The Cambridge textbook of bioethics

community workers to contribute to the development of formal educational material that is part of the Community Ethics Network strategic plan. Specifically, the material will focus on the interprofessional learning required to ensure appropriate ethical decision-making process by these and other workers in the community sector.

How should I approach community healthcare ethics in practice?

The cooperation of the GTA community sector has permitted the development of unique resources to support community healthcare staff as they face an increasing volume and complexity of moral issues. Beyond beginning to address the resulting moral distress staff may experience, the partnerships, tools, and processes of the GTA community sector are also important for addressing an altogether different type of pressure: namely, that brought by changing healthcare accreditation standards.

The Canadian Council for Health Services Accreditation (CCHSA) has expressed concern about the ability of small homecare organizations to build and maintain capacity in ethics (Murphy, 2006). The unique partnership of the Community Ethics Network addresses this concern by pooling resources so that all organizations have access to the same robust set of tools.

Furthermore, some of these tools are themselves relevant to accreditation, as the CCHSA is beginning to move beyond requiring mechanisms for conducting case consultations toward review of their results, and the impact of these outcomes for ethics services (Murphy, 2006). As noted above, the CCED collects the necessary information on service delivery for such evaluation research, which to date has never been conducted with community agencies, and very little among clinical ethics support services (Slowther et al., 2001).

The CCED and other components of the toolkit will be of use in other regions. Indeed, some teaching hospitals in Toronto as well as in other parts of Ontario and Canada have used the toolkit

to assist in the education of their staff. These resources can be freely used with appropriate attribution, and downloaded from the Community Ethics Network website at: http://www.utoronto. ca/jcb/ethics/cen.htm

While the network’s tools will be of use to individual homecare organizations, it is important to emphasize this partnership itself as a model for collaborative approaches to ethical issues facing other catchment areas. Again, this network provides a forum that enhances organizational capacity to review difficult cases that arise, and the resource pool required to further develop and teach new educational materials.

The case

The case illustrates the significant ethical issues arising from the delivery of community health services unique to the community healthcare setting. Using the ethics toolkit, the community care staff member first used the IDEA framework to collect the relevant facts, including the perspectives of the client on the situation. The client consistently maintained that she was quite happy with the quality of her life, and that she had absolutely no desire to be placed in a long-term care facility. While she acknowledged that her son was ‘‘not perfect,’’ she did not feel neglected or abused, and found comfort in having a familiar face around the house.

Directed by the worksheet to reflect on her own emotions, feelings, and values about the situation, the staff member felt that the son’s motives and the impact of his choices on client’s quality of life was her primary concern. His criminal behavior was an issue for her more for this reason than for her own personal safety. Nevertheless, directed by the worksheet to examine the Code of Ethics in articulating the values in conflict (step 2), she felt reassured by the code’s allowance for service being withdrawn where, after all options have been considered, employee safety remains compromised. Further, the code emphasized the need to respect choices that capable clients like this elderly

woman make about their care plan, but to seek guidance in situation where clients like this elderly woman may be at risk. A district supervisor was involved, and together they determined that there was a conflict between their perception of the quality of the patient’s life and her own. Given that the client was capable, and the staff member had informed her of the provider perspective on the potential consequences of her son’s behavior and dependency (e.g., possibly not receiving service, danger in the home), the staff decided to respect the client’s decision to live at home.

Next, the staff member took action (step 3 and step 4) and communicated her respect for the client’s decision to her and her son. At this time, she also communicated to the son that he must offer the resources necessary to provide quality care to his mother, and that his capacity to do so would be evaluated. Further, he was informed that legal action would be taken if evidence of abuse was encountered in the future; that he could relinquish his role as caregiver if he wanted; or that staff would help to educate and support him in meeting his mother’s medical and dietary needs. The son agreed to these conditions.

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REF EREN CES

Aulisio, M. P., May, T., and Aulisio M. S. (1998). Vulnerabilities of clients and caregivers in the homecare setting. Generations 22: 58–63.

Committee to Advance Ethical Decision Making in Community Health (2001). Final Report March 2001– December 2001. Toronto: Community Access Care Centre Toronto.

Elpern, E. H., Covert, B., and Kleinpel, R. (2006). Moral distress of staff nurses in a medical intensive care unit.

Am J Crit Care 14: 523–30.

