 This formulation of the ethics question, you are right, it looks simple, but it's definitely not easy. It's like any skill. It doesn't develop overnight. You did very well with the cases we discussed. You were fabulous. I feel we've accomplished so much already, but we're still only on the first step. Yes, but remember, nobody's asking you to memorize this stuff. You're not cramming for an exam. Everything we're talking about is well documented in the materials you're already using. And believe me, you'll keep using them. It took me a good long while before I didn't have to pull out the pocket card on every case. That's good to hear. So let's move on to A, which the primer says stands for Assemble Relevant Information. You're absolutely right, Ms. Woodley. The next step is to go through a process of data collection that is more intensive than the preliminary information step you'll already have done. At this point, you need to go to as many sources as are available to you. Yeah, it's like detective work. You want to interview all the people who are connected with the case. You want to look at the medical records. Obviously, the patient should be consulted if he's able. Exactly. There is a patient. And even if the patient cannot be an active participant, you should still visit the patient. You can get a lot of important information from that visit. Like maybe no one mentioned that the patient is in restraints. And a really important part of this process is making sure not to take everything at face value. Caveat emptor. Benefits of a classical education, don't you know? So if we're not supposed to take anyone's word for anything... It's not quite that cut and dried. What's important is that everyone on your team be on the lookout for subjective language or predictions and interpretations that are treated as fact. I spent many years as a practicing physician and I know how it can be. We like to think that our clinical judgments are the same as fact. And they just aren't. Not always. I'm not saying a word. You better not. Everyone can make the mistake about believing that their perspective is the only one. And because these cases are so frequently emotional, you have to be disciplined about double-checking every piece of important information. For example, a physician or a nurse might say that a patient is coping nicely with pain. But what does that really mean? The patient's pain is adequately controlled or the patient is in pain all the time but doesn't complain too much. The point is not to let any labels or conclusions just slip by. It's easier to do if you make sure that everyone knows why you're there and to make it clear that you're not taking sides. Expectations again. Exactly. It is also important to review the ethics knowledge relevant to the case which some people call best thinking. Ethics knowledge might include codes of ethics, ethical standards and guidelines, consensus statements, scholarly publications, precedent cases and applicable institutional policy and law. Not everyone is a master of ethics, okay? But the first thing to aim for is to be a master of process. That way you're less likely to make mistakes as you build expertise over time. And recognize when you need help, anybody involved in this work needs help sometimes. You should have access to experts that you can talk things over with. It's just too complicated to go it alone. Does it ever happen during the course of assembling information that you realize your original ethics question no longer applies? It happens. And that's one of your next steps here. To double check the question and make sure you have it right. And if it's not right, you reformulate it? Exactly. Assuming we have a valid formulation of the ethics question, what happens next? At the end of the day this question just boils down to gather as much information as you can and double check anything that's really important. Whenever possible, get your information firsthand. For example, look at the advanced directive yourself. Don't just go by what others say it says. Let's move on to the first S in cases, which stands for synthesize the information. You got this big wad of data. What do you do with it? You pull it together. Once you've reviewed the best thinking, you're ready to begin the analysis of your case. You've got to be willing to use different approaches, such as principalism and casus tree. Well, I'm familiar with several approaches. I'm most comfortable with the casuous approach. But I mix in aspects of several other approaches too. I'm still a novice to these different approaches. That's okay. No single person needs to embody every skill necessary for case consultation. Dr. Burrell's expertise in ethics analysis is an important proficiency. And as long as he's proficient in these areas, his analytic skills will rub off on the other members of the team. He can be a mentor to you. And here we touch again on making sure you attack the question systematically and logically. This isn't a debate where the most passionate person or the best speaker is going to win by force of personality. It's not like a movie critic giving a thumbs up or thumbs down either. Everyone participating has a voice, and every voice is valid. The differing points of view have to be discussed openly and thoroughly. It's a systematized examination of a question. One especially important step is