Chapter 3 Effective Hospital Ethics Policies

1. Chapter 3Effective Hospital Ethics Policies Gretchen Zetoony, J.D., M.A., M.S.W.

2. Objectives Goals of ethics-related policies 5 �fatal flaws� of ineffective ethics policies Strategies to avoid fatal flaws

3. Preliminary understanding Focus is on fatal flaws Drafters should research others� works There is more than one right way

4. Preliminary understanding Drafting is a uniquely local enterprise Templates Clinical and legal direction Review and adoption process Local law Institutional law Organizational values

5. Scope and coverage Patient Rights and Responsibilities Identification and Authority of a Surrogate Withholding and Withdrawing Treatment Do-Not-Attempt-Resuscitation (DNAR) orders Advanced Directives Conflict Resolution Ethics Committee Mechanisms

6. Additional policies Determination of Death Organ Donation Confidentiality/ Privacy Issues in Research Integrity IRB Quality of Care

7. Considerations when drafting Policies should be balanced Policies should demonstrate consistency, both individually and collectively Include dates Include cross-references where appropriate Use consistent terminology (e.g. DNR/DNAR) Include a definitions section Policies should provide a vehicle for facilitation and education

8. What are the Five Fatal Flaws? Creating a policy that is too... 1. Fuzzy 2. Ambitious 3. Tough to find 4. Abstract 5. Laborious

9. #1 - Too fuzzyLacking clarity Original Policy: Advanced Directives �If an attending physician refuses to honor a patient�s advance directive or a treatment decision under Section 166.039, the physician�s refusal shall be reviewed by an ethics or medical committee. The written explanation required by Subsection (b)(2) (B) of the Act must be included in the patient�s medical record. If the patient is requesting life-sustaining treatment that the attending physician and the review process have decided is inappropriate treatment, the patient shall be given available life-sustaining treatment pending transfer under Subsection (D) of this section. The physician and the health care facility are not obligated to provide life-sustaining treatment after the 10th day after the written decision required under Subsection (B) of this section is provided to the patient or the person responsible for the healthcare decisions of the patient unless ordered to do so under Subsection (G) of this section.� Suggested Revision: Ethics Committee Consultation Where a conflict cannot be resolved through informal means, members of the hospital ethics committee, or the committee as a whole, may be asked to participate in the decision-making process. In cases which involve the removal of life-sustaining treatment, the team should maintain the treatments until the conflict has been resolved or the patient is transferred to another provider. Hospital staff are not, however, obligated to provide life-sustaining treatment after the tenth day following the ethics committee�s written explanation of their decision.

10. Assessing clarity Is the title descriptive? Does the policy have a clearly stated rationale? Does the policy contain necessary explanations for clinical or legal terms of art? Does the policy avoid confusing or unnecessary cross-references?

11.  Original Policy: Advanced Directives Pre-1999 Post-1999 Identification and authority of a surrogate DNAR orders Physician certification Suggested Revisions: Advanced Directives Eliminate pre-1999/post-1999 distinction Move identification and authority of a surrogate to a separate policy Separate out DNAR orders Streamline physician certification section

12. Assessing scope Is the policy limited to one topic? Is the policy too long to be practical? Does the policy dictate the practice of medicine? Are outcomes measurable?

13. #3 - Too tough to findPutting the policy where it is difficult to locate DNAR Declaration of death Futility

14. Assessing user-friendliness Do the policies have a table of contents? Is there a definitions section applicable to all policies? Are terms of art clearly defined? (e.g. �competence� vs. �capacity�)

15. #4 - Too abstract Creating a procedure that is too complicated or not well-defined Original Policy Out of Hospital DNR, Changes Effective After September 1, 1999 Under the subchapter entitled Out-of-Hospital Do-Not-Resuscitate Orders, physician assistants have been added to the definition of �health care professionals.� Any adult may execute an Out-of-Hospital Do-Not-Resuscitate Order � a diagnosis of a terminal condition is no longer required for execution of the Advance Directive. At least one qualified relative, not two, may execute an Out-of-Hospital Do-Not- Resuscitate Order. A photocopy or other complete facsimile of the original written Out-of-Hospital Do Not-Resuscitate may be used. If there is not a qualified relative available; another physician not involved in the patient�s treatment or who is a representative of the Ethics or Medical Committee must concur with an Out-of-Hospital Do-Not-Resuscitate. A surrogate decision-maker who wishes to challenge this decision must apply for guardianship under the Probate Code. Suggested Revision Out-of-Hospital DNAR policy A patient or representative may execute an out-of-hospital DNAR at anytime. In order to do so, the individual must sign the document in the presence of two witnesses. The witnesses must be competent adults and one of the two witnesses must be someone other than: a relative, a person entitled to part of the estate, the attending physician, an employee of the attending physician, an employee/officer/director/etc. of the health care facility presently providing care, a person who has a claim against the individual�s estate, or a person designated by the individual to make treatment decisions. Both witnesses must sign the order along with the individual requesting the out-of-hospital DNAR and the attending physician. The attending physician is responsible for ensuring that the form is filled out in its entirety and documented in the patient�s permanent medical record.

16. Assessing complexity What should happen? Does the plan make sense? Are the steps sequential? Are necessary parties/staff identified in the policy? Is the plan workable? Is the plan complete? What happens if there�s a problem?

17. #5 - Too laboriousDiverging too much from �real life� practices Ex: policy on definition of death by brain criteria Applies only to organ donors Requires multiple steps carried out over a significant period of time Is very detailed Leaves no room for clinical judgment

18. Assessing fit: policy vs. practice Is the policy compatible with current practice? Clinical Institutional What kind of feedback is likely? Are significant changes or departures necessary? Are they explained?