Anita Catlin, DNSc, FNP, FAAN ❍ Section Editor
Ethical Issues in Newborn Care
The Hospital Ethics Committee and the Nurse Anita Catlin, DNSc, FNP, FAAN
ABSTRACT This article discusses all aspects of the hospital ethics committee. The nurse’s use of the committee and participation on the committee are delineated. Neonatal examples are given. Key Words: bioethics, ethics committee, ethics consultation, hospital ethics committee, neonatal nurse, nurse
n this article, a review of the hospital ethics committee is provided. The function of the ethics committee or consultation service is reviewed, including the role of the neonatal nurse on the ethics committee, preparation for that role, and contributions that the neonatal nurse can make.
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WHAT IS AN ETHICS COMMITTEE? Access to ethics consultation service is a Joint Commission regulation. Beginning in 1992, The Joint Commission required a means for clinicians to address troubling issues in medical care. The Joint Commission does not distinguish whether there must be an ethics committee or an ethics consultant, only that clinicians have the access to a format for education and resolution. It is estimated that between 80% and 100% of American hospitals have an ethics committee.1 Those that do not have an onsite committee have access to a consultant by telephone. In this article, the hospital ethics committee will be the term used to discuss ethics services. Author Affiliation: Ethics Committee, Kaiser Research and Redesign, Pope Valley, California. The author wishes to acknowledge the hospital ethics committee with whom collegiality is shared. The authors declare no conflict of interest. Correspondence: Anita Catlin, DNSc, FNP, FAAN ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000151 398
HOW DOES AN ETHICS COMMITTEE WORK? A hospital ethics committee “provides a set of services offered in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in healthcare.”2p2 The committee is usually cochaired by a physician and a nurse with at least master’s preparation or another member of the healthcare team with advanced education such as a social worker, clinical psychologist, philosopher, or chaplain. Committees frequently have at least 1 representative from the local community. Both cochairs should have a degree, certification, or special training in the field of ethics. Ethics committee functions follow standards set by the professional organization for ethicists, the American Society of Bioethics and Humanities (ASBH). Guidelines for consultations are delineated in the ASBH Manual for Core Competencies.3 The committee meets regularly and is convened when called for a committee consult. A wellfunctioning ethics committee contains members from all areas of the organization, and all members are given training in basic ethical concepts, communication skills, basic mediation, and conflict resolution. People on the committee must have, as Smith4 writes in the text Guidance for Healthcare Ethics Committees, “honesty, humility, respect for others, and self-knowledge.” The hospital ethics committee has traditionally had 3 main functions within the hospital and clinics setting: (1) education, (2) policy development, and (3) case consultation. The education and policy Advances in Neonatal Care • Vol. 14, No. 6 • pp. 398-402
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work are often not as well known as the availability of the committee for consultation but can lend a great deal to hospital operations. In recent years, many ethics committees have also contributed additional functions, such as (1) difficult situation debriefing,5 (2) participation in ethical operations in the organization,6 and (3) ethical work as risk management and prevention.7 In all situations, the ethics committee is not a decisional body, but a reflective body, which opens and widens discussion and offers ethically based recommendations. The committee is open to issues brought from every part of the healthcare community, such as patients, families, nurses, physicians, leadership, and others. The committee often reports to the medical executive committee of the hospital.
