Clinical Ethics: We’re Here for You

Today we have two wonderful wonderful presenters who will be talking with you about how to integrate ethics into your  clinical practice during the presentation our speakers encourage you to unmute and ask questions you have or add your questions  to the chat as you would like throughout the session today it's my pleasure to now introduce our  two presenters Dr Mark slope the director of bioethics in the department of medical ethics at curling Clinic is  one of our presenters today he's also an assistant professor in the Department of Health Systems and  implementation science at the Virginia Tech Carilion School of Medicine our other presenter is Dr Phyllis  Whitehead a clinical ethicist in the department of medical ethics she's a clinical nurse specialist in palliative  medicine with Korean clinic and she's also an associate professor in the department of internal medicine at the  Virginia Tech early and School of Medicine turn it over to both of you now  excellent thank you thank you so much for that nice introduction uh it's certainly a pleasure to be here with you  all today it's a pleasure and a privilege to present with uh Dr Whitehead we've done this a few times  and um so in all transparency I just want to say that uh Dr Whitehead does give me  sometimes moral distress um I do I do call her the queen of distress so uh but she'll explain that  later in the presentation when we get to that point but thank you it's it's a privilege to be with you and share with  you I'm going to get things rolling before I turn it over to Dr Whitehead um first thing I like to do is tell a  dad joke um so so please humor me um but uh  so here we go so it seems like I only get sick on weekdays I must have a  weakened immune system I've told that one before so you may  have heard it but uh and just one last one what does a baby computer call his father  data anyway thank you all  um slide  so here are our objectives um identify ethics Consultation Services  so we're going to go into that we're going to discuss common ethics consults we're going to delineate how to address  ethical dilemmas in your clinical practice  so right now just for a reflection I want you to think as we talk and we go move on to think of an ethically  challenging clinical situation that you've recently encountered or maybe one that just sticks out in your head one  that's in your heart you know we all need to sleep at night and sometimes these things  um you know are a lifetime these are very complex situations where we get  called in as ethics Consultants to help kind of navigate through some of these complex situations so we certainly  understand that they can certainly weigh on us and give us moral distress as Dr  Whitehead is going to talk about a little bit later slide  so I think if you would like to um if you already know your clinically um challenging situation and you would  like to add to it you can use the QR code here to actually jot it down and we  will come back in a little bit and as we're you may be thinking of clinically challenging situations throughout the  presentation and we'll be happy to hear from it and we're going to build some time in to have those discussions so I  think we go on to the next slide  so before I get to the values and ethics and kind of distinguish with some of these titles and what they mean I like  to talk or just mention about our title so our title is clinical ethics and that  clinical ethics when we talk about clinical ethics it refers obviously to the patient encounter whether it be at  the bedside or whether it being in the office and it focuses primarily on the interaction with the patient and of  course relationships with families is also pertinent to that as well  so going into the values so we all have values um you know the way we grow up  our personal values our personal needs our relationships we get them from very  many different places um whether it be a trusted ant that we  respect our parents so we get values in many different areas but we'd like to  distinguish between values and ethics so if we can pass on to the next slide so  ethics refers to what is right or wrong so we talk about codes of Ethics we talk  about the American Medical Association code of ethics we talk about ethics for Physicians the Hippocratic Oath right so  ethics has been around for a long time but it's very distinguishable from  values values are very more personal private morals you know and we  mistakenly use them interchangeably later on we're going to talk a little bit about whether or not uh religion  should have an influence points on our health care and people's decision making  especially when we talk about end of life issues so we're going to talk about  that a little bit more but just to distinguish between some of these topics is important because ethics  is a standard it is a framework there are ethical principles that throughout  the country in the U.S all ethicists and and Physicians clinicians we all use  them to deal with very complex issues when we talk about medical ethics so  ethics is definitely distinguishable from values I want to just mention also Health policy Health policy refers to  public policies that set context um that the that that delivering care of  the patients you know it deals with health insurance access to care the uninsured that's all Health policy kind  of goes under that umbrella and then of course we talk about bio ethics and  bioethics are refers to a broader questions in our society that are raised  by biomedical advances such as I'll give you an example like cloning which is an easy one right so bioethics  much broader Health policy of course deals with state laws regarding certain  issues even end of life which we're going to talk about in Virginia here a little bit we talk about ethics which  refers to what is right or wrong using a code of ethics using our principles of  medical ethics and we talk about values as far as being different than that those that can be religion some people  might value animals in the sense that they don't eat animals or they don't  um you know you know they respect animals in a very unique way and that  might be a value for them and then of course clinical ethics at the bedside or in the office  next slide please so just going to mention these I'm not  going to go into death with these but these are our ethical principles beneficence autonomy non-maleficence  Justice that's the Georgetown Mantra those are the four standard ones that we've been using for years others have  been added on respect for dignity veracity Fidelity and there have been others as well  next slide please so beneficence of course