you synthesize the information is to identify the ethically appropriate decision maker. That is, the person who should make the critical decisions about the case. Usually the patient or the surrogate gets to make the decisions, but some decisions are a matter of professional judgment. Then comes the discussion of the options. The ethically justifiable options. You identify which options make sense ethically and explain why others might not. If you're going to rule out something as not being ethically justifiable, you have to be able to back it up based on accepted norms or standards for ethical practice. You have to show why it's beyond the bounds of what's accepted. And you try to think outside the box a little bit. Try to come up with options that haven't been discussed. And if they get shot down, so what? It's about examining the question, not winning the prize by having the most people agree with you. Who thinks I'm right? Not about that. Because remember, you're not there to give an answer. You're there to help the ethically appropriate decision maker understand the range of ethically justifiable options which they have in order to make their own decision. Let's say for example that a patient is fed exclusively through a feeding tube because he has a tendency to aspirate his food. The ethics consultant might raise the question of whether allowing the patient to eat some foods by mouth and risk aspiration pneumonia might be an option that is ethically justifiable because it's consistent with the patient's goals and preferences. But if all of this boils down to only one option, aren't you more or less dictating their choice? You're not dictating their choices. You're helping them to navigate all of the complexities. And if in that work you find that only one option is ethically justifiable, then they know how they got there and they can see it for themselves. Now that was a pretty impressive segue. What? He's right. You did a great job of summing up the next step of cases. E, for explain the synthesis. You have to be able to explain to all the key participants what happened in the consult process. And you have to be able to provide educational resources. That's right. Don't take my word for it, check for yourself. If you know of an article that would be especially helpful to them in understanding the case, it would be good to refer them to that information, providing resources helps educate everyone involved, including yourselves. And you don't just have to explain it to the people involved. You have to be able to explain it to the future. Translation, please. Document, document, document. Ah, so anyone who picks up the chart can understand the case. Exactly. The consultation needs to be documented in the patient's medical record. Unless the consult doesn't really involve the patients. For instance, if a healthcare provider had moral objections to participating in withdrawing life-sustaining treatments. In any event, the consultation needs to be documented in the consultation services files. Exactly. The primer offers more advice and examples on how to document a consult. And last but not least, there's the final S, which stands for Support the Consultation Process. Your job doesn't end once you've completed the consultation. That's right. You need to follow up with the participants to find out what ultimately happened with the case. And you need to talk about your own consultation. Talk about what you did well and what you might have done better. The integrated ethics materials include some tools that can be used for evaluation as well. And if you find something that could have gone better, you don't get any points just for recognizing it, you have to adjust your processes accordingly. Sometimes the necessary adjustment isn't within your power. The problem might be systemic. That's true. If you find yourself facing the same problem over and over again, say the case is involving withdrawal of a feeding tube, then you might have a systems problem. It might be that a process change is required on a system-wide level. If you think you've identified a systems issue, don't keep it to yourself. Tell someone to prevent an ethics team, the ethics committee, whoever is responsible for handling this stuff. So, that's cases. Clarify the request, assemble the information, synthesize the information, explain the synthesis, and lastly, support the consultation process. Look, we know that none of this is news. This isn't the first time you've heard of this approach. What we want to do is to help you to implement this technique with the greatest possible effectiveness. So, next we'll be using what we call the team cams. We'll be setting up three very small video cameras, one for each of you, and after obtaining proper consent, those cameras will record your next consultation. Then we'll review that video and record our responses for your future use. You shouldn't feel spied on. This isn't Big Brother or anything. This will be edited into something that you can study and work from. And even use to train your new team members when they arrive. The cameras will begin recording as soon as we leave. You'll do well. Ethics consultation isn't a luxury. It's not an option. It's an absolute necessity for healthcare. And to provide it with skill is an act of courage and compassion. Healthcare facilities are they're places of physical