Health Ethics Committee Toolkit

Transcription

1 Health Ethics Committee Toolkit Part Two: Consultation

2 Information about this resource and others can be accessed via the Manitoba Provincial Health Ethics Network (MB-PHEN) website at Manitoba Provincial Health Ethics Network Reproduction is prohibited.

3 TABLE OF CONTENTS Purpose and Overview... 5 How to Use this Toolkit... 6 Section One... 8 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role...8 Introduction... 8 Key HEC Roles/Functions: Building Competencies... 9 Education and Promotion of an Ethical Climate... 9 Policy Review and Development Approaches to Review and Writing of Policy: Policy as Education Activity for HECs! Healthcare Ethics Consultation (HCEC) Firm Foundations for HCEC: Have you Built Them? Leadership Support Membership HEC Establishment/Integration Expertise/Ethics Knowledge A Consideration of the Core Competencies for Healthcare Ethics Consultation (HCEC) Basic Ethics Knowledge and Skills for HCEC The Use of Frameworks for Ethical Decision Making Advanced Ethics Knowledge and Skills for HCEC Re: Credentials and Role Clarification: The Emerging Discourse Section Two Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) Defining the Objectives of your HEC s HCEC Role Providing General Education Offering Explicit Ethics-Based Analysis Mediation/Facilitation/Consensus Building Presenting Carefully Considered Ethics-Based Recommendations Treading Carefully: The Issue of Legal Liability What will the HCEC Process Look Like? Intake Deliberation Documentation Who Should be Involved in Consults? Advantages of Sub-Committee Disadvantages of Sub-Committee Single Consultants Off-site and Distance Consultations How will the HCEC Service be Evaluated? Policy for the HCEC Role/Function References... 40

4 Section Three Resources Stocking Your HEC Library: Some Suggestions! General Resources for HECs Books Articles Selected Special Topics in Healthcare Ethics Selected Consultation Resources for HECs Books Articles Examples of Ethical Decision Making Frameworks/Tools Selected HEC and HCEC Toolkits Relevant Legislation for HECs Professional Codes of Ethics Standards Policies Healthcare Ethics Websites Associations and Conferences Training and Education Libraries How to Obtain Listed Resources... 58

5 Purpose and Overview ~ 5 ~ PURPOSE AND OVERVIEW Welcome to the Health Ethics Committee Toolkit Part Two: Consultation. The purpose of this toolkit is to support Health Ethics Committees (HECs) as they work to develop competencies and processes related to the role/function of healthcare ethics consultation (HCEC) 1. Over the past few decades, HCEC has emerged in response to needs voiced by health practitioners, patients and families for assistance in addressing the ethical issues they encounter in the process of providing and obtaining health care. This has been attributed to the increasing complexity of patient care such as emerging technologies, large healthcare teams and diverse professions, as well as competing interests in healthcare and moral diversity in our society. These ethics issues have the potential to impact the lives of the involved parties in significant ways and can be complex and at times, not easily resolved. HCEC may be sought to help with identifying, analyzing and evaluating possible solutions. Today s HEC typically has a wide scope and when the membership is well prepared, it can be positioned to consider many of the ethical issues that may be raised in a site, program or region. HECs are ideally, a multidisciplinary forum with the goal of thoroughly and systematically exploring, discussing and debating ethical issues. In our modern healthcare context, they typically have little or no formal decision-making authority. Their primary role is to support decision-makers, not displace them. It is, however, important to appreciate that any opinions or recommendations provided by the HEC can carry significant weight in the clinical setting. For this reason, a HEC must ensure that it has the necessary skills and processes in place if it is to competently take on the complex responsibility of HCEC. Indeed, consultation as a HEC activity when done well can be very valuable. However, this role/function has the potential to invoke a number of concerns in the clinical, ethical, policy, and legal realms because it takes place within the context of relationships within and between recipients of care, their families and various groups of health care providers, administrators, institutions and the community. In light of these concerns, a knowledgeable, thoughtful and systematic approach 1 We follow the ASBH Task Force s suggestion that the term healthcare ethics consultation (HCEC) is a more descriptive term because it refers to the full scope of ethics consultations. This necessarily implies that appropriate knowledge/expertise within any of the subspecialties should be available within your HEC membership in order to competently provide consultation services where there is subspecialty overlap. There can be considerable overlap of subspecialties (i.e. clinical ethics, organizational ethics and professional ethics) and while we should work towards integrating ethics across subspecialties in a site, program or region, it also needs to be appreciated that there is considerable specialized knowledge within each of these subspecialty areas.

6 ~ 6 ~ Health Ethics Committee Toolkit Part Two: Consultation to this activity is absolutely necessary. As Bashir Jawani 2 has cautioned, the consultative role/function should be undertaken only when a HEC is adequately prepared, because it has the potential both for doing immense good and harm (p. 20). HOW TO USE THIS TOOLKIT If you have not already done so, it is highly recommended that you first review Health Ethics Committee Toolkit Part One: Getting Started which was designed to provide guidance with the establishment and integration of a HEC into healthcare sites, programs and regions. HECs can vary from institution to institution along significant dimensions such as the number and qualifications of members, types of activities performed, the visibility of those activities and their perceived quality and usefulness. The effectiveness of a HEC depends in large part on whether it is fully integrated into the functioning of the site, facility, or region. This document, Health Ethics Committee Toolkit Part Two: Consultation is intended to support Health Ethics Committees (HECs) as they develop competencies and processes related to the role of ethics consultation. Section 1 will begin by providing an overview of the common roles/functions performed by HECs; namely education, policy review and consultation. It will discuss some of the necessary foundational ingredients that HECs should have in place before they consider taking on the healthcare ethics consultative (HCEC) role/function. Section 2 will outline the importance of clearly defining the consultation objectives as well as the key procedures and processes for intake, deliberation and documentation. A discussion of various consultative models, along with their advantages and disadvantages will also be included. Consideration will also be given to how consultations might be evaluated. Section 3 contains a listing of some examples of reading and resources for your HEC as you work to build competencies. It is highly recommended that HECs obtain and review the following two recent publications in conjunction with the use of this toolkit: The Report of the American Society for Bioethics and Humanities Core Competencies for Healthcare Ethics 2 Bashir Jiwani s An Introduction to Health Ethics Committees: A Professional Guide for the Development of Ethics Resources (2001) is acknowledged as an important reference and inspiration for this toolkit. The Provincial Health Ethics Network of Alberta (PHEN), is also acknowledged for their extensive bioethics resources which includes A Manual for Ethics Committee Members (2005) which has also serves as inspiration and a resource for both Part One and Part Two of this Toolkit.

7 Purpose and Overview ~ 7 ~ Consultation (2011) as well as their publication, Improving Competencies in Clinical Ethics Consultation: An Education Guide (2009) which can be ordered via the ASBH website These documents are important educational resources for HECs at all stages of their development. They provide an excellent education benchmark for HECs in their early stages as well as providing guidance to the more mature HECs with regard to the recommended core competencies for the consultative role/function.

8 SECTION ONE BUILDING FIRM FOUNDATIONS TO SUPPORT THE HEALTHCARE ETHICS CONSULTATION (HCEC) ROLE INTRODUCTION According to Gaudine et al. in their 2008 survey of Canadian acute care hospitals, 85% of their sample indicated that they had a clinical ethics committee. This demonstrates a gradual increase compared to previous surveys conducted in 1984 (18%) and 1989 (58%). While there is still wide variation in size and composition, fewer administrators or board members and more bioethicists and lawyers are now sitting on these committees. Community representatives are included with increasing frequency as well. This change in emphasis in the membership may reflect the move to a more multidisciplinary and integrative approach to ethics. Further, it may also reflect the recognition that the activities in which HECs participate require members to be prepared with adequate perspectives, knowledge and competencies. It is significant to note that respondents in this survey expressed the need for special training for their committee members, with almost 75% reporting the need but less than half actually receiving it (p. 133). Consistent with previous studies, the majority of committees reported that their role was primarily advisory, with 94% indicating that their decisions were not binding (p. 136). While today s HECs may not have formal authority to make decisions about potentially complex, multifaceted ethical issues, their recommendations can carry significant weight. It, therefore, required more than good intentions and enthusiasm; it requires particular knowledge and skills (Aulisio, 1999). In Health Ethics Committee Toolkit Part One: Getting Started it was emphasized that HECs should work to have a strong vision/purpose, which makes clear their roles/functions alongside careful consideration of committee competencies. The three key activities which are commonly associated with HECs are: 1. Education and promotion of an ethical climate 2. Policy development and review 3. Consultation

9 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 9 ~ In addition to the HEC defining for itself which of these activities it will take on, in each of these activity domains, it is important that committee members clarify their goals and assess how they might attain them effectively. As Judith Wilson Ross et al (1993) observed, It is one thing to say that ethics committees should conduct education on ethical issues, recommend policies that are ethically important and review cases with respect to ethical issues. It is another thing to determine exactly what activities can fulfill that mission. New committees tend to restrict themselves to self-education; after completing that phase, they devote time to educating others, to hearing cases (often only retrospectively), and to writing policies that are requested. More mature committees tend to broaden their notion of the issues identified as ethical (p.11). While a HEC s goals may not be to resolve all ethical issues within the site, program or region, it should work in its early stages to develop an awareness of such issues. In a process of maturing, HECs can gradually make more contributions by working to expand the understanding of ethics in healthcare. HECs should take the time to gradually build expertise and competency within their membership and take on roles/functions with this in mind. It is wise to heed Bashir Jiwani s warning: In my experience, ethics committees that have tried to take on all three of these functions (that would be most committees), have found this very challenging, if not overwhelming I would strongly recommend that HECs ensure that whatever roles they do take on, they do them very well. If a committee has limited resources and/or limited experience, it may be worthwhile limiting the committee s mandate to a set of responsibilities that are within the abilities of the committee, and that the institution/organization that the committee belongs to can reasonably hold the committee accountable for (p. 36). KEY HEC ROLES/FUNCTIONS: BUILDING COMPETENCIES EDUCATION AND PROMOTION OF AN ETHICAL CLIMATE In the Health Ethics Committee Toolkit Part One: Getting Started, education and the promotion of an ethical climate were emphasized as valuable activities of effective HECs. It is important that members of HECs continuously work to improve their own knowledge of healthcare ethical issues. While not all the members of a HEC necessarily need to have extensive training in philosophical ethics, (having some of your membership with such training

10 ~ 10 ~ Health Ethics Committee Toolkit Part Two: Consultation is definitely advisable since they can help guide the committee) members should work to pursue further education in this field to complement the particular perspective they bring to the committee. If you are in the early stages of your HEC development, then education of HEC membership should be a priority in your work plan. Alongside HEC membership education, the delivery of various forms of healthcare ethics education by the HEC members to healthcare providers, institutional staff, patients, clients, residents, families, institutional and regional administration and the public are important HEC roles/functions as well. If the HEC will provide ethics education, then clear goals and/or strategies should be established as part of their work plan. The HEC membership needs to think not only about to whom education should be directed, but in what format and delivery method. As Bashir Jiwani has suggested, it is helpful to ask the following questions as you work to set these goals: Do HEC members have sufficient expertise to teach ethics? Can they improve their knowledge-base through continuing ethics education? What resources or opportunities can be used and/or developed to accomplish these competencies and committee goals? HEC members do not necessarily have to be ethics experts. As a consequence of participating on a thriving HEC however, they should eventually achieve some level of expertise in the field of healthcare ethics. New members should be oriented to basic issues in healthcare ethics, moral rules, principles, relevant legislations and policy. Member education should be ongoing! A HEC whose membership has been provided with education will be better prepared to deal with complex issues and have greater credibility within their site, program or region. HECs should also work diligently to clarify that their role is intended to be supporting rather than displacing decision-makers. Taking such an approach even in the education and policy involvement stages of HEC development helps to set the tone for the approach that the HEC will take if it offers consultation services 3. It is important that committees work to establish credibility through appropriate and diverse membership and the development of clear reporting structures and processes. For example, the development of a strong communication strategy is recommended to achieve not only visibility and accessibility, but to communicate an effective process by which staff in your site, 3 The ASBH Core Competencies advocates an ethics facilitation approach in the healthcare ethics consultation (HCEC) role or function. They assert that ethics committees can best support decision-makers by helping them to identify and analyze the nature of value uncertainties and facilitate the building of a principled ethical resolution (2011, 0. 7).

