Integrating healthcare ethics into everyday practice

Imagine this scenario: You are an emergency department RN on duty when a hurricane sweeps through your city. Your hospital is on full-disaster-alert status, but officials are advising citizens to evacuate the city to safer areas. What is your ethical duty to your patients, co-workers, and hospital? How does that fit with your ethical obligation to your family? Which should take priority? At MGH, nurses and other staff have developed resources for discussing contemporary ethical issues like these. They have implemented guidelines and interventions to assure the best care for patients, as well as an informed and supportive environment for staff.

Developing ethics competency in every clinician
Ellen Robinson, RN, PhD, is a clinical specialist in both cardiac nursing and ethics. Robinson defines healthcare ethics as a discipline that provides clinicians the theoretical background and tools they need to identify ethical issues in practice, usually as they relate to specific patient cases. When professionals understand the theories and analytical strategies involved, they can identify and clarify ethical concerns among team members, patients, and family. Then they can explore alternatives to ensure the patient’s well-being. Robinson says, “The emphasis is on making it safe to get issues out; the language can be added on as you go.”

At MGH, the philosophy is to develop each clinician’s competency rather than to simply single out people who have ethics expertise. To do that, each unit has designated RNs and other staff who have served on the Ethics in Clinical Practice Committee (EICPC), Optimum Care Committee, or Ethics Task Force. In addition, Robison teaches a two-day session on how to become a unit resource. She also mentors staff as they progress through a range of learning opportunities including accompanying her on consultations, participating in conferences, and facilitating ethics discussions on their units.

Educating staff about current dilemmas and approaches
The EICPC is one of seven committees operating under a collaborative governance model founded by Jeanette Ives Erikson, RN, MS, chief nurse and senior vice president for patient care. The primary goal of EICPC, one of several ethics committees at MGH, is to educate committee members and other clinicians in healthcare ethics. Up to 50 multidisciplinary members serve two-year terms, and one of the two co-chairs is always an RN. In her role as coach of EICPC, Robinson develops the co-chairs as leaders. The current co-chairs are Gayle Peterson, RN, C, staff nurse on Phillips House 21, and Susan Warchal, RN, staff nurse in the emergency department.

Each year, the co-chairs bring an issue they consider critical to the committee for investigation and action. For instance, Peterson recently raised a concern that became an EICPC goal: heightening awareness of a clinician’s ethical obligation to address a patient’s pain through an interdisciplinary model. The committee then collaborated with Pain Management Services and the Palliative Care Service at MGH to further measure, define, and address ineffective pain-management issues.

When the EICPC expanded its mission to include patient and family education, advanced care planning was a natural focus. Over 80 clinicians have now been trained to serve as consultants through the nationally acclaimed Respecting Choices program and its Advance Care Planning Facilitator Course]. The two-day course gives participants an overview of legal, ethical, and organizational issues associated with educating people about advanced care planning.

As part of the Respecting Choices curriculum, EICPC members presented a play called Advance Directives: True Life Stories, which emphasized barriers that patients, family, friends, and clinicians encounter in securing advance directives. It also illustrated the end-of-life questions that arise when no advance directive is in place. Author Regina Holdstock, RPh, and other committee members presented a poster about the play at the 2005 meeting of the American Society for Bioethics and Humanities in Washington, DC.

To further raise awareness about current ethical issues in healthcare, Peterson hosts an “Ethics in the News” series with facilitated discussions of issues raised by such things as developments in DNA/RNA sequencing, transplant medicine, disaster situations, and the Iraq war. “Once heart transplants were the issue,” Peterson reflects. “Now we have facilitated discussions about a patient who bought a kidney transplant in Turkey, face transplants, and whether a soldier in Iraq who donates blood can specify that it be received only by his compadres in battle.”