you know acting in the best interest doing good advocating for the  good of the patient you know Bene I always think of Bene Bene you know doing good doing good for our patients  non-maleficence you know doing no harm in the Hippocratic Oath one should not do harm this is when we talk about  benefits should outweigh the burdens or potential harm everything certainly you know  um has has risk and those should need and this is when we talk about risk and benefits  autonomy so you know deciding what happens to us we all know of course from the right to determination  self-determination act uh of 1990 of course you know we've certainly grown  from that that's 30 gosh 32 33 years old now uh there's a lot of trepidation uh  when that came to be about clinicians thinking oh my goodness now I'm going to have um you know patients telling me what  they can and you know and what I can and cannot do of course we've developed and  we've grown a lot from that and we want people to make inconsenses you know in  in dialogue in in discussion with clinicians to make choices that best fit  them and hopefully that happens and I must say and then when we talk about end of life issues or we're going to talk  about some other issues um in ethics and especially the the clinical and the bedside and in the  office autonomy does have limits you know these you know these principles you  know um do have guidelines to have Frameworks um so we need to keep that in mind when  we talk about these these principles next slide please  so Justice is is an important one as well it's one that we don't often talk about  um we have recently talked about this was a big issue with the pandemic of course in allocation and reallocation  when we were developing our carillion policy on crisis situation of what to do  with scarce resources especially you know events became scarce at one point  and we continually deal with scarce resources whether it be blood products  whether it be treatments chemotherapy you know products as well so we've you  know have developed a policy that certainly helps to address some of that and of course it is a case-by-case basis  none of this is is meant to address specific cases but kind of giving an ethical framework of how to do this and  we talked about when we were talking about allocation about you know the greatest number of people  um you know making sure that you know we look at our biases and making sure that we don't discriminate we do take care of  the uh the vulnerable population but also in mind of all the other principles  as well when we're allocating scarce resources  respect for dignity I think that kind of talks about itself in the sense of a title and of course we all do this on a  day-to-day basis having respect and dignity respecting a patient's diversity  their values uh you know recognizing values recognizing our own biases uh  regardless of the person's capacity to make decisions um and recognizing that you know  patience and it's very hard for clinicians sometimes you know can accept or reject  medical recommendations whether or not it's going to benefit them or whether it's or you feel or they feel it's not  going to benefit them people are allowed to make bad decisions um you know in respect to their autonomy  and that gets very difficult when we talk about some of our uh very difficult situations when we know something's  going to benefit a patient and the patient is absolutely refusing a treatment that would benefit them or we  feel that would benefit them medically next slide please  veracity confidentiality non-abandonment truth telling one of the things I know  that's been researched a lot lately um in the past years has been  true telling being honest um being forthright um being realistic and being reasonable  with our patients making sure that they understand um you know the the risk and the  benefits potential risk and benefits um and being honest with them certainly  we want to be upfront we want to allow them the opportunity to make a truly  informed consent and the only way they can do that is when they have the information that is presented to them  next slide please so I'm going to pass this over to Dr Whitehead so when should an Ethics  consult be considered what a great question we you know we get  that all the time right I think part of the many of the things that you've already hit upon particularly when we  have concerns about withholding or withdrawing of life-sustaining treatments  um sometimes it can be really controversial even about CPR status do not resuscitate right which is along  those lines um one of the things that happened and I you know we hear all along it's like okay well when can someone say I want to  be resuscitated or how to be resuscitated what are those limits what are those medical standards and how far  can we push those um we are asked frequently about when our patients lack capacity to make their  own medical decisions and how do we come about then who decides right and we talk  a little bit about surrogacy and we'll get into some other slides about how do  we determine those we have one situation that came up not so long ago when we knew that there were a additional family  members but the the person of contact wouldn't give us those names and numbers ah those kind of things right it's just  amazing when a conflict occurs um when there's disagreement between what the patient wants what the family  wants and what Physicians and the medical and surgical teams are recommending right it's nice to be able  to kind of come together and we can help with that and we go to this whole greater issue when we talk about end of  life it's when treatments and interventions are no longer beneficial or inappropriate  um so more serious to conflict the greater the need for our ethics on consult and many times we are open to  just informal or what we call Curbside so if you're not sure and you're unco you know uncertain if this was if it's  an appropriate consult just reach out because that's what our Consultants that's what we want to hear from you and  we are happy to answer any questions that you may have next slide so life-sustaining um care this is one  that we're often called about a lot of times when patient and family members particularly demand the initiation or  even perhaps the continuation of life-sustaining care  um and when life sustaining medically Medical Care is non-beneficial  treatments whether to continue or discontinue is a major issue and one  that we're often called about and one that clinicians often get into a little bit of a bind particularly talking or at  the request of the family right so it's particularly relevant in  intensive care units