Piecing together the clinical picture of a complex patient is difficult enough. Add to the mix the patient?s value system, that of the family and those of various healthcare providers, and a case that might involve difficult decisions becomes even more daunting. That?s where an in-house ethics committee can step in.
These multidisciplinary committees can provide prompt consultations about patient care dilemmas, give debriefings after a trying case, improve communication processes and offer ongoing discussion about how to determine what's best for various patients.
?A nurse should never have to go home and say, ?Did I do the right thing today?? ? says Leah Veschio, RN, BSN, vice chair of the ethics committee at Flagstaff Medical Center in Arizona and a nurse in patient relations. ?I want to give nurses support because they have such a high-stress job.?
Veschio believes ethics committees can alleviate nurse burnout and improve retention, especially in areas such as the ICU, where life and death issues are common and can be morally wrenching. Her hospital?s committee emphasizes four pillars of ethical care: patient autonomy; beneficence, or helping others; justice, involving fair use of limited resources; and nonmaleficence ? the goal of doing no harm.
More broadly, ethics committees? focus on patient welfare dovetails with nursing practice and goals, says Lois Robley, RN, PhD, professor of nursing at Kennesaw State University?s WellStar School of Nursing in Georgia. ?For all the time we?ve been professionals, from Florence Nightingale on, we?ve had an obligation to do what's best for the patient. And that?s how we advocate ? trying to determine what's best, and dialoguing and negotiating with others to get that to happen.?
Education is a central function of ethics panels, says Mary McCabe, RN, MA, who chairs the ethics committee at Memorial Sloan-Kettering Cancer Center in New York City and is director of the hospital?s Survivorship Program. With her hospital?s focus on cancer care, and the complex decision-making that entails, outreach is vital, she says. The ethics panel at Memorial Sloan-Kettering develops case-based learning, with details of one case used as a prototype for how to think about specific issues. The panel also sponsors grand rounds on ethics and works with staff from the hospital?s communication skills laboratory, an interactive facility that uses actors and videos to model situations such as end-of-life discussions.
McCabe says less-formal reviews of cases, at brown-bag lunches or regularly scheduled clinical presentations, are effective for studying circumstances that arise repeatedly, or for sharing insights into the decision-making in especially difficult cases. ?This not only educates, but I think it also empowers the nursing staff to speak up when they are uncomfortable about an issue,? McCabe says. ?It keeps them from being bystanders in terms of decisions that are being made.?
In fact, nurses are crucial players in the ethics process, helping to recognize problems or elucidate them for the committee. ?Nurses are in tune with the viewpoints of various people who are attendant to the patient,? Robley says. ?Oftentimes they have the conversations with the families ? sometimes long-standing conversations over days, weeks and months ? and are good sources for the ethics committee when it?s trying to see objectively what the problems are.?
Common Conflicts
End-of-life and surrogacy issues are two common problems that ethics panels tackle. The ethics committee at Flagstaff Medical Center is likely to be consulted in cases in which a patient, whose wishes are not known, is sustained on a ventilator, and the family believes care should continue at all costs. ?That?s probably our primary ethical dilemma,? Veschio says.
At Memorial Sloan-Kettering, McCabe says, a key issue involves the goals of care, especially as death approaches. Patients and their healthcare providers frequently weigh the value of additional cancer-focused treatment versus comfort care only, as well as provision of other care such as dialysis, and artificial nutrition and hydration. Advance directives and appropriateness of a DNR order also fall under the goals-of-care umbrella, McCabe says.
Ethics consultations can be sought, too, when a patient or family requests care the clinical team does not think is beneficial; when a patient arrives who never had the capacity to consent to treatment (such as someone with severe autism); or when a person?s capacity may be adequate for everyday living but inadequate to grasp the significance of refusing a potentially curative treatment, McCabe says. Issues also arise surrounding research ? particularly regarding informed consent and the appropriateness of conducting studies in vulnerable populations, Robley adds.
Cultural and religious considerations also are key. While individual autonomy seems endemic to American culture, other cultures rely more heavily on family decision-making or deferral to elders, McCabe notes. At Flagstaff, Veschio says, the ethics panel includes a Navajo interpreter to provide support and cultural insight in working with the local Native American population.
Anatomy of an Ethics Panel
Although the composition of ethics committees can vary, members typically include nurses and physicians, social and pastoral care workers, and patient representatives. Sometimes panels include lay members of the community, even people who have received care at the facility.
At Flagstaff Medical Center, committee members are appointed based on interest and their specialty. Nurses on the committee include a staff nurse, palliative care nurse and Veschio, from patient relations.
Robley says it?s invaluable for hospital ethics panels to have access to an ethics specialist in the academic community, who can study issues and processes in depth and offer perspective on ethics standards across the nation. ?It?s an opportunity to bring in literature, research, a scholarly perspective on these issues,? says Robley, who teaches bioethics and serves as an education consultant on ethics for five WellStar Health System hospitals. ?Sometimes people are thinking the rule of thumb is to do such and such, and we find that evidence in the literature shows us different ways to consider things. It takes time to ferret that out.?
Ethics committees also examine broader, organizational issues and policies, not just situations focused on a single patient?s care. For more than a decade, Robley has served on the steering committee that oversees ethics panels at the five WellStar hospitals. Her committee recently has focused on a campaign for getting advance directives noted on patient charts, and reorganizing and clarifying the hospitals? POLST, or physician order for life-sustaining treatment.
Veschio was a radiology staff nurse when she decided to pursue her longtime passion in ethics and helped to drive formation of a panel at her hospital. She met with the director in charge of process improvement, which led to the drafting of a policy to present to senior managers to seek support. In all, it took about two years to form the ethics panel.
Members then immersed themselves in educational opportunities, sharing knowledge gleaned from conferences, online classes, guest speakers and research. ?It takes several years for a committee to mature,? Veschio says.
To succeed on an ethics committee, nurses should have strong clinical skills and feel comfortable speaking up in front of people in all positions, the experts say.
Nurses also should understand their own value systems and set them aside when needed, because other considerations in an ethics case may trump personal beliefs. ?That?s really hard to do,? Veschio says. ?We?re looking at the values of patients, and not of medical care.?
