building an ethics service | components | new questions and models | physician capacity |...
TRANSCRIPT
building an ethics service | components
| new questions and models
| physician capacity
| empirically driven
• Medical Resident Roundtables
• Bioethics Grand Rounds
• Bioethics focused CME
• Mandatory ethics conferences (ICU)
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
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)