Creating, modifying ethics committee? Choose model
Model depends on hospital’s mission and directives
Ethics committees have, in the past three decades, become ubiquitous in American hospitals. But while most hospitals have ethics committees, the makeup of those committees can vary depending on the institution they serve.
So, how best can hospitals create or re-make ethics committees to ensure they provide the best service to patients and staff?
"The first thing they need to decide is what resources are available and what model they want to use, because there are different models for ethics committees," according to Catherine Marco, MD, FACEP, an emergency medicine physician at St. Vincent Mercy Medical Center in Toledo, OH, and board liaison to the ethics committee of the Society for Academic Emergency Medicine.
Determine committee’s functions
Ethics committees, broadly defined, serve three basic functions: to educate, make recommendations on policy, and provide consultation in cases that present ethical dilemmas.
"It should be noted that today it would be rare for a hospital not to have an ethics committee already in place," says Ellen W. Bernal, PhD, director of the ethics department at St. Vincent Mercy. "Almost all hospitals currently have an ethics committee, and increasing numbers of extended-care facilities, home health agencies, hospices, and other health facilities have them or are in the process of forming them."
St. Vincent Mercy’s ethics committee is headed by an ethicist — Bernal — and is made up of members from throughout the hospital, from both clinical and nonclinical staff. Bernal conducts ethics consultations and presents reports on the consults to the ethics committee several times each year.
Other hospitals use the multidisciplinary approach to ethics consultations, with several members of a committee on call at any given time, and consultations are handled by more than one member of the committee.
"The multidisciplinary approach works nicely because ethical issues are often intertwined [among different aspects of patient care]," says Marco. "At St. Vincent, we have an ethicist who conducts the consults, but not every hospital has an ethicist."
Each model has its benefits and drawbacks (see table).
The first decision a hospital has to make in designing or revamping its ethics committee, Marco says, "is to decide what their interest is in how they want to provide ethics consults."
For example, a children’s hospital would want a heavy presence of pediatric specialists and staff; a trauma center might include several surgeons on its ethics committee, because of the likelihood that ethics questions would arise surrounding traumatic injury cases.
No regulatory requirements
While few hospitals would consider operating without an ethics committee or consultant, there are no real regulatory requirements mandating them. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), based in Oakbrook Terrace, IL, the major accreditation body for hospitals in the United States, requires standard patient rights and responsibilities, as well as a process to resolve ethical issues when they occur. But JCAHO does not require that this be accomplished by an ethics committee.
A review of JCAHO’s patient rights and responsibilities standards, however, makes clear the necessity of an ethics committee. JCAHO requires that accredited hospitals address ethical issues in providing patient care; involve patients in all aspects of their care; allow family participation in care decisions and in resolving dilemmas about care; address the withholding of resuscitative services and withdrawing of life-sustaining treatment; address end-of-life care; and "operate according to a code of ethical behavior."
"I would not recommend — especially a hospital — trying to survive without an ethics committee," Bernal says.
And though JCAHO does not require an ethics committee, per se, Bernal says JCAHO surveyors "want to see if the ethical care of the patient is integrated throughout the entire treatment of the person."
Bernal stresses the importance of administrative support for the ethics committee.
"Those forming the ethics committee must ensure that it will be firmly placed within the organizational structure. The reporting relationship needs to be worked out. Viable options are for the committee to report to administration and/or the board of directors," she says. "There should be an agreed-upon budget for committee support including office staff, educational activities, acquisition of key periodicals and books, community outreach, etc.
"The chair can be selected by administration or elected by committee membership. This individual should have the ethics committee as part of his or her job description."
Bernal says that if a hospital has no one in the organization with an educational and clinical background in bioethics, she would recommend the hospital seek assistance from bioethics centers, combined academic and clinical programs, statewide ethics networks, and national organizations such as the American Society for Bioethics and Humanities.
"It is well worth considering working with a bioethicist who has the needed educational and clinical background to get a committee up and running," suggests Bernal.