WHAT IS THE COMMON WORK OF THE ETHICS COMMITTEE? Before the advent of palliative care committees, most ethics committee consultations were related to endof-life issues. This may still be the case in some organizations and is often the case when the adult palliative care services do not extend to children and infants. The text Palliative Care for Infants, Children and Adolescents, 2nd Edition, edited by Carter et al,8 is a handbook to enhance pediatric expertise with life-limiting conditions. Trained palliative care clinicians who understand neonatal issues can be a tremendous help to the neonatal community. In the neonatal area, many ethics cases are related to complexly ill neonates. Dr Brian Carter, an ethics consultant and neonatologist, and his colleagues9 recently wrote about a typical ethics consultation/ patient situation. In the article, “Four Wishes for Aubrey,” he discusses how an end-of-life situation can go smoothly and without conflict when the team works together to honor the values of the family and staff. The ethics committee often intersects with work done by other hospital departments and committees, such as legal or spiritual services. It is said that “what is legal is not always ethical and what is ethical is not always legal” and that “ethics begins where the law ends.” Healthcare law determines policy, but the implementation and nuances of the policy is the purview of ethics. In addition, the hospital spiritual affiliation is important. If this is a secular hospital, the ethics recommendations will stand. If this is a hospital owned by a religious community (and it is estimated that 25% of US hospitals are), the hospital’s religious mission may override recommendations made by the ethics committee. This was seen in Arizona in a maternal child situation, in which an ethics committee approved ending a pregnancy of a critically ill woman to save her life, and the religious authorities did not agree (see case of Sister Margaret
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McBride10). The hospital’s mission statement most often guides the ethics committee in their work. It is the within role of the committee to offer education about ethical issues. For the neonatal community, examples may include education on religious and cultural family practices impacting care, palliative care barriers,11 and protocols,12 and the use of Resolve Through Sharing Bereavement training for care of families who lose an infant.13 The committee might introduce the use of Penticuff and Arheart’s Family Medical Record14 for families to use to assess their infant’s progress. Conflict over blood refusal in the maternal child department is an example of an ethical issue needing education. The ethics committee might provide a house-wide education program with the local Jehovah’s Witnesses Education Committee. A video called “TransfusionAlternative Strategies—Simple, Safe, Effective”15 teaches new information on alternatives for transfusion and updated information is available from the Jehovah’s Witnesses deacons on which components of blood products Jehovah’s Witnesses might now accept. On occasion, the issue that is brought to the committee is not really ethical in nature. This might be a human resources issue or risk management issue. But ethics committee members never turn colleagues away. Moral distress is always acknowledged, and then referral to the appropriate resource or an offer to call someone on the person’s behalf is offered.
Facilitators of a Good Ethics Committee Gaudine and colleagues16 from Canada have studied barriers to and effective qualities of a wellfunctioning ethics committee. Characteristics of a well-functioning committee include ethics support available within the hospital and clinics, information about the committee freely distributed, easy access to committee members, ethics education in the form of rounds or learning sessions, speedy consultation when asked, expertise of committee members, and an organizational setting that is interested in and supportive of the ethics committee. Nelson,17 from the American College of Health Care Executives, recognizes the committee’s ability to use moral reasoning, incorporate individual cultural values, keep a focus on healthcare law, and provide an ethical compass for the institutional mission. As the work of the committee becomes known throughout the organization, trust in the committee increases.
THE NURSE AND THE ETHICS COMMITTEE Neonatal nurses may interact with the ethics committee in several ways. The neonatal nurse may wish to refer a case to the ethics committee, attend an
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educational session by the ethics committee, ask for support from the ethics committee, participate in a debriefing by the ethics committee, or the nurse may wish to serve as a member of the committee. Each of these roles will be discussed.
Asking for a Consult The neonatal nurse should have access to the ethics committee directly. In some institutions, one might need permission to contact the ethics committee. But this is not the most common or appropriate methodology. Anyone in the healthcare community feeling moral distress over an issue should be able to contact the ethics committee. When the nurse contacts the committee, it is courteous to let the attending physician and nurse manager know. Often it is the nurse who identifies an ethical issue18 because of his or her skill at problem identification at the bedside. The nurse can simply say “I’m not feeling comfortable with what we are doing; I need some support or advice.” The case may come to the ethics committee both formally or informally. There should be a designated phone line for an ethics consultation and the hospital operators should have a method to notify whoever is on call after hours or in an emergency. A member of the committee will be available to set up an appointment to speak with the nurse informally. Often the initial conversation will include only 1 or 2 committee members. And often the initial conversation may be enough to resolve the angst that is being experienced. For the nurse, this may resolve the issue, but the ethics committee members may wish to discuss the situation at a regular meeting for their own learning. Alternatively, the nurse’s call may be evaluated and lead the ethics committee members to say “Yes, this is a complex situation. We need more information, to meet with additional stakeholders, and to really think this over.” The “case,” whether patient related, provider related, or policy related, needs a wider examination. The nurse is thanked and the committee goes to work, setting up a whole committee discussion to come to some recommendations. The committee in this case may organize a meeting of the stakeholders, inviting clinicians, family, and other involved parties, and may use an organized format for conducting the meeting. (The Four Square Method of case consultation is most popular—see Jonsen et al.18 Also see Catlin’s added components for consultations.19) The goal of the consult is to identify and analyze the nature of the value conflict or uncertainty or to facilitate resolution of conflicts in an atmosphere respectful of all involved.2 Unfortunately, ethics consultations are occasionally called at a point late in the decision-making process. So although this case may not be able to be solved to everyone’s liking, the ethics committee is thinking proactively with the stakeholders about
how to prevent such a dilemma from occurring in the future. The nurse who consulted the committee should leave the meeting feeling hopeful that support has been found.