but it's also challenging in other settings most notably with Coleman CPR  um it's funny how we use acronym I can't even pronounce it anymore uh but CPR  um differences of opinion between Physicians and patients families about what are appropriate interventions and  specific clinical situations and it's also it's often fraught with  um very highly strained emotions and perhaps none more so when the family bases their desire perhaps on religious  belief right um so you know people often will say  well I'm praying for a miracle or you know we believe in God and we're very religious and God's going to cure my  father my mother or so on so forth and I ask a question you know to uh the folks  uh on this presentation today I asked the question whether religious belief  can justify providing treatment um that either has no or vanishingly a  small chance of restoring meaningful function is that a valid statement or a  valid request and I often like to conclude that you know generally non-beneficial treatment  by its very definition cannot be helpful and no um indeed it's often often harmful  um to patients and hence cannot be justified no matter what the source or the kind of reason you used to support  its use and this is when I was back talking about values and and so on and so forth there are limits to autonomy  and to um you know certain requests that have no benefit to the patient and ultimately  may even subject them to more more harm right therefore doctors May or  clinicians May legitimately refuse to provide such treatments so long as they do to do so of course for acceptable  clinical reasons right it's based on medical indication what's medically indicated it's based on medical science  we can't base medicine on belief or religious beliefs that you know well  God's going to cure this loved more well you know that may be true and that still may happen and we don't want to squash  that but you know we got to base our decisions on what is medically indicated what is reasonable right and um and and  that becomes very complex and you know I don't want to make it simple and say you know you say no you know we cannot do  that but it becomes a very complex situation that's often when we are called  um you know particularly when we're talking about life-sustaining care next  so life prolonging procedure and these come right out of the code of Virginia  uh is intervention that when applied to the patient in the terminal condition would  only serve to prolong the dying process right so that's what they're talking  about when they're talking about life prolonging procedure prolong the dying process and we've seen it many times  where there's complex situations comorbidities um and you know it might not be today  might not be next week but the person is dying you know there's organ failure there's so many issues with this person  that the treatment becomes non-curable right um and we're only sustaining the person  in the dying process Comfort Care the basic palliative intervention I know Dr  Whitehead can can talk weeks on this of course that provide relief of symptoms in a patient who does not seek to cure  or aggressively treat illness or disease next slide  so we want to as I mentioned Sarah that we want this to be interactive so we  have a question for you in Virginia and a strange spouse is the next of kin unless there is a medical power of  attorney true or false just use the QR code in the corner and let's see what are what you think  this is a good one a little tricky let's see what folks are saying take your time  yes it looks like it's true excellent thank you a couple that fit balls and  then we have the back and forth very good I'm liking this wonderful  so yes the vast majority it is correct that the an estranged spouse even though  they're minus range and it can be and we've had situations where we I've been told oh we they haven't been involved  for 20 years unless they've started the proceedings for a divorce then they are  the next of kin now they can defer but legally they are the next of kin  next slide so let's take just a few moments to review the hierarchy of surrogacy here  in Virginia as Dr Swope mentioned you know autonomy and self-determination is  huge especially here in the states the thing that we hear over and over again  um is well that's what they want I think that we most certainly need to make certain that first of all before we get  consent that we're con being consenting the right folks so anyone who has an  advanced directive or guardianship or conservator papers we need not just to take the word we actually need to have  them in hand so I'm going to start with that hierarchy of surrogacy in a plug we  need that paperwork we cannot just take people's word for it I'm the power of attorney I cannot tell you how many  times when we get the documents that the power of attorney document it's not for  medical decisions but it's for legal and financial decision making so not only do you get the the paperwork I would  encourage you strongly to read the paperwork to ensure sure what rights that they have actually been assigned  so outside of having any of those legal documents the spouse whether they are  estranged or not as I mentioned unless they've started to divorce proceedings then they are the decision maker  followed by adult children and keeping in mind that it's the majority in that  category many times we're asked what about adopted children do they have the  same rights as biological children and the answer is through the statute yes  but not step children so even though the step tool may be very active and and can  maybe contribute to an understanding what the patient's wishes were or are  they are not considered part of a decision making as adult children  next would be parents and we get into this quite a bit for adults we would  need to involve both parents for children both parents have equal  decision making but for children in particular the Virginia statue says that it only takes one to consent not just  what we run we run into some challenges with that one right particularly that well how do you choose  which parent you accept if they both have equal rights  so this gets really tricky and that's where it's a great time to bring in ethics to help you walk through that  siblings the next layer of um the hierarchy of surrogacy and once again  majority and this sounds simple but we have some very large family sometimes  we're looking for 15 plus siblings to try to get the majority to try to pull  them in so it can be quite Hefty and then of course it follows other blood family so down the line and each  category is the majority any questions or comments that you want to