By JUDITH VANDEWATER
ANAHEIM, Calif. — Several years ago, when senior leaders of ethics at CHRISTUS Health reviewed practices of the approximately 40 ethics committees in its hospitals, they found an uneven landscape.
Gerry Heeley, senior vice president of mission integration and leadership formation for the Irving, Texas-based system; and Joann Starr, its system director of ethics, told an audience in an Innovation Forum held June 2 at the Catholic Health Assembly here how CHRISTUS set out methodically to raise the quality and consistency of ethics case consults throughout its network.
Heeley said that the typical hospital-level ethics committee in the CHRISTUS system is composed of four to six volunteers from a hospital's staff and usually includes clinicians, social workers and pastoral care providers. Ethics committee members may come into the post with an interest in ethics but little formal training in the discipline or in mediation or conflict resolution. The latter are relevant skills, given that ethics case consults often derive from poor communication and volatile disagreements that can arise between clinicians and patients' families over the goals of care and the course of care.
According to the American Society for Bioethics and Humanities, ethics case consults are intended to help patients, families and care providers and other involved parties to assess and address conflicts and uncertainty in "value-laden" areas. Such conflicts can involve life-and-death considerations, and they are often tension-filled.
Heeley and Starr wanted to know whether the case consults at CHRISTUS Health hospitals met the needs of the parties who had requested them. Did the doctors and nurses caring for the patients around the clock have ready access to the assessment of the dispute and the ethics committee's recommendation for its resolution? Did they follow those recommendations?
Starr said CHRISTUS Health began its ethics review by engaging leaders in the discipline in its regions and hospitals. It formed an ethics advisory group, drawing ethics experts from across its system. Starr, who directed the initiative, said CHRISTUS Health developed a system-wide case consultation policy that it distributed to all its regions. "It was really important for us to say across the system, 'to ensure quality, we need you to identify who is going to do case consultations.'" The people involved directly in ethics case consultations with patients, their families and clinicians were required to complete seven ethics modules. They had six weeks to complete each module.
Starr said the modules were developed in collaboration with ethicists from Catholic Health East and Trinity Health.
"There is a dynamic that can happen in a consultation," Starr said. "We wanted to make sure someone (in the case consultation) was able to process the group and could acknowledge the feelings and the level of need" of participants. The processor needs to be aware of the family's feelings and how the family might be filtering the information they are hearing from clinical staff. To sharpen those skills of empathy and perception, CHRISTUS hired outside consultants who conducted a two-day training session involving practice cases and role playing.
CHRISTUS Health honed the system's requirements for documenting ethics care consults. The goal was to make the report clear and informative for caregivers who were not present at the case consult session. That reader needed to be able to comprehend the ethical issues under consideration and the family dynamics.
CHRISTUS Health developed and embedded a computerized template in its electronic medical record that has comment space for a narrative summary of a patient's relevant medical and social history, the discussion with family and staff and the ethical analysis. The form sets out the ethics committee's recommendation in the case and the plan for implementing it.
CHRISTUS used case studies to train its ethics committee members on how to document clearly and concisely and convey the story of the patient and the ethical dilemma at hand. It alerted doctors on where to find the ethics notes in electronic medical records. After three months of using the new documentation system, CHRISTUS Health asked its mission vice presidents and the chair of its hospitals' respective ethics committees to convene peer review sessions and examine the documentation with an eye toward standardizing and improving the information in the record.
Next, it expanded the peer review across the system. "People really want to learn how to do this well," Starr said of the case consults and documentation. "It was so exciting to hear people in small rural hospitals who are not trained in ethics, but who are generously serving on ethics committees and who wanted to learn how to say something better."
CHRISTUS Health is mining the metadata drawn from 2012, its first full year of using the electronic reporting system for ethics care consults. Heeley said the system is looking for patterns that might indicate more scrutiny is needed to tease out a root cause of conflicts in an area that is the source of a number of ethics consults requests.
Hospital ethics committee members receive ongoing training in quarterly system-wide calls that include "mock consults," Starr said.