Support Desired Sometimes it is enough for the neonatal physician or nurse to talk things over with a member of the ethics committee. For physicians, support from the ethics committee often provides “permission” to do what they feel is the right thing to do. If, for example, parents do not wish to go along with medically provided advice, the ethics consultant may help the physician to define for himself or herself acceptable alternatives. If, for example, the issue is related to parental request for nonbeneficial care, this may include exploring an established protocol to impede escalation of treatment, such as that written by Clark,20 or considering transferring care to another provider as suggested by Cantor and colleagues.21 The nurse may find guidance from Catlin and colleagues22 on the provision of conscientious objection to nonbeneficial care in neonatal nursing. Debriefing for a Hard Occurrence Occasionally, activities take place in practice that leave a significant “mark” on providers of care. This might be, for example, the unexpected death of a previously healthy, growing preemie. Nurses and physicians may experience guilt, anger, denial, and a host of other imposing feelings. Although a morbidity and mortality review may assess the medical components of the event, the ethics committee offers a safe place to just discuss feelings, offers assurance, and allows providers to build resilience. Maloney5 delineates the steps in an ethics debriefing, which includes the introduction phase, fact phase, thought phase, reaction phase, symptom phase, teaching phase, and reentry phase. Serving as a Member of the Committee Ethics committees should have nurses or physicians from multiple areas within the organization. Usually, the commitment is not more than once per month. As with other hospital committees, persons attending should be paid for their time by salary or an hourly rate. Membership on the committee allows for learning and growth as a nurse. A wellfunctioning ethics committee has no hierarchy and all members have equal voice. Ethics committees explore all areas of a designated problem, and while one might enter the meeting with 1 set belief, members often leave with many fresh ideas. Hearing the opinion of the member services staff member, the community liaison, the chaplain, social worker, or respiratory care provider may open avenues of thought not previously considered. The committee’s work is confidential, and members should feel free to www.advancesinneonatalcare.org
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express thoughts without judgment by others. The neonatal nurse offers a unique perspective23 as his or her continuous relationship with the family, training in communication, and reflective and perceptive attitude24 adds to the collective ethics committee wisdom.
Joining the Committee Nurses may be unaware of the potential contributions they could make to the ethics committee.24 However, serving on the committee can bring to the hospital and clinics community increased respect for the nursing profession. Nurses have indicated a willingness to obtain additional ethics training,25 and those who serve on ethics committees can offer support to their colleagues.26 The nurse desiring to join the committee should put this request in writing to the committee chair. A sample letter might contain the following: Dear ___, My name is ______. I am a nurse in the neonatal intensive care unit. I have a bachelor’s degree and a course in healthcare ethics was included in my program. (If this is the case, put each item from the curriculum in this letter; if you have not taken a special course, say that material was included in each nursing class and list class numbers). I work the night shift. I believe that I can contribute to the ethics committee by representing nurses who work at night and those who care for critically ill newborns. We do not have a palliative care consultant who works in our area and often experience ethical issues in the care of our infants. I am also interested in the areas of informed consent and research we do in our unit. I am willing to attend additional training and attend educational seminars in the ethics field. Currently, we do not have a nurse representing my constituency on the ethics committee. My manager supports this request. Please respond to _____. Thank you very much, ___ Nurses who are invited to join the committee can find direction from their professional nursing organizations, associated medical organizations, and the American Nurses Association (ANA). The National Organization of Neonatal Nurses, the National Perinatal Association, the American Academy of Pediatrics Ethics Committee, and the American College of Obstetrics and Gynecology Ethics Committee all provide position papers that are instructive when considering neonatal ethical problems. The ANA has an Ethics Advisory Board that deliberates on ethical issues that impact the nursing profession, writes position papers, and is available to answer questions of an ethical nature. In addition, there are several journals specifically related to healthcare ethics, such as Nursing Ethics, Journal of Clinical Ethics, American Journal of Bioethics, the
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Health Ethics Committee Forum, and Cambridge Quarterly of Healthcare Ethics.
