 So for our afternoon, I have the privilege of moderating I'm Laney Ross for those who don't know me one of the co-directors Associate directors of the McLean Center this afternoon Our first panel is going to be on ethics consultation and our first speaker is going to be Ellen Fox Who is the chief ethics in health care officer for the veteran health? Administration as well as a physician and internal medicine whose areas of expertise includes ethics consultation professional standard for ethics consultants ethics education ethics evaluation Organizational ethics and ethical issues and end of life care So we could have put her on every single panel for the whole week She also leads the National Center for Ethics and Health Care Which is VHA's primary office for addressing the complex ethical issues that arise in patient care health care management and research Welcome back Ellen. Thank You Laney. It's great to be back. I missed last year So it feels kind of like coming home again. Thanks to Mark Yes, so I'm gonna be talking today. Yes, that's my thanks about the Use of several tools to improve ethics consultation quality You like to acknowledge a number of people on my staff who are involved in the work I'm going to present today, but I'd in particular like to acknowledge dr. David Alpondre Kenneth Berkowitz and Barbara Schenco I'll be describing three practical data collection tools To improve ethics consultation quality along with a few highlights of data That I hope will demonstrate how these tools Can be used to measure and and ultimately improve ethics consultation quality To put this in context These tools are part of a much broader initiative called integrated ethics. Some of you may be familiar with it I presented on it at this conference probably several times, but It's a Comprehensive approach to ethics and health care. It's a model that we've implemented throughout the VA health care system and It really applies principles of business management quality improvement systems redesign organizational change thinking to manage and improve System performance in terms of ethical practices. So it's sort of a different way of thinking about ethics in a health care organization and the Ethics consultation is literally in our model the tip of the iceberg And I'm just going to be talking about some of the tools that we have relating to ethics consultation So these are really three tools from among dozens of tools that we have That make up the broader initiative and I'm just give you a hint of some of the activities In order to improve quality you have to first establish standards, which is something that Sometimes folks have been reluctant to do in terms of ethics consultation to systematically collect and analyze Empiric data and then to use these data to target quality improvement efforts the first tool I'm going to be talking about is EC web. I presented about this a couple of years back here I think and I'm just going to be updating you on some things that some data we have there and this is a Sophisticated web-based software program that we use to track and trend ethics consultation throughout our system To this just to give you an idea of This is the first screen that you get an EC web and I'm not going to have time today to talk about all the different things the program does but It's a relational database that's currently used by over 1700 ethics People performing ethics consultation in VA and those folks are working individually or in groups and It's based on cases CASES which is the an acronym that is the standardized approach we use for ethics consultation and In total there are I believe there's more like 6000 consults now from our 139 medical centers and other facilities entered into the database So here's some data this graph shows The total number of consults per quarter Over time from 2008 through 2010 our fiscal year just ended the end of September and So this is the volume of consults and you can see it's been rising steadily over time We now have about 500 new consults per quarter And I can't tell you whether this is actually an increase in the number of consults Or whether this is just an increase of the usage of EC web. I suspect we are Approaching a hundred percent usage of EC web in our system. So we may be seeing this flatten out and But I can say that You know, I can't really say anything about quality here other than to say that If you're using EC web, you are using a standardized and very consistent and thorough approach to documenting ethics consultation It allows the system allows us to measure any number of different variables And I'll just give you a couple examples So this graph shows the percentage of consultations that were requested by individuals from that Outpatient setting and this percentage has been gradually increasing over time from 23% when we began measuring to Roughly 30% nowadays and we've also seen similar rise in for example the percent of consults that come from mental health relative to Medicine and some of the more common services and this is really In the integrated ethics model, there's an emphasis on integrating ethics across all Parts of the organization inpatient outpatient nursing home, etc. And so we see this as an improvement To not just have consults in your inpatient settings EC web also allows us to measure a variety of steps involved in ethics consultation process measures such as whether the attending position was Notified whether the patient's decision-making capacity was established, etc. Here's a couple examples there. This is Whether the first line is whether the consultant documented what we call the ethically appropriate decision maker This is a step in our model that we think is important and as you can see that's gone up gradually over time the other example is Identification of underlying systems issues So one of the steps again in our process is consultants are supposed to actively review each case after the end of the consult To determine whether it suggests underlying systems issues And so we've seen that number going up gradually over time here from 33% to 44% identified underlying systems issues There's just a couple examples for EC web and I'm going to move on to the second tool so this An important aspect of ensuring high-quality ethics consultation is to satisfy the needs of the those involved in the consult The customers or clients and so we systematically collect feedback on the consults this is our feedback tool and I'm going to show some data from this We encourage consultants to seek feedback on all consults and and this is the Percent of the total take case consultations for which we have at least one evaluation and remarkably We have almost one-third of all case consults in our system throughout our country are now evaluated And that's rising over time and I think that's a pretty remarkable number In terms of the results of those evaluations This graph shows how staff rate their overall experience with the at the oh this is staff data I'm giving you overall experience with the ethics consultation service and on the y-axis is the combined Percent who rated Good or very excellent overall for the their experience and here