clinical and organizational ethical decision-making … · clinical and organizational ethical...

Clinical and Organizational Ethical Decision–Making

Guidelines

Developed by: Health PEI Clinical Ethics Committee

Approved by:

Health PEI Executive Leadership Committee

Guidelines will be revised as required and are subject to an annual review in June. The most current guidelines are available on the Health PEI intranet site. Please ensure you have the most up-to-date version at your work site.

Clinical Ethics Committee Purpose The Health PEI Clinical Ethics Committee provides a forum for dealing with ethical decision-making. Issues may be brought to this multidisciplinary committee from staff, physicians, clients or family members. The committee will act in an advisory capacity to support ethical decision-making in the health system and is a part of the Quality Framework of Health PEI. The Committee is available to provide consultations on both clinical and organizational issues. What is ethics? Everyday, we encounter ethical issues. This is involved with doing what is right, fair, honest, and legal. It is concerned with arriving at the best course of action in situations presenting ethical/moral dilemmas so that the best interests of the patients/clients/residents will be served. Consequently, we might face situations where there are conflicts between one or more values and uncertainty about what course of action to take. At times, there are equally compelling reasons for or against two or more possible courses of action. Thus, ethics is about choosing between goods, which can be challenging! Membership Kim Bustard (chair), Spiritual Care Coordinator, Queen Elizabeth Hospital Kerry Moore, Manager, Social Work, Queen Elizabeth Hospital Cynthia Bryanton, Director, Hospital Services, Prince County Hospital Colin Campbell, Manager, Community Mental Health East Marilyn MacDonald, Nurse Manager Unit 2, Queen Elizabeth Hospital Dr. Rosemary MacDonald, Clinical Ethicist, Community Member Laurie McNally, Quality/Risk Coordinator, Central Vicki MacLean, Nurse Manager Emergency Department, Prince County Hospital Reg McCarvill, Fiscal Analyst/Auditor, Queen Elizabeth Hospital Kim MacPhee, Clinical Resource Nurse, Colville Manor Dr. Abder Sahouli, Clinics Psychologist, Community Mental Health and Additions, East Rev. Paul Wilkie, Chaplain, Prince County Hospital Donna MacAusland, Primary Health Daphne MacDougall, Quality and Access Management Administrative Assistant For further information on the Clinical Ethics Committee or to request an ethics consult please contact Kim Bustard, chair, directly by phone (894-2094) or by inter-office mail. Fill out the Worksheet/Consult Request Form and mail in a sealed envelope marked confidential:

Attention : Kim Bustard Chair Health PEI Clinical Ethics Committee c/o QEH Spiritual Care Department

Contents Ethical Culture–Introduction .................................................................................................. 1 Process for Resolving an Ethical Dilemma ......................................................................... 3 Process to Engage Health PEI Clinical Ethics Committee ............................................ 4 Ethical Decision–making Framework .................................................................................. 5 Overview: Ethical Decision-making Worksheet ............................................................... 7 Guidelines for Worksheet ......................................................................................................... 8 Appendix A Ethical Decision–making Worksheet/Consult Request form (clinical) .................. 11 Ethical Decision–making Worksheet/Consult Request form (non-clinical) ........ 14

Appendix B Data Gathering Question Tool ............................................................................................. 16 Appendix C Clinical Ethics Committee Response Form ...................................................................... 18

1 Version 1.1 June 2009 Version 1.2 June 2012

Ethical Culture Introduction Ethical dilemmas in health care are commonplace. Some of the issues we encounter include those related to end-of–life care, resuscitation, consent and capacity, other care and treatment decisions, and overall organizational healthcare management. The nature of healthcare management is such that decisions with ethical implications are made every day for issues as diverse as access to the organization’s services, a particular employee’s behavior, clinical practices, and the allocation of limited resources. Ethics encompasses not only what ought to be done but also what must be done in a compassionate and just society. Ethics can be referred to as a study of the standards of conduct and moral judgment, as well the system or code of morals of a particular group or profession. Ethics will often be presented in the form of values, theories and/or principles. Ethical theories can influence our ethical decision making. Health PEI Values include: Caring, Stewardship and Excellence When considering an ethical dilemma, Health PEI is guided by the following ethical theories, principles and considerations which can guide the discussion: 1 Theories

• Utilitarianism: An ethical theory that considers an action to be right when it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences, that is, the greatest good and the least amount of harm for the greatest number of people.