11 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 11 ~ program or region might bring forward issues or concerns that they perceive as ethical in nature. Leadership, in collaboration with their HEC, should endeavor to develop guidelines/strategies for the triaging and management of ethics issues and concerns. Communication maps/algorithms can be of great help in guiding staff in this regard. The HEC can play an important role in the promotion and publicity of these processes. The use of selected ethics decision-making frameworks also helps to ensure issues are effectively brought forward and examined in a consistent and systematic manner. This not only provides structure to discussions and deliberations, but it also helps staff to determine when additional ethics expertise may be needed to be consulted. This will be discussed in more detail later in this document. A related activity of a HEC is the promotion of an ethical climate and certainly education activities are an important aspect of this activity. HECs should work actively to integrate ethics into their facility, program or region. This necessarily involves working to raise awareness amongst healthcare providers and staff of the ethical nature of their work. The task of educating those who work in the site, program or region can be challenging but can also be very rewarding! To do this effectively, HEC membership should become familiar with the important ethical issues within health care generally speaking, such as withholding life sustaining treatment, DNR/DNaR orders and resource allocation, but also need to be sensitive to ethical issues that can arise within and between groups of providers and other hospital staff. Indeed, all healthcare contexts can benefit from the HEC membership working to encourage and facilitate opportunities for thoughtful, careful, systematic examination of the values and beliefs that underpin attitudes, decisions and actions. This is why a multidisciplinary committee is especially helpful as it can provide the necessary perspectives to best inform approaches to be taken to accomplish this goal (Jiwani, p. 20). POLICY REVIEW AND DEVELOPMENT Another role/function of a HEC is the examination of ethics-related policies and guidelines 4. It is important that before taking this on, that your HEC assess its goals for policy development and review. Most policies or procedures created by a site, program or region concern the conduct of individuals or the attitudes/approaches the organization wants to adopt in various situations. Such policies can have ethical dimensions because they affect the way we engage with one another and they reflect the values of the site, program or region. Policy review by a HEC can help identify and 4 Interestingly, Gaudine et al. (2008) found less of an emphasis on functions related to the review of policies and procedures than reported previously; however it was still identified as one of the key functions.

12 ~ 12 ~ Health Ethics Committee Toolkit Part Two: Consultation clarify the ethical dimensions of a particular guideline or policy and by doing so, encourage discussion about how the ethical issues identified ought to be addressed. Careful consideration should be given to the question of who is to be involved and how this will be performed. For example, the HEC might collaborate on some policies and take over development of others, depending on the particular policy in question. These are excellent opportunities for individual committee members who also might bring relevant professional experience to also offer relevant subspecialty (such as organizational ethics, professional ethics, quality assurance, safety) as well as ethics expertise. This is also another way in which HECs can ensure that ethics is incorporated and integrated throughout all hospital departments. Policy writing can also be seen as part of a more general educational effort on the part of the HEC to explain and reflect the stated values of the site, program or region. As Wilson Ross et al points out, it is therefore also within the HECs purview to observe where practices, policies, and mission have become disconnected or inconsistently applied and to suggest to some other group in the organization that the issues should be pursued (p. 70). There may also be some policies that be best drafted by the HEC because of the explicit ethical nature of the policy issue being considered. As Bashir Jiwani has recommended some policies (if not most) are best drafted elsewhere and then reviewed by a HEC. Again, it is very important that the HEC be clear about how well it can take on the task of addressing policy issues because requires both the time and the expertise if it is to be done well (p. 32). APPROACHES TO REVIEW AND WRITING OF POLICY: There are a number of approaches a HEC might take to writing policy, and for an extensive treatment of this topic, HECs are encouraged to consult Wilson Ross et al. (1993) pp as a resource on this topic. The approaches are summarized below: Full committee participation In this approach, the whole committee spends time deliberating on the content and wording of the policy. This approach is more time consuming since it involves the entire HEC. The advantage, however, is that the whole committee understands and has ownership of the policy. Sub-committee (standing or ad hoc) A standing/ad hoc sub-committee may be formed to organize all of the policy review and writing duties for the HEC. Members of the sub-committee draft and revise policy with input from the rest of the HEC. An ad hoc sub-committee might be put together specifically to address the development of a particular policy. This is often beneficial because specific members with most interest/expertise on the issue in question can be assigned to the task.

13 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 13 ~ Involve a Clinical ethicist/ethics specialist A HEC needs to consider the fact that sometimes it might be prudent to consult/hire and ethics specialist to do a review of the various ethical issues that are raised by a policy in question. This research can be used to inform the work of the relevant committee or sub-committee that is reviewing or drafting the policy in question. POLICY AS EDUCATION ACTIVITY FOR HECS! As Bashir Jiwani has observed, [o]ften committees are good at creating policy, but not very good at educating staff and/or the patient/client/resident populations about what the policies are and why they have been developed. It certainly makes sense that involving those individuals who will be affected by the policy in the development process increases the chances for a superior policy while also providing opportunity for education. Further, mechanisms should be in place to ensure that new staff are introduced/oriented to such policies. As he points out) acknowledging Michael McDonald s work in this area), education around policy should be seen as a dynamic process, not a static one-off event (p. 35). HEALTHCARE ETHICS CONSULTATION (HCEC) The main purpose in a HEC offering healthcare ethics consultation (HCEC) is to help patients, staff and others resolve ethical concerns in the healthcare setting. It is to work to improve the quality of health care through the identification, analysis, and resolution of ethical questions or concerns. As the ASBH Task Force Core Competencies report has suggested, this general goal is more likely to be achieved if consultation accomplishes the intermediary goals of helping to: Identify and analyze the nature of the value uncertainty or conflict that underlies the consultation. Facilitate resolution of conflicts in a respectful atmosphere with attention to the interests, rights and responsibilities of all those involved (2011, p. 3). The discussion up to this point has emphasized the importance of HECs taking the time to build their collective education and experience before taking on the role/function of HCEC. Depending on the setting in which a HEC is situated, some consultations may involve questions which traverse the full range of healthcare ethics subspecialties such as clinical ethics, organizational ethics, professional ethics, business ethics, education ethics or research ethics. While there is value in the trend toward integrating ethics across all subspecialties within a site, program or region, this also implies the potential for a very wide scope. It is important to appreciate that clinical ethics consultation activities in particular, have the greatest potential to

14 ~ 14 ~ Health Ethics Committee Toolkit Part Two: Consultation cause harm if the HEC is inadequately prepared in terms of knowledge and skills. As the ASBH task force (2011) has noted: Although many of the core competencies identified in this report overlap with those needed to address ethical concerns and conflicts in other subspecialties, it is in the clinical subspecialty where unqualified HCE consultants have the highest potential to directly harm patients and families (as well as others involved in a consultation). Moreover, the Task Force considers clinical ethics case consultation in which the patient s medical ( case consultation ) to be where the stakes are often highest (p. 3). The consultative role/function should be undertaken only when a HEC is adequately prepared, because it has the potential both for doing immense good and harm (Jiwani, p. 20). With this in mind, before your HEC decides to take on the HCEC role, they should thoroughly assess the following foundational elements. An honest assessment will allow you to best decide whether you are ready to consider the consultative role. FIRM FOUNDATIONS FOR HCEC: HAVE YOU BUILT THEM? LEADERSHIP SUPPORT A HEC will not flourish in any of its roles/functions without the support of its site, program or region s leadership. It is the leaders who establish organizational priorities and allocate resources to support these priorities. Unless leaders support and are perceived to support, the ethics consultation function will be compromised. Leaders at all levels and throughout the organization can support the HEC and its services in several ways, such as having a clear understanding of the scope and roles of their HEC, directing others to utilize the HEC services, and routinely recognizing staff for their HEC involvement. Leaders of health care facilities as well as those who will be responsible for HCEC should ensure that your consultation service has the requisite

15 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 15 ~ expertise. Individual members of the service may have different competencies/expertise, and some skills may be represented by only one individual. It is important that leaders appreciate the need for, and ensure that the full set of core competencies for ethics consultation (which will be discussed in more detail shortly), be represented in their HEC if they are to take on the HCEC role/function. Facility leaders should also ensure that adequate staff time is available for HCEC activities. Ethics consultation can be time consuming and individuals responsible for this service need dedicated time to do this work. It is important that those who participate in HCEC, especially if they hold other primary roles within the site, program or region, have a clear understanding with their leadership about how much time this activity actually involves. The time required will vary depending on the types of consultation handled. HCEC as a role/function should not be viewed as an optional or voluntary activity, but as an assigned part of an HEC member s job that requires dedicated time. Leaders should also ensure that individuals who perform ethics consultation have ready access to needed resources such as workspace, clerical or data entry support, library materials, and ongoing training and/or education. MEMBERSHIP Of course, also key to the success of a HEC in a general sense, are the individual members who sit on a HEC. A strong, knowledgeable and well respected committee chair is critical to HEC survival. Apart from supporting the operations of their committee they function as a liaison between the HEC and the rest of the site, program or region. While ethics committees of the past were often made up entirely of physicians, it is now well appreciated that a committee with such a limited range of members is unlikely to have a varied and broad enough lens for the most optimal exploration of ethical dilemmas. Nurses, social workers and other health professionals are distinct professionals who adhere to specific codes of ethics and confront dilemmas that can differ from those that physicians face. Ethnic and cultural diversity is also important within the HEC because a significant number of consults stem from differences in religious practices and culture expectations (Post, Blustein & Dubler, 2007, p. 2). The membership stability of HEC is important as well. The HEC cannot build upon the experience and training of its membership if it is constantly changing. Therefore, poor meeting attendance and attrition needs to be addressed. As Part One of the toolkit emphasized, the committee needs to address every aspect of its functioning from who chairs meeting, how they are run, and whether goals are clear, realistic, useful and adequately met. It is important to have all these processes well established before taking on the HCEC role/function.