How Can a Nurse Be Trained in Ethics? Nurses serving on committees can attend the annual ASBH conference. At this conference, training sessions for new ethics committee members occur and updates are provided on healthcare policy, law, and consultation practices. There are sessions on ethical ramifications of new advances in medicine, such as technology or genetics. The ASBH also has a robust area of interest groups, such as rural ethics, dental ethics, palliative care, mental health, instructors in medical schools, nurse ethicists, and more. The Nursing Ethics Subsection has an annual meeting at the ASBH conference to update nurses on current issues in ethics. The ANA director for the Center on Ethics and Human Rights also gives a report on ethics issues that have come in to the ANA that year. For nurses desiring more advanced ethics education, such training can be obtained through various universities in masters or certificate programs or week-long seminars. Such schools as the University of Washington, Seattle; Georgetown University in Washington, DC; University of Wisconsin, Milwaukee; Albany Medical Center in New York; and Loyola University or Rush University in Chicago offer in-person and online programs.
SUMMARY Nursing can benefit from and contribute to the ethics committee. The ethics committee can provide a venue for working through conflict or moral distress. The ethics committee can provide education on issues important to neonatal nurses. As nurses continue to be recognized as partners in the interdisciplinary team, as they are encouraged to perform at the highest level of their education,27 and as more and more nurses are accepting executive operations roles,28 the ethics committee offers 1 more opportunity for problem solving and professional enhancement.
References 1. 2.
3.
4.
5.
6.
Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007;7(2):13-25. American Society of Bioethics and Humanities. Core Competencies for Healthcare Ethics Consultation. 2nd ed. Glenview, IL: American Society of Bioethics; 2011:2. Tarzian A. Health care ethics consultation: an update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ core competencies update task force. Am J Bioeth. 2013;13(2):3-13. Smith ML. Mission, vision and goals: defining the parameters of ethics consultation. In: Hester DM, Schonfeld T, eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012:36-37. Maloney C. Critical incident stress debriefing and pediatric nurses: an approach to support the work environment and mitigate negative consequences. Pediatr Nurs. 2012;38(2):110-113. Rorty M. Ethics in and for the organization. In: Hester DM, Schonfeld T, eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012.
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8.
9. 10.
11.
12. 13.
14.
15.
16.
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Parsi K. Education as prevention. In: Hester DM, Schonfeld T., eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012. Carter BS, Levetown M, Friebert SE, eds. Palliative Care for Infants, Children and Adolescents. 2nd ed. Baltimore, MD: Johns Hopkins Press; 2011. Carter BS, Brown JB, Meyer EC. Four wishes for Aubrey. J Perinatol. 2012;32:10-14. Ryan Z. Excommunicated sister finds healing. National Catholic Record Online. http://ncronline.org/news/people/excommunicatedsister-finds-healing. Published 2011. Accessed October 29, 2014. Kain V, Gardner G, Yates P. Neonatal palliative care attitude scale: development of an instrument to measure the barriers to and facilitators of palliative care in neonatal nursing. Pediatrics. 2009;123(2): e207-e213. Catlin AJ, Carter BS. Creation of a neonatal end of life palliative care protocol. J Perinatol. 2002;22(3):184-195. Gundersen Lutheran. Resolve through sharing bereavement services. http://www.gundersenhealth.org/resolve-through-sharing . Published 2014. Accessed October 30, 2014. Penticuff JH, Arheart KL. Effectiveness of an intervention to improve parent-professional collaboration in neonatal intensive care. J Perinat Neonatal Nurs. 2005;19(2):187-202. Watchtower. Transfusion-Alternative Strategies—Simple, Safe, Effective. Jehovah’s Witnesses Watchtower Online Library; 2000. http://wol.jw.org/en/wol/d/r1/lp-e/1200276918 Gaudine A, Lamb M, LeFort SM, Thorne L. Barriers and facilitators to consulting hospital clinical ethics committees. Nurse Ethics. 2011;18(6):767-780.