we've gone up From 76 to 88 percent overall, but you'll notice there's an interesting shape to this graph And I'm gonna say a little more about that we were curious when we saw this couldn't quite figure out what's going on and if you If you think about what it really appears to be is there's a rather steep slope upward And then there's a sudden fall really and then there's another steep slope upward There's actually other data that that supports that same shape And when we look to try to figure out what was causing this this is what we found This is a the number of case consults that were evaluated in our system and so the arrow marks where we actually made a change in practice and we asked our our Facilities to start using evaluation data and do an improvement plan That year and you can see roughly there was roughly a doubling of the number of facility of the number of case consults evaluated so what we think happened is are the early adopters in our Who are evaluating things voluntarily early on were probably the better programs And they they got better even better and then it dropped down again when more programs were evaluated And now we're seeing it come up again Okay, and I'm getting the time signal and didn't realize that Okay, so this is the same pattern for Other aspects of the same Instrument you can see here We're up to 95% in terms of being timely enough to meet your needs so the final instrument is a Self-assessment tool for consultants based on the ASPH core competencies and they rate themselves on number of knowledge and skill areas so this is How consultants rated themselves on identifying the nature of the value uncertainty or conflict Underlying the needs for a need for ethics consultation. You can see five percent thought they were novice 55% basic and 40% advanced in terms of their skills and we've provided education on this particular skill And so this makes sense Contrast that with moral reasoning and ethical theory as it relates to ethics consultation and you can see their ratings are a little worse here not so many a lot more people rate themselves novice and we haven't had quite as much emphasis on that in our education and Another example here's how our consultants rated themselves on shared decision-making with patients in terms of content knowledge Most of the consults that we have on the national level are in the domain of shared decision making so that's a good thing that they think They're competent in that area only two percent of our consults are on resource allocation and here you can see a different pattern where there's a less Confidence in people's Competency in that area I'm gonna I think my time is up so I guess I'm gonna have to skip this slide But there are certainly a lot of limitations for all the data I presented today So these are practical data collection tools. They are available On the internet along with other tools that are free for you to use With the exception of EC web and that's our computer program We would love to Be able to make that available and we're trying to figure out a way to partner with other Organizations and get funding to make that happen, but we haven't been able to do that so far We're gonna have a lot of data published in a special issue American Journal of bioethics in the coming months It'll cover a lot more of the integrated ethics data in our systems. Thank you Next speaker is Dr. Robert war who is co-chair of the Healthcare Ethics Council and senior fellow at the Center for Bioethics and Human Dignity at Trinity International University, he's professor of bioethics at both the Graduate College of Union University and Trinity International University and a professor of Medical Ethics at Loma Linda University He's also chaired the Council on Ethical Affairs of the California Medical Association and was vice president of the American Society for Bioethics and Humanities Dr. Orr today will be talking about a comparison of methods of training clinical ethics consultants Well, thank you, Lanny. Thank you mark and thank you to the McLean's and thank you to Liz and Kate for putting this program together I'm one of the few people here today who was present at the very first McLean conference 23 years ago, and I've been back for probably more than half of them and Some things have changed over time like the size some things have not changed Like when you put mark and charge at the clock the program goes to hell in the handbasket Now for those of you who came from a great distance to hear the talk that was published in the brochure You're gonna be disappointed because that's not exactly what I'm gonna talk about I'm gonna talk about instead how to draw an ethics a clinical ethics consultant. This is a more focused question than was then was advertised and it's a part of a Presentation I gave in Amsterdam last spring So the question I'm going to address is of the various training programs and clinical ethics What factors are associated with actually doing bedside ethics consultation after the training? I don't need to show this slide to anybody in this room, but I'm showing it for a purpose Clinical ethics is the identification analysis and resolution of moral problems that arise in the care of an individual patient In the consultation process that I'm talking about is the individual consultant model as we learned here With a formal report on the chart discussed at a weekly multidisciplinary clinical ethics case conference for accountability With a short summary to the ethics committee to look at educational opportunities policy issues and so on Wayne Shelton who I think is here He and I there's Wayne he and I published in the Journal of Clinical Ethics a couple of years ago a piece about the process of Doing consultation and format for writing a report And that format includes of course the demographic Demographic information the question that's being asked the narrative the story of what's going on then an assessment Which is a brief and this is the hardest part for students to pick up But it's a brief summary of the clinical situation and of the ethical issue And then a discussion broken into two parts a generic discussion about that ethical issue Then an application to this case and then some recommendations And you'll see that that fits nicely with the With the definition of clinical ethics because are the identification appears in the Assessment analysis appears in the discussion and the resolution hopefully in the recommendations Now I chose to look at only the seven ethics training programs that I've been involved with over the last 20 years The first of course one year here at University of Chicago full-time 12 months full-time fellowship And I went to Loma Linda and helped to establish a master's program I taught the clinical part of it and the clinical part was a seminar format that lasted for two quarters Then I was and continued to be involved with the master's program at Trinity University just outside Chicago here Which the clinical part is really quite condensed. It's an intensive in just one quarter Then when I went back to the unit when I went to the University of Vermont I put together a faculty training seminar so that I could