Goals of Care

Goals of care is a term so common to health care professionals and yet, our guests describe significant clinical experiences in which the lack of discussion around goals of care led to problematic cases. A goals of care conversation is an important element at the foundation of high quality discussions around code status. In this episode lead contributor Mark Repenshek, Executive Director of Ethics and Mission at Hospital Sisters Health System in Wisconsin, is in conversation with national experts and clinicians who discuss this important topic.

Our guests in this episode are:

  • Dr. Kenneth A. Berkowitz, MD FCCP Chief, Ethics Consultation at VHA National Center for Ethics in Health Care, Associate Professor of Medicine and Population Health at NYU School of Medicine
  • Dr. Tim Jessick, DO, Chair/Co-Founder Palliative Care Network of Wisconsin
    Palliative Medicine Physician, AdvocateAuroraHealth
  • Dr. Jill S. Lowery, Psy.D., Chief, Ethics Policy, National Center for Ethics in Health Care at Veterans Health Administration
  • Dr. James A. Tulsky, MD, Chair, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine at Brigham and Women’s Hospital, Professor of Medicine at Harvard Medical School

Helpful Goals of Care Resources:

Informed Consent: Supporting Patient Autonomy

Informed consent is one of the foundational ethical principles in health care that supports patient autonomy, or stated differently, the patients right to self-determination. More and more the standard for what clinicians should inform patients about the risks benefits and alternatives of treatment are no longer determined by what a responsible body of physicians deems important, but rather by what a reasonable patient deems important. What is needed to meet that goal is a collaborative communication process between clinicians and patients that integrates the best evidence available with the patients values and preferences to promote high quality health care decisions. In the United States at least half of the states have adopted the reasonable patient standard regarding informed consent.

This episode of EthicsLab Essentials is led by lead contributor Rachelle Barina, VP – Mission Integration at SSM Health based in Wisconsin and is in conversation with two nationally known guests:

  • Dr. Jenny Heyl, Director of Ethics at Mercy Hospital in St. Louis
  • Dr. Kayhan Parsi, Professor of Bioethics at the Neiswanger Institute for Bioethics: Loyola University Chicago

Organ Donation: Foundational Ethical Approaches

The big picture is that 115,000 men, women and children await organ transplants in the United States. Even the largest football stadium in the US could not fit the number of patients on the national transplant waiting list. In 2016, 33,600 transplants brought new life to patients and their families. Since 1988, 683,000 transplants have taken place in this country.

In this episode, our lead contributor Becket Gremmels, speaks to a transplant surgeon, an ICU doctor and a health care ethicist about some of the foundational ethical approaches that honor organ donors, the patients who receive those organs, and the health care professionals who care for both.

Our guests in this episode include:

  • Dr. Carol Bayley, past Vice President for Ethics and Justice Education at Dignity Health, San Francisco
  • Dr. Anji Wall, Abdominal Transplant Surgeon at Baylor Medical Center, Dallas
  • Dr. Wes Ely, Intensivist at Vanderbilt University Medical Center and Nashville VA Hospital, Nashville

Do Not Resuscitate Orders: Key Ethical Issues

As patients, surrogate decision makers, and clinicians discuss goals of care, questions arise regarding what interventions will physiologically work and what interventions will honor the patient’s values. Do Not Resuscitate Orders are one of the interventions frequently discussed. Our lead contributor on this episode (Mark Repenshek, Executive Director for Ethics & Mission at Hospital Sisters Health System, in Wisconsin) is in conversation with guest to explore a number of ethical issues related to Do Not Resuscitate orders that include, but are not limited to: a) Patient/Surrogate desires for full resuscitation despite the intervention’s lack of efficacy in specific clinical circumstances, b) Consideration of partial codes as a “compromise” co-status, c) A physicians’ professional right to limit the use of resuscitation efforts in certain circumstances. The episode also introduces a new series within the EthicsLab Podcast called EthicsLab Essentials. This new series is designed to be an introductory series of modules to enrich ethics committee members.

Moral Distress and Moral Resiliency-ele

Have you ever experienced an event, a situation or a decision where you felt that your professional integrity had been compromised? It may have occurred because of something you did, something someone else did or simply a number of events that lined up in a way that made you feel that you were between a rock and hard place. In that moment you probably experienced moral distress. In this episode, we look at moral distress in the health care environment. What are the clinical situations that cause moral distress to arise, what can be done to respond, can it be cured or is it a part of our moral life?

