Ethical issues warrant hospice-specific group
Concerns may change when nurses are guests
Are the medications safely out of reach of children? Can the family caregiver handle tasks required to care for the patient? Are family members following the wishes of the patient as indicated before he or she developed dementia? Is the patient safe in the home setting? Is the employee safe in the patient's home?
Hospice and other home health nurses, who might or might not have the support of an ethics committee within their agency, face those issues on a regular basis. Even when hospice nurses have access to ethics committees, not many take advantage of the support.
"The origin of ethics committees was to provide support to health care providers who were faced with an ethical dilemma for which they needed objective guidance," explains Sigrid Fry-Revere, PhD, JD, medical ethicist and president of the Center for Ethical Solutions in Lovettsville, VA. "The purpose of an ethics committee or ethics service was to provide peer-to-peer support to encourage open discussion without intimidation or fear." By creating an atmosphere of open discussion, an ethics committee was designed to help health care staff work through ethical problems and come up with solutions, she adds.
Although ethics committees still exist, they have evolved into policy review or creation groups, or they only discuss specific cases when a problem is brought to their attention, says Fry-Revere. This evolution has made ethics programs appear to be a formal, difficult-to-access process.
Within a hospital setting, informal discussion of ethics issues can be held at the coffee pot in the employee lounge or at a nurses' station, says Fry-Revere. There is no nurses' station for home health employees, she says. "Home health agencies might address some issues at case conferences, but those meetings are usually so crammed with items to be covered that lengthy discussions are not practical," Fry-Revere says. Home health personnel also are working independently, so they don't have personal contact with other nurses every day during which a conversation can comfortably take place, she says.
For those reasons, it is important to offer home health employees an opportunity to participate in ethics discussions in informal settings, says Fry-Revere. "Ethics rounds or ethics lunches that bring up issues for discussion in a 'what-if' approach are very effective," she says. She suggests lunches to which people bring their own "brown bags" as a way to fit people's schedules and create a nonthreatening environment for discussion.
Even home health agencies that are owned by or affiliated with a hospital should offer an ethics service specific to home health employees, suggests Fry-Revere.
"When a patient is in the hospital, the hospital staff has total control over the patient's environment," she points out. "In home health, we are visitors in the patient's home, and the patient is king of the castle," Fry-Revere says. This creates a different situation when a nurse or aide is faced with situations related to family, unsafe living conditions, or unsafe work conditions for the employee, she adds. "Hospital personnel cannot relate to these situations if they are only familiar with compliant patients in a hospital setting."
Creating an effective ethics service might mean a change in the agency culture, points out Leslie Kuhnel, MPA, clinical ethics officer for Alegent Health in Omaha, NE. "Creating a culture that views ethics programs or committees as a valuable and supportive resource, rather than a disciplinary or punitive body, is the first step," she says. At Alegent, a variety of direct caregivers serve on the committee, she points out. Kuhnel has worked with managers to define the role of the committee and provide experiences for deliberation for their staff.
"The other key [to success] is to make the discussion relevant to the experiences of staff," says Kuhnel. For example, invite staff to identify a case or situation from their own experience to present to the committee rather than using only hypothetical case studies, she suggests.
Another way to expand the understanding of an ethics committee is to let your community know that you offer this resource, suggests Mary Miller-Hyland, RN, BBA, NHA, administrator of Winona (MN) Health's Senior Services. "Our ethics committee has had very few cases to hear in recent years, so we used a community event to increase awareness of the support we offer," she says. Even when home health or hospice employees need help, they don't have to appear before the full committee. They might just talk with one or two members of the committee who can walk the employee, the patient, or the family through the process of determining the best decision, Miller-Hyland explains.
Having a home health employee on the health system's ethics committee is a big plus, says Pam Slocum, RN, director of home care and hospice for Winona Health. "Our social worker who serves on the ethics committee is often called upon by our staff to talk with families who might have to make the decision to move their family member from the home to another facility," she says. Because staff members are aware of the issues that might arise among family members, and because they know of the social worker's ethics committee experience, they can ask her to intervene at an early point in the process to minimize conflicts, Slocum adds.
Lucia Wocial, RN, CCNS, PhD, nurse ethicist at Clarian's Charles Warren Fairbanks Center for Medical Ethics in Indianapolis, says, "It is important that employees realize that I am not the ethics police. An ethicist doesn't tell someone what the right decision is; instead, an ethicist provides support while a person deliberates."
A good decision related to ethical issues is a decision for which a person can articulate how the decision was made, she explains. "Ethics is personal; but if people can get over their feelings that they have to defend their decisions and begin to have an open mind during discussions, reaching a decision will be less stressful," she says. "My job is to lessen the distress of people who care for other people."
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