16 ~ 16 ~ Health Ethics Committee Toolkit Part Two: Consultation HEC ESTABLISHMENT/INTEGRATION Along with having a clear reporting structure, the HEC should be well situated within the overall structure of their site, program or region. As previously mentioned, a HEC will not flourish and may not even survive in a useful way unless it has the support of leadership and staff. A HEC that can show that it is relevant and that its planned services are important and effective is more likely to win initial and sustained support than one that cannot define its goals or its accomplishments. The task of clearly defining goals and seeking more effective ways to attain them is a KEY aspect of earning and deserving support from your leadership. It is important to appreciate that support does not only come from leadership. A HEC must gain a broad base of support from staff in different departments and roles. The best way to earn support is to provide a valuable service! A HEC that is actively seeking out ways in which it can be helpful and provides useful assistance in addressing ethical problems will enjoy support. A successful healthcare ethics consultation service develops and maintains positive relationships with various individuals and programs that shape the site, program or regional ethical environment and practices. A fully integrated healthcare ethics consultation service responds directly to a wide range of ethical concerns faced by the site, program or region including concerns involving shared decisionmaking with patients, ethical practices in end-of-life care, patient privacy and confidentiality, professionalism in patient care, and ethical practices in resource allocation. By establishing effective working relationships, a fully integrated HEC carries out its activities in coordination with other offices and programs that address ethical concerns in other domains. Thus, a HEC is best positioned for success in HCEC if has a history of seeking out opportunities to share activities and skills and identify and work to achieve mutual goals with other professionals in their site, program or region. EXPERTISE/ETHICS KNOWLEDGE HECs perform an important and unique function within their site, program or region by virtue of the fact that they possess some expertise in the area of healthcare ethics. While not all members need extensive philosophical training in ethics, every HEC should ideally have among its members, someone with some formal background or training in this area that is familiar with relevant ethics literature and can educate or direct other committee members to current and relevant resources in the fundamentals of healthcare ethics. Members should also critically look into their own value systems biases. As Jiwani pointed out, HECs can be seen as microcosms of the site, program

17 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 17 ~ or region and thus need to develop an understanding of the values they espouse personally and on behalf of their site, program or region (p. 46). As a consequence of participating on a thriving ethics committee, all HEC members will eventually achieve some level of expertise/knowledge in healthcare ethics. It is important that this expertise be nurtured. New members, depending on their past education and experience, must be oriented to the basic issues in health ethics. A HEC whose members have been exposed to extensive education will not only be significantly better prepared to deal with ethical issues, but will often also acquire greater credibility within their site, program or region which is an important component of an effective and well-functioning HEC. Over time, members should become familiar with basic ethical theories and their respective strengths and drawbacks. Members should become adept at understanding these theories without being dogmatically driven by any one of them. This is to ensure that issues can be discussed in a balanced way and that an environment is created where solutions to difficult problems can be approached with openness. Members should also become familiar with the various issues upon which consensus has been reached in Canadian society such as informed consent in clinical practice, the idea of personal or advance directives and surrogate decision-making policy (Jiwani, p. 46). HEC membership should not only be multi-disciplinary, but also work towards possessing a broad range of skills and knowledge. The American Society for Bioethics and Humanities report (first published in 1998, and recently revised in 2011) Core Competencies for Health Care Ethics Consultation is a very important resource for HECs, whether they are currently participating in HCEC or simply interested in learning more about the role/function. While it is specifically geared to the task of describing the necessary core competencies for HCEC, this document is also a useful educational benchmark for HECs that are in their earlier stages of development. This resource is relevant for: Those individuals that perform HCEC Educational programs that help prepare individuals, teams, or committees to perform the HCEC Healthcare organizations that offer HCEC services (2011, p. 1)

18 ~ 18 ~ Health Ethics Committee Toolkit Part Two: Consultation It is important to note that in the HEC context, the skills and knowledge described in the Core Competencies document need not all be present in one individual. Indeed, a great benefit of a HEC structure is that the collective expertise can surpass that of any one person. HECs that function at a high level, monitor their strengths and gaps in expertise and skill, and address those gaps by adding skilled members and/or encouraging continuing education for individual members and the group as a whole. In addition to ongoing education for individual members, a HEC can also devise an orientation manual and a set of educational expectations for new members. Such a manual might include a list of useful reference works, and journals in medical ethics, as well as copies of relevant institutional policies. Mentorship by a senior committee member for members new to the committee can be helpful as well. The American Society for Bioethics and Humanities; document Improving Competencies in Clinical Ethics Consultation: An Education Guide (2009) is another helpful document to help address the various core knowledge areas that HECs should have in place before taking on HCEC. Section 3 of this toolkit also contains books, articles and other resource suggestions to help support the ongoing education of your HEC membership. A CONSIDERATION OF THE CORE COMPETENCIES FOR HEALTHCARE ETHICS CONSULTATION (HCEC) As the ASBH Core Competencies (2011) report has pointed out, ethics consultation can be defined as a set of services provided by an individual group in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in healthcare 5. While healthcare providers all, by the nature of their roles, engage in ethical decision-making as part of their everyday work, consultants differ in that they have been assigned by their site, program or region the distinctive role/function of responding to specific ethical concerns and questions that arise in the delivery of health care. This is often performed in conjunction with other healthcare ethics activities that have already been established as HEC roles/activities such as educating of healthcare professionals and involvement with policy development and/or review. 5 With regard to the term value, these authors clarify that these values are embedded in many different domains (law, morals, professional practices, various communities, individual conceptions of the good). They use this term value as a general term to capture the various normative dimensions of issues that emerge in health care. Value uncertainty or conflict often arises because of core values from these different domains. (p. 2).

19 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 19 ~ There are a number of concerns that can arise in the healthcare setting that the HCEC offered by your HEC must be prepared to address. Certainly, any time there is uncertainty, a perceived conflict of values or questions raised about appropriate decisions/actions, this presents an opportunity for HECs to be consulted. It is important to appreciate that these everyday questions confronting patients, families and healthcare providers have become increasingly complex and therefore the stakes can be high. Because these questions surround issues such as professional/personal obligations, resource allocation and beneficence and non-maleficence in the provision of clinical care, it can result in staff experiencing moral distress. This is why it is so important that competent HCEC is available to those who are requesting the help (ASBH, p. 6). 6 Type and/or Scope of Concerns HEC members may need to address: Shared decision-making with patients Ethical practice in end of life care Ethical practice at the beginning of life Patient privacy and confidentiality Professionalism in patient care Ethics practices in resource allocation, business and management Ethics practices in the everyday workplace Ethics practices in research 7 (ASBH, 2011, p. 4) 6 Again, it is highly recommended that HECs obtain their own copies of the ASBH Core Competencies publication as well as Improving Competencies in Clinical Ethics Consultation: An Education Guide (2009) as well as the afore mentioned Core Competencies for Healthcare Ethics Consultation (2011) as these publications can help to guide HEC membership education as they work towards the HCEC role/function. 7 HECs may be in an excellent position to review REB approved research in terms of its feasibility within their particular regional context.

20 ~ 20 ~ Health Ethics Committee Toolkit Part Two: Consultation BASIC ETHICS KNOWLEDGE AND SKILLS FOR HCEC Individual consultants who perform HCEC must have advanced healthcare ethics knowledge and skills across multiple areas. When the HEC sub-committee or full committee model is used, this requisite knowledge and skills might be distributed across the various members of the group. Of course, the greater the collective expertise in an ethics consultation service, the more useful and effective that service will be. Although basic knowledge and skills may be developed through practical experience, development of advanced knowledge and skills generally requires a more rigorous and systematic approach to learning (i.e. formal coursework and in-depth reading, graduate degrees and supervised practice with expert feedback). The ASBH Task Report Core Competencies identifies three categories of skills for HCEC, namely assessment and analysis, process and interpersonal skills. Some of the skills noted in Core Competencies (2011) are considered basic abilities and skills for HCEC, and others are considered advanced. The following have been recommended for common and straightforward consultation 8 and may also represent a reasonable skill benchmark for HECs if they are considering being involved in the HCEC role/function. Some selected examples 9 of basic competencies are: Assessment and analysis skills Identify the nature of value uncertainty/conflict and analyze a values conflict Access relevant ethics literature, policies, guidelines and standards and to be able to clarify relevant ethical concepts Process skills Communicate and collaborate with other responsible individuals, departments or divisions Effectively facilitate meetings 8 The Task Force acknowledges that the distinction between basic and advanced skill is necessarily vague and somewhat arbitrary. They suggest that level descriptors in post-secondary education may provide some insight into this distinction. They also cite Benner, PE (2000). From novice to expert. Upper Saddle River, NJ: Prentice Hall and Pape D. & Manning, S (2006). The educational ladder model for ethics committees HEC Forum 18(4), Please see the ASBH Core Competencies (2011) and the Education Guide (2009) for more discussion and guidance on this question. 9 Please consult the ASBH Core Competencies for Healthcare Ethics Consultation (2011) for a full discussion of these basic competencies.

21 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 21 ~ Effectively document and communicate HCEC activities Interpersonal skills Listen and communicate well and elicit the moral views of others Facilitate discussion and mediation of ethical conflicts THE USE OF FRAMEWORKS FOR ETHICAL DECISION MAKING Related to the development of ethical assessment and analysis of skills, is the use of frameworks for ethical decision-making. A significant part of ethical enquiry is the systematic and organized examination of the values that guide our decisions. Frameworks for ethical decision-making are tools that can be used to gather and process the relevant facts in an analysis of the ethical dimensions of a particular situation. There are many examples of such tools and your site, program or region can benefit by identifying specific frameworks for use in consistent and systematic exploration of ethics issues in the clinical as well as organizational healthcare realm. Some frameworks may be more suited to acute care clinical contexts, while some will be focused on organizational issues, community health issues or personal care home issues. Jonsen, Siegler and Winslade s Four Topics Method 10 for example, is particularly helpful for working through the various aspects of acute care clinical ethics issues/dilemmas. Questions brought forward for HCEC often overlap into other subspecialty ethics areas, such as organizational ethics. A HEC is best positioned if it is familiar with frameworks that are best suited for thorough exploration of the particular dilemma and its particular subspecialty focus. Section 3 Resources of this document will provide some examples of frameworks that HECs may want to explore depending on their context. Once decision-making frameworks are selected as resources for HEC, intentional and frequent practice using these frameworks is the best way to become comfortable using them. Practice will also help to identify gaps in their usefulness for your particular site, program or region. It is advisable that members of a HEC that will be taking on the HCEC role to practice using these frameworks retrospectively, through various case studies to gain confidence and expertise. Educating other staff throughout your site, program or region about the use of selected frameworks for ethical decision-making is also helpful in working towards integration of systematic and consistent approaches to perceived ethics issues by all staff who encounter 10 Please see Jonsen, AR, Siegler, M, Winslade, WJ (2010). Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. McGraw-Hill.

22 ~ 22 ~ Health Ethics Committee Toolkit Part Two: Consultation them. These frameworks are not just for HECs and their staff who encounter them. These frameworks are not just for HECs and their members but are helpful decision-making frameworks for all healthcare providers since these frameworks seek to enhance ethical decision-making by structuring the decision maker s approach in an ordered fashion. Use of a decision-making framework helps to get the decision-maker to think from the various stakeholders perspectives and refer them to guiding principles and values in order to help in the achievement of a reasoned conclusion. It is important to appreciate however, that frameworks in and of themselves, cannot make the decision; they are, essentially tools that stimulate thought and facilitate the decision-making process. ADVANCED ETHICS KNOWLEDGE AND SKILLS FOR HCEC According to the ASBH Task Force, at least one individual in a HCEC service must have advanced knowledge and skills required to perform complex ethics consultations, and at least one individual (often the same individual) must have the knowledge and skills to effectively oversee and run the services itself (p. 24). While basic knowledge can be thought of as a general, or introductory, familiarity with the area specified, advanced knowledge is a detailed grasp of the area specified: (p.26). As the ASBH Task Force has pointed out, there are multiple ways that one might come to have basic knowledge. This includes regional health ethics education programs, intensive courses, conference attendance, in-service attendance, reading relevant literature. There are a number of excellent websites which provide direction and access to resources as well (please see Section 3 for some examples). There are also excellent tools that have been developed based on the ASBH Core Competencies which help HECs assess their current level of both basic and advanced knowledge of skills. 11 Advanced knowledge is developed through formal academic preparation through graduate degree programs in various subspecialty domains of HCEC. The nine knowledge areas identified by the ASBH Task Force for ethics consultants or HEC consultancy teams are: 11 The Veterans Health Administration National Center for Ethics in Healthcare has adapted the ASBH basic and advanced skill and knowledge recommendations into an Ethics Consultant Proficiency Assessment Tool. It is an excellent way to assess individual HEC membership skills and knowledge with the goal of developing individualized professional development in the realm of HCEC.