• Deontological: An ethical theory whereby rules are established to determine what is right or wrong based on one’s obligations and duties.

• Ethic of Care: An inductive process in which the starting point is the individual’s circumstances or personal story. It values feelings and emotions, empathy and care.


Principles

• Autonomy: Capable and competent individuals have the basic right to self-determination, independence and freedom, enabling them to make informed choices.

• Nonmaleficence: to do no harm. This principle obliges us to act in such a way that we prevent or remove harm from our clients and ourselves.

• Beneficence: to do good. This principle requires that we perform acts that will

benefit clients.

• Justice: the obligation to be fair to all people, treating people according to their need. The principle of justice can be further expanded to include distributive justice such as fair access to, and allocation of, resources and procedural justice or shared decision- making. It involves including people in the decisions that affect them.

Other Considerations

• Quality of Life: The ability to function physically, emotionally, spiritually, and socially as perceived by the client and care providers.

• Dignity: Considers the worth of the human person

• Consent: The client freely authorizes and agrees to treatment.

• Capacity (or competency): The client understands his/her condition/situation, options, and appreciates the consequences of the various choices being considered.

• Confidentiality: The obligation to hold in confidence the client’s and

organizational information which is shared in trust.


Process to Resolve an Ethical Dilemma

1. Ethical dilemma is identified. 2. Resolution is first attempted at the work site using the Ethical Decision Making

Worksheet/Consult Request Form. 3. If the dilemma is resolved at the worksite, skip to Step 6. 4. If unable to resolve the dilemma at work site refer to the Clinical Ethics

Committee to help with resolution. See page 7 5. The Clinical Ethics Committee will conduct an ethical analysis and provide

recommendation(s) to help resolve the dilemma. Documentation completed on a Clinical Ethics Committee Response Form ( Appendix C)

6. Documentation of resolution to be recorded appropriately to include the following:

• What was the resolution? • What is the plan to implement? • How will the plan be evaluated? • Who is accountable? For what results?

Ethical Dilemma Identified

Use of Decision Making Worksheet

at work site

Resolution obtained

Unable to resolve refer to Clinical Ethics Committee

Document resolution on patient/client/resident chart or for non-clinical issue file appropriately

Ethics Committee conducts an

ethical analysis

Ethics Committee response form

placed on chart or file


Process to engage Provincial Ethics Committee

1. A request for an ethical consultation is submitted to the chair of the Clinical Ethics Committee through interoffice mail in a sealed envelope marked confidential and addressed to the Chair.

2. Requester submits pertinent data of the situation using the Ethical Decision Making Worksheet/Consult Request Form.

3. The chair shall assign committee member(s) to gather any further necessary

information pertaining to the submitted ethical dilemma for review.

4. Designated committee member(s) conducts on ethical analysis.

5. Designated committee member(s) work through issues using the Ethical Decision Making Framework.

6. Designated committee member(s) complete the Clinical Ethics Committee

Response Form.

7. Identify possible recommendations for site consideration i.e. follow-up required, staff training/education

8. Chair submits Response Form to requestor based upon urgency of request.

9. The Chair will advise the full committee of all consults received at the

committee regular monthly meetings.


Ethical Decision Making Framework An Ethical Decision Making Framework1 is a process to help assist staff in making decisions regarding ethical dilemmas encountered within the workplace. An ethical dilemma arises when a situation occurs where there are compelling reasons both for and against a particular course of action due to conflicting values or principles, and a decision must be made.

1 This framework is adapted from “A Framework for Ethical Discernment,” Appendix 1 of the Health Ethics Guide published by the Catholic Health Association of Canada (CHAC), 2000. Permission was granted by the CHAC for this adaptation.

8. Implementation of recommendation(s)

Ethical Decision Making

A. Explore 1. Identify the Issue(s)

2. Acknowledge feelings/ Identify interests

3. Gather the information and facts

B. Discuss

5. Examine ethical principles and organizational values

9. Evaluate outcome

7. Document the recommendation(s)

4. Consider all options 6. Analyze option(s)

Ethical Culture

Principles Autonomy Nonmaleficence Beneficence Justice

Values Caring Excellence Stewardship

Theories Utilitarian

Deontological Ethic of Care

C. Act


An Ethical Decision Making Framework can be used in doing case analysis. Two types of case analysis are:

1. Retrospective (case review): The purpose is to learn from the case to assist us in resolving similar cases in the future.

2. Prospective (case consultation): The purpose is to help facilitate decision-making to assist us in coming to resolution around the issue in an ethically appropriate way.