get other people to do consults with me that training lasted 10 months And if I had two mentoring Experiences one in California one of them, I'll tell you a little more about those later and then Bob Baker's online program from Union Graduate College in Schenectady I've been teaching the clinical part of that the practicum which is one quarter online None of the fellowship experience that we've just completed at Loma Linda our training five clinicians to do ethics consults that lasted for two years So what are the variables in these programs well the purpose of the program not every program in clinical ethics is designed to develop an ethics consultant The duration of the program quite variable Whether or not it gives academic credit Who are the trainees who come into the program? What's the content of the program and what's the consultation experience? So I did a very short survey Asking participants which program and when What was their position at the time of the training primarily where they clinician versus non-clinician? What was their content there excuse me their consult experience prior to taking the training? If they had done some what model was used in their consult experience after the training and What model they used? Had a 63 percent response rate and I just mentioned that those who surveyed You see only six at the University of Chicago. Those are the six who were in the year that I was here in 1990 didn't Inquire of all of you folks for a couple reasons one at the time I was doing the survey the the Database here was being upgraded and really was not available So I can send it out and the program has changed significantly since I was here So it's more uniform to look at just those six So 179 surveys went out got a hundred thirteen back confusing slide, but it's really quite simple some preliminary conclusions Programs associated with the highest percentage of ethics consultants among its alumni Are undertaken by clinicians? Longer in duration Have more patient contact and have more consult write-up experience Then of those programs Went from three who did consults before to all six doing consults afterwards the mentorship One person in California one in Vermont Neither one had done consults before and they both did afterwards In the fellowship program. We've just completed at Loma Linda Five clinicians came into the program and all five were doing consults afterwards. So looking at just those three That twenty three percent who were doing consults before their training and a hundred percent afterwards Now just to look at those three programs and again, this was the McLean Center program 1989 The purpose was to train physicians at that time in the theory and practice of clinical ethics No academic credit the trainees the year that I was there were all six were physicians The content weekly seminars university courses rounds teaching Supervised consults weekly case conference research and publication The content of the consult experience varied quite a bit I did 26 consults during my year here some did only two or three, but everybody had some Consultation experience Skipping on to mentorship In California the director of the pediatric ICU approached me soon after I arrived there Saying, you know, I'm convinced that I'm doing some things that are unethical to these kids and need some help in working through this So we spent a year working with me Learning how to do consults learning how to do the issues and in the first two years. I was there I did 58 consults in pediatrics And then right after that dropped way off because he was then comfortable doing the consultations And I knew when I got a consult from his unit. It was going to be a singer Then in them when I went back to Vermont I did that faculty development seminar first to get some some colleagues, but then I Recruited a young physician a pediatrician was also an Episcopal priest and had an MA in ethics from Oxford But he had no clinical ethics experience over a period of three years Well, actually two years of mentoring and then my third year. He took over the program with my planned retirement That's my first retirement which I failed for the first time. I've since failed the second reserve And he now directs directs the program there neither one of these Got academic credit. They were both physicians and the content as you can see up there was was fairly intensive And they did a lot of consults the fellowship that we've just completed at Loma Linda involved five physicians and I was asked specifically to train physicians and clinical ethics to join the ethics consult service because after I left in 2000 I left two people that I had trained in charge of doing consults and One left the institution. The other got overwhelmed and busy with other things and so the consult service was Not doing as was not as robust as it had been So I was asked to come back and train five physicians again. No academic credit these trainees They were all faculty physicians and They were given 10% time freed time to do Ethics and some of them had graduate training ethics. Others did not We had bi-weekly seminars with long readings They practiced writing up consults done okay, and They did they did a lot of a lot of consults Couple personal observations The quality of analytic thinking Increases with a number of cases discussed whether that's in the seminar or in case conference The qualification that excuse me the quality of the consultation report Increases with a number of reports written whether practice reports or real Thank you. Thank you Bob. Our next speaker is Susan toll who's the camellia Stevens endowed chair in health care ethics at Oregon Health Sciences University She's a practicing internist in the division of general medicine and geriatrics Susan founded and has directed the Oregon Health and Science University Center for Ethics and Health Care since 1989 and has Successfully gotten three endowed chairs in the program as well as has a very robust program today She's going to be speaking when resuscitation is not the most important question. Welcome back It's wonderful to be back. I was a fellow here in 1988-89 and This is my 21st McLean conference and you've grown mark We were much smaller then This year I will focus only on things that have happened within the last month Because so much is happening with the physician orders for life-sustaining treatment program that will focus on an article That was published this month and Jags On a article that is in abstract form only but will be published and I can only share with you What is in the abstract and a lawsuit that was filed last week? I do not make money on the post program an opportunity to fundraise for it and support it So how anyone completes the post form or requesting or declining or a mix of both? Does not benefit me financially The post program has grown since we last spoke of it here in this context And in fact has grown since I made the slide a couple of weeks ago with Montana now being an endorsed program Endorsed means you have all core elements. You're working with your EMS. You have a functional coalition You have no laws or obstruction and you have a plan for rollout even