23 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 23 ~ 1. Moral reasoning and ethics theory, including familiarity with a variety of approaches to ethical analysis, such as principles-based and casuist (case-based). 2. Bioethical issues and concepts in the subject areas of shared decision-making, end-oflife care, privacy and confidentiality, professionalism, resource allocation, research, organizational ethics and ethics of the everyday workplace. 3. Health care systems as they related to HCEC 12 such as federal and provincial funding systems, health policy, healthcare organization administration, REB policy and guidelines for the region, resource allocation and so on. The HCEC should be able to access an individual with advanced knowledge if it is relevant for a particular consultation. 4. Clinical context as it related to HCEC. Clinical literacy such as the ability to understand medical terms, and descriptions of disease processes, treatments and prognoses; familiarly with medical decision-making, current or emerging technologies, and the different roles, relationships and expertise of health care providers. 5. Knowledge of the site, program or region relevant to HCEC such as mission statements, organizational structure, decision-making processes or frameworks, range of services, medical record system, etc. 6. Knowledge of the site, program or regional policies such as informed consent, withholding and withdrawing life-sustaining treatment, pain management and palliative care, advance directives, surrogate decision-making, healthcare agents, durable power of attorney, DNR/DNAR, death by neurologic criteria/determining death, medical futility, confidentiality and privacy, HIV testing and disclosure, organ donation and procurement, human subjects research, conflicts of interest, disclosure of adverse events or errors, admissions, discharge and transfer, impaired professional, and whatever is relevant to HCEC. 7. Knowledge of cultural and religious issues, including how culture, religious tradition, ethnicity, beliefs, and perspectives shape both providers and patients responses to illness, death, and medical treatment. 8. Health care environment including mission statements, organizational structures, range of service and points of care, and policies (e.g. informed consent, advance directives, privacy and confidentiality, organ and tissue donation, medical records). 12 These have been altered to reflect the Canadian context.

24 ~ 24 ~ Health Ethics Committee Toolkit Part Two: Consultation 9. Health law, significant legal cases and concepts, and relevant codes of ethics and professional conduct. Ethics consultation also requires specific skills. Those who perform ethics consultation must be able to: Identify the nature of the uncertainty at the heart of the case Analyze the ethical concerns Identify and evaluate the ethically justifiable options Facilitate formal and informal meetings, including those involving highly charged issues or participants who may be emotionally distressed Build consensus when there are competing moral views and/or multiple ethically justifiable options Collect and verify clinical and other relevant information Demonstrate critical thinking Listen well Communicate effectively and respectfully Recognize and address barriers to communication Foster a respectful, supportive environment for expression of moral views Educate participants about ethical issues Document consultations in the health and consultation service records Utilize institutional resources effectively Evaluate consultation (2011, pp )

25 Building Firm Foundations to Support the Healthcare Ethics Consultation (HCEC) Role ~ 25 ~ RE: CREDENTIALS AND ROLE CLARIFICATION: THE EMERGING DISCOURSE There is agreement in the literature that individuals providing clinical ethics consultation should be qualified to do so. In the American context it has been proposed that a certification process for individual practicing ethicists/bioethicists who perform HCEC could be a simple and effective means to help hospitals and health systems determine quality in consultants. As Mark Kuczewski, past president of the ASBH has suggested, [h]ealthcare providers need readily available ways to recognize clinical ethicists who are appropriate for credentialing to conduct ethics consultations ASBH is the appropriate organization to develop any such process and bring it to fruition (p. 5). The Core Competencies for Health Ethics Consultation (1998, 2011) and Improving Competencies in Clinical Ethics Consultation: An Education Guide (2008) are landmarks in the development of standards for ethics consultants. The Clinical Ethics Consultation Affairs (CECA) Committee was formed in 2009 to address a growing concern that individuals who provide clinical ethics consultation do not have sufficient qualifications. They identified the potential elements of evidence of an individual consultant seeking certification as: Evidence of having performed a minimum number of consultants as lead consultant Graduate degree in the applicant s field Evidence of clinical ethics consultancy education and training Letter of recommendation from supervisor or colleague Written case study analysis and example of medical record documentation Oral interview (p. 6) In the Canadian context, in 1999 at the annual meeting of the Canadian Bioethics Society (CBS), a motion was put forward to establish a Working Group to look at the issues of employment and working conditions for ethicists practicing in non-tenured environment. In 2008, a Task Force met in Toronto, Canada and developed the Role Description, recognizing a need for understanding the role of ethicists. The influence of past literature was identified, such as The Profile of the Ethics Consultant (Baylis, 1994) and the American Society for Bioethics and Humanities (ASBH) Core Competencies for Health Care Ethics Consultation (1998) which focused on the responsibilities, skills, and knowledge related to case consultation was acknowledged. Further, Accreditation Canada s (2009) establishment of more rigorous standards with regard to ethical processes within healthcare organizations has been an important development. Their Qmentum program addresses the vital role of ethics in health

26 ~ 26 ~ Health Ethics Committee Toolkit Part Two: Consultation care in all of its standards, whether they are related to front-line staff duties or governance and leadership responsibilities. In 2009 a Canadian grassroots organization of healthcare ethicists concerned about the lack of standardization in the field was formed. This organization, Practicing Healthcare Ethicists Exploring Professionalization (PHEEP) included representatives from 5 provinces and has had as its primary aim to explore options for enhancing and supporting the professionalization of ethicists in Canada and for developing practice model(s) and standards to ensure the quality of ethics programs and services in healthcare organizations. The work of PHEEP builds on and extends emerging best practices in the field, including relevant projects and activities of the Canadian Bioethics Society (CBS) and the American Society for Bioethics and Humanities (ASBH). It established formal affiliation with the CBS who endorsed the goals and activities. In January 2010, PHEEP conducted a nation-wide bilingual survey of ethicists in Canada and demonstrated that a top priority for Canadian ethicists is to develop standards of practice in the field. In 2011, PHEEP was granted a Canadian Institutes of Health Research (CIHR) Meetings, Planning and Dissemination Grant to hold a national, interdisciplinary symposium to develop consensus around a conceptual framework and deliberative process for the creation and dissemination of practice standards. The goal of this project is to enhance the quality of ethics services in Canadian healthcare organizations, and make the most efficient use of the public resource invested in ethics programs. A national symposium of practicing healthcare ethicists was held in June of This symposium had the following goals: 1. To develop consensus on key elements of the conceptual framework as previously described 2. To develop consensus on an inclusive and deliberative process for creating, refining and disseminating practice standards based on this conceptual framework 3. To identify next steps and areas for future collaborative research 13 This will be an evolving and important discussion in the coming years in both the Canadian and American contexts. It is important that HEC membership as well as leadership in the various sites, programs and regions be aware of these developments since it will have important impact on practice standards and credentialing for those involved in consultation roles/functions in Canada. 13 Please see the full background paper Developing Practice Standards for Health Ethicists in Canada: Definitions, Concepts and Processes authored by Practicing Healthcare Ethicists Exploring Professionalism (PHEEP).

27 SECTION TWO GETTING ORGANIZED: ESTABLISHING CLEAR OBJECTIVES AND PROCESSES FOR HEALTHCARE ETHICS CONSULTATION (HCEC) As the preceding discussion has emphasized, a HCEC service offered by a HEC responds to requests for assistance from patients, families, healthcare professionals. It focuses on addressing uncertainty or conflict regarding value-laden concerns in a healthcare context and should be conducted by those who are designated to perform this role and who have the requisite competencies to thoroughly address the concerns raised (ASBH, 2011, p. 10). If it has been established that the requisite competencies are in place, then the next step is working to establish clear objectives, and processes. As Bashir Jiwani points out, whatever consultation objectives the HEC and organization agree upon, it is recommended that these be made very clear and explicit to those requesting/taking part in the consult to ensure that everyone comes to the process with a shared set of expectations and a fair understanding of the activity they are agreeing to participate in (p. 21). He has suggested that before officially taking on the role of responding to requests for clinical ethics consultation it is important that HECs reflect carefully on the following questions: 1. What will be the objectives of providing clinical consults? 2. What will the consultation process look like? 3. Who should be involved in the ethics consult? 4. How will the consult be evaluated? DEFINING THE OBJECTIVES OF YOUR HEC S HCEC ROLE As we ve discussed, the role of ethics consultation in health care is to address uncertainty or conflict regarding value-laden concerns that emerge in the healthcare context. There are a number of ways that this can be accomplished depending on the collective expertise of the HEC. When thinking about your objectives for HCEC it is again important to stress that the typical HCEC service is not intended to displace decision-makers, but to support and facilitate decision-making. Indeed, over the last 30 years, various approaches to HCEC have been described, ranging from authoritarian, I ll tell you what to do models to those which seek pure consensus/agreement among all stakeholders. As one would expect, pure authoritarian

28 ~ 28 ~ Health Ethics Committee Toolkit Part Two: Consultation approaches emphasize an single consultant as primary moral decision-maker and as a result, this tends to suggest that the consultant s values are more valuable or correct than the perspectives of others participating in the consultation process. There is danger that using this model can minimize or exclude the values of key stakeholders such as patients and surrogates. A pure consensus approach on the other hand attempts to attain agreement among involved parties and may, in its focus on achieving agreement between all stakeholders, fail to properly consider the ethically justifiable norms and values that should guide decisions. Recent literature supports the ethics facilitation approach as the best approach for HCEC because it can be adapted to many different methods and models for HCEC. As the ASBH Core Competencies report has pointed out, the ethics facilitation approach: rests on a two-fold professional and social ideal. First, recommendations made should comport with the bioethics literature, medical literature, other relevant scholarly literature, current professional and practice standards in the field of HCEC, statutes, judicial opinions, and pertinent institutional policies. And second, the process of pursuing resolution should be respectful of all partied involved and their interests. The knowledge, skills and the facilitative strategies of the HCEC should improve the likelihood of building an ethically supportable consensus among stakeholders (p. 6). The facilitation approach is focused upon bringing forward the issues, helping with communication between parties, and working to acknowledge and integrate the perspectives of relevant stakeholders. The consultant/team work towards deriving a plan that takes into consideration the values of those involved while ensuring that it is within the bounds of ethical and legal and policy guidelines. As Dubler and Liebman (2004) in their publication, Bioethics Mediation: A Guide to Shaping Shared Solutions suggest, the concept of Principled Resolution is a plan that falls within clearly accepted ethical principles, legal stipulations and moral rules defined by ethical discourse, legislatures, and courts and that facilitates a clear plan for future intervention (p. 11). 14 With this facilitation model in mind, let us consider some possible objectives for HCEC as offered by a HEC. 14 See Section 3 Resources for a full citation of this resource.

29 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 29 ~ 1. To provide general education to institutional staff on ethics concerns/issues as they are brought forward to the HEC 2. To offer ethics-based analysis of situations which can be performed to provide coaching/moral support, help to identify next steps for institutional staff or as a debrief through retrospective case review 3. To provide Mediation/Facilitation which involves 3rd party consensus-building and principled resolution in situations of conflict 4. To present carefully considered ethics-based recommendations on the most appropriate course of action in the clinical case in question to the individuals involved PROVIDING GENERAL EDUCATION As Jiwani points out, the clinical consult encounter can present an ideal opportunity for members of a HEC to facilitate some ethics education of the individuals on both sides of the front lines of care delivery. Using a particular case for which a consult is requested in their site, program or region, consult team members might endeavor to examine the values of underpinning the various perspectives in tension that have given rise to the consult request. This is an opportunity to raise awareness of accepted moral norms in society, as well as to explore methods of ethical decision-making that staff can use not only in the context of the case at hand, but in future cases. Thus the consult experience as Jiwani suggests, can allow for skill development and capacity building for the front line staff as well as for patient and family members involved (p. 22). This is also great practice for HECs to hone their skills at using the frameworks. Indeed, sharing expertise through the objective of education is also consistent with an ethics facilitation approach. OFFERING EXPLICIT ETHICS-BASED ANALYSIS Beyond general education, consults present the opportunity for the HEC or consult team to deliberate as a group on a case itself and offer through this consultation objective, a thorough analysis of the ethical issues involved. This involves a higher level of participation by the consult team. The HEC members, possibly with the aid of an ethics decision-making framework would:

30 ~ 30 ~ Health Ethics Committee Toolkit Part Two: Consultation Collect the facts of the case Identify the various perspectives in tension Analyze the values underpinning the perspectives Identify any other relevant factors that impinge on determining the right thing to do in the context of the situation Importantly, team members performing the consult will have to have the necessary knowledge and skills to perform this ethics-based analysis. Depending on the case and its complexity the entire HEC membership may wish to provide consideration to the team s recommendations since this would allow it to be considered thoroughly and from the broadest perspective (Jiwani, p. 22). Some cases have a number of options that are all ethically justifiable and consistent with prevailing ethical and legal standards. The role of the consultant/team would be to provide analysis and education on this analysis in a way that enhances clear understanding of the positions and options that are ethically viable. As the ASBH Competencies report has noted, there is a fine line between educating (which may involve some degree of persuasion) and manipulating. Ethics consultants need to be sensitive to their personal moral values and should take care not to impose their own values on other parties. This requires that consultants be able to identify and articulate their own views and develop self-awareness regarding how their views affect consultation activities (p. 9). MEDIATION/FACILITATION/CONSENSUS BUILDING Facilitating communication between various parties involved in the situation involves a process that is particularly attentive to the different relationships that comprise the context of the situation and the needs and responsibilities entailed in their relationships. It aims to be extremely sensitive to the contextual features of each case that are often lost in the more philosophically nuts and bolts approaches (Jiwani, 23). For example, many of the issues that ethics consult services are asked to deal with are issues of poor communication between various parties involved in a given situation, or arise because the patient/family are still coming to terms with health issues that they are forced to face. The objectives of this approach include providing support for the relationships of those involved in the situation, clarifying values and educating participants on the ethical issues involved. The objective is NOT to make decisions for participants, but rather to facilitate the understanding of various perspectives involved so that participants may develop their own solutions. The consultants are there to support the process and facilitate a positive outcome,

31 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 31 ~ whereas the results of the process come from and are the responsibility of the participants and not the consultants (p. 24). The ASBH Competencies report also strongly advocates ethics facilitation as most appropriate for HCEC. In order to best identify and provide analysis of a situation where there is value uncertainty or conflict, taking a facilitation approach works to: Clarify the specific ethics question that needs to be addressed Gather relevant information (via discussion, review of medical records and other relevant documents such as codes of ethics, books, articles) Clarify relevant concepts (such as confidentiality, privacy, decision-making capacity, informed consent, best interests) Clarify related normative issues (such as implications of societal values, law, ethical standards and policy) Identify the ethics issue being addressed Help to identify the range of ethically acceptable options within the context and provide appropriate rationale for each option Facilitate the building of principled resolutions by ensuring that involved parties have their voices heard (this includes patients, families, surrogates, professionals). Assist clarification of values, facilitate understanding of factual information and recognition of shared values, identify and support ethically appropriate decision makers, and apply mediation or other conflict resolutions if relevant (2001, p. 5-6). PRESENTING CAREFULLY CONSIDERED ETHICS-BASED RECOMMENDATIONS This objective requires the HEC to go beyond describing values and now to evaluating them. This essentially involves making recommendations about the right or best thing to do in the situation presented. Here the HEC or members of the HEC must be competent in their ability to weigh the values of those involved in the case against broader value commitments which might also include standards of practice, policy, legislation or law in the health ethics realm. Bashir Jiwani points to two particular concerns with this level of involvement and which the committee must be wary. They are:

32 ~ 32 ~ Health Ethics Committee Toolkit Part Two: Consultation 1. The HEC should be clear in their communications that whatever judgments they arrive at, they are based upon their own subjective analysis and not upon any objective, selfevident truths about what is right and wrong. 2. The HEC should be aware that while they may only be intending to offer recommendations merely suggestions or helpful advice their feedback will often be taken as judgments from the moral high ground (after all, who is a lowly human being to disagree with The Ethics Committee?!) Not only must pains be taken to identify any recommendations as such, but one must be prepared to accept that such efforts notwithstanding, recommendations will often be perceived and treated as pronouncements (p.23). As the ASBH Task Force has pointed out, the ethics facilitation approach does not preclude making recommendation as an ethics consultant. It is important that HECs offering HCEC consider the following advice: specific recommendations are often very helpful and appropriate. The consultant might give recommendations regarding the process of decision making, such as attempt to contact the patient s daughter, conduct a clinical assessment of decision-making capacity, or convene another family meeting in 1 week s time. In other cases, a proposed course of action may be unethical and the consultant should recommend against it. Finally, in some relatively simple cases only one of the proposed courses of action is ethically justified. When this is the case, consultants should explain why alternative actions are not ethically justified. However, consultants should be careful about recommending a single course of action if more than one course of action is ethically acceptable. For consultations involving an active patient case, the consultants should remember that the right substantive decision is ultimately the responsibility of the ethically appropriate decision-makers (generally the patient, the surrogate, the healthcare professional, the institution, or at times some combination of these) and not the consultants. The consultant s role is to help these parties think more clearly about the ethical implications of their actions to optimize decision-making (p. 8).

33 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 33 ~ TREADING CAREFULLY: THE ISSUE OF LEGAL LIABILITY These four possible objectives of consultation require different levels of expertise and commitment. It is imperative that any HEC taking on the role/function of HCEC consider very carefully what they hope to achieve, and what they can competently provide. All of these consultative objectives/approaches require that HEC members genuinely listen to and hear the stories of the various people involved with the consult, be respectful of these perspectives, and strive to facilitate the broader understanding of each other s stories. However, if the HEC will be providing recommendations, they must thoroughly explore with their leadership at their site, program or region the authority on which they act, and other important related issues such as legal liability. The HEC membership should ensure what legal protection is extended to consult team members, since individuals involved with the consult process may be open to legal action as a consequence of their participation in this service. While the liability aspects of performing clinical ethics consultation have been discussed to some degree in the Canadian context, it has yet to be fully explored. Emerging literature on this topic should be an important part of your HEC s ongoing education. It is extremely important that anyone performing HCEC explores the question of legal liability for consultation services with their site, program or region and it is recommended that this should be addressed within the HEC terms of reference. WHAT WILL THE HCEC PROCESS LOOK LIKE? For any healthcare service, some standardization is important for quality delivery. Process standards with regard to HCEC services offered by HECs because quality cannot be determined merely by assessing the final outcome or product (ASBH Competencies, p.10). Deciding to take on the role/function of HCEC requires that HECs consider other basic questions about how consults are to be carried out. This process can be broken down into three subsections: Intake Deliberation Documentation

34 ~ 34 ~ Health Ethics Committee Toolkit Part Two: Consultation INTAKE As mentioned earlier, the consultation service must be clear about the authority from which it offers guidance. For example, do recommendations of those providing the consult represent the HEC, the site, program or region as a whole? What weight do the recommendations carry and what, if any, legal liability issues arise? It is important for the HEC to be clear on what procedures ought to be in place and are actually in place for an ethics consult to be requested. Other intake issues might include ensuring the committee is accessible to all participants in the delivery of health care within the HECs area of responsibility. If patients are to have access to the committee, but they have little or no knowledge about the committee s existence or the protocol for how to access it, this would be problematic. One way of addressing this is by publicizing and marketing the committee s existence and methods by which to access it to all new patients admitted to the institution or to their family members. 15 Indeed, to be effective, a HCEC service must be accessible to the patients, families and staff it serves. HECs should therefore take steps to ensure that patients and staff are aware of the HCEC services, what it does, and how to access it. Like most other health care services, the HCEC service should be available throughout normal work hours. After-hours coverage arrangements may vary. If the volume of consultation requests is high, the HCEC service should be available by beeper over weekends, nights and holidays. In other facilities where there are fewer ethics consultations, requests may be triaged by an administrator who has access to a HEC s HCEC service member as needed. It s most desirable for HCEC service members to work on site, but in some sites, programs or regions this may not be possible. Video conferencing, teleconferencing and to a lesser extent, or secure online messaging may be required. This is especially relevant for geographically remote facilities but must be used cautiously. Requests for ethics consultations that involve ongoing patient care should only be accepted from someone involved directly with the case. That is, a person who is rightfully involved. Requests involving other matters can be accepted from a broad range of individuals such as requests for policy clarification or document review. Anonymous requests are problematic and should not be accepted since the consultant cannot properly clarify the nature of the concern or determine whether the requester has standing the case. They often amount to allegations of unethical conduct, which must be addressed through other means. An ethics consultation service cannot be effective if it earns the label of ethics police. If an anonymous request suggests a serious break of compliance with policy or law, it should be referred to the appropriate office or service. 15 See Health Ethics Committee Toolkit Part One: Getting Started for suggestions.

35 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 35 ~ Occasionally, an individual requests an ethics consultation in a non-anonymous fashion, but asks to have his or her identity protected. Trainees, nurses or others, who feel vulnerable in the site, program or region, might make such requests. The HCEC service representative responsible for intake should privately explore why the requester doesn t wish to be identified. For such case consultations, the requester should be advised that although the HCEC service will not intentionally reveal identity, others might infer it. Alternatively, the consultant can encourage the requestor to consider other ways to address the concern. Ethics consultation must have a clear system of accountability. Day to day responsibility for the activities of the ethics consultation service should rest with a designated individual. They should respond in a timely fashion to the requests for consultation, and determine if a request is appropriate for ethics consultation. DELIBERATION It is very important that the HCEC service work out what the process of the consult will look like and what type of decision-making framework or procedures are to be used during a consult. In terms of the process, the HEC needs to consider what information will be gathered at the outset of a consult and by whom, how quickly a response will be offered and how will consult team members be contacted. Each site, program or region will have its own unique ways of facilitating this process. In terms of decision-making frameworks, as was mentioned earlier in this document, there are many available. Each framework has its own benefits and drawbacks and it is recommended that your HEC become familiar with several models of decision making and come to an agreement on the basic pattern a consult ought to take. DOCUMENTATION The committee should consider how the various elements of the consult are to be documented and by whom. Attention will have to be paid to issues of confidentiality, since the content of the process will likely contain information that is of a private nature requiring utmost sensitivity. HECs should become familiar with Manitoba Legislation (Personal Health Information Act) governing how information should be handled. They should develop information management policies which are reflective of site, program or regional policy and provincial legislation. As Bashir Jiwani has suggested, it is recommended that both the process and the outcome of each consult be documented for the following reasons:

36 ~ 36 ~ Health Ethics Committee Toolkit Part Two: Consultation To ensure that the entire HEC has access to what happened and can evaluate the process with the aim of improving the committee s consultation service. So that the case itself is available for future guidance when similar cases arise. To make clear the kind of activities in which the HEC is involved if for no other reason than the purpose of proving its worth to the institution s administration (p.28). HECs will have to determine how best to document the intake and deliberation process. They should pick a method that best suits the HEC in their particular site, program or region. There are a number of excellent resources on this subject. See Section 3 of this toolkit for some other resources that may be of help with the establishment of these important processes. WHO SHOULD BE INVOLVED IN CONSULTS? As we have already discussed, HCEC can be performed by individuals, teams, or committees. Each method has its strengths and weaknesses. While the first ASBH Core Competencies report (1998) was neutral on the question of whether HCEC is best performed by individuals, teams, or committees, they now, in their revised report, suggest that ideally, a HCEC service should vary the model used depending on the nature of the particular consultation request (2011, p. 19). Some HECs feel most comfortable with having the entire committee meet with the various participants involved in a particular case in something like a roundtable discussion. Indeed, the strength of HECs is that they are multidisciplinary and represent various groups from within a site, program or region. As we have already discussed, the HEC should strive collectively to have the full range of core competencies for HCEC. It is important that each member have certain basic skills and knowledge for addressing the types of issues that often come before it. This is important for ensuring different viewpoints are heard in the discussions/deliberations. The advantage of large groups (the entire HEC) is that it allows for several perspectives and diverse expertise. It also allows all members to get consultative experience. Some disadvantages to the entire HEC being involved is that it can become cumbersome organizationally for requests that require a rapid response. Further, it is worth noting that in a larger group, the diffusion of responsibility can contribute to complacency or a lack of accountability and patients and families may be intimidated by large groups. The sub-committee model allows for tasks to be divided among members of the team. For example, it is not necessary for all members to go to the bedside or attend a family meeting. A

37 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 37 ~ single member may perform both roles and then report back to the others on the team. While it does so at the expense of more input into decision making, many committees find that having a sub-committee bring the more interesting and contentious cases to the whole committee as part of the debriefing is both useful and educational. ADVANTAGES OF SUB-COMMITTEE Several perspectives and diverse expertise Flexibility for rapid response requests Composition of team can vary to meet the situation Less intimidating for patients and family Support and reflection amongst participants DISADVANTAGES OF SUB-COMMITTEE Less efficient than the individual consultation model Fewer checks and balances than the committee model SINGLE CONSULTANTS When an ethics consultation is handled by an individual consultant, the consultant should have all the core competencies required for that ethics consultation. 16 Depending on the consultant s professional background, life experience and personal attributes, they bring different strengths and weaknesses to the HCEC (2011, p.19). It has been suggested that there are indeed advantages to making use of a single ethics consultant. The consultation process can be time consuming and this may be difficult for volunteers to do and do well. Further, a paid ethicist will be afforded the resources to give the consultations the appropriate time needed, has the advantage of having particular training in ethics and thus in recognizing and analyzing ethical dilemmas. This includes knowledge of decision frameworks, and up-to-date information on relevant literature and legislation. Depending on your site, program or region, accessing an ethics consultant may be challenging since availability to such individuals with appropriate training and expertise can be limited. For this reason, many HCEC services choose 16 Please consult sections 2.2 and 2.3 of the ASBH Core Competencies for Healthcare Ethics Consultation (2011) for full discussion.