Overview Ethical Decision Making Worksheet/Consult Request Form

The Worksheet will provide a step-by step guide based on the Ethical Decision Making Framework. It is designed to assist and help guide staff through the process of addressing an ethical dilemma. The Worksheet is comprised of three key sections:

1. Explore Step 1: Identify the Issue(s) Step 2: Acknowledge the feelings/identify the interests of all parties Step 3: Gather the information and facts

2. Discuss Step 4: Consider all the options Step 5: Examine Ethical Principles and Organizational Values Step 6: Analyze the option(s)

3. Act Step 7: Document the recommendation(s) Step 8: Implementation of the recommendation(s) Step 9: Evaluate the outcome

The worksheet can be used in the following situations:

a) When staff in the field face an ethical dilemma as a worksheet to resolve the

dilemma at the worksite or b) As a formal request for a consultation to the Clinical Ethics Committee.

The worksheet allows staff to address complex and challenging issues in a comprehensive and logical manner. The worksheet can also be used to help explain the rationale for challenging decisions that must be made.


Guidelines–Ethical Decision-making Clinical and Non–clinical Worksheets/Consult Request Form

A. Explore

Step 1: Identify the Issue(s) During this stage clearly identify and objectively articulate the issue(s). What dilemma(s) need to be solved? What is the ethical conflict? Step 2: Acknowledge the Feelings/identify the interests of all parties Reflecting on the initial emotions and feelings is an important step as it may influence how one responds or reacts to the situation. What are the “gut” reactions? Are there biases, loyalties? Considering the interests and concerns of all parties helps to provide a more complete understanding of the issue(s) Step 3: Gather the information and facts Clinical Application - Criteria to assist in completing the Ethical Decision-making worksheet(Clinical).For more self- guiding questions see Appendix B.

Clinical Application-Ethical Decision-making CRITERIA2

Medical Indications

Consider each medical condition and its proposed treatment. Ask the following question: • Does it fulfill the goals of care? • What is the probability of success?

Patient/Client/Resident (Patient) Preferences

Address the following: • What are the patient’s wishes? • Does the patient have the capacity to decide? Yes /No • If not, who is the substitute decision maker of the

patient? • Do the patient’s wishes reflect a process that is:

- Informed? - Understood? - Voluntary?

Quality of Life

• Describe the patient quality of life in his/her terms.

• What is the patient’s expectance of the probable outcome?

• What are the views of the care providers about the quality of life?

Contextual Features

Social, cultural, religious, legal, economic and institutional circumstances in the case that can :

• Influence the decision • Be influenced by the decision

e.g. inability to pay for treatment; inadequate social support, family dynamics

2 (n.d.) Retrieved March 19, 2009 from http://depts.washington.edu/bioethx/tools/4boxes.html


Non-clinical Application – Criteria to assist in completing the Ethical Decision-making Worksheet (Non-clinical)

Non-clinical Application-Ethical Decision-making CRITERIA

Context

EExternal EEnvironment

PPolitical } Consider each of these EEconomic } aspects in identifying SSocial } the issue(s) and as you TTechnological } analyze the options GGovernance CContext

HHow are the issues and analysis congruent and impacted by: the direction of Government, the strategic plan, laws, politics?

Service, Quality and Performance

• WWhat are the patient/organizational outcomes?

• DDoes it enhance or undermine quality and risk issues?

• DDoes this affect efficiency? • AAre we using resources properly?

Stewardship

• DDoes this impact work life? Workload? Relationships? Communication?

• WWhat is the overall wellness of the person? the system?

• DDoes this enhance retention? • WWhat are the financial implications?

Values and Ethics IIn what way(s) is this consistent with or compromise:

- the organization’s values? - ethical theories and principles? - personal integrity?

09HE43-22371

B. Discuss

Step 4: Consider Option(s) Explore as many options as possible. Step 5: Examine Ethical Principles and Organizational Values Identifying principles and values will not provide solutions, rather they assist to clarify and articulate the issues. Consider the preferences of the person receiving care and views of all parties. Are there values/principles in conflict? Step 6: Analyze Option(s) In exploring your option(s) you need to consider the benefits, risks and consequences of each one. Consider the following question(s) to help you: Which option will produce the greatest good and do the least harm for all involved? Who is the appropriate decision maker(s)? Document option(s) on the Worksheet/Consult Request Form.