17. 18. 19. 20. 21. 22.
23. 24.
25.
26. 27.
28.
Nelson WA. Necessary competencies for ethics committees. Health Care Exec. 2013;28(4):46-48. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 7th ed. New York, NY: McGraw Hill; 2010:8. Catlin A. Doing the right thing by incorporating evidence and professional goals in the ethics consult. JOGNN. 2013;42:478-484. Clark PA. Building a policy in pediatrics for medical futility. Pediatr Nurs. 2001;27(2):180-184. Cantor MD, Braddock CH, Derse AR, et al. Do-not-resuscitate orders and medical futility. Arch Intern Med. 2003;163(22):2689-2694. Catlin A, Armigo C, Volat D, et al. Conscientious objection: a potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept. Neonatal Network. 2008;27(2): 101-108. Savage TA. The nurse’s role in ethics committees and as an ethical consultant. Semin Nurse Manag. 1994;2(1):41-47. Cusveller B. Nurses serving on clinical ethics committees: a qualitative exploration of a competency profile. Nurse Ethics. 2012;19(3): 431-442. Rubinstein D, Tabak N. Nurses’ knowledge, attitudes and willingness to participate officially in workplace healthcare ethics committees (HEC). Med Law. 2012;31:163-176. Dalby J. Nurse participation in ethical decision making in the clinical setting. AWHONN’s Clinical Issues. 1993;4(4):606-610. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010. Englebright J, Perlin J. The chief nurse executive role in large healthcare systems. Nurs Adm Q. 2008;32(3):188-194.
www.advancesinneonatalcare.org Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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Ethical Issues in Newborn Care
The Hospital Ethics Committee and the Nurse Anita Catlin, DNSc, FNP, FAAN
ABSTRACT This article discusses all aspects of the hospital ethics committee. The nurse’s use of the committee and participation on the committee are delineated. Neonatal examples are given. Key Words: bioethics, ethics committee, ethics consultation, hospital ethics committee, neonatal nurse, nurse
n this article, a review of the hospital ethics committee is provided. The function of the ethics committee or consultation service is reviewed, including the role of the neonatal nurse on the ethics committee, preparation for that role, and contributions that the neonatal nurse can make.
I
WHAT IS AN ETHICS COMMITTEE? Access to ethics consultation service is a Joint Commission regulation. Beginning in 1992, The Joint Commission required a means for clinicians to address troubling issues in medical care. The Joint Commission does not distinguish whether there must be an ethics committee or an ethics consultant, only that clinicians have the access to a format for education and resolution. It is estimated that between 80% and 100% of American hospitals have an ethics committee.1 Those that do not have an onsite committee have access to a consultant by telephone. In this article, the hospital ethics committee will be the term used to discuss ethics services. Author Affiliation: Ethics Committee, Kaiser Research and Redesign, Pope Valley, California. The author wishes to acknowledge the hospital ethics committee with whom collegiality is shared. The authors declare no conflict of interest. Correspondence: Anita Catlin, DNSc, FNP, FAAN ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000151 398
HOW DOES AN ETHICS COMMITTEE WORK? A hospital ethics committee “provides a set of services offered in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in healthcare.”2p2 The committee is usually cochaired by a physician and a nurse with at least master’s preparation or another member of the healthcare team with advanced education such as a social worker, clinical psychologist, philosopher, or chaplain. Committees frequently have at least 1 representative from the local community. Both cochairs should have a degree, certification, or special training in the field of ethics. Ethics committee functions follow standards set by the professional organization for ethicists, the American Society of Bioethics and Humanities (ASBH). Guidelines for consultations are delineated in the ASBH Manual for Core Competencies.3 The committee meets regularly and is convened when called for a committee consult. A wellfunctioning ethics committee contains members from all areas of the organization, and all members are given training in basic ethical concepts, communication skills, basic mediation, and conflict resolution. People on the committee must have, as Smith4 writes in the text Guidance for Healthcare Ethics Committees, “honesty, humility, respect for others, and self-knowledge.” The hospital ethics committee has traditionally had 3 main functions within the hospital and clinics setting: (1) education, (2) policy development, and (3) case consultation. The education and policy Advances in Neonatal Care • Vol. 14, No. 6 • pp. 398-402
Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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work are often not as well known as the availability of the committee for consultation but can lend a great deal to hospital operations. In recent years, many ethics committees have also contributed additional functions, such as (1) difficult situation debriefing,5 (2) participation in ethical operations in the organization,6 and (3) ethical work as risk management and prevention.7 In all situations, the ethics committee is not a decisional body, but a reflective body, which opens and widens discussion and offers ethically based recommendations. The committee is open to issues brought from every part of the healthcare community, such as patients, families, nurses, physicians, leadership, and others. The committee often reports to the medical executive committee of the hospital.