38 ~ 38 ~ Health Ethics Committee Toolkit Part Two: Consultation to implement the sub-committee approach in order to ensure that at least, collectively, they can meet the required competencies necessary to responsibly address the consultation requests. There are also disadvantages attached to relying upon an ethics consultant: it can be perceived as an expensive solution to the problem. As Jiwani points out, this solution may also lead to ethics exclusivity and the (mis)-understanding that ethics expertise lies only with this professional to whom others must defer on questions of values. There may also be an expectation that the ethicist has all the answers placing inappropriate expectations on the clinical ethicist (26). Whatever approach is adopted for dealing with a request for consultation, it ought to follow a reasoned discussion at the committee level about the benefits and drawbacks of each option, within the context of the resources and abilities of the particular HEC and the expectations of the organization (Jiwani, p. 27). OFF-SITE AND DISTANCE CONSULTATIONS It is of course, most preferable for HCEC services to take place on site, but in some situations this may be challenging, such as in the case of rural or remote settings. Video conferencing, teleconferencing, and encrypted secure messages may be technological options to explore. As the ASBH Task Force points out, these methods must be used cautiously (p. 21). They point out that rigorous attention is required to ensure that evolving expectations and standards for the security of sensitive information are met. It can at times be challenging for example, to obtain access to a health record, impossible to interview a patient, and establish trusting relationships without face-to-face meetings. Some of the aforementioned technological approaches may effectively augment our traditional on-site approaches. HOW WILL THE HCEC SERVICE BE EVALUATED? Finally, consideration to how the HCEC service will be evaluated. Generally, evaluation of any function or activity is valuable in order to assess whether or not it is effective in achieving its goals, and the evaluation of HCEC is essential for a number of reasons. HECs should be able to demonstrate that their HCEC service is a value to those it is intended to serve. It is also necessary to ensure that the HCEC service is meeting established delivery standards. As the ASBH Task Force reminds us, Because HCC often involves high-risk (sometimes life and death) situations, poorly managed HCEC can have devastating effects on the patient, family,

39 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 39 ~ staff, or organization (p. 34). Evaluation can also provide insight into what can be done to improve effectiveness of the HEC in its various defined roles/functions. While the general goal of the HCEC role/function is to help improve the clinical situation for all participants, the ways this might be achieved is quite variable and valuating success can therefore be challenging. It is not enough for a committee to feel that because its consultation service is generally regarded as a good thing by hospital staff, no further evaluation is required (Jiwani, p. 30). Indeed, the goal of evaluating an ethics committee s consultation service must be to improve the service which can only be done by ensuring what the various communities served by the service (patients, staff, and ethics committee members) provide feedback. 17 Please consult the ASBH Core Competencies for a thoughtful discussion of evaluation of a HCEC service quality via the components of the structure, processes and outcomes of the service offered. They also provide strategies for evaluating access to and the efficiency of your HCEC service. POLICY FOR THE HCEC ROLE/FUNCTION As the ASBH Task Force (2011) has pointed out, One element of a sound consultation process is a clear policy for HCEC. Policy for your HEC s HCEC service essentially reiterates the various aforementioned areas of concern addressed in this Toolkit. Similarly, the ASBH Task Force suggests the following as the minimum content areas that should be addressed: 1. Structure/Organization of the HCEC service. Including who may request an HCEC, how the service is to be contacted, the roles and responsibilities of the various members of the HCEC service, the competencies required of those individuals, and who is accountable for the quality of the HCEC. The expected standards for response time for urgent vs. non-urgent requests should be included as well. 2. The scope of the HCEC needs to be delineated. The policy should include the goals of the HCEC and define what are considered appropriate and inappropriate requests. E.g. The requester may seek resolution of a conflict among healthcare professionals, patients, and/or family; values clarification; interpretation of institutional policy; a forum for discussion; an explanation of ethically justifiable options, specific recommendations, and/or moral support. 17 Judith Wilson Ross et al (1993) Health Care Ethics Committees provide an extensive selection of sample questionnaires for evaluation purposes. See Section 3 Resources for full publication information.

40 ~ 40 ~ Health Ethics Committee Toolkit Part Two: Consultation 3. Finally, the process for HCEC should be identified. Who is involved in which types of requests, what approaches or frameworks will be employed depending on the type of consultation, and the steps that will be followed for the various types of consultation requests (e.g. clinical case vs. non-clinical case). The policy should also include guidelines for handling of anonymous requests and requests from those asking not to be identified. 4. Policy should specify the documentation expectations. E.g. which consultations will be documented on the medical record, what will be documented and what will be documented in the HEC s HCEC internal files. 5. In the policy, the plan for evaluation and quality improvement should be delineated. This should include how the quality of the HCEC service will be assessed and addressed (2011, p. 14). REFERENCES American Society for Bioethics and Humanities. (2009). Improving Competencies in Clinical Ethics Consultation: An Education Guide. Glenview IL: ASBH. (May be purchased through ASBH Website American Society for Bioethics and Humanities. (2011). Core Competencies for Healthcare Ethics Consultation (2nd ed). The Report of the American Society for Bioethics and Humanities. Glenview IL: ASBH. (May be purchased through ASBH Website Aulisio, M.P. (1999). Ethics Consultation: Is it enough to mean well? HEC Forum, 11 (3), Dubler, N.N. & Liebman, C.B. (2004). Bioethics Mediation: A Guide to Shaping Shared Solutions. New York: United Hospital Fund of New York. Gaudine, A., Thorne, L., LeFort, S.M., Lamb, M. (2010). Evolution of hospital clinical ethics committees in Canada. J Med Ethics 36: Jiwani, B. (2001). An Introduction to Health Ethics Committees. Alberta: Provincial Health Ethics Network. Post-Farber, L. Blustein, J. Neveloff, Dubler, Nancy (2007). Handbook for Health Care Ethics Committees. Baltimore: John Hopkins University Press.

41 Getting Organized: Establishing Clear Objectives and Processes for Healthcare Ethics Consultation (HCEC) ~ 41 ~ Provincial Health Ethics Network of Alberta. Clinical Ethics Committee Member Manual. Alberta: Provincial Health Ethics Network. Wilson Ross, J., Glaser, JW., Rasinski-Gregory, JD., McIver Gibson, J., Bayley, C. (1993). Health Care Ethics Committees: The Next Generation. American Hospital Publishing Inc.

42 SECTION THREE RESOURCES STOCKING YOUR HEC LIBRARY: SOME SUGGESTIONS! GENERAL RESOURCES FOR HECS BOOKS Ahronheim, JC., Moreno, JD., Zuckerman, C. (2000). Ethics in Clinical Practice (2nd ed.). Aspen Publishers. American Society for Bioethics and Humanities. (2009). Improving Competencies in Clinical Ethics Consultation: An Education Guide. Glenview IL: ASBH. (May be purchased through ASBH Website Baylis, F., Downie, J., Feedman, B., Hoffmaster, B., Sherwin, S. (2004). Healthcare Ethics in Canada. Toronto: Thomas Nelson. Beauchamp, T.L. and Childress, J.F. (2009). Principles of Biomedical Ethics (6th ed.). Oxford University Press. Canadian Nurses Association. (2004). Everyday Ethics Putting the Code into Practice. Ottawa: Canadian Nurses Association. Charon, R., Montello, M. (2002). Stories Matter: The Role of Narrative in Medical Ethics. Routledge. Downie, J., Caulfield, T., Flood, CM. (2011). Canadian Health Law and Policy (4th ed.) LexisNexis Canada Inc. Doucet, J., Larouche, J., & Melchin, K.R. (2001). Ethical Deliberation in Multiprofessional Health Care Teams. University of Ottawa Press. Fisher, J. (ed). (2009). Biomedical Ethics A Canadian Focus. Oxford University Press. Hebert, P.C. (2009). Doing Right. A Practical Guide to Ethics for Medical Trainees and Physicians (2nd ed.). New York: Oxford University Press.

43 Resources Stocking Your HEC Library: Some Suggestions! ~ 43 ~ Jonsen, A.R., Siegler, M. and Winslade, W.J. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. (7th ed.). McGraw-Hill. Keatings, M., Smith, O.B. (2000). Ethical and Legal Issues in Canadian Nursing (2nd ed). WB Saunders. Kuhse, H., Singer, P. (eds). (2001). A Companion to Bioethics. Blackwell Companions to Philosophy. Blackwell Publishing. Levan, Christopher. (2000). Knowing Your Ethical Preferences. Edmonton, AB: St. Stephen s College, University of Alberta. Lo, B. (2009). Resolving Ethical Dilemmas: A Guide for Clinicians. (4th ed). Lippincott Williams & Wilkins. Loewy, E.H. Springer Loewy, R. (2004). Textbook of Healthcare Ethics. Dordrecht: Kluwer Academic Publishers. Johnson, A.G., & Johnson, P.R. (2007). Making Sense of Medical Ethics. London: Hodder Arnold. Martin, C.W., Vaught, W., & Solomon, R.C. (2010). Ethics Across the Professions: A Reader for Professional Ethics. Oxford University Press. Parker, M., Dickenson, D. (2001). The Cambridge Medical Ethics Workbook: Case Studies, Commentaries and Activities. Cambridge University Press. Peppin, J.F., Cherry, M.J. (eds). (2003). Regional Perspectives in Bioethics. Annals of Bioethics. New York: Taylor & Francis. Post, S.G. (ed). (2003). Encyclopedia of Bioethics (3rd ed). New York: Thomson Gale. Scott, R. (2009). Promoting Legal and Ethical Awareness: A Primer for Health Professionals and Patients. St. Louis, Mosby Elsevier. Singer, P.A., Viens, A.M. (eds). (2008). The Cambridge Textbook of Bioethics. Cambridge University Press. Singer, P. (ed). (1993). A Companion to Ethics. Blackwell Companions to Philosophy. Blackwell Publishers.

