Discharge Dilemmas: Patients with Disabilities

Consider someone leaving a hospital, after their care is completed at that location, to return to their home and local community. As discharge plans are made to continue their care, their healing, their rehabilitation, are there ethical challenges that arise? Can there be biases that shape that plan because of their ability, disability, lack of family support systems or resources available in the community? What are the frameworks, tools, approaches that an assist all involved? Our guests will offer their experience in these discharge plan dilemmas and offer the practical approaches they have utilized every day.

Joining us in conversation in this episode are:

  • Debjani Mukherjee, trained as clinical psychologist and clinical ethicist, is Director of the Donnelley Ethics Program at the Shirley Ryan Ability Lab, Associate Professor of Physical Medicine and Rehabilitation and Medical Education at Northwestern University, Feinberg School of Medicine.
  • Preya Tarsney, trained as a lawyer Bioethicist – Donnelley Ethics Program at the Shirley Ryan Ability Lab and a Lecturer of Physical Medicine & Rehabilitation at Northwestern University Feinberg School of Medicine and faculty lecturer at the University of Chicago, MacLean Center for Clinical Medical Ethics.
  • Kristi L. Kirschner MD is a physician in physical medicine and rehabilitation and has practiced in this area for 30 years. She also has a background in clinical ethics and physical disability ethics and a faculty member of the university of Illinois College of Medicine where she directs the sub-theme of Humanities in Ethics for the College of Medicine.

Brain Death: A Foundational Yet Emotional Ethical Concept

Brain death is a fundamental ethical topic that is complex and often fraught with emotion. As ethics committees are faced with considerations involving brain death, these cases are often those that stick with professionals the most. Our lead contributor in this episode Becket Gremmels, System Director of Ethics at CHRISTUS Health in Irving TX is in conversation with two nationally recognized ethicists who explore the complexities and challenges surrounding this foundational ethical concept.

Our guests in this episode include:

  • Dr. Alexander M. Capron, University Professor, Vice Dean for Faculty and Academic Affairs, Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Professor of Law and Medicine, Keck School of Medicine, Co-Director, Pacific Center for Health Policy and Ethics at the University of Southern California
  • Dr. Michael Rubin, neurointensivist and clinical ethicist in the department of neurology and neurotherapeutics in the Peter O’Donnell Jr. Brain Institute at the UT Southwestern Medical Center

Feeding Tubes: Are Things What They Seem?

Why would the question of whether to provide food and water to a patient come up at all? One might assume it is always helpful and never harmful to offer nutrition and hydration to patients. Is that accurate? When might it be appropriate or not appropriate? Our lead contributor in this episode is Alan Sanders, Vice President of Ethics Integration and Strategy at Trinity Health is in conversation with guests in this episode to explore a number of ethical issues related to providing nutrition and hydration to patients who cannot feed themselves.

Our guests in this episode include:

  • Dr. George J. Giokas M.D., Director of Palliative Care, Palliative Care Partners, Inpatient Palliative Care Consult Service, Ellis Hospital
  • Fr. John J. Raphael, SSJ, Catholic Chaplain and Staff Chaplain at Saint Thomas West Hospital in Nashville, TN

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 guests 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.

Our guests in this episode are:

  • Dr. Jacqueline K. Yuen, MD, geriatrician, palliative care physician and medical educator. Dr. Yuen is now Assistant Clinical Professor, Department of Medicine at the University of Hong Kong
  • Dr. Michael Ruben, M.D., M.A., neurointensivist and clinical ethicist
  • Dr. Gregory Holt, M.D., Ph.D., pulmonary critical care physician at the University of Miami and VA Medical Center in Miami

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