drop into the chat box about about the hierarchy  of surrogacy we're happy from an Ethics perspective if you have questions to um  to ask us we will be happy to help the other really great resource in this is  social our social workers they can do it what we call a skip Trace to try to identify all these folks and help us be  able to sort through so that we know who we are working with and all of which is  important under the informed consenting process and that leads to autonomy  next slide please so what's the surrogacy responsibility  well quite frankly it's to be that patient's voice right they should be knowledgeable of the values and the  preferences of the patient they have and if they don't know or if it's in a situation where they're not certain to  be able to then put themselves in that patient's um shoes to have that substituted judgment  and many times uh if they don't have any idea of the the what the patient would  want then it's to put the be the best interest of the patient and we use this principle best interest for children  most of the time and that's where we comes back to having the medical teams  and the surgical teams to actually put down their recommendations based upon what is medically  appropriate and beneficial so you can see how it's really important to have  that information as we make decisions gonna pause here questions comments  this is really challenge it sounds really simple but it isn't next slide  please so how do we go about creating a process  of our construct of substituted judgment and these are some of the questions that I really use Dr Swap and I we we  actually bounce these off of one another quite a bit so when we're looking and talking to the patient to try to seek  some clarity one of the questions that we will ask I think is a great list that what would  the patient have wanted if he or she had been able to foresee the circumstance or maybe they had another friend or a  relative that were was in a similar situation and we always have this weighing benefit  versus burden so what are we talking about here we're talking about beneficence and non-malfeasance here  right how do we know because it's such it's like there's never zero percent risk or a hundred percent benefit right  they're somewhere in the middle so how do we balance that with what is the appropriate medical intervention or  treatment for that particular patient right not for the group of patients  that's what we're all heart failure patients or renal failure patients but for this particular patient  and then being able to have that analysis by someone who hopefully knows the patient and even ideally had  conversations about these situations is pulling in back to what Dr Swartz was  saying values what are their values what's important to them what gives them pleasure what are things that they would  never ever ever want to ever happen to them because of the the things that they've experienced  and always like this statement which is such an incredibly uh helpful uh  processes what would the patient tell us if and then you add it in what would  they tell us if they could take in all this information and process it and make an informed decision what do you think  they would tell us to do next slide  so as we know that it we we work and live in a very very complex Health Care  system with lots of things and many interventions  so what are some of the challenges that we run into right well it's easy because of being so large and having such great  teamwork but we work in sub-specialties right so that can many times lead to  poor team communication or collaboration and when we come to patients and  families they probably make the assumption that we're actually talking to one another versus just reading the  electronic medical health care record right and this lack of communication or this  perception of lack of communication contributes right that we already have a  lot of work we're seeing there's we have a large patient caseload we know that there are Workforce challenges  and that can lead to when we have a handoff and even just how we're structured from a systemic perspective  institutional we're on seven all seven or a delay we work that there's a lot of folks back and forth and that can lead  to what appears from patients and families that there's confusion about what is the right thing what is the  correct recommended medically appropriate and ethically appropriate course of care for this particular  patient and when these concerns arise over time what that can foster is mistrust and distrust among patients and  Families and unfortunately it's not happening just at our institution this is happening Across the Nation next slide  so what we want to be able to do is course collaboration we won't the most certainly to be able to properly as we  talked about identify and determine does the patient have capacity to make their  own decisions um and of course for per our statue and per our policy it takes two folks to  take capacity away and only one to restore so our policy states that it can  be the attending of record and then it can be a second person it can be  Psychiatry of course but it also can be another physician that has not directly  been involved in their care so someone who's more objective right it's very important that we don't take a patient's  capacity away from them but as we value that now my question is is autonomy the  most important principle does that outweigh all the other ethical principles when it comes to making decisions and I think sometimes it feels  that way but the reality is no they're all equal right so how do you balance all of them that they all come into play  and that's part of why it can be very helpful to have a team approach to have not only ethics involved many times we  will bring in legal when there is a just last week I reached out to our legal  counsel because we had a different type of um Advanced Directive it was from a  different state and it had a listing from primary surrogate decision maker  there were three people listed on it and it had a comma and an and then it had a  question there was a question about well then in the event that the above were not available and then it had another one of the one  of the three people listed again so the person had taken that to mean that that  individual person that they were the real decision maker and it's like no no no it's all three of you equally now see  that there's a question for a comment in the chat box let's see  how does this capacity assessment policy work in the hyper acute setting in the  Ed and labor and delivery wow that's such a great great question  um Dr swep I'm going to jump into this and