EP17 Nurses use available resources to address ethical issues related to clinical practice and organizational ethical situations.
Provide one example, with supporting evidence, of nurses using available resources to address ethical issues related to clinical practice.
OR
Provide one example, with supporting evidence, of nurses using available resources to address an organizational ethical issue.
NAME OF INITIATIVE
Ethics Consultation Related to Clinical Practice
BACKGROUND AND PURPOSE
Over the past 30 years, the practice of clinical ethics consultation has emerged in response to the growing needs from patients, families, and healthcare professionals for assistance with ethical concerns encountered in practice (American Society for Bioethics and Humanities, 2009). Ethical dilemmas are often controversial and require the skills from consultants to help identify, analyze, and evaluate for possible solutions. In 1991, the Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission, 1993) introduced new patients’ rights standards that mandated hospitals seeking accreditation to develop a system to address ethical issues that arise in patient care. As a faith-based organization, Baptist Health South Florida (BHSF) has always subscribed to the highest ethical standards in all areas of operations and communicated this expectation to its employees and staff through the “Code of Ethics – A Guide to Ethical Standards” and annual required education. Additionally, BHSF has put various systems in place in order to assist staff in “doing the right thing” all the time. These best practices earned BHSF the recognition from Ethisphere Institute as one of the “World’s Most Ethical Companies” from 2011-2014.
The BHSF Bioethics department was developed in 2002. Its mission is to foster and maintain high quality system-wide ethical practices. This mission is upheld by offering and supporting numerous educational programs in ethics to hospital staff (clinicians, administrators, and committee members) and establishing the BHSF Bioethics Committee. The committee creates, reviews, and integrates system-wide ethics policies. Each hospital has their individual Clinical Ethics Committee that reports back to the system committee. Due to the complex nature of bioethics, each hospital has support from the BHSF Bioethics department through the Bioethics and Patient’s Rights Coordinator Christine Edozie, RN, who acts as a representative and liaison between corporate BHSF and Homestead Hospital. Her responsibilities include organizing Homestead Hospital Clinical Ethics Committee meetings; providing staff support; and educating them on policies and procedures related to bioethics.
In response to the need to have a structure and process in place for staff members to report any ethical concerns in the clinical setting, the BHSF Bioethics Committee in collaboration with all of the entities developed a policy in 1993. The policy outlines the process for seeking an ethics consultation. (EP17 01 HH-100-7940-1320 Ethical Issues and Ethics Consultation Requests Policy) A component of the policy includes the presence of a Bioethics Consultant. Each hospital selects members from their Clinical Ethics Committee to act as a consultant. The consultant is expected to be available, as assigned, to participate in the ethics consult(s). At Homestead Hospital, the Clinical Ethics Committee meets on site on a regular basis. (EP17 02 Homestead Hospital Clinical Ethics Committee Meeting Minutes) The committee is comprised of both hospital staff and community physicians. Dr. Janice Milligan, a private practicing physician in the community with privileges at Homestead Hospital, is the chairperson. Other members of the Clinical Ethics team include the chaplain, Bioethics and Patient Rights Coordinator, Palliative Care Nurse Practitioner, a community member, clinical nurses, nurse leaders, and physicians. The committee members selected who also act as ethics consultants are Palliative Care Manager Linda Long, ARNP, Case Management Manager Patricia Brodie, RN, Bioethics Director Rose Allen, RN, ICU Clinical Nurse Specialist Rosemary Lee, ARNP, Chief Nursing Officer and Vice President Gail Gordon, RN, Social Worker/Case Manager Catherine Scigliano-Rodriguez, MSW, Chaplain Eliane Menezes, Chaplain Neil Skjoldal, and Pastoral Care Chaplain & Director Gregorio Marin. These members have completed the Bioethics Department Consultant Workshop and demonstrated expected core competencies of a clinical ethics consultant. They also received training to include annual education and ongoing education, as needed.
METHODS AND APPROACH
Ethics Consultation Services
The Homestead Hospital Clinical Ethics committee appoints one or more members to be consultants and provide on-call services. Requests for an ethics consultation may come from any individual who is concerned about an ethical issue regarding a patient’s care. The request can be made by contacting the primary on-call ethics consultant through the Homestead Hospital Operator. When a consultation request is received, the ethics consultant on-call notifies the chair of Homestead Hospital’s Clinical Ethics Committee, the Bioethics and Patient’s Right Coordinator and/or the corporate BHSF Bioethics Director of the requestor’s name and the nature of the case. All the other members of the on-call ethics consultation team are notified of the consult at the next Clinical Ethics Committee meeting.