if you haven't extensively rolled out yet Developing means a whole range of things from you have a coalition meeting Do you really are very near the level of endorsement and? 20 states are in the process of development What I'd like to argue over the next eight minutes is that? The action within a post form Which is called many different names in many different states, but the action is in section B That's section a which discusses Resuscitation for a post appropriate population People with advanced illness and frailty post is not for healthy people Post is for people who may be long-term residents of nursing homes. They may be enrolled in hospice They may have advanced frailty and be in a retirement community with a walker That this group of individuals has an extremely low level of success if Resuscitation were attempted and whether or not you want it. It's not going to have a very substantial impact on your long-term outcome Section B. However, we'll have a profound impact on What happens in the next months of your life and it will help determine the location of your death this study? Examined 90 nursing homes with an equal number of pulsed and non-pulsed using nursing homes in Oregon, West Virginia and Wisconsin 20 people in each of those 90 nursing homes Traditional practices meant you did not use post and you had traditional DNR orders or whatever orders You may have written in your chart, but there was not a structured format and Compared to an equal number of facilities using the post and looking only at section B You can see that slightly ahead of any other category for long-term care residents That limited interventions was the most frequent one chosen. I want the easy things done I want to go back to the hospital treat dehydration Treat my pneumonia. Don't send me to the intensive care unit I don't want to be intubated and if you look at the number of long-term nursing home residents who actually Wanted full treatment and wanted to go to the ICU. It's 12% So when we ask people and record what they want Long-term nursing home residents typically do not want ICU care now. This looks at what happened During a 60-day period of time for people. However, they had marked their pulse form Remembering that people who mark comfort measures only Tend to be a little older and a little sicker than people who marked that they want more treatments So the opportunities for hospitalization are actually greater in the comfort measures only Category because they're a sicker more frail group They had a 67% reduction in hospitalization and ICU visits in a 60-day period of time for those with a pulse form The newest study which is in this month's Journal of the American Geriatric Society Looks at every single inconsistency If you had pulsed orders in a 60-day period of time How often were those orders not followed? for resuscitation Almost half of the residents in the study died not a single one received CPR who had a do not resuscitate order Not many people get CPR at long-term care if they have a Resuscitate order that appears completely unrelated to post that appears to be traditional practices in nursing homes for unwitnessed arrests comfort measures only though is a option that was Recorded more effectively with the pulse program than traditional practices and when people are transferred to the hospital the first presumption is Were their pulse to orders ignored or was there an excellent reason why the transfer was done of The patients in this study from the nice 90 nursing homes 35 were transferred to the hospital when they had orders for comfort measures only of those 26 Reviewing the records. We had an excellent Identifiable reason why the transfer was needed for comfort would not stop seizing fell and broke their hip in fact half were trauma and Something needed to be done for their comfort that could not be managed in the current setting of chair So 74% of the time in the record we found an identifiable Excellent reason why the transfer did occur and should have occurred and within the design of the program what we would have desired There's a lot more data in that article and I'll commend you to take a look at it about what happens if you say Limited trial of artificial nutrition the bottom line is you're likely to keep the feeding tube So there are certain things that go beyond that But the numbers are quite small and in general post wishes were remarkably well respected This is the next Study this one is in abstract form only I will not be able to answer further questions beyond the slide because it is embargoed This is a study that is the first study led by Eric from me Of the Oregon Post registry the registry has been in effect for less than two years This is the first year where anything signed and dated within the first year of registry operation Was included in this study How do people use the form? It's from all settings of care Oregon has about 32,000 deaths a year and During that first year twenty-five thousand post forms were submitted Which is remarkable for something that's just getting started that you're educating about statewide and did exceed our Expectations for the first year in the registry today. We have Just over eighty thousand post forms submitted to the Oregon Post registry This is what a broad sample of persons with advanced illness and frailty in an entire state look like Most people are over age 65, but we do have newborns children born dying But only about 1% of the population is under age 18 Majority are female. We have a lot of nursing home residents as part of the study and the registry Majority people have a do not resuscitate order, but it is only three quarters It's not all What I want you to look at for just a moment is if you mark Do not resuscitate or I want resuscitation. You tend not to mark the same thing all the way down That very few people mark. I want everything or I want nothing The typical is to want some and not others and that the pulse program really allows For the mixture of what people want Because it's published in another place and monthly we report to the state on the registry and it's available on the website I will tell you that 10% of forms coming into the polls post registry every month are Revisions of someone who has an existing form. This is very much a living document things do change over time and This is the major findings reported in the abstract if you know code status You know code status You do not know if the patient would like to go back to the hospital in section B and it's exactly 50 50 Do you want limited interventions, which is the larger category of the two and go back and have the easy things fixed Do you want I see you care, which is the smaller of the two or would you prefer to stay in your current setting of care and Of the focus on your comfort that you are completely unable to predict whether the patient wanted to go back to the hospital or not If you know that the patient had a DNR order our appeal is do not resuscitate does not mean do not treat and That when you know code status, that's really all you know It should not be used in any way to predict whether or not the patient wishes to return to the hospital There's a lot