C. Act

Step 7: Document the recommendation(s) Document the recommendation(s) on the Ethical Decision-making Worksheet/Consult Request Form. (Appendix A) Record/document recommendation only on patient chart (do not place the worksheet on patient/client/resident’ chart).

Step 8: Implementation of the recommendation(s)

Decide how to communicate the plan to the people involved in this issue. Implementation of the recommendation(s) is the responsibility of the person who requested the consult.

Step 9: Evaluate the outcome What recommendations were implemented and what were the results? Is follow-up necessary? When? With whom? Worksheets can be forwarded to the Clinical Ethics Committee for data collection and safekeeping.


Appendix A


Ethical Decision–making Worksheet/Consult Request Form–Clinical (Completed form can also be used to request a consult from the Clinical Ethics Committee) Patient/Client/Resident Name PHN/MRM Age Marital Status Gender

Explore

1. Identify the Issue(s).

2. Gather the information and facts (as outlined in the guidelines).

Medical Indications

Patient/Clients/Resident Preferences

Quality of Life

Contextual Features


DISCUSS

Act

Division/Team/Location

Consultation requested from Clinical Ethics Committee by

Date of Consultation Request:

Requestor contact number

Patient and/or family members notified of consult Yes No

3. Consider all Options based on ethical principles and organizational values.

4. Identify the recommendation(s).

5. Evaluate the outcome(s)-what recommendation(s) were implemented and the results.


Ethical Decision–making Worksheet/Consult Request Form–Non-Clinical (Completed form can also be used to request a consult from the Clinical Ethics Committee)

1. Explore

What are the problems? Is this your problem to solve? If not, to whom does it belong? What do you want to achieve? What do you want to avoid?

2. Discuss

What are the options?

Apply criteria (as outlined in the box framework) to each option.


Consultation requested from Clinical Ethics Committee by

Date of request for Consultation

Requestor Contract Number

3. Act

Identify the decision(s)

4. Implementation: Who Leads? Who needs to know? What are the results? How will the results be measured?

Division/Team/Location/Facility


Appendix B


3Clinical Application- Ethical Decision–making Data Gathering Question Tool Some questions to help guide discussion around gathering the information. Medical Indications:

1. What is patient’s medical problem? History? Diagnosis? Prognosis? 2. Is the problem acute? Chronic? Critical? Emergent? Reversible? 3. What are the goals of the treatment? 4. What are the probabilities of success? 5. What are plans in case of therapeutic failure? 6. In sum, how can this patient be benefited by medical and nursing care, and how can harm

be avoided? Patient Preferences:

1. What has the patient expressed about preferences for treatment? 2. Has the patient been informed of benefits and risks, understood, and given consent? 3. Is patient mentally capable and legally competent? What is the evidence of incapacity? 4. Has the patient expressed prior preferences? E.g. Advanced Directives. 5. If incapacitated, who is the appropriate substitute decision maker? Is the substitute decision

maker using appropriate standards? 6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why? 7. In sum, is patient’s right to choose being respected to extent possible in ethics and law?

Quality of Life

1. What are the prospects with or without treatment, for a return to the patient’s normal life? 2. Are there biases that might prejudice provider’s evaluation of patient’s quality of life? 3. What physical, mental, and social deficits is the patient likely to experience if treatment

succeeds? 4. Is the patient’s present or future condition such that continued life might be judged

undesirable by them? 5. Any plan and rationale to forgo treatment? 6. What plans are there for comfort and palliative care?

Contextual Features

1. Are there family issues that might influence treatment decisions? 2. Are there provider (physicians and nurses) issues that might influence treatment decisions? 3. Are there financial and economic factors? 4. Are there religious, cultural factors? 5. Is there justification to breach confidentiality? 6. Are there problems of allocation of resources? 7. What are the legal implications of the treatment decisions? 8. Is clinical research or teaching involved? 9. Any provider or institutional conflict of interest?

3 Adapted from Jonsen, A., Siegler, M., and Winslade, W.(2006), Clinical ethics: A practical approach to ethical decision in Clinical Medicine (6th ed.). NewYork:Mcgraw-Hill


Appendix C


Clinical Ethics Committee Response Form

Name–Patient/Client/resident/Issue PHN/MRN if applicable

Date consultation requested: Consultation requested by whom:

Consult provided by:

Response Given

Date Consultation completed:

Signature(s)

It is recommended that a copy of this clinical consult be placed on the patient/client/resident chart; or if non-clinical consult placed on file.

clinical and organizational ethical decision-making … · clinical and organizational ethical...

Documents