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Guidelines offer models for improving quality
Revision could be springboard to better processes
Hospital ethics boards now can refer to national guidelines when developing procedural standards and processes for evaluating quality of ethics consultations (EC) and institutional EC processes.
The revised "Core Competencies for Health Care Ethics Consultation" contain these and other new sections relating to health care ethics consultations. The original core competencies guidelines, introduced in 1998, and the 2011 revised version are published by the American Society for Bioethics and Humanities (ASBH) in Glenview, IL.
"These guidelines are one of the most effective and cited documents ever published in the field of ethics consultation in the world," says Andrea Frolic, PhD, a clinical and organizational ethicist at Hamilton Health Science of McMaster University Medical Center in Hamilton, Ontario, Canada. Frolic is on the core competencies task force for the second edition of the guidelines.
Frolic has used the revised core competencies guidelines as they were evolving to recruit and train a team of health professionals who desired specific expertise in ethics consultation. "I also used that document for a performance evaluation of their skills, knowledge, and attributes as consultants," Frolic says. "I've found it a guiding light throughout the recruitment period and training process."
The hope of members of the core competencies task force is that the guidelines will serve as a go-to resource for people who are doing ethics consultations in hospitals, says Anita J. Tarzian, PhD, RN, associate professor, family & community health, University of Maryland School of Nursing, and program coordinator for the Maryland Health Care Ethics Committee Network, Law & Health Care Program, University of Maryland School of Law, all in Baltimore, MD. Tarzian chairs the core competencies task force for the second edition. "We are looking at strategies for getting the guidelines into the hands of people on ethics committees and who are doing ethics consultations," she says. "When it first came out in 1998, it was seen as a core resource for people on ethics committees. At that time, there was a focus on voluntary standards and a fear that you would usurp the health care providers doing this as part of their job. Since then, we've learned you can't have a handle on medical ethics if you don't include the clinical piece."
Healthcare decision-making and ethics consultations have reached a level of complexity that calls for standardization and a way to assess and ensure quality and competency, Tarzian notes. "It's time to take ethics consultation to another level, focusing on the standards of the service as opposed to the competency of the individual consultant," she says.
The revised guidelines carry this philosophy forward with a new focus on procedures and measuring or evaluating quality and effectiveness, Tarzian says. The guidelines hold institutions accountable for having some process for measuring the quality of their ethics consultant service, Frolic says. "A lot of academic medical centers already do this," she adds. "For those folks who have a more informally structured service, this will challenge them to really enhance their program. It's a radical concept, and I'm excited about that."
While some ethicists might take issue with the idea of measuring quality and efficiency in this realm, there are some practical reasons why it's necessary, Tarzian notes. Ethics consultants are responsive to timelines, for example. "To take a month to ponder whether or not it's OK to allow a family to keep a brain-dead pregnant woman alive on a ventilator so they could keep the baby is not helpful," Tarzian says. "Also, if you have 30 people involved in formal ethics committee meetings, and you don't need 30 people, then you are taking up their time and should figure out how to provide a quality service that makes good use of your institution's resources."
One model for assessing quality that is cited in the revised guidelines is the Department of Veterans Affairs' Integrated Ethics model from the National Center for Ethics in Health Care. It's a comprehensive approach that is implemented throughout the VA health care system's 153 hospitals, says Ellen Fox, MD, chief ethics in health care officer with the Department of Veterans Affairs (VA) in Washington, DC. Fox is on the core competencies update task force. "Much has been written about the need for ethics consultation services to establish clear standards and metrics, but there has not been a great deal of progress," Fox says. "So in our system we were really responding to that need."
The guidelines task force looked for models, approaches, standards, and tools to reference and use in the revised document. Repeatedly, they returned to the VA's integrated ethics approach, Fox notes.
"The guidelines are very closely related to the integrated ethics model, and the tools are heavily referenced," she adds.
The VA also has a web-based program called ECWeb, short for ethics consultation web, that enables an ethics consultant to document consults and generate notes that can be catalogued electronically and, often, placed in the patient's record.
"It improves ethics consultation practices by tracking, trending, and documenting the critical steps taken throughout the documentation process," Fox says.
Revision addresses organizational ethics
Members of hospital ethics committees could expand their role if they embraced organizational ethics, which is another area highlighted in the revised guidelines, says Mary V. Rorty, PhD, MA, an adjunct clinical associate professor in the Center for Biomedical Ethics at Stanford (CA) University. Rorty also is on the guidelines task force.
Clinical, organizational, and ethical ethics all are part of a broader and more inclusive term called health care ethics, according to the guidelines.
"There are broader ethical concerns that don't have to do with didactic bedside clinical consultation but have to do with the ethical issues associated with quality in hospitals and concern for the ethical climate in their institutions," Rorty says.
The task force deliberately chose not to distinguish between subspecialties such as clinical ethics, organizational ethics, and professional ethics, opting instead to use the broader and more inclusive term health care ethics, the guidelines state. The guidelines gave examples of overlaps in ethics subspecialties, including these two:
The revised guidelines also are notable for what has remained the same in the 13 years since they first were published, Frolic says. "Most of the tables on knowledge and skills were only changed very minimally," she says. "That speaks to the staying power of the work that was done in the 1990s. They got a lot right in basic skills and competencies."