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The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics CHE.ORG/ PowerPoint Presentation
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The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS. Goals for today’s conversation. Is the role of the chaplain any different than ethics facilitation? Boundaries The nature of ethics & facilitation

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slide1
The Role of Chaplains in

Applying Ethics in Spiritual Care

Philip Boyle, Ph.D.

Vice President, Mission & Ethics

www.CHE.ORG/ETHICS

goals for today s conversation
Goals for today’s conversation
  • Is the role of the chaplain any different than ethics facilitation?
  • Boundaries
  • The nature of ethics & facilitation
  • Responsibilities of those engaging in ethics facilitation
    • Common risks
cases
Cases
  • The curbside consult
  • Religious ethical differences
  • Interpreting the ERDs
  • Looking for moral approval
slide4
Case
  • Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.
nacc standards
NACC Standards
  • 302.4 Incorporate a working knowledge of ethics appropriate to the pastoral context
    • 302.41 Demonstrate an understanding of the ERDs
who is providing consultations
Who is providing consultations?
  • ASBH study
  • 15,000 consults annually
    • 36% MDs
    • 30% RN
    • 11% LSW
    • 10% Chaplains
    • 10% Administration
slide7
The nature of ethics
  • The nature of ethics mechanisms
    • Promoting appropriate moral agency
  • Distinctions
    • Consultation
    • Mediation
    • Facilitation
what is ethics facilitation
What is ethics facilitation?
  • A service provided by individual or groups to help patients, families, surrogates, healthcare providers to address uncertainty or conflict regarding value-laden issues.
what s the goal of facilitation
What’s the goal of facilitation?
  • “The proper role of ethics facilitation is to advocate for an unbiased robust process and not to privilege the needs and agenda of any one part.” ASBH, 2007
commonly performed tasks
Commonly performed tasks
  • Navigating clinical setting
  • Gathering information
  • Evaluating, interpreting, and analyzing info
  • Facilitating meetings, understanding each perspective, assessing options for moral acceptability
  • Promoting ethically acceptable plan of action
  • Implementing quality assurance measures
qualified facilitation model
“Qualified facilitation model”
  • Identify and analyze nature of value uncertainty
    • Gather relevant data
    • Clarify relevant conceptual issues
    • Clarify related normative issues
    • Help identify range of morally acceptable options
  • Resolve value uncertainty by building consensus
    • Ensure concerned parties have voices heard
    • Assist in clarifying values
    • Help build morally acceptable share commitment
core competencies
Core competencies
  • Skills of ethical assessment
    • Identify the nature of the value uncertainty
    • Analyze the value uncertainty
  • Process and interpersonal skills
the facilitation
The facilitation

Ability to facilitate meetings

  • Introducing oneself properly, explaining what an ethics facilitation is and what a person taking the lead does, the purpose and limitation of the facilitation and his or her recommendations, and the relationship between the ethics facilitation mechanism and institution.
  • Ensure that all relevant parties have been invited and encouraged to participate.
  • Ensure that all parties are introduced and explain their perspective roles
  • Explain the goals and process of meeting and what can be expected.
  • Elicit medical facts
  • Elicit views and values of principles regarding issue
  • Facilitate reflective listening, clarifications, summarizing interests.
the facilitation14
The facilitation

