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BY: JUDY CASSIDY

Integrating Clinical and Organizational Ethics Meets Needs of a Changing Healthcare System

"We are in the second generation of healthcare ethics," said Bart Collopy, PhD, at a conference on "integrated ethics" sponsored by Calvary Hospital, Bronx, NY, April 30. The conference was part of Calvary's program to ensure ethical behavior in the organization's practices as well as in clinical decision making. Collopy explained that the first generation of ethics involved patient rights and care issues such as quality of care and outcomes, and decisions about life-sustaining treatment. Second-generation issues are nonclinical and relate, for example, to how an organization treats employees, acts as an advocate for high-quality patient care whenever quality is threatened or diminished, makes budgeting decisions, or resolves conflicts of interest.

The nonclinical, organizational issues arise from patient care concerns, however, so first- and second-generation ethics must all be considered together. To illustrate how clinical and organizational ethics are linked, Collopy, associate chair, Theology Department, Fordham University, New York City, used the example of determining appropriate care for incapacitated persons who are unable to make decisions about their treatment. This clinical treatment issue raises questions about the organization's structures for bringing proxy decision makers into the decision-making process: Does the facility involve proxies as early as possible, preferably while the patient can still discuss his or her wishes? Does it help prepare proxies, who may feel overwhelmed by the decisions they have to make?

Calvary's Commitment to Ethics
To ensure integration of clinical and organizational ethics, 200-bed Calvary Hospital created an organized approach to respond to managed care and other developments that were increasing the ethical questions faced by its 650-member staff in all departments throughout the organization.

Calvary, whose unique mission is to provide palliative care to adult patients with advanced cancer, has been committed to ethical patient care for almost 100 years. Through a variety of activities such as therapeutic recreation, religious observations for all denominations, and bereavement support groups, the hospital works to meet physical, psychosocial, and spiritual needs of patients and families.

In 1991, an ethics committee was formed to promote excellence in patient care through education. To take this approach to patient care further, and raise awareness of ethical issues throughout the facility, in 1997 Calvary established a Patient Rights and Organizational Ethics Functional Committee to serve as an educational and advisory body to the hospital's medical and administrative staff. This committee, which was a subcommittee of the hospital's existing Quality Assessment and Improvement Committee, included the hospital's patient advocate and representatives from the departments of medicine, nursing, administration, social work, home care, clinical review, pastoral care, and nutritional services.

Organizational Ethics Subcommittee
The committee established an organizational ethics subcommittee — under the direction of Calvary staff members Catherine Seeley, director of bereavement services, and Sara Goldberger, a social worker — to assist in identifying ethical issues that arise in nonclinical areas (see "Calvary Hospital's Patient Rights and Organizational Ethics Function," below). Members represented many units: admitting, environment, information systems, staff development, human resources, medicine, nutritional services, public relations, fund development, and finance.

Objectives The objectives of the organizational ethics program were to improve understanding of ethics, strengthen institutional policies, enhance communication among staff, delineate roles, and promote actions consistent with ethical principles.

Organizational Values Assessment Seeley and Goldberger began the organizational ethics program by asking each department to conduct a "values audit." Staff identified what values they used every day in their work. For example, the human resources department listed the values of confidentiality, respect, and stewardship.

The current values were then compared with those in Calvary's Mission Statement, including compassion, dignity, and nonabandonment; the Ethical and Religious Directives for Catholic Health Care Services; principles of business ethics such as truth telling and promise keeping; and the standards of the Joint Commission for Accreditation of Health Care Organizations.

The Ethical and Religious Directives, which cover a wide range of concerns, demonstrated the need to include the entire staff in ethical education. In the area of social responsibility, they emphasize:

• Adherence to Catholic moral tradition
• A spirit of respect and compassion
• Service and advocacy for those at the margins of society
• Concern for mission and stewardship of resources
• Collaboration with others
• Just treatment of employees
• Employees' obligation to uphold Catholic healthcare's mission

The directives also address the formation of partnerships, with attendant concerns about Catholic identity; and they cover advance directives, patient rights, informed consent, and surrogate decision making.

In addition to identifying pertinent values, the departments identified factors that make it difficult to live out these values in the workplace. On the basis of this information, Goldberger and Seeley oversaw an educational program for the hospital that targeted areas for improvement. They are also writing an education tool, "Decisions in Healthcare Corporate Life: Creating Moral Space in the Workplace."

Calvary developed an Organizational Ethics Statement to clarify how the hospital translates integrated ethics into everyday work. This document gives concrete examples of ethical problems, specifies the role of the organizational ethics subcommittee, and states how the organization will ensure that its goals are carried out — that is, through policies that ensure fair business practices, protect quality of care, and address potential conflicts of interest; the establishment of clear lines of authority and scope of employees' authority; and an appeals process whereby employees and patients/families can resolve disputes involving organizational ethics.