The primary ethics consultant on-call will contact the requestor within 24 hours to discuss the concerns, gather facts and determine the ethical nature of the case using an established tool. The consultant notifies the attending physician, accordingly, if they are not the requestor. If the attending physician objects to the consultation, the Clinical Ethics Committee chairperson is responsible for contacting the attending physician to directly discuss the case. It is the responsibility of the primary ethics consultant to conduct a thorough review of the medical record. Additional data gathering may include interviews and meetings with healthcare team members, the patient, and family members as deemed necessary and appropriate. During the preliminary case review, if the consultant(s) had any previous involvement with the case in their role as nurse, physician, social worker/case manager or chaplain that can be construed as an actual or potential conflict of interest, the primary ethics consultant will pass the case to a secondary consultant.
Upon completion of the consultation, the primary on-call consultants will present the case to the chair and/ or Bioethics and Patient’s Right Coordinator and/or Bioethics Director. If it is determined that the nature of the case does not require a formal ethics consultation, the on-call consultant will notify the requestor of the decision and may suggest alternative actions, as appropriate. If an ethical issue is identified, the ethics consultant and the other team members will analyze the case and make a recommendation based on consensus. The team will not make direct patient care decisions. The Bioethics and Patient’s Right Coordinator will write a summary of the case. If selected by the Clinical Ethics Chair, the case may be presented by the primary ethics consultant as a case study at the next quarterly Clinical Ethics Committee meeting. A debriefing of the case will be scheduled as soon as possible, within one to two weeks, preferably with the consultants.
An Example of Nurses Using Resources to Address an Ethical Issue in Clinical Practice
The Code of Ethics published by the American Nurses Association (ANA) establishes the ethical standards for the nursing profession. Its first provision states “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” In its interpretive statements under the “nature of health problems”, the Code of Ethics expound that nursing care is aimed towards meeting the holistic needs of the patient across the continuum (particularly at the end-of-life and death) and that this care extends to the family. This principle is further elucidated in Homestead Hospital’s Professional Practice Model (PPM) in the areas of clinical practice, communication, collaboration and patient-and family-centered care (part of the care delivery system). The following case study demonstrates how Homestead Hospital nurses exemplified the first provision of the Code of Ethics and the PPM. It also showcases the resources they tapped to assist them in resolving a clinical ethical dilemma regarding end-of-life.
Two calls were received by the ethics team in September 2012 concerning the care of a 68-year old woman who suffered anoxic encephalopathy status post cardiac arrest and who was receiving Therapeutic Hypothermia (TH). The family had requested the treatment be stopped, stating she had previously expressed wishes to be off life support if her prognosis was poor. The first call to the ethics team was from the eICU Lifeguard physician to the BHSF Bioethics Chair concerning a communication with the Intensive Care Unit (ICU) Clinical Nurse Claudelle Stafford, RN, who stated that the family had requested to discontinue therapies and Stafford requested some input from the eICU physician. In contrast to the family’s request, the eICU physician’s recommendations were to continue TH. Of concern to Stafford and the rest of the nursing staff was that as part of the TH protocol, patients are given sedatives and paralytics in order to prevent shivering and untoward effects and facilitate reaching the desired temperature of 33 degrees Celsius for a 24–hour period. After 24 hours, the patient is slowly rewarmed and returned to normothermia. Best practice regarding TH indicates that withdrawal of care should be done at least 72 hours after the patient has returned to normothermia. This process would ensure that all medications are adequately eliminated and would allow for a clearer and more definitive neurological exam. There was unease that consideration was being given to withdrawal of care under the current conditions. However, it was also acknowledged that another medical diagnostic testing can be done to evaluate neurological status.
While discussion ensued between the ICU nurse and the eICU physician, a few hours later a second call came from the Palliative Care ARNP to the BHSF Bioethics Director regarding the same issue. During this time, the ICU nurse was in a quandary as to what elements of care should or should not be performed. It was decided among the nursing team and the eICU physician that aggressive treatment of TH was to be continued until the ethics consultation was completed and a decision made. Support was provided to the ICU nurse by the ethics consultant, chaplain, unit nurse leadership, physician and the Palliative Care ARNP.
The on-call ethics consultant came to the ICU to conduct the review. (EP17 03 Ethics Consultant Note) In the mean time, the critical care physician evaluated the patient and confirmed that the patient’s prognosis was poor and supported withdrawal of life support. However, the ethics consultant did not find sufficient evidence or documentation in the patient’s medical record to give a clear medical or neurological prognosis. Specifically, there was limited documentation regarding an end-stage or terminal condition. Therefore, after consultation with the ethics team, the ethics consultant recommended that all treatments be continued until the medical and neurological prognosis could be ascertained. This was communicated by the ethics consultant to the ICU nurse, attending physician, critical care physician, the eICU physician and the Palliative Care ARNP. All parties involved were clearly aware of the family’s wishes that the patient would not want to remain on life support if her prognosis was poor.