catastrophe. And in the face of catastrophe, it's easy for anyone to lose his way. Each one of you is a kind of rescue worker. And if someone is lost, you're right there for them. You're not always going to know the way yourself. But you're always going to be the beginning of an answer. You'll always be the reason that no one is facing their fear and confusion alone. And it's an honor to work with you. So come on guys, let's get out of their way. Everybody's looking good. The images are all clear. Now let's see what their day was like. I've called Nurse Ruiz and Dr. Burrows. Dr. Ingersoll's conversation with the patient's wife about the feeding tube doesn't seem to have gone too well. The three of us are going to meet in Dr. Burrows office right now and hope we can find some way to patch things up before the wife gets even more upset. We're going to Dr. Burrows office. Turns out this case is a long way from being settled. Somebody's in trouble. Okay, let me fill you all in. So that's the size of it. I kept things too informal and Dr. Ingersoll went back to the patient's wife feeling as though she had received a verdict from on high. Especially because that's what she wanted to hear. And the wife went through the roof. How bad is it? She's talking lawsuits and she's going to go to the TV station. She was outraged. What do we do? Well, I have a call into the facility director to give my heads up. Just in case 60 minutes shows up at the front desk. But what I'd really like to try to do is find a way to resolve this conflict. And I'm going to need as much help from the both of you as I can get. That's great. We'll try to get a copy of the patient's advance directive right away. In the meantime, if you could hit the literature, try to gather the relevant ethics knowledge. Anything with a conflict between a surrogate and an advance directive? I'm going to try to gather as much clinical data as I can to try to build a more complete picture of the patient's condition. Assembling the information, getting the facts, excellent. Maria, stop by calling the wife. It's crucial we understand her perspective of things. I'd call her myself, but I'm worried that she'd be too angry to want to discuss anything. Okay, I'll take care of that. I think we can salvage this one. Let's get busy. Yes. We understand completely, ma'am. That's why we want to do everything we can to make sure that your husband's wishes are fully respected. Oh, she's good. Keep it on the patient, not on the conflict. This is very good. Tracking down the ethics knowledge using both print and internet media. And what is your analysis of the patient's condition? Well, there are a variety of problems, but basically he's dying of his osteomyelitis. And from what I understand, it's essentially untreatable. And there was something about a sister and... Right. The sister said that he signed an advanced directive, but I've actually never seen it. Oh, I agree with you 100%, ma'am. And that's why I think we need to talk about this further. Well, of course, sisters matter. We'd really appreciate it. Oh, and please, this is very important. Be sure you bring that copy of your brother's living will. Okay? Thank you. I know it's not published yet, Linda. I'm not going to show it to anyone. I just want to see what you have to say on the subject. Part of my job is to assemble the best current thinking on the issue, and you're my best source for that. Can you send it as an attachment? Thanks. I owe you one. Hi, Hal. Listen. You were the ID specialist who looked at Mr. Johnson, right? This footage was shot while Dr. Burroughs was looking for another opinion about whether the patient was truly dying from the infection or not. This is right on the money. Yeah, I need a little clarification on your prognosis for the osteomyelitis. Do you think you could walk me through your assessment of things? Mr. Johnson. I'm Dr. Burroughs. I'd like to speak to you for a few minutes. No substitute for seeing the patient yourself. Ms. Whitley had the idea that the patient's primary care physician might be able to shed some light on the patient's wishes. She's really covering all the bases. This is Tina Whitley. I'm doing an ethics consult on Mr. Everett Johnson. Right, that's the one. Now, you're his primary care doctor, right? Great. I have a couple of questions. Have you by any chance talked to Mr. Johnson about his wishes for end-of-life care? So it's decided then. I'll go ahead and set up the formal meeting. I'll be there. Now, we're not here to make a decision or to provide a single final answer. My team's function is to help people work through a difficult decision by listening to what everyone thinks and then helping them to understand the range of options. Nicely put. Now, Mrs. Johnson, since you're here not only as the patient's wife, but also as the designated health care agent, why don't you try to give us your impression of where things stand? The point is that you people want to remove my husband's feeding tube and I don't understand why. I assure you that everyone here has your husband's interests in mind. But first, let's try to be sure we understand his wishes. Now, your sister-in-law brought in a copy of this living will that he made. Have you ever seen this before? No. All I can figure is he must have done it years ago without ever telling me. You people must understand. What is when