WHAT IS THE COMMON WORK OF THE ETHICS COMMITTEE? Before the advent of palliative care committees, most ethics committee consultations were related to endof-life issues. This may still be the case in some organizations and is often the case when the adult palliative care services do not extend to children and infants. The text Palliative Care for Infants, Children and Adolescents, 2nd Edition, edited by Carter et al,8 is a handbook to enhance pediatric expertise with life-limiting conditions. Trained palliative care clinicians who understand neonatal issues can be a tremendous help to the neonatal community. In the neonatal area, many ethics cases are related to complexly ill neonates. Dr Brian Carter, an ethics consultant and neonatologist, and his colleagues9 recently wrote about a typical ethics consultation/ patient situation. In the article, “Four Wishes for Aubrey,” he discusses how an end-of-life situation can go smoothly and without conflict when the team works together to honor the values of the family and staff. The ethics committee often intersects with work done by other hospital departments and committees, such as legal or spiritual services. It is said that “what is legal is not always ethical and what is ethical is not always legal” and that “ethics begins where the law ends.” Healthcare law determines policy, but the implementation and nuances of the policy is the purview of ethics. In addition, the hospital spiritual affiliation is important. If this is a secular hospital, the ethics recommendations will stand. If this is a hospital owned by a religious community (and it is estimated that 25% of US hospitals are), the hospital’s religious mission may override recommendations made by the ethics committee. This was seen in Arizona in a maternal child situation, in which an ethics committee approved ending a pregnancy of a critically ill woman to save her life, and the religious authorities did not agree (see case of Sister Margaret
399
McBride10). The hospital’s mission statement most often guides the ethics committee in their work. It is the within role of the committee to offer education about ethical issues. For the neonatal community, examples may include education on religious and cultural family practices impacting care, palliative care barriers,11 and protocols,12 and the use of Resolve Through Sharing Bereavement training for care of families who lose an infant.13 The committee might introduce the use of Penticuff and Arheart’s Family Medical Record14 for families to use to assess their infant’s progress. Conflict over blood refusal in the maternal child department is an example of an ethical issue needing education. The ethics committee might provide a house-wide education program with the local Jehovah’s Witnesses Education Committee. A video called “TransfusionAlternative Strategies—Simple, Safe, Effective”15 teaches new information on alternatives for transfusion and updated information is available from the Jehovah’s Witnesses deacons on which components of blood products Jehovah’s Witnesses might now accept. On occasion, the issue that is brought to the committee is not really ethical in nature. This might be a human resources issue or risk management issue. But ethics committee members never turn colleagues away. Moral distress is always acknowledged, and then referral to the appropriate resource or an offer to call someone on the person’s behalf is offered.
Facilitators of a Good Ethics Committee Gaudine and colleagues16 from Canada have studied barriers to and effective qualities of a wellfunctioning ethics committee. Characteristics of a well-functioning committee include ethics support available within the hospital and clinics, information about the committee freely distributed, easy access to committee members, ethics education in the form of rounds or learning sessions, speedy consultation when asked, expertise of committee members, and an organizational setting that is interested in and supportive of the ethics committee. Nelson,17 from the American College of Health Care Executives, recognizes the committee’s ability to use moral reasoning, incorporate individual cultural values, keep a focus on healthcare law, and provide an ethical compass for the institutional mission. As the work of the committee becomes known throughout the organization, trust in the committee increases.