Consult Teams In addition, two consult teams were established to help staff, patients, and families resolve, respectively, patient care and organizational ethical issues. The teams respond within 24 hours (including weekends) to requests for consultation from staff or patients and families.

Goldberger and Seeley met with staff to explain how to contact the consult teams and to help them distinguish ethical issues from management or personal values issues.

Staff Education Over 18 months, they also held seminars with small groups of 6 to 12 staff members. They discussed issues such as how to include patients in care planning, the need to weigh benefits and burdens of treatments, and how to deal with patients who lack decision-making capacity. At first, some staff resisted devoting time to a 45-minute seminar, but by the end of the session, Goldberger said, "We had to kick people out."

Recently requests for clinical consults have declined, indicating that staff are discussing problems and resolving them within their units. Seeley said staff do not act on the basis of personal judgments or habitual, unquestioned practices, but, rather, with professional consistency.

New Issues
Seeley and Goldberger anticipate that organizations will continue to face patient care issues that have ethical implications for the entire organization. Managed care is one example of an issue that has forced Calvary to balance its duty to conserve resources with its duty to protect patients, who are vulnerable to being overpowered by insurers. Calvary's organizational ethics program invites full exploration of tensions that escalate when, for example, a needed but unprofitable service such as psychiatric treatment is not covered. In raising questions about practices that devalue or neglect relationships and responsibilities, Seeley and Goldberger believe Calvary's program helps staff members develop their own moral values and act accordingly.

By identifying ethical concerns and raising questions about business decisions, managed care, and other forces, Calvary fulfills its mission as a part of the Church, which is a voice for the weakest members of society.

— Judy Cassidy

For more information, contact Catherine Seeley at 718-518-2125 or Sara Goldberger at 718-518-2661.

CALVARY HOSPITAL PALLIATIVE CARE INSTITUTE

Calvary Hospital Palliative Care Institute was founded to transmit, through education and research, the knowledge the hospital has developed in its 100 years of service to cancer patients. Calvary, which is sponsored by the Archdiocese of New York, serves more than 2,400 inpatients annually. Seventy percent of patients are over age 65. Their average length of stay is 26.5 days.

Since its founding in 1994, the Palliative Care Institute has developed a curriculum for medical students and a program for visiting physicians. The institute also sponsors lectures and palliative medicine conferences, and supports clinical investigation. The April conference, "Integrated Ethics: Blueprint for the Future," was jointly sponsored by the Palliative Care Institute and the Patient Rights and Organizational Ethics Committee of Calvary Hospital.

For more information, contact the institute's director, James E. Cimino, MD, at 718-518-2202.

KEY AREAS OF SECOND-GENERATION ETHICS

Second-generation ethics, according to Bart Collopy, PhD, is the phase in which organizations look beyond internal issues and ask broader, external questions such as, Should we be networking with other organizations? What is our obligation to provide public education on advance directives? How should we provide a moral context for a legal instrument?

Managed Care Issues
Managed care raises second-generation ethical concerns about whether patient care will suffer if care is denied, whether patient autonomy will be compromised, whether managers will intrude on the patient-physician relationship, and whether costs will drive decisions. For the organizational ethics committee, managed care raises questions in several areas:

• Advocacy for patients. How does the institution appeal an insurer's denial of coverage? Who pursues and monitors appeals? How are patients and families informed about the institution's appeals policies?
• Gaming the system. Are deceptive practices accepted in the organization? If so, what are likely to be the long-term effects on staff and the organization?
• Institutionalized anger. Does anger against aspects of managed care foster cynicism and engender fear in patients and families?
• Common ground. Could managed care organizations and healthcare facilities work together, recognizing that both face the dilemma of trying to meet needs with limited resources? Could alliances of institutions and agencies find solutions together?
• Absorbing costs. Does the institution have clear policies about when it will swallow costs of care when coverage is denied? Who decides when costs will be absorbed? How does the organization ensure care of the poor and uninsured?

Staff Issues
In second-generation ethics, the organization looks at staff in relation to the institution, rather than only to patients, as in first-generation ethics. Following are some questions ethics committees may deal with:

1. Are staff involved in decision making? When decisions come from above, do employees understand the rationale for them?
2. How does the organization handle hiring, firing, family leave, grievances, use of part-time staff, and downsizing?
3. Is the institution committed to staff education and sensitive to staff morale? How does the organization deal with overwork?

Long-Term Care Issues
In addition to classic first-generation patient care issues, institutions serving aging persons face organizational questions such as, How is the institution organized to work with noncompliant patients? Does the organization provide staff with the time and resources to deal effectively with such patients? Does the institution have processes to respond to frailty and suffering? Does it provide care as well as it gives treatments?

Collopy noted that the healthcare organization's overall moral goal is to alleviate human suffering. How the organization organizes its resources and sets policies and procedures determines how well it meets that goal.