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02/01/2016

TOUGH CASES: Code of Ethics Now Available for Healthcare Ethics Consultants

Tarris Rosell, PhD, DMin    
Consider the following hypothetical case scenarios:

Case #1

Jessica, APN, is a member of the Hospital Ethics Committee and serves also on the HEC’s ethics consultation team. Each week, one of eight volunteer consultants takes first call on the dedicated Ethics pager. Two other team members serve as back up to the on-call ethics consultant. 
One day, a consult request is forwarded to the Ethics pager, which Jessica is carrying. It involves a patient on the Medical ICU where Jessica is also a nurse manager. She knows the patient and family, and is all too aware of their conflicted situation with hospital staff regarding goals of care. Jessica also supervises the nursing staff, which rotates care duties on Patient Joe so as not to get too burned out, given his dementia-related raging and flailing. As Jessica reads the ethics consult order, she feels conflicted about her multiple roles in this challenging situation. She wants to be of assistance for ethics, but isn’t certain that she can do so without confusion about what “hat” she’s wearing up on the unit.
What ought Jessica to do, and how would she know?

Case #2

Jonathan, PhD, is taking first call on the Ethics pager this week. One of three consult requests received involves a very messy situation involving a difficult discharge. The 56 -year old female patient, Helen, is homeless and had come to the emergency department weeks earlier in a police cruiser.
At the point when she becomes medically stable, a dilemma is encountered. How could we safely discharge this patient back to the street where she insists on going “if,” as she says, “you won’t let me stay here?” It’s cold outside, and Helen is barely ambulatory, with some signs of dementia. Follow-up self-care would require daily insulin injections and finger sticks for glucose monitoring. While the patient claims ability to do so, the attending isn’t convinced. 
Ethics is consulted, and Jonathan convenes a multi-disciplinary care meeting, including the patient. Consensus eventually is reached on a discharge plan. Helen agrees to go to a homeless shelter with a clinic. 
However, after leaving the hospital, the cab driver lets her off at a downtown intersection instead, as directed by his rider. It is a blustery and frigid winter day. Helen is wearing the thin autumn coat and sandals she had been wearing upon admission. A newspaper journalist happens to stop at the intersection where Helen stands shivering, and notes her hospital bracelet. He rolls down the window and asks if Helen is okay. She mutters that City Hospital left her off here to die. The journalist calls 911, and then makes a call to the hospital operator asking to speak with someone in Ethics. 
When Jonathan receives this page and phone call, what should he say, or not say, to the journalist, and how would he know?

Code of Ethics 

Ethics consultation, like any other professional practice in healthcare, requires professionalism of the consultant. Ethics consultants can either help or hurt those who request assistance. Sometimes even life and death hang in the balance, especially when it is unclear as to which of those two options would be the worse outcome for a critically ill patient. Always there is confidential information to be handled with care and in compliance with HIPAA rules. 
Ethics professionalism matters.
Until recently, healthcare ethics consultants familiarized themselves with the codes of ethics pertaining to other professions, but had none of their own. Jessica and Jonathan might have discerned successfully what they ought to do about their professional ethics dilemmas in the scenarios described. Now their decisions may also be guided by a code of ethics and responsibilities drafted specifically for healthcare ethics consultants.
The American Society for Bioethics and Humanities has posted A Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants as a downloadable document at http://asbh.org/publications/books. The document lists seven ethical responsibilities for healthcare ethics consultation (HCEC):
1. Be competent.
2. Preserve integrity.
3. Manage conflicts of interest and obligation.
4. Respect privacy and maintain confidentiality.
5. Contribute to the field.
6. Communicate responsibly.
7. Promote just healthcare within HCEC.
Each of these responsibilities is explained in the ASBH document, with illustrative examples provided. 

Applying the Code

In Jessica’s case, she might recuse herself from ethics consultation on grounds of #3, the need to manage conflicts of interest and obligation. One of her back-up consultant colleagues can be called upon to respond instead. 
Jonathan would be guided in his own ethics dilemma by responsibilities #4 and #6 especially, and possibly #7. The probably well-intended journalist may benefit from clarification of the situation with Helen; but any communications with him must be done responsibly, perhaps by a designated hospital spokesperson, and with HIPAA-protected privacy ensured both for the patient and her healthcare providers.
Center for Practical Bioethics personnel contributed to the development and publishing of the ASBH Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants. It is currently being utilized in hospitals in Kansas City and elsewhere for professional performance improvement toward the goal of excellence in ethics consultation.

Tarris Rosell, PhD, DMin, is the Rosemary Flanigan Chair at the Center for Practical Bioethics. He also serves as Co-Chair of the Hospital Ethics Committee and Director of the Ethics Consultation Team at the University of Kansas Hospital.

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