44 ~ 44 ~ Health Ethics Committee Toolkit Part Two: Consultation Sneiderman, B., Irvine, JC and Osborne, PH. (2003). Canadian Medical Law. An Introduction for Physicians, Nurses, and other Health care Professionals (3rd ed). Ontario: Thomson Carswell Stone, D. Patton, B. Heen, S. (2010). Difficult Conversations: How to Discuss What Matters Most. 10th Anniversary edition. Harvard Negotiation Project. New York: Penguin Books. Storch, J P. Rodney, and R. Starzomski (eds) (2004). Toward a Moral Horizon: Nursing Ethics for Leadership and Practice. Toronto: Person Prentice Hall. Purtilo, RB. Doherty, RF. (2011). Ethical Dimensions in the Health Professions. (5th ed). Elsevier Saunders Tong, R. (2007). New Perspectives in health care ethics: an interdisciplinary and crosscultural approach. Upper Saddle River, NJ: Pearson/Prentice Hall. Wilson Ross, J, Glaser, JW, Rasinski-Gregory, JD, McIver Gibson, J, Bayley, C. (1993). Health Care Ethics Committees: The Next Generation. American Hospital Publishing Inc. ARTICLES Callahan, D. (2003). Individual good and common good: A Communitarian Approach to Bioethics. Perspectives in biology and Medicine 46 (4) Callahan, D. (2001). Doing Good and doing Well. Hastings Centre Report, 31 (2): Baker, R. (2009). In defense of bioethics. Journal of Law, Medicine & Ethics, 37 (1), Bailey, S. (2006). Decision making in acute care: a practical framework supporting the 'best interests' principle. Nursing Ethics, 13(3), Collier, J., Rorty, M., & Sandborg, C. (206). Rafting the ethical rapids. HEC Forum, 18(4), Daniels, D. (2000). Accountability for reasonableness. Establishing a fair process for priority setting is easier than agreeing on prinicples. BMJ November 25;321 (7272): DeRenzo, E. G., Mokwunye, N., & Lynch, J. J. (2006). Rounding: How everyday ethics can invigorate a hospital's ethics committee. HEC Forum, 18(4), Duzinski, DM (2004). Integrity in the relationship between medical ethics and professionalism. The American J of Bioethics 4 (2),

45 Resources Stocking Your HEC Library: Some Suggestions! ~ 45 ~ Gibson, JL, Godkin MD, Tracy, CS, MacRae, SK. (2008). Innovative Strategies to improve effectiveness of clinical ethics. in Singer, PA and Viens, AM (eds). The Cambridge Textbook of bioethics. Cambridge: Cambridge U Press pp. Gibson, JL. Martin DK. & Singer, PA. (2005). Evidence, Economics and Ethics: Resource Allocation in Health Services Organizations. Healthcare Quarterly;8: Grover, SM (2005). Shaping Effective Communication Skills and Therapeutic Relationships at Work: The foundation of Collaboration. AAOHN Journal 53 (4) Hurst, SA, Hull, SC, DuVal, G., Danis, M. (2005). How Physicians Face Ethical Difficulties: A Qualitative Analysis. Journal of Medical Ethics 31 (1) Jecker, NS. (1996). Caring for Socially Undesirable Patients. Cambridge Quarterly of Healthcare ethics. 5, Kaufert, JM. RW Putsch. (1997)Communication through interpreters in health care: ethical dilemmas arising from differences in class, culture, language, and power. The journal of clinical ethics 8: Nelson, W. A. (2008). Addressing organizational ethics: how to expand the scope of a clinical ethics committee to include organizational issues. Healthcare Executive, 23(2) Turner, M. H. (2003). A toolbox for healthcare ethics program development. Journal for Nurses in Staff Development : JNSD : Official Journal of the National Nursing Staff Development Organization, 19(1), 9-15; quiz 16. Pape, D., & Manning, S. (2006). The educational ladder model for ethics committees: Confidence and change flourishing through core competency development. HEC Forum, 18(4), Winn, P., & Cook, J. (2000). Ethics committees in long-term care: A user's guide to getting started. Annals of Long-Term Care, 8(1), Yeager, S. (2005). Interdisciplinary collaboration: The heart and soul of healthcare. Critical Care Nursing clinics of North America 17, Yeo, M., Williams, J.R. & Hooper, W. (1999). Incorporating ethics in priority setting: a case study of a regional health board in Canada. Health Care Analysis, 7,

46 ~ 46 ~ Health Ethics Committee Toolkit Part Two: Consultation SELECTED SPECIAL TOPICS IN HEALTHCARE ETHICS Angelos, P. (2008). Ethical Issues in cancer patient care. 2nd ed. New York: Springer. Bosek, M, DeWolf, MS (2007). The Ethical Component of nursing education: integrating ethics into clinical experience. Philadelphia: Lippincott Williams and Wilkins. Bowman, D. Spicer, J. (2007). Primary Care ethics. Oxford Radcliffe Pub. Butts, JB. Rick KL. (2008). Nursing ethics: across the curriculum and into practice. Udbury, Mass: Jones and Bartett Publishers. Catholic Health Association of Canada (2ooo). Health Ethics guide. Coward, H, Ratanakul, P. (eds) (1999). A cross-cultural dialogue on health care ethics. Waterloo, Ont. Wilfrid Laurier Press. Duquenoy, P., Carlisle, G, Kimppa, K (eds) (2008). Ethical, legal and social issues in medical informatics. Hershey, PA: Medical Information Science Reference. Emaneul, Ezekiel J. (2008). The Oxford textbook of clinical research ethics. Oxford: Oxford University Press. Fry, ST. (2008). Ethics in nursing practice: a guide to ethical decision making. 3rd ed. Chichester, UK Whiley-Blackwell. Guttman, D. (2006). Ethics in Social Work: a context of caring. New York: Haworth Press. Jiwani, B. Nathoo, AN. (2003). Tough Choices: The Ethics of Allocating Health Resources. Calgary: Provincial Health Ethics Network Jones, JW. McCullough, LB, Richman, BW. (2008). The Ethics of surgical practice: cases, dilemmas, and resolutions. Oxford; New York: Oxford University Press. Nelson, WA (ed) (2009). Handbook for Rural Health Care Ethics. A Practical Guide for Professionals. Dartmouth College Press. Oakes, J. Riewe, R. Koolage, S. Simpson, L. Schuster, N. (2000). Aboriginal Health, Identity and Resources. Department of Native Studies, Winnipeg, Manitoba: Native Studies Press. Oberle, K. (2009). Ethics in Canadian Nursing Practice: navigating the journey. Toronto: Person Prentice Hall. Powers, Bethel Ann (2003) Nursing Home Ethics. Everyday Issues Affecting Residents with Dementia. New York: Springer

47 Resources Stocking Your HEC Library: Some Suggestions! ~ 47 ~ Roberts, Laura Weiss, Dyer, AR. (2004). Concise guide to ethics in mental health care. 1st ed. Washington Dc American Psychiatric Publication. Veatch, RM., Haddad, A. (2008). Case Studies in Pharmacy ethics. New York: Oxford University Press. Webster, G, Baylis, F. (2000). Moral residue, In S. Rubin and L. Zoloth, (eds). Margin of error: The ethics of mistakes in the practice of medicine. pp Haggerstown: University Publishing Company. Yeo, M. (1993). Ethics and Economics in Health care Resource Allocation. Ottawa: Queen s University of Ottawa Economic Projects. SELECTED CONSULTATION RESOURCES FOR HECS BOOKS American Society for Bioethics and Humanities. (2011). Core Competencies for Healthcare Ethics Consultation (2nd ed). The Report of the American Society for Bioethics and Humanities. Glenview IL: ASBH. (May be purchased through ASBH Website American Society for Bioethics and Humanities. (2009). Improving Competencies in Clinical Ethics Consultation: An Education Guide. Glenview IL: ASBH. (May be purchased through ASBH Website Aulisio, Mark P, Arnold, Robert M. Youngner, Stuart J. (2003). Ethics Consultation from Theory to Practice. Baltimore: John Hopkins Press Baylis, FE. (1994). The Health Care Ethics Consultant. Humana Press. Dubler, N. N., & Liebman, C. B. (2004). Bioethics mediation: a guide to shaping shared solutions. New York: United Hospital Fund of New York. Ford, PJ, Dudzinski, DM. (2008). Complex Ethics Consultations: Cases that Haunt Us. New York: Cambridge University Press Hester, D. Micah. (2008). Ethics by Committee. Textbook on Consultation, Organization and Education for Hospital Committees. Rowman & Littlefield. Hester, D.Micah & T. Schonfeld, eds., (2012) Guidance for Healthcare Ethics Committees. New York: Cambridge: University Press. Available August 2012

48 ~ 48 ~ Health Ethics Committee Toolkit Part Two: Consultation Jiwani, B. (2001). An introduction to health ethics committees. Alberta: Provincial Health Ethics Network. Kuczewski, MG. Pinkus, RB. (1999). An Ethics Casebook for Hospitals. Washington, DC: Georgetown University Press. Meyers, C. (2007). A Practical Guide to Clinical Ethics Consulting: Expertise, Ethos, and Power. Lanham, Md: Rowman & Littlefield Publishers. Post-Farber, L. Blustein, J. Neveloff, Dubler, Nancy(2007). Handbook for health care ethics committees. Baltimore: John Hopkins University Press Schildmann, J. Gordon, JS, Vollmann, J. (eds) (2010). Clinical Ethics Consultation: Theories and Methods, Implementation, Evaluation. Medical Law and Ethics Series. Burlington: Ashgate Publishers. ARTICLES Agich, GJ and SJ Youngner. (1991). For experts only? Access to hospital ethics committees Hastings center Report 21, 5 : Agich, GJ (2001). The Question of Method in Ethics consultation. American Journal of bioethics 1 (4) Anderson, CA (1996). Ethics committees and quality improvement: a necessary link. Journal of nursing care quality 11, 1: Andre, J. (1997). Goals of ethics consultation Towards clarity, utility and fidelity. The journal of clinical ethics 8 : Aulisio, M. P., & Arnold, R. M. (2008). Role of the ethics committee: Helping to address value conflicts or uncertainties. Chest, 134(2), Aulisio, MP, Arnold, RM, Youngner, SJ.(2000). Health care ethics consultation: nature, goals, and competencies. Annals of internal medicine 133 (1): Aulisio, M.P. (1999). Ethics consultation: Is it enough to mean well? HEC Forum, 11 (3), Bayley, C. (2006). Ethics committee DX: Failure to thrive. HEC Forum, 18(4), Bloch, S. & Green, S.A. (2006). An ethical framework for psychiatry. British Journal of Psychiatry, 188, 7-12.

49 Resources Stocking Your HEC Library: Some Suggestions! ~ 49 ~ Brody, B. Dubler, N, Bluestein, J. Caplan, A. Kahn, JP, Kass, N, Lo, B, Moreno, J, Sugerman, J, Zoloth, L. (2002). Bioethics Consultation in the Private Sector. Hastings Center Report; 32 (3): Carter, M. A. & Klugman, C.M. (2001). Cultural engagement in clinical ethics: a model for ethics consultation. Cambridge Quarterly of Healthcare Ethics, 10, Chidwick, P. Bell, J, Connolly, E, coughlin, M, Frolic, A, Hardingham, L, Zlotnik Shaul. Exploring a Model Role Description for Ethicists. (2010). HEC Forum, 22: Childs, BH (2009). Credentialing clinical ethics consultants: lessons to be learned. HEC Forum, 21 (3), Crosthwaite, J. Moral expertise: A problem in the professional ethics of professional ethicists. Bioethics 9: Cummings, D. (2002). The Professional Status of Bioethics Consultation. Theoretical medicine, 23, Donaldson, T. (2001). The Business ethics of bioethics consulting. Hastings center report, 31, (2) Fletcher, JC and M. Siegler. (1996). What are the goals of ethics consultation? A consensus statement. The journal of clinical ethics Fox, E. Myers, S,. Pearlman, RA. (2007). Ethics Consultation in United States Hospitals: A National Survey. The American Journal of bioethics 7 (2): Frolic, A. (2011). Who are we when we are doing what we are doing? The case for mindful embodiment in ethics case consultation. Bioethics 25 (1) Frolic, A.N, Chidwick, P. (2010). A Pilot Qualitative Study of conflicts of interests and/or conflicting interests among Canadian bioethicists. Part 1 Five Cases, Experiences and Lessons learned. HEC Forum, 22:5-17 Frolic, AN, Chidwick, P (2010). Part 2: Defining and Managing Conflicts, HEC Forum 22: Gibson, JL, Martin, DK, Singer, PA (2005). Evidence, Economics and Ethics: Resource Allocation in Health Services Organizations. Healthcare Quarterly 8 (2) Howe, EG (1996). The three deadly sins of ethics consultation. The Journal of Clinical Ethics 7: Kipnis, K (2009). The certified clinical ethics consultant. HEC Forum, 21 (3), ,

