alternative models for its operation. Silva proposed the consultation team model.

“Rather than call for ethics consults with the assumption that there’s a problem or something bad happened,” she said, “the idea is to cultivate and invite ethics questions. We want to create a mechanism for people to receive a nimble response to their questions, whether from a patient, family member or member of an SMH interdisciplinary care team.”

At the same time, the committee formed two three-person consultation teams with backups. Team leaders can be reached immediately depending which team is on call. If the leader can’t answer a question right away, he or she gathers appropriate records and contacts team members and others involved in the case. The model is designed so that the need to bring the full committee together to address a question will be rare.

“This model is appropriate and effective for the SMH culture,” said Silva. “No matter how small a question, providers, families and patients will know that if they have an ethics question they can get an immediate response. It’s about facilitating communication that is timely and responsive.”

At SMH, there is a dual-pronged emphasis on consultation effectiveness as well as education.  SMH provided consultation team members with a personal copy of Guidance for Healthcare Ethics Committees (Cambridge Medicine, 2012). The members of the consultation teams (including back-up members) meet quarterly to review assigned chapters to take a deeper dive into the material as well as discern its application for their hospital system.

Focus on Education

The focus on education is observable at SMH as well as at other hospitals in the region.

The full complement of the SMH ethics committee now gathers bi-monthly for mid-day meetings that include lunch sponsored by SMH. The agenda includes a review of any ethical questions and/or consultations that may have taken place over the ensuing 60 days. The emphasis, however, is on education regarding ethically linked trends and cases within the SMH sphere.  Silva and Stoddart envision this educational emphasis as the forum to offer continuing education credit that will be open to all SMH clinicians and staff.

Education is also a cornerstone of ethics committee invigoration efforts at North Kansas City Hospital and Liberty Hospital in Missouri. North Kansas City Hospital has invested in providing Guidance for Healthcare Ethics Committees to all members of their ethics committees and prioritized education as a key activity. The ethics committee chair at North Kansas City assigns chapters of the textbook to a specific member to present when the group convenes bi-monthly. While the “assignment” may be moderately ambiguous for the presenter, the presentation serves as the springboard for full committee analysis and discussion.

At Liberty Hospital, there is a resurgence of interest and dedication to the work of their ethics committee. Leaders in the hospital system from both the clinical and spiritual realms of healthcare have raised their hands to acknowledge the hospital’s decades-long commitment to quality care based on ethical principals and to support renewed emphasis on education as well as timely response to ethical questions from patients, families and staff. The immediate focus is on the revision of an online administered education module for hospital staff.

“It’s gratifying to see members of these hospitals’ ethics committees actively participating in the Kansas City Regional Hospital Ethics Committee Consortium,” said Silva. “Strengthening ethics committees is a significant part of the Center’s history and continues as a key component of our efforts to provide practical resources to those wrestling with complex ethical questions.”
Download free print, audio and video resources about ethics committees at

Trudi Galblum provides marketing and communications support for the Center for Practical Bioethics.


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