more information about the pulse program at pulse.org About each individual state about each individual contact and it's exciting to see Illinois be a developing state since I was here last Thank You mark and Thank you for all your mentorship Angela Bradbury sends her regrets and so we're going to continue with Dr. Alberto Federe Who is a professor and chairman of surgery at the University of Buenos Aires? Dr. Federe's was an international guest scholar of the American College of Surgeons And he's the appointed chair of the Department of Surgery at the hospital Dr. Carlos a Ocalando in Buenos Aires, Argentina welcome back. Thank you, Lenny. Thank you mark First of all, I want to recognize my clinical ethics Fellowship which was a landmark in my academic career and in my personal life Let's move to this nothing to disclose and this the preliminary answer to the question is Yes Exception made of special situation of circumstances and it depends of what we explain and how we explain This statement may be very funny But it reflects the different approaches to the issue of informed consent and we must struggle to Get some uniformity and that the goals of the informed consent process be known and be the same for all Participants in the care of patients Includes those who are going to judge sometimes our behaviors and that way meaning that they should issue a system Taking to conservation that we in Argentina. We are enduring a Huge litigation process, especially from the criminal point of view. So physicians can go to jail. That makes a big difference This is a lecture plan for this small This lecture and we are going to start with the uniqueness of surgery And that's what makes the difference between the informed consent and the surgical informed consent surgery harms before kills It's invasive and penetrates the patient body as was recognized by judge Benjamin Cardoso So we are committing an assault. So we have to have the patient permission or his or her surrogates Besides surgery it's prone to error fallibility marks our everyday activity Our decision-making is many times especially in the acute care situation under uncertainty That was all times and now in new times you have to rely on the internet and besides we have morbidity and mortality that means in Capacity to this capacity. So we have risk errors and complications So the surgeon patient relationship is unique for many. It's a contractual agreement But for many others must be fetish a reason What relies on this is trust and faith between patient and physician or its desertion Ronald Katz was the former chair of anesthesiology at the UCLA And he put this in two words honesty and integrity of physicians and a good patient-physician relationship based on Fiduciarism but who started with this concept of fiduciarism in the patient relationship We have to go back to Scotland and to the figure of John Gregory Who was the one who introduced the concept of medicine at the fiduciary profession He belonged to a family who were known as the Gregory Academics he was not the physician. He was professor of philosophy and medicine at King's College and he Professor of practice of physics at the University of Edinburgh and he told us that the physician Must be in a position to not reliable The patient's interest should promote and protect the patient interest interest and only secondary Promote and protect his own interest. So this is very present and actual Let's move to the surgical informed consent process. There is this is not The process this is just a piece of paper. Maybe it's have some legal value But that's not what we are looking for. We are looking for an informed Illustrated and educated consent If we turn back to our classics, let's see what Hypocrates told us He recommended to conceal most patients more things from the patients Plateau it's interesting in the laws in Book 11, I think he makes a distinction between the slave doctor and The free doctor and this is the first term of informed consent He will not prescribe for him until he has first convinced him and Oliver Wendell Holmes Simply stated don't be consistent. Simply be true There's a big difference as I say between the informed consent just forgiving appeal or medication and the surgical informed consent and In this relationship the surgeon has a role as an authority Due to his background his expertise his wisdom his skills, but the patient is In authority to say yes or to say no that means to refuse or to accept the proposal or just to seek another consultation And here we see the preconditions the information and the consent an important point regarding information is This is not a menu of options like you go to a restaurant and you have it the choice The surgeon has to make a recommendation Recommendation it will not work or act or propose a surgery according to the patient's desire We have to have this there must be an indication and we do not need to perform a necessary surgery Applebaum and Grisso related and describe the abilities of the patients which are really very important, but Usually we find clashes between what we try to explain Especially we biased our bias to risk and complications while the patients come more simple interests or concerns especially pain period of disability some sequelae What do Physicians especially surgeons and as sociologists think or which attitudes do they have regarding the informed consent process? as stands for surgeons and a forensic sociologist 22% of surgeons consider that disclosing Information about potential harmful risk may be worrying or disadvantages 22 and there you can see the difference in a recent publication What do we need to inform our surgical patients? everything according to the Capability common risk or very serious risk, but we do not May need to make them stressful before a huge operation if we are going to perform a Callus tectomy you can give some type of information, but we are if we are going to perform Bile duct repair after a by that injury the situation is diametrally opposite The standards have been described the reasonable physician a standard the reasonable patient standard They have moved to the subjective standard Basically solely on a specific interest of what the patient considers and I think that we have to switch to another position, which is the balance model Based on the most important and relevant Interests values and goals of the patients as have been identified by both the patient in Physician and that's a reason why the informed consent is not the piece of paper or legal document, but the process Let's move to competence and capacity. These are the definitions according to those for dictionary, but mostly Capacity is a legal consideration Why the competence is mostly a cognitive neurological assessment of the ability of the patient to understand? But this complicates because we thought that it's just one consent But according to this publication by anesthesiologist There a patient can be capable of giving Social care informed consent, but not being conditioned to give anesthesia consent I haven't understand very much with this, but I would recommend reading because they can provide some insight Let's move to