50 ~ 50 ~ Health Ethics Committee Toolkit Part Two: Consultation Kuczewski, M. (2010) Stewarding our Legacy: Attesting to the Quality of Clinical Ethics Consultants. Presidents Corner, ASBH Reader 3-7 Leeman, C. P., Fletcher, J. C., Spencer, E. M., & Fry-Revere, S. (1997). Quality control for hospitals' clinical ethics services: Proposed standards. Cambridge Quarterly of Healthcare Ethics, 6(3), MacDonald, C., Coughlin, M., Harrison, C, Lynch, A.M Murphy, P., Rowell, M. Webster, G. (2000). Working Conditions for Bioethics in Canada. Draft Discussion Paper. V. 8.0 (October 18, 2000). MacDonald, C. (2003). Model Code of Ethics for Bioethics Draft. McGee, G. Caplan, AL, Spanogle, JP Asch, DA. (2001). A National Study of Ethics Committees. American Journal of Bioethics Fall 1 (4) McCruden, P., & Kuczewski, M. (2006). Is organizational ethics the remedy for failure to thrive? Toward an understanding of mission leadership. HEC Forum, 18(4), doi: /s z McLean, S. A. M. (2007). What and who are clinical ethics committees for? Journal of Medical Ethics, 33(9), Moreno, J. D. (2006). Ethics committees: Beyond benign neglect. HEC Forum, 18(4), Neitzke, G. (2007). Confidentiality, secrecy, and privacy in ethics consultation. HEC Forum, 19(4), Neveloff Dubler, N, Webber, MP, Swiderski, DM et al. (2009). Charting the Future. Credentialing, Privileging, Quality, and Evaluation in clinical ethics consultation. Hastings center report Nov Dec Pedersen, R., Akre, V., & FØrde, R. (2009). Barriers and challenges in clinical ethics consultations: The experiences of nine clinical ethics committees. Bioethics, 23(8), Practicing Healthcare Ethicists Exploring Professionalization (PHEEP). Developing Practice Standards for Healthcare Ethicists in Canada: Definitions, Concepts and Process. Background Paper for the National Symposium on Practicing Healthcare Ethics in Canada. Canadian Bioethics Society (CBS)

51 Resources Stocking Your HEC Library: Some Suggestions! ~ 51 ~ Pope, T. M. (2008). Multi-institutional ethics committees: For rural hospitals, and urban ones too. American Journal of Bioethics, 8(4), Royal Society of Canada Expert Panel (2011) End of Life Decision Making. Ottawa: The Royal Society of Canada, The academics of Arts, humanities and Sciences of Canada. Schneiderman, L. et al. (2006). Dissatisfaction with ethics consultations: the Anna Karenina principle. Cambridge Quarterly of Healthcare Ethics, 15, Slowther, A, Hope, T. (2000). Clinical Ethics Committees: They can Change Clinical Practice but Need Evaluation. BMJ Slowther, A. Johnston, C, Goodall, J. and Hope, T. (2004). Development of Clinical Ethics Committees. BMJ Smith, M, Sharp, R, Weise K, Kodish, E (2010). Toward competency-based certification of clinical ethics consultants: a four-step process. The Journal of Clinical Ethics, 21 (1) Smith, M. L. et al. (2004). Criteria for determining the appropriate method for an ethics consultation. HEC Forum, 16 (2), Spike, JP (2009). Resolving the vexing question of credentialing: finding the Aristotelian mean, HEC Forum, 21 (3), Tarzian, AJ. (2009). Credentials for Clinical Ethics Consultation Are We There Yet? HEC Forum, 21 (3), White II, E. D. (2006). Reflections on the success of hospital ethics committees in my health system. HEC Forum, 18(4), Williamson, L. (2008). The quality of bioethics debate: Implications for clinical ethics committees. Journal of Medical Ethics, 34(5), Williamson, L. (2007). Empirical assessments of clinical ethics services: implications for clinical ethics committees. Clinical Ethics, 2(4),

52 ~ 52 ~ Health Ethics Committee Toolkit Part Two: Consultation EXAMPLES OF ETHICAL DECISION MAKING FRAMEWORKS/TOOLS American Association of Critical Care Nurses Ethics Work Group. The 4A s to Rise Above Moral Distress. American Association of Critical Care Nurses Capital Health Clinical Ethics Decision-making tool Organizational Decision-making tool. Nova Scotia. Community Ethics Network Steering Committee (CEN). (2008, July). Community Ethics Toolkit. Toronto Central Community Care Access Centre. Daniels, N and Sabin, J. (2002) Setting limits fairly: Can we learn to Share Learning to Share Medical Resources? (2nd ed) New York Oxford University Press. (Accountability for Reasonableness Framework) Jiwani, B. (2001). The 3 questions approach to decision-making in health ethics. In An introduction to health ethics committees (pp ). Edmonton: The Provincial Health Ethics Network. Jiwani, B. (2001). Sample frameworks. In An introduction to health ethics committees (pp ). Edmonton: Provincial Health Ethics Network. Jiwani, B. (2011) Incorporating Ethics into daily practice. Ethics Services Fraser Health. Jonsen, A.R., Siegler, M. and Winslade, W.J. (2010). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. (7th ed). McGraw- Hill. Manitoba Provincial Health Ethics Network (MB-PHEN) Frameworks McDonald, M. Framework for ethics decision-making: version 6.0 Ethics Shareware by Michael McDonald. Center for applied ethics, University of British Columbia. Making.pdf McDonald, M. An Ethical Framework for Make Meso-Level Health Care Allocation Policy Decisions. 9FF0581E25FE/0/macdonald_resource_allocation.pdf

53 Resources Stocking Your HEC Library: Some Suggestions! ~ 53 ~ Powers, Bethel Ann (2003) Frameworks for assessing resident-focused issues Nursing Home Ethics. Everyday Issues Affecting Residents with Dementia. New York: Springer pp Trillium Health Center. IDEA Ethical Decision-Making Framework Guide and Worksheets kingframework.pdf SELECTED HEC AND HCEC TOOLKITS Toronto central Community care Access Centre (2008). Community Ethics Toolkit. United States Department of Veterans Health Administration. National center for Ethics in Healthcare. Ethics Consultation United States Department of Veteran Health Administration National center for Ethics in Healthcare Integrated ethics tools and resources. United States Department of Veterans Affairs Health Administration Ethics Consultancy Proficiency Assessment tool. ment_tool_ pdf Winnipeg Regional Ethics Council. (2009). Health Ethics Committee Toolkit Part One: Getting Started. Wallace, D. Pekel, J. Ten Step Method of Decision Making (Organizational Ethics Framework). Twin cities-based Fulcrum Group. Yeo, M., Williams, J.R. & Hooper, W. (1999). Incorporating ethics in priority setting: a case study of a regional health board in Canada. Health Care Analysis, 7,

54 ~ 54 ~ Health Ethics Committee Toolkit Part Two: Consultation RELEVANT LEGISLATION FOR HECS To function effectively, your HEC members need to be familiar with applicable federal and provincial legislation, including, WORKPLACE HEALTH AND SAFETY PRIVACY AND CONFIDENTIALITY The Freedom of Information and Protection of Privacy Act (FIPPA) The Personal Health Information Act (PHIA) PROXY DECISION MAKING The Health Care Directives Act The Mental Health Act The Vulnerable Persons Living with a Mental Disability Act PROFESSIONAL GOVERNANCE The Regulated Health Professions Act PROFESSIONAL CODES OF ETHICS HEC members need to be familiar with their Canadian and/or Manitoban professional codes of ethics and also encourage their colleagues to recognize them as a valuable resource in terms of professional ethics learning and decision-making. For example, NURSING Canadian Nurses Association Code of Ethics - College of Registered Nurses of Manitoba - who provide a link to the CNA Code of Ethics College of Registered Psychiatric Nurses of Manitoba College of Licensed Practical Nurses of Manitoba ALLIED HEALTH Canadian Association of Medical Radiation Technologists Canadian Association of Occupational Therapists

55 Resources Stocking Your HEC Library: Some Suggestions! ~ 55 ~ Canadian Physiotherapy Association Code of Ethics Canadian Association of Social Workers - College of Occupational Therapists of Manitoba Dietitians of Canada Code of Ethics - Manitoba Association of Registered Respiratory Therapists - Manitoba Speech and Hearing Association - ORAL HEALTH Canadian Dental Association: Canadian Dental Hygienists Association - PHYSICIANS Canadian Medical Association Code of Ethics - PHARMACY Manitoba Pharmaceutical Association: SPIRITUAL HEALTH Canadian Association for Spiritual Care Manitoba Health Mental Health and Spiritual Health Care - STANDARDS Canadian College of Health Leaders Code of Ethics. Qmentum Standards. Accreditation Canada - Agrément Canada. Alternatively, contact your Quality Manager for information.

56 ~ 56 ~ Health Ethics Committee Toolkit Part Two: Consultation POLICIES To function effectively, HEC members need to be familiar with applicable site, program or regional policies. Examples of policies to explore in your particular site, program or region include the following examples: Advance Care Planning Code Blue Non-Resident Access to Care Patient Consent/Information/Privacy/Confidentiality Restraints Workplace HEALTHCARE ETHICS WEBSITES Applied Ethics Resources Ascension Health. (see menu option on main page). Note: For the Public section especially helpful. Incorporating Ethics into Daily Practice. Ethics Services Fraser Health and Provincial Health Ethics Network Canadian Bioethics Society Website Chris MacDonald. EthicsWeb.ca. Cleveland Clinic Bioethics Department. Services & Policies. Manitoba Provincial Health Ethics Network. Nova Scotia Health Ethics Network. Regina Qu'Appelle Health Region. Programs and Services: Ethics Support Services. United States Department of Veterans Affairs. (2010, April 1). National Center for Ethics in Health Care.

57 Resources Stocking Your HEC Library: Some Suggestions! ~ 57 ~ University of Toronto Joint Centre for Bioethics. (2009, Dec 9). Joint Centre for Bioethics: Community Ethics Network. Community Ethics Network. West Virginia Network of Ethics Committees. Ethics Committee Tools. W. Maurice Young Center for Applice bioethics (UBC) ASSOCIATIONS AND CONFERENCES A range of health ethics associations exists both in Canada and internationally, and some interesting conferences are offered annually. For example, The Canadian Bioethics Society (CBS) The American Society for Bioethics and Humanities (ASBH) International Global Ethics Association Bioethics Associations TRAINING AND EDUCATION The following are some of the regional ethics education opportunities created and offered by the Manitoba Provincial Health Ethics Network (MB-PHEN): 1. Level I Health Ethics Workshop 2. Level II: Ethics Resource Workshop 3. Ethics in the Healthcare Organization Workshop 4. Strategies & Work Plan Development for Ethics Committees 5. Ethics in Pandemic Planning Workshop 6. Ethics in Accreditation Presentation Check university and college catalogues for credit courses in ethics. To receive news of upcoming ethics events, subscribe to Ethics News: at [email protected] or visit

58 ~ 58 ~ Health Ethics Committee Toolkit Part Two: Consultation LIBRARIES Libraries are great resources for health ethics print, e-journal and AV resources. For example, University of Manitoba Libraries Search or link via Speak with a hospital or campus librarian or contact the WRHA Librarian at HOW TO OBTAIN LISTED RESOURCES If you are having difficulty locating any of the above resources, or if you have other good resources to suggest, contact MB-PHEN at , [email protected] or

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