 and welcome to today's course on ethics consultation. In this first of two parts, we'll be exploring the need for procedural consistency in your ethics case consultation process. Ethics consultation is one of the three core functions of integrated ethics. The other two functions, ethical leadership and preventive ethics, are covered by other videos in this series. Before we go any further, be sure you have your worksheets handy. You'll need them for the activities later on in the video. You know, most VA facilities are committed to improving their mechanisms for handling healthcare ethics. Today's complex healthcare environment costs for a more systemic and pervasive approach. But transitioning from an ethics committee model to an integrated ethics program can be challenging. And that's where the integrated ethics coaches come in. The integrated ethics coaches, three makeover specialists determined to help facilities transform their traditional ethics committees into integrated ethics programs. Frank, the analytic ace with years of clinical experience and ethics expertise. Danielle, the communications connoisseur with a background in ethics related customer service. And Scott, the process pro with an eye towards streamlining work processes and procedures. The integrated ethics coaches ready to help you make sure your core functions are functioning. In today's episode, the integrated ethics coaches will be working with Prospect VAMC, a typical VA medical center in any town USA. This is Dr. Mike Burrows, head of the Cancer Center over at Prospect VA Medical Center. He's also chair of their ethics committee and has been for the last eight years. We'll be sitting down this morning with Dr. Burrows and some other members of his group. So these folks have been at it for a while. It seems like they would have a pretty good handle on where their program is going. Maybe Danielle, but I understand they're still struggling with how to incorporate an integrated ethics approach. Yeah, plus they all have other jobs and responsibilities at the hospital. I mean, these are some busy, busy bees. But at least that's a buzz eye here. So who else are we seeing today, Frank? This is Maria Ruiz. She's a nurse specialist for geriatrics and has been an ethics consultant for the last two years. Bzzz. And finally, Tina Whitley. She's a licensed clinical social worker who works primarily in surgery. She's also a founding member of Prospect's ethics committee. So she's been around the hive for a while. Why don't you buzz off? Ouch. That really stings. Okay, okay. Our job right now is to help these seasoned ethics consultants improve and enhance their consultation process. All right, folks, we'd better get moving. Time to make the honey. You should comb your hair. You're so sweet. Our files indicate that your ethics program has been around for a while. It sure has. I myself have been involved in the committee for, well, it's got to be at least 14 years, the last eight as chair. So are you three the core team for ethics consultation? Well, that's one of the things we're trying to figure out. We know that not everyone on the ethics committee has the proficiency required for ethics consultation, but at the same time, we feel that we might need more than just the three of us. As far as what the ideal size team would be, there's no simple answer. No standard formula. Every facility is different. Take one clinician, one nice, one clergyman, stir-in medium-sized conference room, season of taste, voila, instant ethics consult team. No, I don't think so. But I will say this. I think you guys are in pretty good shape. I mean, you have a nice mix of backgrounds and skills. What? I can say nice things sometimes. Oh, and me without my tape recorder. Okay. Presenting for your edification and enlightenment the knowledge, skills, and traits necessary for top-notch ethics consultation in the center ring. We have the knowledge. Knowledge is power. You gotta have knowledge. If you don't got it, you gotta know where to get it. You gotta know your ethics. So what do you gotta have? Anyone, someone, tell me something. This is the part where you respond back. Yes, you little itty, front row. Something on your mind? Oh, oh, how about clinical literacy? You know, understanding of medical jargon? Ding, ding, ding, ding, nurse Ruiz takes an early lead with 50 points. Well, what do you mean points? No way, kid, you bother me. Look, anyone else wanna try to ring the bell? Well, of course you need to be familiar with a broad range of ethics topics, informed consent, conflicts of interest, life-sustaining treatment, and so on. Oh, Dr. B roars into lead with 100 points. How come he got 100? There's a long list of things you need to know about. It's all in the ethics consultation primer. Oh, and Ms. Whitley out of nowhere roars into the lead. She's right, folks, it's in the primer. You should have all read the primer by now. Okay, now you may be asking yourself, is it worth all this effort for that knowledge? Well, let me tell you, neighbors and friends, ladies and gentlemen, it's an effort that pays you back. Because without this knowledge, it will turn a seemingly normal consultation into the kind of master that can ruin you, your patient, and the whole program. Is it always like this around you guys? The fun never stops. I think we all take the need for ethics knowledge seriously, but it's not as simple as just checking it off some list. You can't just go to the knowledge mart and pick up two bags of bioethics concepts. I like you. Developing your ethics knowledge