then you grab it if it's an emergent situation  then um and at that point then you are not required legally to get informed  decision consent right so then that's where the capacity would fall in because of course unless there was some  indication that the patient would not want these like a durable DNR or a post form or of some sort then in those hyper  acute situations in an emergent situation then we always err on the side  of treatment unless there's something that we could see that they definitely would not want so you're acting in good  faith and you're doing with the in in the best situation and I assume that from a labor and delivery and you can  um uh it elaborate but it would that are you thinking about more of an emergent situation because depending sometimes in  labor and delivery right you have plenty of time to be able to get that and of course a laboring you know Mom versus  someone who doesn't yes emergent absolutely so if it's emergent then you  you are covered and you're not required to get informed consent unless you know definitively they wouldn't want it Dr  Swope what else would you like to add to that no you're spot on I think you know unless you have uh proof otherwise then  you act in in good faith in in the emerging situation like they always do  in the Ed um that was a great question please keep them coming I love that  um and I think the other aspect we had a group meeting um the other day about  um a really challenging very sad situation and we ethics was part of it we had all the Medical Teams coming  together I think that we don't do this enough is have conferences care conferences with the Medical Teams the  nursing teams the other services involved along with legal along with  risk and patient advocacy it's important for us to come together to have a and to  sort through this to figure out what is the course uh best course of action so that we speak in a consistent uh similar  voice right so that we can help hopefully dispel any mistress or distrust  next slide so the special friend's uh appointment  this determination um please help work through with your social worker on this because they they  know this well and they've done this many many times um this does go through ethics in the in  the selection of a special friend appointment um so if a physician has determined that  a patient is incapable of making informed decisions about their health care and the patient has no available  next of kin then uh bioethics uh ethics  Department can appoint what we call a special friend appointment and a special friend can authorize medical or surgical  care or a treatment that will address a specific condition or discharge planning which is often the  case as well but most one of the important things is that a special  friend cannot authorize withholding or withdrawing medical or surgical care or  treatment that will prolong the patient's life such as a do not  resuscitate order um end of life or Comfort Care Focus if  that's what's the medical recommendation and so what we do for here is the social worker will petition legal uh to  schedule a Judicial authorization hearing and that's when the judge comes to bedside  um and legal does the attending will fill out the paperwork and say a comfort  focus is medically recommended and why what's the reason palliative will often  need to weigh in as far as what a comfort Focus would look like for this particular patient and then ethics will  do an Ethics consult and we'll weigh in as far as why it's medically and  ethically appropriate to move into a comfort focus and all three and plus a social worker  and plus our legal department so all five of us are present for that judicial authorization but after hearing the  evidence the judge then makes a decision whether or not to move forward whether or not medically we can move forward  with the Comfort Focus or not but a special friend is someone that hopefully has a relationship with the patient of  some sort that they may know what their wishes their values as Dr White has spoken about uh would be so a special  friend is a very important aspect when there is absolutely no one no nexup can  that we know of at least you know and if someone were to be identified as an  exitkin well then they would certainly be the one to take over uh and the special friend would need to step aside  but um so a special friend is very important we use them often the carillion  um so you know please work with your social worker when it's very hard to identify a NEX of kin next slide  so I just I mentioned the judicial authorization and that's basically the ethics console a palliative consult it's  the hearing at the bedside uh it's the attending um what the medical recommendation is  and when there's no surrogate to to agree to moving forward with a comfort  focus and that's when we were due in the legal process called as a Judicial  authorization next slide so protesting patient I will pass this  over to Dr Whitehead because she loves protesting patients thank you Dr smoke  so one of the things the safeguards that we are so incredibly um that we want to  guard is that autonomy so even if your patient has been deemed to lack capacity  by the appropriate two individuals and but yet they're still saying no no I don't want this surgery and they're you  know they're being very adamant about it there is a process to actually have a  Judicial authorization to go through and to just ensure that we are not  um discounting their autonomy discounting their values and their preferences and so this is what we would  then deem as at protesting patient a person who a patient who has already been deemed not to to lack capacity to  make their own decisions but yet still above and beyond they are protesting they're saying uh you're not taking me  to surgery they're they're fighting it is it example so in that event at that  judicial authorization that Dr Swope has already you know reviewed it will be  that special Justice who then makes the determination that yes or no that you  can either treat or not treat above and be beyond that those protests of that  patient we see this um quite um unfortunately frequently and it is a  hard one I was involved with Dr sweep and I with a protesting patient who lack  capacity at an outlying hospital and to a point where the patient was refusing  standards of care basic care would not allow for instance was pretty much  bedridden and would not allow their staff to raise the head of the bed to  feed safely right wouldn't allow dressing changes would not allow turns  and positioning and and there was a worry of skin breakdown down and so we  he this patient was considered a protesting patient and