Often the call to ethics is a call of last resort. Even embedded ethicists, working proactively, get involved in cases that become unwieldy with elements well beyond the purview of ethics. Additionally, there are cases where the ethicist's recommendation is one that the physician believes might leave her legally

exposed and she wants organizational support to implement the recommendation. The 'Complex Care Team' (CCT) at Mercy was developed as a result of cases with seemingly intractable and far-ranging issues and those where ethics' recommendations press for cultural change.

Some organizations might address these cases within the ethics committee. However, we believed it was important that senior leadership lead this group; ethics would be one of several important disciplines participating. Currently the co-chairs of this group are the CMO and the CNO, with members including senior leadership (both administrative and clinical), chairs of critical care and the hospitalist group, nursing leaders, care management, mission, ethics, legal, pastoral care, members of the treating health care team, and other disciplines as appropriate.

The Complex Care Team's purpose is three-fold:

• To promote procedures to proactively identify potential problems,
• To facilitate the removal of barriers to safe, effective, appropriate, and ethical care of patients, and
• To support health care team members with extremely complex medical and social issues of patients and their families.

The CCT is a standing weekly meeting and is cancelled if no cases are submitted four hours prior to the meeting time. Urgent issues are scheduled on an ad hoc basis. Ideally, the case is presented by the attending physician and other members from the team. The patient's primary care physician is included if possible, usually by phone. The cases range from extremely difficult discharges to behavioral issues to family (or surrogate) requests for inappropriate medical treatment at the end of life. Perhaps the greatest success of this team is the development of mechanisms to provide clear and consistent communication among the care team, patients, and their families. One example is the 'Strategy of Care' chart note, which documents the agreed upon plan of care reviewed at the CCT and then discussed with the patient (or family), which is clearly flagged on the chart when first opened, and which informs all current and future caregivers of the agreed upon plan of care. We have found this to be successful at preventing unnecessary readmissions and supporting physicians in holding to a plan of care that has been established.

Additionally, CCT affords frontline staff the opportunity to sit at the table with senior leadership to discuss the challenges these cases present; this results in the staff feeling heard and empowered and gives senior leadership a realistic view of the daily challenges faced by the staff. The physicians also feel that the organization is behind them when a difficult plan of care needs to be implemented.