the cognitive status of the social care patients We are not speaking about the patients who is under The respiratory distress with mechanical assistance, but just the one who is going Entering walking our office. I Work in a state-run hospital to the University of Buenos Aires in two of their Hospitals of the universities and we have been trying to see the educational level in 400 patients who were mostly Performed GI drug surgery and we have a huge proportion 71% people having only primary education then we Move to evaluate them from a cognitive point of view using the false and take the minimal state evaluation And those are the results though We have the important proportion of normal and some normal ranges the people were really very happy very Satisfied with the process of informed consent and one of their perceptions It was that they were receiving too much information regarding risk and complications I did not like to listen to that many times Here you find the correlation between the minimal mental state evaluation and the degree of education of these 400 patients These are all preliminary data from my research team and This is an impairment of function that we have fine having home patients achieve one or more of those but maybe you are surprised by the Incidents of lack of recall but just make this experience ask one of your patients who has been operated If she or he remembers the name of the surgeon who took the operation And you will be surprised because 90% will not recall the name of the sergeants Maybe the institution but not the sergeant in chief or the one who was in charge of the operation Move let's move to health literacy and comprehension. That's the definition given by the IOM 2004 and This is a paper from the veterans administration. Dr. Fing is from Emory University We are the strongest predictor for comprehension using web-based Tool is total consent time many times This is difficult to achieve because one receive a patient for an operation and We just place a schedule for one month time And there's not the possibility to achieve a very good patient physician Relationship This is the realm Published by Davis and we have started another court of our surgical patients These are just to remind you of the different score the 0 to 18 1944 45 60 It's reading level compare comparison and this is the education level we have in 550 surgical patients This is from this year data from this year And this is the multiple realms test in this group of patients where most belong to the inferior scales less than six rates Nonetheless, all of these patients were really 98 percent of satisfaction with the inform process Some of the opinions you can see in the literature are the ones you have you can read in this slide And This is what a recent paper in mental analysis regarding how much and what do patients understand they include only 23 Studies for surgical informed consent. Those are the Issues they were looking for and The conclusions were the following that the adequate overall understanding by the patients of the various aspects of the surgical informed Consent reported in less than one third of the studies and then degree may not in fact be satisfactory and That appreciable proportion of patients may not comprehend the risk of the proposed surgical intervention We are not discussing if it's useful But they do not understand that and this is more recently and this pushed us to Make a modification a change in our purple surgical populations So we rely in PowerPoint presentation, but we offer group Sessions for our patients and we have encountered a great success For example for morbid obesity surgery for God rather disease for colon cancer So we gather a court of about 30 to 35 patients We we listen to all the pay the questions which are referred from the different patients and the satisfaction is really very high in conclusion I Will paraphrase this Salgo versus Leland Stanford Board of Trustees verdict 1957 the first time that the term informed consent was used in in the legal literature One is to explain to the patient every risk attendant upon any surgical procedure of operation no matter how remote This may well result in alarming a patient who is Apprehensive and who may as a result refuse to undertake surgery in which there is in fact minimal risk It may also result in actually increasing the risk by reason of the physiological results of the apprehension itself and the other is To recognize that each patient represents a separate problem that the patient's mental and emotional condition is important And in certain cases may be crucial and in discussing the element of risk a Certain amount of discretion must be employed consistent with the full disclosure of facts necessary to an informed consent Last but not the least More communication open a honest on both sides and patient should be VIP very informed patient Thank you very much if I could have all the speakers back up for a panel and We're opening the floor for questions Hi, this is a question for dr. Ferrara's So I actually had the privilege of coming to your operating room in Buenos Aires and visiting with you and I was struck when I was there by a Different issue from the consent process, but just the issue the sort of approach to privacy and that really in terms of my being there and visiting that patients seem to have or seemed to Feel that that was less important for them. And so I wonder if You commented on education, but I wonder to what extent you think culture actually Changes Kind of the issues of consent and other other things that patients here seem to really place as top priorities And maybe not so much in your practice actually have to deal with the everyday Patient mostly literate or with a very low degree of Literacy and In the afternoon according to our practice in our in my country I have to move on private practice. So I have a different approach the way I Provide information But by the end of the year the difficulties encountered by the informed process They are more or less the same in the literate in in in the Population which I take care in the hospital and that Patients which those patients which I take care in my private settings. So it's only a question of time and the development of Faith and trust between both parties. This is not an issue. You have to discuss in the courts It's it's only time it may be one more consultation I'm now in a time in a situation, which I can employ maybe 30 minutes 45 minutes It's only a question of time and to develop a bond a real bond between the patient His or her family and that's I think it's a very important point and at least for our Population and the healthcare group Hi, my question is for Bob. Thanks for your presentation Bob In the last two decades or so whenever I've been on a hiring committee for an academic position and Medical ethics at the faculty medicine. We get scores of applicants. Most of them have impressive credentials And there I've been on a hiring committee for a clinical ethics position at the bedside in the hospital We're really hard-pressed to find anybody With in whom we have confidence that they can go right in there So I'm reading into your