is a never-ending pursuit. You need to continually reeducate yourself, attend conferences, read journals, and don't forget that ethics expertise is about more than just knowledge. You also need to develop certain skills. Analytical skills. Communication skills. The ability to facilitate and foster dialogue. The ability to identify ethically justifiable options. Pickle thinking. Listening well. And consensus building. The skills you need are all outlined in the primer, along with the traits that make these skills achievable. Like patience. And tolerance. And humility. She's got loads to be humbled about. We'll be moving on in just a moment. I'd like you folks to show us around the facility a bit, if you don't mind. Sure. But first, we always have to ask, what would you say is the single largest obstacle between your current situation and a first-rate ethics consultation service? Staffing. Manpower. Time. Our administration is very supportive of the idea of ethics consultation. But in actual practice, it tends to be treated more like a collateral duty than a primary function. It's something we have to make time for. I hope that's all going to change soon. It's one of the things we address in our session on ethical leadership. In the meantime, there may be some things you can do. How has your supervisor handled the situation of having to make time? Well, I haven't really pushed it. I mean, I've said generic things like, well, the consultation service seems busy, but it doesn't seem like she's gotten the hint. This is Ginny Ansey you're talking about. I know you probably already know this, but for the record, hinting isn't the same thing as communicating. I know. It's just that I don't want to see. You just don't want to complain. Oh, I love this woman. Please, please, can I take this one? Look, look, I can fix it. I'll be very persuasive. Scott. I'll be good, I'll be good. Ginny Ansey, you said? Yes. Up, up, and away! It's going to be interesting. Maybe you could show us around. Certainly. One of the first things I'd like to address is access to your consultation service. It's important for staff, patients, and families to know what the ethics consultation service is there for. Excuse me, if you had an ethics question related to one of your patients, what would you do? The patient number for ethics consultation is right there on the board. It is, look, have an ethics question, page the beeper. That's great, let me try something else. Oh, excuse me, can you tell us when it's appropriate to request an ethics consultation? Sure, it's basically any time you have uncertainty or conflict about the right thing to do. We get literature on it every year, plus, I think there's something about it in employee orientation, if you remember. If you have any questions, just contact your supervisor or else, call the ethics consult service. Excuse me, please. I gotta start working out. Well, it certainly seems your service is well publicized. Are the patients as aware of all this as the staff? They get a brochure about our service when they're admitted and that same brochure is available in most of the waiting rooms and at every nurse's station. And there's an ethics link on Prospect's homepage. You guys are good. I wonder what's going on upstairs. I'm on my way to talk with Jeanne Yancey and find out why poor Maria Ruiz doesn't feel like her work on ethics consultation is valued and since this is a federal government job, I'm gonna go into GMAT mode just for a minute. It's gonna be real Joe Friday type stuff. Jeanne Yancey? Yes. Ms. Yancey, I'm here in an official capacity and it's imperative that I talk with you. I don't. It'll save a lot of troubles later on if you just follow me, please, ma'am. You know, I really don't. Sir, could you wait a moment, please? It'll only be a minute, ma'am. Sir, I really, what is your name? You can call me Scott. And I need to know why you're here, Scott. I'm doing a friend a favor and actually I'm doing you a favor too in the long run. Now, do you recognize this desk? Of course I do. It's Maria's, nurse Ruiz. It's very good. Now, tell me what you see. I don't understand what you're asking. And I am gonna have to ask you. I'll tell you what I see. I see files that need to be filed. I see beef surprise. I see stacks and stacks of policies. And what am I missing? I'm missing something. Patience. Nurse Ruiz provides care, doesn't she? Well, of course she does. Now you're really letting me know it. You look fabulous, by the way. Can I ask you something? Do you think this hospital values the work that nurse Ruiz does on the ethics consultation service? Well, we value that work as highly as we do all the other aspects of patient care. Then why aren't her ethics responsibilities made explicit in her performance plan? I really haven't considered. And couldn't you buy her a little more time if you took her off the nursing policy committee? I guess. You see, here's the thing. Nurse Ruiz, she doesn't want to complain or anything. So she's never told you how overwhelming all this stuff is. And believe me, we're gonna be teaching her how to speak up and how to express her concerns because we know it's not fair to you to turn into a mind reader or anything. But in the meantime, anything you can do to let her know that you value her ethics responsibility and that you want her to have the time to do it will be absolutely terrific. Don't you think? I guess. You are just too great. I am serious. She's gonna be thrilled. Don't be a stranger. May I ask what happens when someone pages the ethics consultation