building an ethics service | components

| new questions and models

| physician capacity

| empirically driven

“To educate and hope is a futile strategy.” - Jack Glaser

systems | a different dilemma

capacity | mentors and aces

| Relationship

| Culture

| Meaning

spread | early adopters

Engaging Physicians

EducationIntegration

• Medical Resident Roundtables

• Bioethics Grand Rounds

• Bioethics focused CME

• Mandatory ethics conferences (ICU)

Building an Ethics Service | metrics

Context for Ethics ConsultationContext for Ethics Consultation

Columbia St. Mary’s Health System– Four Acute Care Hospitals ~700 beds– 35+ physician clinics with ~240 employed physicians– FY 2008: 342,182 outpatient visits; 69,346 ED visits; 25,891 inpatient

admissions

– Ethics Consultation Service:• Two Medical Staff Ethics Committees• One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model

– Advisement: ERD Clarification; Ethics Policy Elaboration; family care conference attendance

– Consultation: all non-advisement matters

– Ethics Consultation for Database:• 278 consults from January 2003 through December 2008• Cases:

– Identified ethical reason for consultation– Identified discipline requesting– CSM Ethics consultation service engaged– Ethics consultation documented– Ethics recommendations made to case

Ethics Consultation Intake: Requestor InfoEthics Consultation Intake: Requestor Info

Clinical Ethics Consultation: Columbia St. Mary’s Health System

Clinical Ethics Consultation: Columbia St. Mary’s Health System

CSM Ethics Consultation for Database:– 278; January 2003 -

September 2008

No. of Consults/Literature:255; Swetz, et al. Mayo Clinic Proceedings

2007; 82(6): 686-691.150; Schenkenberg. HEC Forum 1997; 9;147-

158.104; La Puma, et al. JAMA 1988;260: 808-811.31; Forde & Vandvik. J Med Ethics. 2005;

31:73-77.39; Waisel, et al. Mil Med 2000; 165:528-532.

Male 102 40.60%Female 125 49.80%Unknown 24 9.60%

Median Age Range 70 (27d-98y)

Location of PatientICU 97 38.70%Medical/Surgical 76 30.30%

MDC-Major Diagnostic Category4 Respiratory System 42 18.50%5 Circulatory System 25 11.00%1 Nervous System 21 9.30%

18 Infectious/Parasitic 20 8.80%6 Digestive System 11 4.80%

Unknown 64 28.20%

Demographic and Clinical Characteristics of 278 Ethics Consultations

Characteristics

Clinical Ethics Consultation:Quantitative Measures of Ethics Integration

Mean Days Consult from DoA

Clinical Ethics Consultation:Quantitative Measures of Ethics Integration

Mean Days Consult from DoA

Clinical Consultation Changing Organizational Practice

Clinical Consultation Changing Organizational Practice

Ethics Tracker Database– August 2006-October 2006– 3 consults related to Intra/peri-operative Code Status

Physician Association Guidelines – American College of Surgeons: ST-19 Statement on Advance Directive by Patients: “Do Not

Resuscitate” in the Operating Room

– American Society of Anesthesiologists: Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders

Goal: Initiate opportunity within existing pre-precedure processes for MD to address with patient or designated surrogate(s) existing directives to limit the use of resuscitation procedures

Dept of Surgery follow-up re: Ethics Case Consultations Grand Rounds follow-up with CME Accountabilities for CIP

Clinical Consultation Changing Organizational Practice

Clinical Consultation Changing Organizational Practice

Medical Staff Pre- Procedure Checklist Adopted:

•Dept Anesthesiology

•Dept Surgery

•Dept Orthopedic Surgery

•Dept of Medicine (Exec Council)

actionpoints