so there was we were able to get a J.A to actually take  it to make a determination that hey there there yes even though we're we hear this patient we hear the protests  but yet it is um not appropriate for them not to receive standards of care  questions about protesting patient for additional I also remember one other  case uh which was interesting to um Phyllis was a person who had  um intellectual disability um and she had um she had vaginal bleeding and they wanted to do a biopsy  and they wanted to investigate a little bit more um and um after talking to her and there was a  team meeting and and other folks talking to her she understood the risk and benefits although she you know she had  an intellectual disability um but she understood the risk and benefits she said my mother died of  ovarian cancer I'll never forget that she said you know she said I don't want to deal with this right now she said I  will come back or I will deal with this in the future he said but I just I I need to get home I need to attend to  some other things and she said then I will deal with it so she understood and you know I know there was a lot of  concern that she wasn't dealing with this right at the moment while she was in-house  um you know as far as um you know looking into this this vaginal bleeding but she was pretty adamant and she  understood she said I know I can die from this my mother died from ovarian cancer she said but I want to you know  take care of some other things so she was discharged it was deemed that she knew the risk she knew the benefits  potential benefits and so she was allowed to make that decision  that's a great example thanks Dr next slide  the the console process is actually pretty easy although we were asked this quite a bit I can't find an order in  Epic well that's because there isn't an order in Epic for ethics um all you have to do is go through our  perfect serve um paging system and there is a consultant  on 24 7. and that's what you would do what we would ask is that what's your ethical dilemma for you to tell give us  a little background and typically what we're going to ask that well what do you recommend should happen under the  circumstance and then we'll start working through that process um next slide  and part of that is gathering information you know just like we want to make certain that we have all the  information so that we can also make a balanced appropriate weigh-in on the  decision but once again epics will not be determining what the clinical practice or the medical recommendations  that comes from you as the medical and surgical teams what we will then review is the ethical aspects of it based upon  the the rationale the the medical reasoning that you have given next slide  so many times we want to make certain that because this is a team and it's collaborative and also communication we  will ask well actually which service is making the console and if it's not the attending we want to make certain that  people are aware of this um so once again complete transparency it's important that we involve the right  for instance in the ICU critical care providers maybe there are others that are weighing in if we're talking about  dialysis or if we're talking about a trach or a peg who are the players so that we have the right people at the  table who have weighed in to be able to make certain that we have all the right information not only for the ethics  consultant but the entire team next slide so medical indications so most certainly  we're going to ask a little bit about the medical history their problem or diagnosis we're going to die get dive  into the chart we're going to talk to staff and many times we'll go and actually interview the patients and and  the families we want to understand what is happening are these um you know the  treatment recommendations or lack of treatment and you know recommendations based upon is this a chronic you know  critical emergent or reversible sources what do we hope to accomplish by this  intervention or treatment if you've been able to weigh the beneficence and  non-malfeasance principle upon what's the odds of success what are the odds of failure and some how can we create that  ratio benefit to harm ratio next slide  we it's important to weigh in patient preferences autonomy right  um but as Dr soap said there are limits to autonomy right the autonomy is that  you have a right to weigh in on the medically the medically acceptable  standard of care right what's medically appropriate and beneficial and I give the example is that it's not a candy  store you don't get to go and pick a little bit of this and a little bit of that it truly is the standard of care  and then patients preferences must certainly weigh in upon that right and then if we have surrogacy then does the  family or their medical power of attorney understand what those patient preferences are and do you share that  because that can help shape what your medical recommendations are right next slide  quality of life this is a tough one right Dr Swope we get into it how do you  weigh the difference between the medical standard of a care and what what's a meaningful recovery and the quality of  life if if a patient is going to be institutionalized for the rest of their life and requiring constant 24 hour uh  in nursing care is that a quality of life that the patient would or would not be desirable  next slide and then there are all these other contextual features right nothing is  ever we we work in a very very complicated complex Healthcare um situation Healthcare is just  complicated in itself and so there's always issues of Psychosocial issues about are there family dynamics of  course it's a family conflict it's a motivation Beyond just the patient why  families or surrogates are making the decisions that they're making are there financial and economical you know  factors are there other religious or cultural issues you know what is you  know are the families members or this arrogant decision makers even aware of all the information to make informed  decisions so a lot of this comes into play which is part of how we can help sort through it next slide  most certainly too I'm not just to have mentioned there are limitations of course through the the of of of  resources and and and services right and we saw that particularly during  um covet but we continue to see that with Workforce I would argue that in many  situations we're Limited in just who our Specialists are our nurses our bedside  clinicians are those are resources as well so how do we go about allocating  and the justice of it right the ethical principle of Justice how do we make certain those who need it