service? Well, that all depends. On what? Well, for one thing, it depends on who's wearing the pager that day. Oh, it depends. Exactly. It's not that complicated. I get the page, I call the other two and we get to the bedside ASAP. I try to get a little preliminary information from the caller first, or I might review the patient's history myself before I call the other two. Exactly. It depends on circumstances. Sometimes I'll see the patient first myself to see what's why, but I mean it depends on how much time I have. No problem. I beg your pardon? You need to be consistent with your initial response. And the first step of that response should be to clarify the consultation request so that you can come up with your game plan, including which members of the team that you wanna involve. Based on the complexity of the case, the subject matter, the nature of the request, not on how much time you happen to have at that moment. No matter which one of you gets the page, this needs to be your initial step. What we're saying is for ethics consultation to work best, you have to have procedural consistency. Both you and the people you serve have to know exactly what to expect at every phase. Jill Ingersoll just sent me a page. She has an ethics question. Do you mind if I step out a minute? Actually, why don't you call her on the speaker phone? That way we'll be able to follow along and talk about it later. All right. Extension three, two, one. Jill Ingersoll. Hi, Jill, this is Mike Burrows returning your page. Your call came at a really good time. We have the whole console team here doing a little training. Have you on the speaker phone? Is that OK? Sure. What's going on? I've got this patient with a living will that says he doesn't want his life prolonged. It also names his wife as the durable power of attorney. She thinks it's too early to give up and wants to do everything. I want to honor the patient's wishes and remove the feeding tube. Well, it sounds a little too complicated to give a quick yes, no answer. Can you back up a minute and give me some more specifics on the case? Sure. The patient is Everett Johnson. He's 75. He's had multiple strokes. And he has a feeding tube. It's been one thing after another. His wife says do everything. So that's what we've been doing. And then yesterday, out of the blue, his sister shows up with his living will that says he doesn't want to be tube fed, specifically that his wife needs to follow his wishes as stated in the living will. So I think it's pretty straightforward. It sounds pretty straightforward. But let's clear up a couple of things just so we know for sure what we're dealing with. Shoot. Is it a VA living will? Yes, it's our standard form. And the tube? Yes. Signatures there and everything? Absolutely. Two witnesses, everything seems right by the book. And it says specifically that he doesn't want a feeding tube. OK, next. What is the patient's prognosis? Really poor. The way things are going, I seriously doubt he'll survive another trip to the ICU. And why does he have a feed? No, he's NPO, recurrent aspiration pneumonia. Practically everything he eats goes straight to his lungs. So there's no way he could be fed orally? No way. He doesn't talk at all. Oh, can he communicate non-verbally? Intermittently. He's pretty out of it most of the time. Has he had a formal assessment of decision-making capacity? I think so. I'll check. Well, you should be sure that that's adequately documented in the chart, especially if you're thinking of withdrawing the life-sustaining treatment. Good point. You're right. I'll do that. OK, let me summarize here by formulating the ethics question. Should you remove the feeding tube over the objections of the surrogate based on the patient's clear, advanced directive? That's exactly my problem. Now, what if? Not yet. I thought I should talk to you first. What I want to tell her is that we need to follow the patient's advanced directive. He said no feeding tube, so there's really no choice. Isn't that our policy? Right. VA policy states that the surrogate must follow the patient's wishes as far as they're known. It's a matter of patient autonomy. The patient still gets to make his own decisions even after he's lost decision-making capacity. See, that's what I thought. Tell you what, Mike, I'm going to talk to her and see how it goes. I'm hoping I can get her to go along with it. It would sure make things easier. It definitely would. These conversations can get a little dicey. Do you want me involved? I don't think so. I'm going to do what we talked about before. You know, make sure we stay focused on what the patient would want us to do. Sounds good. One more question. Anybody on the team have a problem with the feeding tube withdrawal in this case? No. I don't anticipate any problems on that front. And the patient? Definitely. Given the condom. I've already got to call into them. Hey, listen, I've got to run. Someone's paging me. How are you? You bet. Hey, do me a favor. Would you do a consult? No for the chart? Yeah. Yes. Great. Talk to you. Well, sorry about that. I guess it was pretty much a false alarm. What? What's wrong? Is there anything wrong? What did you see that went right? What did you see that you would have done differently? Let's pause for 10 minutes to analyze this telephone conversation between Dr. Ingersoll and Dr. Burrows. Use the worksheet labeled Exercise 1. There's a transcript of the telephone conversation and a few questions for you to discuss. When the clock on screen reaches zero, we'll come back to the action.