Ability to build moral consensus

  • Help individuals to critically analyze their underlying assumptions
  • Negotiate between competing moral views
  • Recognize possible areas of conflicts between personal moral views and one role in facilitation
practical considerations
Practical considerations
  • Focus on “interests” not arguments
  • Ethics facilitator is not a judge!
    • No constraints on evidence
    • But some statements are more useful in resolution
practical considerations16
Practical considerations
  • Summarizing—most critical aspect
    • Lets the parties know facilitator is listening
    • Lets the facilitator test her understanding
    • Helps parties organize thoughts
    • Helps parties to hear what others are saying
    • Shows areas of common interest
    • Provides order to discussion
    • Lets facilitator remind parties of progress
    • Repeat in nondestructive language
    • End with question: “Have I missed anything?”
practical considerations17
Practical considerations
  • Questioning
    • To obtain a broader view
    • To obtain information
    • To clarify abstract ideas/generalizations
    • To focus discussion
    • To introduce hypothetical
    • To generate new options
    • To encourage participation
practical considerations18
Practical considerations
  • Generating movement
    • Asking problem solving questions
    • Reframing
    • Raising issues
    • Hearing proposals
    • Stroking
    • Allowing silence
    • Holding caucuses
    • Reality testing
    • Reversing roles
    • Normalizing
place of personal views
Place of personal views
  • Cannot remain value neutral
  • Do you offer your personal views?
  • How to attend to sociological power and authority?
slide20
Case
  • Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.
potential risks
Potential risks
  • Scope & limitation of role
  • Conflicting interests
  • Challenges of the role
  • Responding to unethical practice
  • Evaluation & accountability
role limitations
Role Limitations
  • Institutional role v. ethics facilitation
  • Misperception & misuse of role
  • Explaining the role
  • Appearance, comportment, interpersonal skills
  • Power & ethics consultations
role limitations23
Role Limitations
  • Role confusion
    • Primary institutional role
      • Administrator
      • Chaplain
      • Lawyer
      • Nurse
      • Physician
      • Social worker
    • How could there be role confusion?
    • How do you avoid role confusion?
role limitations24
Role Limitations
  • Misperception & misuse of role
    • Should ethics facilitators be held to a higher standard of comportment?
    • Common presumptions:
      • Moral police
      • Exemplar
      • Fixing the institution
    • Common requests that are inappropriate?
    • How do you or institution describe ethics facilitations?
role limitations25
Role Limitations
  • Appearance, comportment, interpersonal skills
    • Implications of wearing white coat, scrubs, stethoscope, clericals
    • How does appearance of gender, ethnicity influence facilitation?
      • Can you name a time that appearance, gender or ethnicity influenced a facilitation?
role limitations26
Role Limitations
  • Power & ethics consultations
    • Expertise as power
    • Negotiator as power
    • Insider as power
  • What are the reasons why judgments & actions of ethic facilitator be misinterpreted and misunderstand and lead to abuse of power?
  • How do you limit the abuse?
conflicting interests
Conflicting interests
  • What situations would be considered conflicts of interest?
    • Under what set of circumstances would you recuse yourself?
  • Competing obligations
    • Name primary obligations
  • What ways to avoid
    • Individually
    • By all members of team
    • During the actual consultation
challenges to the role
Challenges to the role
  • Boundaries & moral weight of consultations
  • Distinctions among
    • Moral uncertainty: is there a dilemma, which values apply
    • Dilemmas: good reasons for opposing actions
    • Distress: discomfort & unable to act
  • Experience of marginalization
    • Silencing
    • “Obviously unethical”
what does it mean to incorporate ethics
What does it mean to incorporate ethics?
  • Case of Fr. Dave
    • Place ERD 58
      • 302.4 Incorporate a working knowledge of ethics into pastoral context
    • Help parties apply theory to case
    • Help RN with moral distress and issues of conscientious objection
directive 58
Directive 58

As a general rule, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically-assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.”

directive 5831
Directive 58

For instance, as the patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore, not obligatory in light of their very limited ability to prolong life or provide comfort.

conclusion
Conclusion
  • Dual agency:
    • Ethics facilitator & pastoral counselor
  • At minimum: qualified facilitation
  • Religious interpretation
  • Helping patients in religious coping over values disputes
    • Feeling at odds with religious norms
  • Clarity about what you are being asked and transparency in what you can & cannot do
evaluation
Evaluation
  • http://www.meddean.luc.edu/depts/bioethics/online_masters/ethics%20consult/ethics_consult_eval.html
  • Q1: Does the ethics facilitator do an adequate job of gathering the facts of he case from the physicians? What kinds of things must the ethics consultant gather in advance of facilitating a conference?
  • Q2: Does the ethics facilitator give the physicians an adequate idea what they might expect from an ethics case consultation, in general, and in this case, in particular?
  • II. The Case Conference
  • Q3: Does the ethics facilitator do an adequate job of introducing himself and explaining what he does or what the goal of the conference is? Should he have said anything else?
  • Q4: Does the case conference result in the patient’s surrogate decision maker, understanding the medical facts of the case adequately?   
slide34
Q5: Does the case conference result in the patient’s attending physician understanding the patient’s values and wishes adequately? Does he adequately understand the surrogate decision maker’s understanding of the situation?
  • Q6: Does the ethics facilitator do a reasonable job of “supporting” the surrogate decision maker through the conference? That is, does the consultant reinforce the notions that the surrogate’s understanding of the case is welcome in the discussion and that the patient’s legitimate rights will be respected?
  • Q7: Does the conference “flow” well or should the facilitator have redirected it at points? If so, please be specific regarding when.
  • Q8: Does the facilitator help to summarize and delineate the acceptable options? Is it clear what will happen next and how matters will proceed?
  • Q9: Are the options highlighted within ethically acceptable norms?
resources
Resources
  • Bioethics Mediation: A Guide to Shaping Shared Solutions, Nancy Dubler and Carol Liebman, United Hosptial Fund, 2004.
  • Mediation Information Resource Websites
  • Http//www.mediate.com
  • http://www.crinfor.org/narrative_new _developments.cfm