Ellen Fox

Ethics Consultation in United States Hospitals: A National Survey

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices.

Patients who want their family and physician to make resuscitation decisions for them : Observations from SUPPORT and HELP

OBJECTIVE: To determine the extent to which older or seriously ill inpatients would prefer to have their family and physician make resuscitation decisions for them rather than having their own stated preferences followed if they were unable to decide themselves.

Rethinking fundamental assumptions : SUPPORT's implications for future reform

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision‐making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

Advance Care Planning by Proxy for Residents of Long-Term Care Facilities Who Lack Decision-Making Capacity

This report examines whether long‐term care facilities should implement policies and procedures to support advance care planning by proxy for residents who lack decision‐making capacity. The report focuses on advance care planning in the Department of Veterans Affairs. After reviewing clinical, legal, and ethical perspectives, the authors conclude that advance proxy planning is ethically sound and can improve patient care. However, because experience with advance proxy planning is still fairly limited, the authors do not recommend that a particular standardized approach be mandated at the national level. Instead, local facilities are advised to develop their own policies and then evaluate their effect. The report contains specific recommendations for the advance proxy planning process.

Disclosing Adverse Events to Patients

BACKGROUND The rationale for, and recommended approaches to, disclosing adverse events to patients are examined on the basis of the experience of the Veterans Health Administration (VHA). The VHAs National Ethics Committee endorses a general policy requiring the routine disclosure of adverse events to patients and offers practical recommendations for implementation. PRACTICAL APPROACHES TO DISCLOSING ADVERSE EVENTS Disclosure is required when the adverse event (1) has a perceptible effect on the patient that was not discussed in advance as a known risk; (2) necessitates a change in the patients care; (3) potentially poses an important risk to the patients future health, even if that risk is extremely small; (4) involves providing a treatment or procedure without the patients consent. From an ethical perspective, disclosure is required and should not be limited to cases in which the injury is obvious or severe. Disclosure of near misses is also discretionary but is advisable at times. In general, disclosure by a clinician involved in the patients care is appropriate. CONCLUSION Although a variety of psychological and cultural factors may make clinicians and organizations reluctant to disclose adverse events to patients, the arguments favoring routine disclosure are compelling. Organizations should develop clear policies supporting disclosure and should create supportive environments that enable clinicians to meet their ethical obligations to disclose adverse events to patients and families.

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records.

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool (ECQAT). ECQAT enables raters to assess the quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation (ethics question, consultation-specific information, ethical analysis, and conclusions and/or recommendations), established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT, the resulting product, and recommended future testing and potential uses for the tool.

Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons.

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondents role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions.

Preventive Ethics: Addressing Ethics Quality Gaps on a Systems Level

BACKGROUND Preventive ethics (PE) is a key component of IntegratedEthics (IE), an innovative model developed by the Veterans Health Administration (VA)s National Center for Ethics in Health Care which establishes a comprehensive, systematic, integrated approach to ethics in health care organizations. Since early 2008, IE has been implemented throughout all 153 medical centers and 21 regional networks within the US Department of Veterans Affairs (VA) health care system. ISSUES A STEP-BY-STEP APPROACH TO ETHICS QUALITY IMPROVEMENT: PE employs a systematic, step-by-step process improvement approach called ISSUES Identify an issue, Study the issue, Select a strategy, Undertake a plan, Evaluate and adjust, and Sustain and spread. After the ethics quality gap is described, a measureable and achievable improvement goal based on the gap is developed. One of the most challenging aspects of describing an ethics quality gap is to establish an appropriate ethical standard on which to base the operational definition of best ethics practice. PRACTICAL STEPS TO DEVELOPING A PREVENTIVE ETHICS FUNCTION: Within the VAs IE model, PE is situated as a subcommittee of the IE council, which is chaired by the facility director (equivalent to a hospital chief executive officer) and oversees all aspects of the organizations ethics program, including ethical leadership, ethics consultation, and PE. Each VA medical center is required to have a PE team led and managed by a PE coordinator and may need to address ethics issues across the full range of health care ethics domains. CONCLUSIONS The VAs IE model establishes a robust conceptual framework, along with concrete tools and resources, to integrate PE concepts into the day-to-day operations of a health care organization and is directly transferrable to other health care organizations and systems.

Evaluating Ethics Quality in Health Care Organizations: Looking Back and Looking Forward

To spark a conversation about how best to evaluate ethics quality, this article draws on the collective experience of the IntegratedEthicsTM evaluation team to reflect on what we have learned and to envision an agenda for future work. The article emphasizes the importance of beginning with a well-defined conceptual model, building an expert team, committing the resources necessary to do evaluation well, and tailoring the evaluation methods to the target audience. The article then describes a five-point agenda for future work on ethics quality in health care: further evaluate and improve ethics programs; further evaluate and improve specific ethical practices; examine the relationships among various aspects of ethics quality; examine the relationships between ethics quality and other important organizational outcomes; and foster cross-institutional collaborations to evaluate and improve ethics quality. The hope is that some day ethics will be fully integrated into the mainstream of health care quality management.

The IntegratedEthicsTM Staff Survey: A Tool to Evaluate and Improve Ethical Practices in Health Care

Background: To improve ethics quality in health care, health care organizations need a way to characterize whether ethical practices throughout the organization are consistent with accepted ethics standards, norms, and expectations for the organization and its staff. We developed the IntegratedEthics™ Staff Survey (IESS) to fill this need. Methods: The IESS was developed and validated through a rigorous multiyear process. This process included reviews of the bioethics and health care literature to develop conceptual maps of common ethical issues in health care; focus groups and interviews with institutional stakeholders to identify key ethical concerns; cognitive testing, pilot testing, and field testing to ensure that questions were understandable and useful; and item reduction and modification to reduce respondent burden. Results: The IESS addresses staff perceptions of ethical practices in nine domains: everyday workplace, business and management, government service, patient privacy and confidentiality, resource allocation, shared decision making with patients, professionalism in patient care, end-of-life care, and research. The 2010 version of the survey consisted of 76 questions (excluding 8 demographic questions), including questions about the degree to which facility staff demonstrate behavior consistent with specific ethical practices, systems-level or organizational factors that support or interfere with ethical practices, and the ethical environment and culture. The IESS has served as a catalyst for multiple quality improvement and educational activities. Conclusions: The IESS represents an across-the-board approach to measuring ethics quality in multiple areas encompassing clinical, organizational, and research ethics. In addition to its use in quality improvement efforts, the IESS may be used to assess whether there are systematic differences across different disciplines, services, and supervisory levels; to evaluate the effectiveness of ethics programs; and to identify trends in ethical practices over time.