that are  getting it and that the most vulnerable are not overlooked from all the many reasons that we've already discussed  and we've already talked a little bit about special friend limits and why it's important that we not just completely  ignore the patient even of those that we feel have lost capacity  and then conflict of interest we all have biases that we bring to the table every one of us and those are some are  implicit and some are explicit but that's why it takes a team approach to really be aware of that and to just not  that we don't have those biases is that we're just mindful of those next slide  so the summary of the process is mostly we really want to get a good feel of what is happening clear discussion we  want to make certain that we don't lose the voice of the patient as well as the voice of the stakeholders which includes  you right the medical team surgical teams nursing teams the entire team because it's important it's important to  also State the positions of the care providers which means you have recommendations what do you recommend  for this patient and why and then you know sometimes there is disagreement  there or maybe not this agreement but lack of consensus among the providers and being able to come together to talk  it through until we can come up with well okay I appreciate that we're not all going to be in agreement but what  can worst to compromise what consensus can we come to that we can then present to the patient and or to surrogate his  his or her surrogate next slide please and then the recommendation we just  can't say this enough please please please put your medical recommendations in the chart I know that that's not  something that you are necessarily taught but it is and it can be different than your plan but in the rationale for  it so if there's something that you feel very strongly about it should it's not just verbal but it should be in a chart  and a rationale surrounding that next slide  so what is medically inappropriate so this is not defined by Statute so you  won't find this in the code of Virginia uh but these are Professional Standards right  um so what is medically inappropriate so when we're looking at a case  um and we'll talk a little bit uh or mention I guess our talk um Group which does uh treatment  appropriateness Review Committee um when we're in discussion about what is medically inappropriate uh these are  the things that we look for will not produce a desired physiological effect or and these are not end so you only  need one of these will not achieve the patients expressed and medically achievable goals or will harm or cause  harm to the patient significantly disproportionate to the benefit  or will not secure patient survival outside of acute care hospital or  qualifies exclusively as life prolonging as we talked about as defined in the code of Virginia only prolongs the dying  process so to me these are key things to look at when we're looking at uh what is  medically inappropriate next slide please  um yeah go ahead well I was just going to say when you have these medically inappropriate situations what can lead  to it is moral distress right from the health care clinician perspective and  this occurs since I am the queen of moral distress as steamed and crowned by Dr Swope earlier is this occurs when you  feel like you know the ethically morally appropriate course of action but for some reason you're not able to act upon  it and it's contrary to your core values and obligations and what it truly means is that your moral Integrity is being  compromised next slide so some examples of course is when we  feel like we are you know providing medically non-beneficial and necessary  treatments that we're inflicting unnecessary pain and suffering we're prolonging a dying process going against  patients wishes or giving false hope to patients or families or that we feel is just providing care of this it's truly  not in the best interest of the patient next slide so what can we do about that and so part  of the ethics consult service is that we offer a moral distress consult service and this is an opportunity to really be  able to support you as the clinicians and Physicians and practitioners who  having to deliver this so whereas an Ethics consult you know console is dealing with the patient or a particular  situation a moral distress console is really focused on you as the  practitioner right how can we support you what is happening what are the sources of this moral distress and it  brings us together as a an interprofessional team for Frank on his conversation about what are the sources  of the moral distress but more importantly and what I really think is special about the world is just consult  is that we devise strategies on how to mitigate moral distress and it's so  incredibly empowering so that you move from a sense of helplessness and powerlessness to actually one of action  next slide so if you are or do you feel as though  you are experiencing moral distress just like the ethics consult there's someone on call the same ethics Consultants or  on call for moral distress um you reach out to them they'll get in touch with me I take the lead on this  um but we will schedule a meeting work with your staff to really start to  tackle and address the moral distress that folks are happening moral distress is devastating it leads to burnout at  least to people leaving positions at least the folks leaving the profession in all overall next slide  so Dr swep do you want to talk about how folks can get involved more sure so throughout the year we do have ethics  training opportunities um we have an Ethics Committee um and we have the ethics Consulting  Group so I just want to distinguish between the two so when you perfect serve ethics you don't get somebody on  the committee you get an Ethics consultant so we have a group of about eight folks of diverse experience from  surgeons to we have a surgeon we have a clinical psychologist  um we geriatrics yeah an anesthesiologist palliative anesthesiologist so these folks will  actually help you know go through uh an Ethics consult and the Ethics Committee  membership and what the Ethics Committee does is they look at the overall broader  kind of context of clinical ethics so the overall kind of like the bio ethics  so where I was before we used to call it the bioethics committee this is kind of the overall thing policy review writing  new policies and so forth so that's more of the Ethics Committee and certainly we  do have uh training opportunities so please reach out I'm happy to talk to anybody about opportunities to get more  involved in our services here at carillion um you know we do  um