PARTICIPANTS
The Homestead Hospital Clinical Ethics Committee members and staff who were involved in the case were as follows:
Name/Credentials |
Title |
Department |
Role in the Team |
Claudelle Stafford, RN |
Clinical Nurse |
ICU |
Primary Nurse |
Linda Long, MBA, MSN, ARNP-BC, CHPN |
Palliative Care ARNP & Manager |
Palliative Care |
Palliative Care ARNP/ support staff |
Rose Allen MSM/HM, RN |
Bioethics & Palliative Care Director |
Bioethics & Palliative Care |
Bioethics Coordinator/ Ethics Consultant/ Support staff |
Dr. Raul de Velasco |
BHSF Bioethics Chair |
BHSF Bioethics |
Support/ guidance for Clinical Bioethics team; liaison for medical staff members |
Dr. Janice Milligan |
Physician |
Medical Staff |
Clinical Ethics Committee Chair |
Eliane Menezes |
Chaplain |
Pastoral Care |
Clinical Ethics Committee Member / support staff |
Dr. Alfredo Melgar |
Physician |
Medical Staff |
Attending physician |
Dr. Juan Lopetegui |
Intensivist/ Pulmonologist |
ICU |
Medical Director ICU/ Consulting Physician |
OUTCOMES
Clinical Outcome
Further medical history was provided by the patient’s pulmonologist and cardiologist with documentation that the patient had a poor prognosis with history of severe chronic obstructive pulmonary disease, diabetes mellitus, and severe cardiomyopathy with an ejection fraction of 30% documented from a cardiac catheterization 1-year ago. Patient had now suffered a cardiopulmonary arrest at home and resuscitative attempts were complicated by excessive pulmonary secretions causing delayed intubation until the patient arrived in the emergency department. Patient had return of spontaneous circulation, was placed on TH protocol and was diagnosed with anoxic encephalopathy based on neurological scanning images and exam.
The ICU nursing staff was comfortable knowing that due diligence was done in evaluating the patient’s medical and neurological prognosis and due consideration was given to their concerns. Two physicians later declared the patient terminal and end-stage. The Palliative Care team discussed the goals of care at length with the family and staff. The medical team agreed to change her resuscitation status to comfort measures only, with the intention that TH would be completed with plans to withdraw life support the day after patient was re-warmed. The two adult children were proxies and signed authorization to withdraw life support. After being re-warmed and reevaluated by the neurologist, the patient was found to have fixed pupils and no neurological response. The following afternoon, the patient was withdrawn from life support and expired a few hours later.
Organizational outcome
As a result of this case and to provide criteria for caregivers based on best practice, the policy for Brain Death Determination in Adults was revised to include a statement regarding brain death testing in patients receiving TH. (EP17 04 HH-400-5830-800 Brain Death Determination in Adults Policy) Ethics rounds are conducted on occasions by the Bioethics department with difficult cases upon patient’s death or after discharge from the hospital. The Bioethics department arranges a date and time with the unit where the ethics consult was requested. Staff is invited to participate in this educational session as a way to increase knowledge and awareness, specifically with regards to ethics consult. One of its primary goals is to resolve ethical tensions. The ethics rounds were initiated by the department three years ago as a medium for an open forum and providing education to staff. On some occasions, ethics rounds are not conducted for various reasons. An ethics round was not conducted for this case. However, a debriefing was conducted on the unit with the social worker, chaplain, Palliative Care ARNP, and nurse manager. Staff members including nurses, secretaries, clinical partners and respiratory therapists attended. They expressed their initial concerns and their confidence that the “right” thing had been done. Afterwards, additional feedback was solicited by the nurse manager during the ICU staff meetings for further education. (EP17 05 ICU/PCU Staff Meeting Minutes and Roster)
Exhibit EP17a: Summary of HH Ethics Consultations 2009-2013
Analysis: Each year, the ethics department analyzes the reason for the number of ethics consults. Historically, they are usually related to discord between family members and/ or the medical team about the treatment plan. In recent years, the number of consults related to other reasons had been trending upwards due to increased staff awareness of the Ethics Committee’s role.
Summary of Attachments/Hyperlinks/Evidences:
EP17 01 HH-100-7940-1320 Ethical Issues and Ethics Consultation Requests Policy
EP17 02 Homestead Hospital Clinical Ethics Committee Meeting Minutes
EP17 03 Ethics Consultant Note
EP17 04 HH-400-5830-800 Brain Death Determination in Adults Policy
EP17 05 ICU/PCU Staff Meeting Minutes and Roster
Exhibit EP17a: Summary of HH Ethics Consultations 2009-2013