An ethics committee already in place can benefit from periodic internal evaluation, Bernal and Marco say.
"They can conduct informal surveys of clinical personnel, to find out if [personnel] have used the committee, if they’re informed about it, if they know the ethics processes," says Bernal. "Is the committee getting a steady stream of consults? Does the committee check with patients and family to see how helpful the ethics consult was?" (See checklist).
Face-to-face interviews with clinical personnel may work better than surveys to help gauge the organization’s needs, Bernal continues.
"It is a good idea to develop ongoing rounding, ethics brown bag lunches, case discussions, and other brief clinical education to increase visibility of the committee," she says. "Grand rounds, seminars, and other venues are also important."
The committee must begin with and continue good education at every meeting. As the committee develops, it can begin to offer case consultation by full committee, subcommittee, or individual consultants, says Bernal. These activities need to be tracked and evaluated, and as recurring issues are identified, the committee should explore policies or decision trees to help expedite their resolution.
And like any other committee, an ethics committee should have yearly goals and an annual evaluation, she says.
Ethical questions arising out of end of life were the reason ethics committees first sprang up in great numbers in the 1960s and 70s, and end-of-life issues are still the most frequent cause of ethics committee consults.
"There are always some new situations that come up, but still, the bread and butter for an ethics committee is end of life, where the most difficult decisions come up," Marco says.
Bernal points out that while bioethics issues have always been around, they began getting more attention 30 or 40 years ago with high-profile end-of-life cases such as that of Karen Ann Quinlan.
"People began questioning, We have all this technology, but do we always have to use it?’" she says. "Then as the dialogue continued and broadened, we became a little more comfortable with it, but then in the last 10 years, end-of-life cases have changed a little, often with patients and their families tending to view all the technology that can be provided as their right or within their purview to ask for and receive.
"And then, of course, there was the well-publicized [Terri] Schiavo case, which raised all these issues again."
New technologies such as genetic testing, stem cell therapies, assisted reproduction, and others are raising and will continue to raise new questions for ethics committees to wrestle with.
Depending on a hospital’s stated mission and code of ethics, those questions can vary from one hospital to the next. St. Vincent, like many Catholic hospitals, might not have the ethical dilemmas posed by some assisted reproduction or contraception procedures that other hospitals do, simply because such procedures may be barred by the hospital’s ethical and religious directives, Bernal points out as an example.
Education of staff is another part played by a hospital ethics committee. While medical schools are doing a better job of teaching ethics and giving residents a good foundation in ethics, it often falls to the ethics committee to provide education that helps integrate an ethics program throughout the care continuum.
Brown bag lunch conferences, participation in rounds, and one-on-one conversations are a few of the educational opportunities ethics committees can take to educate staff, Bernal suggests.
Developing and maintaining connections with other ethicists and ethics committees outside the institution is important, as well, for exploring emerging issues and sharing ideas. Ethics committees from different institutions in geographic regions occasionally collaborate on policies that provide consistency within a region, Bernal explains.
"The ethics committee should become involved in other related groups within the organization — the institutional review board is one," she continues. "Other areas that would benefit from ethics involvement would include advance directives, do-not-resuscitate policies, palliative care, patient satisfaction, mission services, and pastoral care/chaplaincy. Quality improvement is a newer area for ethics committees."
Above all, Bernal says, to make an ethics committee truly integral and useful to staff and patients, it needs to be accessible.
"Don’t hide out in the office or the boardroom," she urges. "Talk with those whom you serve, be present in the clinical service areas by rounding, brief education, and make presentations at organizational meetings."
Source
- Ellen W. Bernal, PhD, director, ethics department, St. Vincent Mercy Medical Center, 2213 Cherry St., Toledo, OH 43608. Phone: (419) 251-3232.
- Catherine Marco, MD, FACEP, St. Vincent Mercy Medical Center, Toledo, OH. E-mail: [email protected].
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