THE NURSE AND THE ETHICS COMMITTEE Neonatal nurses may interact with the ethics committee in several ways. The neonatal nurse may wish to refer a case to the ethics committee, attend an
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educational session by the ethics committee, ask for support from the ethics committee, participate in a debriefing by the ethics committee, or the nurse may wish to serve as a member of the committee. Each of these roles will be discussed.
Asking for a Consult The neonatal nurse should have access to the ethics committee directly. In some institutions, one might need permission to contact the ethics committee. But this is not the most common or appropriate methodology. Anyone in the healthcare community feeling moral distress over an issue should be able to contact the ethics committee. When the nurse contacts the committee, it is courteous to let the attending physician and nurse manager know. Often it is the nurse who identifies an ethical issue18 because of his or her skill at problem identification at the bedside. The nurse can simply say “I’m not feeling comfortable with what we are doing; I need some support or advice.” The case may come to the ethics committee both formally or informally. There should be a designated phone line for an ethics consultation and the hospital operators should have a method to notify whoever is on call after hours or in an emergency. A member of the committee will be available to set up an appointment to speak with the nurse informally. Often the initial conversation will include only 1 or 2 committee members. And often the initial conversation may be enough to resolve the angst that is being experienced. For the nurse, this may resolve the issue, but the ethics committee members may wish to discuss the situation at a regular meeting for their own learning. Alternatively, the nurse’s call may be evaluated and lead the ethics committee members to say “Yes, this is a complex situation. We need more information, to meet with additional stakeholders, and to really think this over.” The “case,” whether patient related, provider related, or policy related, needs a wider examination. The nurse is thanked and the committee goes to work, setting up a whole committee discussion to come to some recommendations. The committee in this case may organize a meeting of the stakeholders, inviting clinicians, family, and other involved parties, and may use an organized format for conducting the meeting. (The Four Square Method of case consultation is most popular—see Jonsen et al.18 Also see Catlin’s added components for consultations.19) The goal of the consult is to identify and analyze the nature of the value conflict or uncertainty or to facilitate resolution of conflicts in an atmosphere respectful of all involved.2 Unfortunately, ethics consultations are occasionally called at a point late in the decision-making process. So although this case may not be able to be solved to everyone’s liking, the ethics committee is thinking proactively with the stakeholders about
how to prevent such a dilemma from occurring in the future. The nurse who consulted the committee should leave the meeting feeling hopeful that support has been found.
Support Desired Sometimes it is enough for the neonatal physician or nurse to talk things over with a member of the ethics committee. For physicians, support from the ethics committee often provides “permission” to do what they feel is the right thing to do. If, for example, parents do not wish to go along with medically provided advice, the ethics consultant may help the physician to define for himself or herself acceptable alternatives. If, for example, the issue is related to parental request for nonbeneficial care, this may include exploring an established protocol to impede escalation of treatment, such as that written by Clark,20 or considering transferring care to another provider as suggested by Cantor and colleagues.21 The nurse may find guidance from Catlin and colleagues22 on the provision of conscientious objection to nonbeneficial care in neonatal nursing. Debriefing for a Hard Occurrence Occasionally, activities take place in practice that leave a significant “mark” on providers of care. This might be, for example, the unexpected death of a previously healthy, growing preemie. Nurses and physicians may experience guilt, anger, denial, and a host of other imposing feelings. Although a morbidity and mortality review may assess the medical components of the event, the ethics committee offers a safe place to just discuss feelings, offers assurance, and allows providers to build resilience. Maloney5 delineates the steps in an ethics debriefing, which includes the introduction phase, fact phase, thought phase, reaction phase, symptom phase, teaching phase, and reentry phase. Serving as a Member of the Committee Ethics committees should have nurses or physicians from multiple areas within the organization. Usually, the commitment is not more than once per month. As with other hospital committees, persons attending should be paid for their time by salary or an hourly rate. Membership on the committee allows for learning and growth as a nurse. A wellfunctioning ethics committee has no hierarchy and all members have equal voice. Ethics committees explore all areas of a designated problem, and while one might enter the meeting with 1 set belief, members often leave with many fresh ideas. Hearing the opinion of the member services staff member, the community liaison, the chaplain, social worker, or respiratory care provider may open avenues of thought not previously considered. The committee’s work is confidential, and members should feel free to www.advancesinneonatalcare.org
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The Hospital Ethics Committee and the Nurse
express thoughts without judgment by others. The neonatal nurse offers a unique perspective23 as his or her continuous relationship with the family, training in communication, and reflective and perceptive attitude24 adds to the collective ethics committee wisdom.