again we call them curbside ones where we just talk through sometimes so if you have any questions or whatever  you just something doesn't feel right you know we often encourage you to to give us a call and we would be happy to  chat when you would have time to do that and then move to an ethics console if it were to be  more more involved so I do see a question what about a Community member  under I'm sorry I didn't see the question did you see the question  uh to Dr Pharaoh do you want to just unmute and talk this through because it's actually the next one is reflection  in the next slide and this is perfect timing yeah maybe it wasn't paying attention  and I heard a lot of Medical Specialties but I was wondering if it was a Community member maybe you retained under a CDA that also provides is on the  committee yes we do have some Community uh community community members for the  committee not um from the consultant perspective but yeah we do and I think  it is important to be able to get that perspective um one of the things that we just recently did again was from um from a  perspective of blood products do you want to talk a little bit about the Jehovah Witness you know in community liaison so that we make certain that we  understand and because they have their own Jehovah Witnesses have their own advance directive that specifically  discusses about blood transfusion so I think that that's a great example and it's important to have that Community  membership absolutely and it's it's pretty um even on a Statewide when we developed  uh policies that would reflect uh the code of Virginia or potential code of Virginia when we're doing State policies  uh Phyllis and I have been actively involved in different committees uh when  we did the real when we did the allocation uh policy for ourselves here at carillion but there's also a state  one uh that we were involved in helping to create and develop and certainly community members are always a part  we're always thinking you know how can we involve the community how can we get the messaging out how can we involve  them in this decision making um and it's it's for um you know the different complex  situations but we certainly are always looking of ways to involve the community  and input let's go to the next slide and let's come back we have about five minutes left and we want to come back to the  initial question that we asked or for you to think of an ethically challenging clinical situation that you've recently  encountered and we would love for you to you know drop it in the chat or unmute  yourself and we can chat for a few moments about that because that's the whole purpose of clinical ethics right  is to make it helpful and useful for you in clinical practice it's not something  philosophical that you learn in school but actually how does it make how do we integrate these principles these uh  these Frameworks into your practice any any comments anyone wanting brave  enough to share their ethically challenging situation it's that reassurance or hearing you  know from somebody you know with ethics um thinking um to kind of reassure you you know  because everybody has to lay their head down at night and and get a good night's sleep and we don't want anybody you know  stressing over some of these situations so you know if there's any way you know I feel sometimes it's it's just support  um you know going through some of these difficult situations so please don't hesitate to reach out uh if something  does feel uneasy or if you want to chat something or just run something by we're happy to hear and and to support you  I see David you have your hand up to music yes thank you I don't have an ethically  challenging clinical situation but I did want to make one comment if you don't mind please two comments actually first  thank you for a wonderful presentation very very thorough and practical really appreciate it I want to go back to  something you talked about pretty early uh Mark in the presentation we were talking about people's religious or  spiritual beliefs I think it's important to point out that many times those beliefs are a source of of  um of Good Vibes of good things so I don't you know and I don't think you intended to do this but I don't think we  want to give the impression that if somebody has religious beliefs that's always going to end up in a situation where it's sort of an adversarial thing  does that make sense oh absolutely thank you for bringing it up because you know we have an Ethics or we have a wonderful  chaplaincy group of folks here and that's one of the first questions that ethics will raise you know has has  um the chaplain been involved you know and oftentimes we'll reach out to that chaplain to kind of get a feel for  what's going on in a complex situation so thank you for bringing that up  and I'm sorry you had another point or I think he had both the points I think  oh okay really great and I think the other piece of it that you just remind us is that we all bring our own biases  our beliefs our values um and where we struggle is when the folks that we encounter that potentially  have different values than us we assume that everyone has the same values as as we do right I mean that's just that's  who how we're made is our DNA but the reality is we don't um and how do you  come to some resolution how do we expect that we're going to have different perspectives and what how do we do this  fairly justly and allowing at people to truly have a voice in their care you  know I think that that's what I love about this is that every case is unique every I mean and of course and what is  also frustrating is that we never have an absolute answer that you can say absolutely this is going to apply over  and over and over again so thank you it's a great comment I really appreciate all the participation how  about you Dr swole yeah absolutely it's been great thank you so much for everybody for your attendance and uh for  the questions and comments thank you both so much for taking the time to share with us your wisdom and expertise  and what what a great reminder that we have this outstanding resource in these very very complex clinical roles  um this is something that you can just sort of dial a number and say please come help please I I we just need your  your assistance in helping to make these decisions so thank you so much for providing that resource wonderful  you're welcome and I like to point out that we have quite a few of our other Consultants on this presentation so  thank you all for your support and just know that we're here for you so call us  have a wonderful rest of the day everybody thank you all good start to the week.