you're young, you're proud and you're bulletproof and you would never want some machine feeding you. But then you get older and even little things become terribly precious. I'm telling you all, this is not his time, not yet. Okay, just so that we're clear, you're saying that you do not believe that the living will tells us what your husband would say if he were able to talk to us right now? That's right. I remember that a lot can change in six years, but six years ago he signed this language. If I should have an incurable or irreversible condition that will cause my death, it is my desire that my life not be artificially prolonged by administration of life-sustaining procedures. That's why I thought it was so important. I'm not trying to be an evil witch here or anything, but when I read that, my brother didn't want to suffer or be hooked up to a bunch of machines or tubes keeping him alive. I don't want anyone to feel trapped by a piece of paper, but I have to say the language sounds awfully straightforward. It might seem straightforward on the face of it, but studies have shown that health professionals vary widely in their interpretation of advanced directives. And often they're not as useful to the decision makers as we would like them to be. Ooh, very good. What review of the best thinking can do for you? Isn't the advanced directive itself the decision maker? No, not exactly. Mrs. Johnson is the official surrogate and as such, it's her job to try and act according to her husband's wishes. The advanced directive is simply a piece of evidence about those wishes. But isn't it a pretty powerful piece? Generally, yes. But not as much so if his condition is unclear. And there may be some ambiguity here. The staff here reached the conclusion that his infection is terminal. But the infectious disease specialist said he may continue with his osteomyelitis for some time. He may even recover. That's very... Okay, I'm surprised because that's not what I understood. I must say, I don't entirely agree. We have to remember that our role here is to identify the areas of ambiguity and try to work our way through it so Mrs. Johnson has the clearest sense of her husband's wishes and her options. Shouldn't we talk about the information Tina Whitley got from his primary care physician? Yes, certainly. Apparently, about 18 months ago, Mr. Johnson told his doctor that he used to have an advanced directive. But he tore it up. He was afraid that the doctors would let him die before his time. Exactly. There are several areas of ambiguity. First of all, there's the question of prognosis, about which we have conflicting opinions. And then there's the question of whether the six-year-old advanced directive reflects the patient's present-day wishes. The VA policy states that a patient may revoke their advanced directive at any time simply by stating their intent to do so. Such a statement was noted by Mr. Johnson's primary care physician. So how do we resolve this? We don't resolve anything. Mrs. Johnson is the appropriate decision maker. This meeting is happening at the University of Washington to clarify the range of options that are ethically justifiable. We're here to help Mrs. Johnson. That's very good work. Very strong. Keeping everybody's expectations exactly where they need to be. Mrs. Johnson, in that role, it's your duty to represent what your husband would tell us if he were able to. Do you believe you're able to perform that function? I do, yes. I know him better than anyone. Let's try to clarify the goals of care. Mrs. Johnson, if he could tell us himself, what do you believe would be his hopes for the near future? What would he like to see happen? A magical cure isn't one of the choices, is it? Well, I think he'd want to be comfortable and hope to get well enough that he can move out of here and maybe into the nursing home or just to our house so that our son and I and Rebecca would be able to visit him. You mentioned comfortable. What would be his hopes when it comes to comfort, pain management, and so on? Well, he's a tough old dog, I'll tell you that. What I call pain, he calls pesky. He seems okay on the pain meds he's getting. What if he took a turn for the worse? What if he struggles with his breathing again? Oh, I don't think he'd want to go back on that ventilator. He'd say at that point that's it. Or if he could no longer interact with or recognize us, he would not want to be kept alive. At that point, his goals of care would change? And now that we understand what he would want, I assure you that we'll do everything we can to try to achieve his goals. I want to thank everyone for all their hard work. Very well done, folks. Very well done. Yeah, I think Dr. Burroughs is feeling pretty relieved right about now. He felt he'd really screwed that one up. It's like medicine itself. Ethics consultation is an art, not an exact science. And like medicine, it becomes more natural with practice. She said, don't worry, we didn't forget the E or the S of cases. We provided a review article about interpreting advanced directives and we documented everything in the patient's medical record and in our case files. We're doing all of our follow-up communications. And as soon as we get your tapes, we'll start evaluating and adjusting. I couldn't be more impressed. Second the motion. I'd like to toast them all of well done. Here, here.