Catawba Valley Medical Center has had for many years, policy, procedures, and a core group of individuals in place to handle ethical issues as they became apparent. Nurses at every level of the organization are committed to the pursuit of ethical treatment for all patients and the preservation of their rights. Nursing leadership has encouraged and empowered nurses at the bedside to make decisions which are in the patients’ best interest and ensured that they are familiar with the processes necessary to do so. By working collaboratively with other disciplines, the patients, and their families, nurses are strategically poised to act as the first-line of defense in protecting patients on every front.
Over time, the organization recognized an additional need which existed outside the confines of the organization. Nursing leadership, in conjunction with a multidisciplinary team, formulated a plan to help fill the gaps in the community’s understanding with respect to ethics, ethical dilemmas, and the ethical decision-making process. This effort culminated in what has become monthly educational luncheons known as “Conversations in Ethics.” Open to both staff and the community, these luncheons offer a venue for a pre-selected topic to be presented. Often taken from current events the topic gives rise to dialogue about the ethical issues involved with that particular scenario and helps to demonstrate how similar issues may be dealt with in the organization.
As the organization has grown and as patients present with more varied and complex conditions, nursing leadership recognized that it was time to re-examine policies and procedures concerning ethics and how these delicate situations are handled. It was decided that a new group would be charged with doing this work of re-examination and determining what gaps existed and where opportunities for improvement could be found. Nursing leadership saw several areas of need that seemed to have a somewhat common thread.
As a result, the Patient Rights Committee was formed. This committee is chaired by Greg Billings, Administrator of Psychiatric Services, and includes an interdisciplinary group of healthcare professionals. The committee has identified three main objectives as strategic goals: 1) Initiate, coordinate, and prioritize compliance efforts to all applicable patient rights regulations, 2) ethics consultation process and oversight via The Ethics Advisory Council, and 3) staff education on ethics and patient rights issues.
Though still a relatively new committee, the group has made significant progress. Members of the committee have reviewed The Joint Commission standards regarding rights and responsibilities of the individual with the objective of identifying potential gaps within CVMC’s policies and procedures. Reports on compliance with advanced directives and restraint use are currently under review and work has almost been completed on the creation of a placebo policy.
The Ethics Advisory Council has evolved from the long standing ethics committee. The council now reports to the Patient Rights committee and is comprised of a multi-disciplinary membership team of professionals and community representatives that gather to consider ethical issues arising in the care of patients. The council is identifying new ways to bring ethics to the bedside. Their first efforts are directed towards enhancing the ethics consult process.
Ethical consults can be requested by members of the medical team, registered nurses, patients, or their representatives as well as administrative personnel. The process for requesting an ethics consultation is much the same as it has always been. However, the results of that request are delivered much more expediently. Consult requests are being considered virtually in real-time, allowing an almost instant response. Members of the council who are on site gather and perform a preliminary investigation involving the person/people who initiated the consult request. Depending on the complexity of the situation, this group may be able to make immediate recommendations. For situations where it is appropriate, the group sets in motion the process required to convene the full council.
The Ethics Advisory Council approved a new framework for conducting the investigation of ethics consults known as “The Four Boxes.” The boxes consist of four areas of exploration: 1) medical indications, 2) patient preferences, 3) quality of life and 4) contextual features. Each criterion is associated with appropriate ethical principals. The framework can bring more clarity and consistency to a very complex process. Additional plans involve the creation of an ethics Intranet link, educational opportunities for staff and council members, and the creation of a database to tabulate and categorize ethics consults.
Ethics education is provided to all new graduates through the CNIP program for new graduate nurses. This initiates new nurses to the importance of considering ethics in their patient care. The program is also provided to patient care coordinators, medical social workers, direct-care nurses, advanced-practice nurses, members of the patient rights committee, and nursing leadership.
Patient care coordinators are equipped with the bedside ethics tool. They are instructed to consider ethical principals during their evaluation of patients and during the design of patient care plans. This information is then communicated to the bedside nurse and provided during hand-off. Specific situations are also introduced during shift huddles with the goal of informing staff about particular situations existing on the unit.
Charge nurses are educated and equipped with the tools for dealing with ethical situations. In their role on the units, it is critical that they are proficient in identifying ethical situations and also in accessing and utilizing resources available to them in dealing with such circumstances.
From the bedside to the boardroom, patients’ rights and ethics are more in the forefront. Conversation in Ethics, the creation of the Patient Rights Committee, and the enhancements within the Ethics Advisory Council are testaments to how CVMC as an organization, and nursing leadership in particular, engage with the ethical dimensions of healthcare.