Liaschenko, J. (1996). A sense of place for patients: living and dying. Home Care Provider 1: 270–2.

Murphy, T. (2006). Ethics and CCHSA’s Accreditation Program. Toronto: Joint Centre for Bioethics.

Rushton, C. H. (2006). Defining and addressing moral distress: tools for critical care nursing leaders. AACN Adv Crit Care 17: 161–8.

Slowther, A., Bunch, C., Woolnough, B., and Hope, T. (2001). Clinical ethics support services in the UK: an investigation of the current provision of ethics support to health professionals in the UK. J Med Ethics 27: (Suppl. I): i2.

Wojtak, A. (2002). Practice based ethics as a foundation for human resources planning in community health care.

Healthc Manag Forum 3: 67–72.

A recent study was done in Canada to identify what clinical ethicists felt were the top 10 clinical ethical challenges facing Canadians in healthcare. (Breslin et al., 2005; Table VII.1).

What is clear from this list is that many of these ethical issues are core to challenges of healthcare more broadly today. While this study was conducted in Canada, it is likely these same challenges may be similar in other healthcare systems, at least in the developed world.

Clinical ethics is a comparatively recent endeavor in healthcare, but despite its relative newness it provides an ideal model for initiatives that can impact healthcare because of its inherent interdisciplinary make-up and its unique capacity to impact care across the healthcare spectrum from ‘‘boardroom to bedside.’’ While clinical ethics offers this unique perspective to address healthcare problems, it is often missing from the meetings where significant system-wide decisions are made. Many decision makers miss the key point that much of healthcare is grounded in values and many of the solutions may be found in the ethical field of inquiry. The most likely reason for this absence of clinical ethics at the decision tables in healthcare is related to the still developing nature of this work. What the chapters in this section show, however, is that perhaps clinical ethics is ‘‘coming of age’’ and is beginning to make serious arguments to the healthcare community about how its activities and frameworks can offer useful, real-world contributions to help to guide system decision makers, healthcare professionals, and the public.

In Ch. 40, the authors outline the importance of systems thinking in the practice of clinical ethics with the goal of impacting the overall professional and organization ethics culture and accountability of hospitals and other healthcare settings. The authors built their chapter around a challenge by Singer, Pelligrino and Siegler from their 2001 article ‘‘Clinical ethics revisited,’’ who stated that the two significant challenges in the field of clinical ethics for this decade are (i) for clinical ethics practice (consultation and committees) to integrate clinical ethics work into the culture of health care organizations and (ii) to improve organizational accountability for clinical ethics. The authors take this challenge and offer systems thinking as an important response to these problems by arguing that clinical ethics must focus more on the underlying systems factors that give rise to many of the ethical concerns in healthcare rather than focusing only on cases and acute situations. The three authors provide leadership to major clinical ethics programs in Canada, the USA, and the UK and have each independently evolved to this systemic approach to clinical ethics. In this chapter, they describe their reasons for and experience with this approach. At the end of the chapter, the authors highlight their own top 10 leading practices in applying systems thinking to clinical ethics.

Chapter 41 reviews four innovative strategies that may improve clinical ethics effectiveness in healthcare organizations: (i) the hub and spokes model for clinical ethics service delivery, (ii) leadership and management skills training for clinical

From Breslin et al., 2005.

ethicists, (iii) ethics strategic planning and (iv) evaluation of clinical ethics services based on process indicators. These innovations were developed in the ‘‘laboratory’’ of the University of Toronto Joint Centre for Bioethics, where 15 healthcare organizations and 25 bioethicists collaborate across a broad spectrum of health care organizations (from acute care, home care, specialty hospitals, and a genomic institute) to model, pilot, test, and share innovations in clinical ethics service and practice. This chapter reviews these innovations in the context of clinical ethics effectiveness. In so doing, they give a brief history and outline some of the complexities involved in evaluating clinical ethics effectiveness. They make a further point that the unique patient populations, variability of ethics capacity in any given institution, and the different missions and values of different organizations will demand that ‘‘some component of evaluating clinical ethics effectiveness will necessarily [be] context-dependent.’’ Nevertheless the authors challenge us to take this notion of effectiveness seriously, as ethics is increasingly recognized as an important component of high-quality clinical care and valued strongly by patients and their families.

