Academic centers provide education, resources to colleagues

An obligation to help community institutions

Smaller, community-based hospitals may face many of the same types of patient cases that require ethical decision-making; however, these hospitals often have fewer resources than large urban or academic centers with which to receive training in this area.

And that's where the academic centers — in certain cases — step in to provide education and resources for consultation, when necessary, for their smaller community colleagues.

Susan Tolle, MD, director of the Center for Ethics in Health Care at Oregon Health & Science University (OHSU) in Portland, OR, has referred to this large academic center as the "mother ship for smaller hospitals" in that state, since it is the only health sciences center in the state of Oregon.

She has noted that the those who do serve on ethics committees at smaller hospitals would not otherwise have "the time or ability to pursue additional training, and so we attempt to help them by providing policy and helping on some of their cases."

In 2009, OHSU won the National Circle of Life Award for "exactly this" type of effort to train and educate smaller hospitals and other institutions, Tolle says.

"It really emphasized the fact that we do make this a very high priority to reach out to our colleagues at smaller hospitals, long-term care facilities, [and] hospice programs all over Oregon," Tolle tells Medical Ethics Advisor.

Likewise, some 20 years ago, Atlanta's Emory University Center for Ethics, headed by the center's current associate director, Kathy Kinlaw, used a small grant to parlay that grant into what is now known as the Health Care Ethics Consortium of Georgia (HCECG).

Today, HCECG has about 50 member organizations, including larger hospitals, community hospitals, nursing homes, and hospice organizations, as well as some individuals who are not affiliated with a particular institution but are interested in health care ethics, Karen Trotochaud, MN, MA, assistant director for the HCECG and senior program associate for the Center for Ethics, tells MEA.

Tolle explains that in order to provide the services that OHSU offers to its statewide colleagues in ethics, she is required to fund-raise.

Trotochaud says that Emory charges modest fees to its member organizations for its workshops and other programming, but HCECG is also supported by the Emory University Center for Ethics.

Structured training

In June, OHSU's Center for Ethics and Health Care will hold a statewide conference at the convention center in Portland to offer training to colleagues at smaller institutions, and about 500 people typically attend, Tolle says. The focus of the conference is palliative care.

"Last year, they represented 52 cities," she notes. "That means you're reaching pretty small cities in Oregon . . .we're down to towns of 5,000 who are coming." It is a day spent partnering with the smaller institutions and to address whatever policy questions "might be troubling them the most," Tolle explains.

"Our goal is not that they keep needing us, but that we strengthen that region, so that they are better able to partner with others to honor the talent they do have," Tolle says, noting that such individuals "may have significant contributions that they can make in their region."

Tolle says it is "not unsusual" for OHSU to conduct a conference in a different region of the state that partners with smaller hospitals in the area. Often, if the area is remote, there may be only one hospital serving it, she says.

At the local conferences, a local person always chairs the event, Tolle says, even if OHSU assists that person with his or her presentation. Those local conferences are co-chaired by an individual trained specifically in bioethics from OHSU.

The community individuals who attend the OHSU conferences are referred to as "change agents, because they are people who are our partners around the state," Tolle says. There is a "recruitment for change agents that's a mutual agreement, just as we invite people in the community to be chair of a [local] conference."

At the conferences, OHSU staff will assist with whatever policy concerns the community hospital or other institution has, as well as meet with its ethics committee, if those community members are interested.

"So, then, we would meet with the ethics committee and walk them through the policies [and] adapt it to their facility," Tolle says. "Being a smaller facility, there might be just some logistical adaptations of how it was handled . . . and we teach them enough about the policy so that they can then do their own education about the policy."

The consortium organized by Emory's Center for Ethics was originally known as the Georgia Ethics Committee Consortium. Emory, when first forming the consortium, "broadly invited provider organizations to join what we refer to as the consortium. And if they joined, what they would get in return was educational programming, access to those at the Center for Ethics with expertise in health care ethics, as well as the ability to network with other providers who were interested in health care ethics," Trotochaud says.

At its beginnings, there were a large number of member organizations, she says, "but the health care environment has changed in the last 20 years a great deal; many organizations merged and closed, and we've had lots of changes in the way health care has been provided."

Emory Center for Ethics programming

When an institution joins the HCECG, each employee of that institution is considered a member, she explains, so any individual within an organization can benefit from the Emory University Center for Ethics programming, Trotochaud tells MEA.

Emory typically has three or more workshop-type programs a year, plus one two-day conference.

"Our smaller programming is usually focused on the more nitty-gritty," Trotochaud says.

For about the past five years, the Center for Ethics has held an annual program that it calls the Ethics Committee Workshop, which typically has anywhere from 30 to 50 attendees. That workshop covers such topic as the history of ethics committees, for example.

"We talk about some of the moral theories and principles that are important in looking at ethical questions in health care; and we talk about how ethics committee are organized," Trotochaud notes. "There are a lot of different ways they're organized, but we give them some of the usual ways they're organized."

The most sought-after information at these gatherings is typically information about ethics case consultations. The basic workshop is only five and a half hours, she says. So, the Center for Ethics offered a second workshop this past year that only focused on case consultation.

Trotochaud says Emory's Center for Ethics staff are also available to all member organizations for consultation, if the smaller institution concludes that other perspectives are necessary.

Trotochaud says the center get calls from its member organizations often, fielding requests for help in thinking through various situations and potential next steps, as well as sometimes discussing problems within their individual organizations.

Dilemmas similar at all sizes of institutions?

Those interviewed by MEA suggested that problems are fairly similar at all levels of institutions, with the exception of certain services that might create their own dilemma, such as organ transplantation services, which involves scarce resources.

"I would argue that the questions are very similar: disclosure of medical errors — [small facilities] have the problem too; respect for conscientious objection — they have the problem, too; but the way it plays out in process when you are so intimate with each other" is very different, Tolle notes.

Tolle suggests a high level of sensitivity in communicating with colleagues in smaller communities.

"How you handle disagreements and conflicts has to be so much more sensitive with your fellow health care professionals," Tolle says. "And it means that someone coming in [from] outside to help you can be, for example, the bad guy [who is] suggesting something that would be hard to bring forward in your community."

In a small community, the practice of saving face is also very important, she says, noting that as smaller facilities implement new policies or procedures related to ethics, one must be "particularly sensitive to how the health care professional will be treated and respected — and not embarrassed in the process of your implementation."

Sources

Susan Tolle, MD, Director of the Center for Ethics in Health Care at the Oregon Health & Science University, Portland.

Karen Trotochaud, MSN, MA, Senior Program Associate for the Emory University Center for Ethics, and Assistant Director, Health Care Ethics Consortium of Georgia, Emory University, Atlanta. E-mail: ktrotoc@emory.edu.