Our guests in this episode are:

  • Dr. Cynda Rushton, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University
  • Dr. M. Sara Rosenthal, Ph.D., Professor and Founding Director, Program for Bioethics, Departments of Internal Medicine, Pediatrics and Behavioral Science Chair, Hospital Ethics Committee, University of Kentucky and co-creator of the Moral Distress Education Project
  • Dr. Beth Lown, Chief Medical Officer of the Schwartz Center for Compassionate Healthcare

Resources referenced in this episode:

 

Practical Tools Helping Ethics Committees

Health care ethics committees help patients and clinicians with tough choice decisions. Within this work of clinical ethics consultation, what are practical tools being used to improve their competence and impact? In this episode, our guests present such practical tools that help health care ethics committee members become more competent, become more aware of gaps and trends, and have more impact on improving the care and health experience of patients.

Our guests in this episode include:

  • Becket Gremmels, PhD, System Director of Ethics, Mission Integration Department. CHRISTUS Health
  • Katherine Wasson, PhD, MPH, Associate Professor, Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago
  • Mark Repenshek, PhD, Executive Director, Ethics & Mission, HSHS Eastern/Western Wisconsin Division, Door County Medical Center
  • Laura J. Bishop, Ph.D, Associate Teaching Professor and Academic Program Manager, Kennedy Institute of Ethics, Georgetown University

Additional Resources in this Episode: 

10 Week Free Online Introduction to Bioethics (presented by Laura Bishop)

Ethics Tracker Screenshots (presented by Becket Gremmels)

REDCap Software  (presented by Becket Gremmels)

The ACES Project: Online Clinical Ethics Consultation Skills Assessment (presented by Katherine Wasson)

HCEUSA Dashboard Article 2012 (presented by Mark Repenshek)

Dashboard 2011 Data (presented by Mark Repenshek)

Beyond Capacity: Assessing Challenging Cases

One of the challenging areas in clinical practice today is wanting to honor patient wishes but not being clear on the competency or capacity level a patient with dementia or behavioral health issues. In this episode we explore different challenging situations that ask: a) What is the best assessment of capacity? b) What level of risk should be supported? c) How might health care professionals approach these situations at a deeper human level? Our guests, who are national experts in this area and will offer insight and practical consideration and approaches to the questions list above and others.

Our guests in this episode include:

  • Sherri Boggs, Quality, Patient Safety & Education Manager, Our Lady of Peace Hospital
  • Dr. Stephen Post, international speaker, best selling author and the Director for the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University
  • Dr. Paul S. Appelbaum, New York State Psychiatric Institute and Columbia University Department of Psychiatry
  • Dr. Ali Abbas Asghar-Ali, Michael E. DeBakey VA Medical Center

Traction: Innovative Practices Honoring Patient Wishes

Health care professionals, patients and family members could all agree that patient wishes about their care are important and need to be respected. Why then, nationally, do only 30 percent of adults have an advance directive that documents those wishes? Given that statistic, how could the town of La Crosse, Wisconsin, achieve the surprising goal that 96% of people who die there have an advance directive or similar documentation…such a difference from the national average? Some wonder how to begin such a conversation while others ask what the best systems to put in place are? Yes, there are better tools, practices and systems that can help us.

Our guests in this episode include:

  • Bernard “Bud” Hammes, PhD, Executive Director, Respecting Choices, A Division of C-TAC Innovations
  • David Bailey, Physician ENT and Chief Medical Officer for Memorial Health in Lufkin, TX.
  • Kate (O’Rourke) DeBartolo, National Field Director, Institute for Healthcare Improvement at The Conversation Project
  • Suzanne Engelder, MSW, ASW, The Center for Advance Care Planning and Advocacy

Thinking Differently: Building Blocks for a Quality Ethics Program

Are there better ways to build and support a culture of clinical ethics in healthcare? What might that look like? What has worked and how could the ideas and tools offered be implemented? In the late 1990’s the idea was proposed, why not marry the work being done in health care ethics with quality improvement methodology. Would this type of “Thinking Differently” help us get traction and improve the systems and initiatives that clinical ethics tries to accomplish? These are some of the questions and issues that our guests will wrestle with as well as offering concrete examples and even practical solutions being tested today.

The Unrepresented Patient

Deciding for another is difficult. One of the most challenging ethical issues faced in clinical practice today is deciding for unrepresented patients – patients who have no advance directive or no family and  friends who can make decisions on behalf of the patient (surrogate decision makers) when the patient cannot speak for themselves. The moral distress of clinicians can run high especially given the diverse and complex national legal environment surrounding these patients. Our expert clinical and legal guests, experienced in the daily life of the healthcare environment, will offer insight into these challenges and offer both an overview and practical solutions being tested today.