In Ch. 42, the authors tackle the challenge of bioethics teaching in clinical practice and advocate for a clinician–teacher approach. The authors intend the chapter to encourage clinician–teachers

to accept the important responsibility of teaching bioethics and to provide them with some practical advice. While the focus in this chapter is on medical students and medical residents, the authors acknowledge that a similar clinical approach applies to teaching other clinicians, such as nurses. The authors organize their chapter around five questions for the clinical teacher. (i) Why should I teach? (ii) What should I teach? (iii) How should I teach? (iv) How should I evaluate? (v) How should I learn? The authors review the importance of a bedside or case-based approach as a way to capture the interest of the clinical audience. The authors quite extensively review various evaluation strategies for clinical training, including in-training evaluation reports, chart audits, objective structured clinical examination using standardized patients, multiple choice examinations, and short answer or essay examinations. Finally, the authors encourage clinicians to seek continued and further education for themselves if they are to teach bioethics as a specialized skill. The authors provide an extensive list of bioethics teaching resources in an appendix at the end of the chapter.

This section is a limited examination of only a few innovations in clinical ethics that strive to make an impact on the healthcare system. There are others in the field working toward the same goal. Perhaps it is now time for those individuals

interested in clinical ethics as a vehicle for quality improvement and influence in healthcare to collaborate and share lessons and strategies. There are considerable opportunities to further research and gather evidence to demonstrate how changing the ethical culture in healthcare can make a significant impact to the current problems we face in healthcare.

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R E F E R E N C E S

Breslin, J. M., MacRae, S. K., Bell, J., for the University of Toronto Joint Centre for Bioethics Clinical Ethics Group (2005). Top 10 health care ethics challenges facing the public: views of toronto bioethicists. BMC Med Ethics 6: 5.

Singer, P. A., Pelligrino, E. D., and Siegler, M. (2001). Clinical ethics revisited. BMC Med Ethics 2: 1.

A health region, with multiple hospitals and community healthcare organizations, is faced with increased pressures to improve the ethical care of patients and improve staff experience across the system. Currently the patient satisfaction scores at many of the sites are quite low and recent Health Commission inspections in some hospitals have highlighted management of consent issues and patientcentered care as areas of major concern. The staff ’s morale is waning and moral distress seems to be increasing. The CEO of the Strategic Health Authority believes that clinical ethics could potentially make a significant difference to the overall culture of the system but feels that the existing mechanisms are not that effective. She begins to consult with experts in the field to discuss how clinical ethics can help her to improve her health system.

‘‘ABC Health Care’’ has an established clinical ethics program that performs a variety of functions including case consultation, education, policy work, and scholarly writing. Although ABC has received positive accreditation ratings relating to clinical ethics, many within ABC – including both administrators and clinical staff – have a general sense that ABC’s current clinical ethics program may not be fully addressing the organization’s needs. For example, the program tends to focus on a narrow range of ethical concerns, mostly related to high-profile acute situations in the intensive care and emergency units. In contrast, staff experience a much broader range of ethical issues in their work day to day, and many issues and areas go unserved. Although the clinical ethics program devotes many hours to ethics consultation, similar ethical issues continue to recur again and again. At times, ethics program staff seems more concerned about philosophical questions and principles than about the practical realities

experienced by patients and healthcare staff. Overall, the clinical ethics program’s impact on everyday behavior or on organizational culture is unclear, and no measures exist to evaluate the program’s effectiveness. The CEO feels strongly that the clinical ethics program should be held accountable for its effects on the system (or lack thereof). He looks to other organizations for models of how clinical ethics programs can be used to make systems change.

What is systems thinking in clinical ethics?

According to Silverman (2000), systems thinking ‘‘is concerned with the key interrelationships, structures, and processes that control and monitor behaviour . . . With systems thinking, the focus is not on individuals as objects of improvement, but rather, on examining interrelationships, communications, ongoing processes, and underlying causes of behaviour with an eye towards changing interactions or redesigning the system to produce different behaviours.’’

In the healthcare arena, systems thinking has been increasingly evident since the late 1980s (Berwick, 1989). Don Berwick, President of the Institute for Healthcare Improvement in the USA, has been instrumental in instilling the concept, now well recognized in healthcare, that ‘‘every system is perfectly designed to achieve the results it achieves’’ (Berwick, 1996). Also in the USA, the major organization that accredits