conclusions and it seems to me that when we want somebody Your slide seems to suggest we either have to train them ourselves Or we got to go back to in the McLean Center graduates or possibly the University Toronto Clinical Fellowship I don't know if that's true. That's my impression seems to corroborate what you're saying I wonder what you folks think about that. I'd be also curious about what mark thinks about that two decades later When we need help at the bedside The graduates have to train and more we have to go back to you Most the academic center seem not to be giving us what we need. Is that a fair judgment? Interesting question and I and I think my mind when you ask that my mind goes back to the Society for Biowethics consultation meeting in St. Louis in 1989 And up till that time there was really two camps the clinicians doing Consultations and the philosophers or humanists doing the consultations and at that meeting there was really a reproach mom between Dr. Siegler and John Fletcher saying whoever is going to go to the bedside needs to have training and or experience in both medicine and ethics and Which is primary is not that critical and I think that was a good platform to set In my own Experience and in these several programs. I think clinicians grab onto the ethics concepts more quickly than non-clinicians Grabbing on to the medical concepts. So that's why my bias is towards Clinicians which includes physicians nurses social workers But I've known several non-clinicians who do excellent bedside consultations as well Your slide that showed 26 of 35 were transferred out because they couldn't get the comfort care They needed in the place Did they receive anything beyond comfort care or they transferred back? Were you able to track that data any deeper in looking at the 36 people the people who were transferred? But had marked comfort measures only 26 of them we identified the very specific reason and in the Jags article each one is listed as to what the reasons were They did not go on to get for example intubated That portion did work well and And later if there's time I'll tell you about the lawsuit about polls that just got filed last week Yeah, thank you Ellen and Bob Question sort of for the two of you together because you both talked about ethics consultation Ellen it sounds like you have a Large condry of people doing ethics consultation in the VA and so maybe in light of that previous question Where did those people come from? How were they trained and how does that relate to what Bob said and vice versa? We do have a Large number of people who are involved in consultation We use primarily a team approach and so in each hospital. There's a small team of consultants and they Really have a fairly minimal amount of training and They're essentially self-taught and supported by a very robust set of Standards that they're expected to follow and then they If they get into trouble they call our National Center for the difficult cases I don't know if everybody knows that there's a We now have a joint fellowship program between VA and University of Chicago. We have three fellows this year they're there and At least one from last year here so far today and and so we are but we see those people as Sort of regional leaders. There aren't that many people that we have in our system around the country That have that high level of knowledge and skills. There's probably Less than 10 in the country other than the people, you know I've got 29 people on my staff not all of them are other consultants, but you know in the National Office We have highly trained consultants, but not so much in the facilities and I would say You know corresponding to the study that I published an a job in 2006 or whatever was seven of of A random study of US hospitals the model you're seeing in VA is very similar to what the usual model is in the country And it's the academic medical centers Which are not that many a number that are complete outliers among the 6,000 hospitals in the country At the Oregon Health Sciences University We train our own ethics leaders and we deliberately go out and recruit and we have a two-year Educational program that's very intensive and no one sits on our consult service who hasn't had at least a year of formal training in ethics Ron Miller University, California Irvine for Bob and others what data if any are there about the efficacy of consultation by Clinicians versus non clinicians on the one hand and by Consultants individual consultants versus teams versus committees I'm not aware of any data that addresses this There really aren't any and we did a review for the core competencies report. I wrote the Draft of the chapter on an evaluation. We looked systematically at the data. That was like a little over a year ago That that was published The only thing the closest thing I know of is that study. I just referenced that We did where we have things like You know, it wouldn't go to quality Or efficacy, but we have some comparative data So for example, you can say it takes longer in terms of person hours if you use a Committee model than if you use an individual consultant model, but there's no data comparative data. I'm aware of in terms of Satisfaction or any other Quality outcomes most of the training programs. I've been involved with are actually training people to do consultations But I've trained a number of people who I would not recommend to do consultations So much of it is a personal Personality interpersonal relationships and so on and I've had some people complete training that I have done Asking for a reference to do clinical ethics consoles. I'm sorry. I just can't do it So a lot of it has to do with the person as much as the training I'm Abe Schwab Philosophy Department at IPFW. I have a slightly different question and maybe it's a little unfair, but After spending about 15 years Studying and working a little bit in clinical ethics and bioethics in Chicago in New York City I moved to a town of about 350,000 people in Indiana and there The problem is the opposite problem that is I'll meet a doctor and they'll be like, oh you study clinical That's we need somebody like you Right and but you know, I'm not a doctor and I'm you know still working on getting to the position where I can actually get Into the hospitals because you know, they have concerns about the care that they're doing and about how things are going And so I guess rather than ask the question how you grow a clinical ethicist My question is how do you plant a clinical ethicist? And I don't I don't know if that's a fair question or not, but that's at least the worry that I have It really depends on experience Going to the bedside and doing consultations and how do you get there if you haven't had that experience? I'm not sure but affiliating with a Hospital ethics committee and stepping forward and being willing to work serve on a subcommittee or whatever may may get you there But I don't think there's any any substitute for going to the bedside I mean I teach two online courses and I told Bob Baker when I started teaching for him You can't do this online and this has got to be done at the bedside and so there has to be some some