Pastoral aspects of medical ethics
Katrina Scott, MDiv, medical oncology chaplain, is a member of the EICPC and Optimum Care Committee, which consults on end-of-life issues. Scott sees a perfect fit between the traditional chaplain’s role of being a nonjudgmental listener who meets the person where he or she is and her role as facilitator and listener on ethics committees and in forums.

On her unit, half the patients have hematological disorders and many undergo bone-marrow transplants. Scott tries to help the interdisciplinary staff work through their own dilemmas concerning treatment issues and goals of care. Scott explains the Greek origins of the word dilemma: “Lemma is Greek for an established point of view; a dilemma occurs when two people holding opposing views on the same subject come to a disagreement.” The goal, according to Scott, is to come to consensus, or at least have a forum on the issue in question.

On the gynecological oncology unit, staff recently dealt with bereavement issues arising from patient deaths and demoralization following staff changes. Scott set up a monthly lunch meeting called “What’s on Your Heart and Mind?” to assist staff in putting words to the ethical and emotional issues they face. She often asks, “What’s creeping up the back of your neck?” as a way of helping staff identify their dilemma.

Warchal, because she was interested in the interaction of medical, religious, spiritual, and cultural aspects of ethical practice, completed MGH’s Clinical Pastoral Education for Healthcare Professionals program. “That gave me the courage and direction to go forward with prioritizing issues with the ED population, such as homelessness, alcoholism, and pain control,” says Warchal. The complex healthcare needs of homeless patients is one of Warchal’s clinical specialties.

Ethics in the ED
The emergency department began holding ethics forums in 1999. Discussion and education are meant to lead to new initiatives, policies, and interventions. Mary Jo Cappacilli, RN, CNS, who co-chairs the ED ethics forum with Warchal, started the high-risk patient task force as an initiative, which resulted in a collaboration with Boston Healthcare for the Homeless to streamline and coordinate care of patients. As a result, Warchal says, the medical care at MGH for this population is better, and patients can now be tracked for continuity and appropriateness of care.

Family presence at the patient’s bedside during CPR is an issue that has recently raised concerns and discomfort for some staff. Traditionally, families were excluded from witnessing extreme medical efforts, but families have been advocating to be with their loved ones. Warchal says, “We thought staff would be more at ease if we had guidelines and rules to follow, in addition to education about the ethics issues raised by CPR.” Therefore, Warchal and Patricia Meehan, CNS, obtained a research grant to investigate best practices and adapt the guidelines established by Parkland Hospital in Dallas, Texas.

Now, if a crisis situation meets the criteria, the patient’s family is given the option of being present during resuscitation efforts, along with a staff member who explains what is happening. According to Warchal, what was once a dilemma is now an accepted part of practice within MGH’s patient- and family-centered care model. On one occasion, when Warchal stayed with a woman who witnessed her husband being defibrillated, she suggested that the wife touch his toe and speak to him before he was rushed to the cardiac catheterization lab. The woman said, “Honey, I’ll be here when you get out.” The patient later told staff he had heard and remembered what his wife said.

The art of effective ethics forums involves bringing extremely busy clinicians together to discuss their concerns at an appropriate time. The ED has many subspecialty locations, so Warchal often goes to the staff for impromptu, perched-on-a-desk sharings when that is more effective than formal presentations. Many units at MGH have established ethics forums tailored to the needs and realities of medical practice in that particular specialty.

The most important thing to learn in ethics
Peterson summarizes the most important things to learn in ethics: “A lot of times you think, ‘This is not what I would want done,’ but you have to think about what the patient wants.” To that end, a nurse might ask, “What is most important to you at this moment?” and facilitate that outcome with help from the treatment team. Peterson says, “With ethics education, your perspective broadens, your whole scope of practice changes, and the patient benefits.”

This is the first in a three-part series on medical ethics in the Greater Boston area. Janet Cromer is a freelance writer and regular contributor to On Call. She received the Will Solimene Award for Excellence in Medical Communication for her On Call article “Drawing Out the Best in People” (September 2005), which described the work being done at the Boston Institute for Arts Therapy.