compromise there I teach the residents from internship PG y2 PG y3 five hours each year on seminars on ethics and professionalism and one thing that comes out very clear is That the PG y1s when they see their Residents senior residents twos and threes demonstrating the ability to resolve ethical conflicts It creates a very different learning environment where the stress and the moral distress is greatly reduced and So I've now used Mark's book to really teach principles in conflict resolution around ethical complex to help develop a set of competencies That can create a more optimal learning environment So one my question is do you think that ethical consultation needs to become now a core? Skill that we need to teach our residents in a more systematic fashion And secondly in the era of performance measurement. Do you think there's enough data? Both Ellen and Susan to look at Criteria around performance of ethical consultation and end-of-life care first of all Preston I think a rising tide lifts all boats and that the more we're able to educate a large number of faculty and change the culture and the climate and the expectations and My personal interest has been changing the culture of end-of-life care primarily in my state and By reaching out to a lot of other people with similar passions giving them tools And helping provide resources There will always need to be someone to help with the very toughest cases Whether it's palliative care Consultation for someone whose symptoms we can't manage or whether it's the ultimate Conflicted family that requires an extremely high level of skill And so I think we won't outgrow a job We'll just be doing the toughest end of the whole spectrum when we teach our communities a higher level of skill And that's what we find But in the era performance measurement Chris talked about 240 measures being used by Medicare for physician quality reporting and I sit on the ACP's performance measurement committee and We've reviewed 600 measures over the last three four years and most of them are crap absolute crap So the thought that we're going to use these measures for accountability is very very very worrisome But Ellen you're now creating an enormous database. It's looking at very concrete measures for how to do this well And does that now need to be? Really standardized in terms of what you expect out of your consultation service Yeah, I mean I think that it's tough to evaluate Quality of consultation And we're actually just now embarking on a project to try to do that to look at The content of consults as opposed to just process measures and so forth To see if we can score them and and I you know we're already making progress We have some dimensions to find and you know We're going to be looking at an early rate or liability and so on that's fairly work intensive I actually think where the money is or where the the best you know bang for your buck is in terms of evaluating Systems performance in terms of ethics is not going to be in terms of the content of the consult I mean I'm with Bob that you know I would rather have a completely untrained Person who just has a good sense of things than somebody with a whole bunch of training that never had a good sense of Things with regard to consultation. So, you know, I'm not sure about whether we need Well enough said there, but but in terms of practice I think there's a lot of things you can measure in terms of ethical practices and we're we're measuring some of those things We have not in the consultation component of our Integrated ethics program in terms of the what we call preventive ethics, which is quality improvement cycles We're measuring all kinds of things about privacy practices, you know talking to patients informed consent practices Even resource allocation practices you can actually measure lots of behaviors and I think those things are probably better as measures of ethics quality of health care organization then focusing on the consulates alone With regard to the lawsuit Last week the first lawsuit that I'm aware of was filed in California related to failure to follow a post form and This lawsuit involves and all I know is reading the lawsuit. I don't have any Inside knowledge of the case But the lawsuit involves someone who had a brain tumor at age four and at age 18 was completely incapacitated continuing to be cared for by her mother in Southern California, she was a Kaiser patient two months before the lawsuit was filed a detailed conversation had taken place between the mother and The care providers that were the long-term care for riders with her daughter and a post form was completed The post form said do not resuscitate and limited interventions So she wanted to go back to the hospital to have seizures treated those kinds of things But did not wish to be intubated did not wish the ICU Was aware that her daughter's illness was reaching its most advanced stages The daughter was found to be comatose and the mother Took her to the hospital. We do not know the details of what was happening at the time We do not know the perspectives from the emergency room physician the daughter was intubated over the mother's verbal objections and Calling attention to the fact that there was a post form whether it was reviewed or not reviewed in The Kaiser electronic records since it was filled out two months previously should have been accessible and the Young woman was intubated the mother Pleaded and that they were transferred to another Kaiser facility where life support was withdrawn and she died the next day So the ability to litigate this and Dudley says is likely in a much more powerful position than Disputing whether or not an advanced directive was followed a little bit more details. I was on a run Miller University, California Irva, I was unaware of the case until so Susan told me last night my only information is from a blog by Thaddeus Pope a lawyer who has its utility blog and He indicated that the Physician who intubated the patient was in a Kaiser affiliated hospital Not a Kaiser hospital and it seems to me the devil is going to be in the details here number one number two that I want to be sure that Kaiser appreciates the importance here in fact had an ethics consultant involved in the discussion leading up to the post form and has made a huge effort at hiring people in Ethics consultants throughout their system great. Thank you Well, the other thing to remember is that 10% of the post forms entered in the registry every month are revisions that people do change their mind that there are revocations and Until we hear everything on the other side. It is indeed possible That something is not as clear when you hear just one side of the situation and the Oregon regs Related to following polls and some other states are adopting very similar ones Indicate that you follow what you have until or unless you have information to the contrary So we don't yet know if there was some information to the contrary and a change of heart in some way But it is indeed worrisome and we'll clearly put a spotlight on the post program and issues related to not respecting it Great well, I want to thank the panel for a very interesting panel