Joining the Committee Nurses may be unaware of the potential contributions they could make to the ethics committee.24 However, serving on the committee can bring to the hospital and clinics community increased respect for the nursing profession. Nurses have indicated a willingness to obtain additional ethics training,25 and those who serve on ethics committees can offer support to their colleagues.26 The nurse desiring to join the committee should put this request in writing to the committee chair. A sample letter might contain the following: Dear ___, My name is ______. I am a nurse in the neonatal intensive care unit. I have a bachelor’s degree and a course in healthcare ethics was included in my program. (If this is the case, put each item from the curriculum in this letter; if you have not taken a special course, say that material was included in each nursing class and list class numbers). I work the night shift. I believe that I can contribute to the ethics committee by representing nurses who work at night and those who care for critically ill newborns. We do not have a palliative care consultant who works in our area and often experience ethical issues in the care of our infants. I am also interested in the areas of informed consent and research we do in our unit. I am willing to attend additional training and attend educational seminars in the ethics field. Currently, we do not have a nurse representing my constituency on the ethics committee. My manager supports this request. Please respond to _____. Thank you very much, ___ Nurses who are invited to join the committee can find direction from their professional nursing organizations, associated medical organizations, and the American Nurses Association (ANA). The National Organization of Neonatal Nurses, the National Perinatal Association, the American Academy of Pediatrics Ethics Committee, and the American College of Obstetrics and Gynecology Ethics Committee all provide position papers that are instructive when considering neonatal ethical problems. The ANA has an Ethics Advisory Board that deliberates on ethical issues that impact the nursing profession, writes position papers, and is available to answer questions of an ethical nature. In addition, there are several journals specifically related to healthcare ethics, such as Nursing Ethics, Journal of Clinical Ethics, American Journal of Bioethics, the
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Health Ethics Committee Forum, and Cambridge Quarterly of Healthcare Ethics.
How Can a Nurse Be Trained in Ethics? Nurses serving on committees can attend the annual ASBH conference. At this conference, training sessions for new ethics committee members occur and updates are provided on healthcare policy, law, and consultation practices. There are sessions on ethical ramifications of new advances in medicine, such as technology or genetics. The ASBH also has a robust area of interest groups, such as rural ethics, dental ethics, palliative care, mental health, instructors in medical schools, nurse ethicists, and more. The Nursing Ethics Subsection has an annual meeting at the ASBH conference to update nurses on current issues in ethics. The ANA director for the Center on Ethics and Human Rights also gives a report on ethics issues that have come in to the ANA that year. For nurses desiring more advanced ethics education, such training can be obtained through various universities in masters or certificate programs or week-long seminars. Such schools as the University of Washington, Seattle; Georgetown University in Washington, DC; University of Wisconsin, Milwaukee; Albany Medical Center in New York; and Loyola University or Rush University in Chicago offer in-person and online programs.
SUMMARY Nursing can benefit from and contribute to the ethics committee. The ethics committee can provide a venue for working through conflict or moral distress. The ethics committee can provide education on issues important to neonatal nurses. As nurses continue to be recognized as partners in the interdisciplinary team, as they are encouraged to perform at the highest level of their education,27 and as more and more nurses are accepting executive operations roles,28 the ethics committee offers 1 more opportunity for problem solving and professional enhancement.
References 1. 2.
3.
4.
5.
6.
Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007;7(2):13-25. American Society of Bioethics and Humanities. Core Competencies for Healthcare Ethics Consultation. 2nd ed. Glenview, IL: American Society of Bioethics; 2011:2. Tarzian A. Health care ethics consultation: an update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ core competencies update task force. Am J Bioeth. 2013;13(2):3-13. Smith ML. Mission, vision and goals: defining the parameters of ethics consultation. In: Hester DM, Schonfeld T, eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012:36-37. Maloney C. Critical incident stress debriefing and pediatric nurses: an approach to support the work environment and mitigate negative consequences. Pediatr Nurs. 2012;38(2):110-113. Rorty M. Ethics in and for the organization. In: Hester DM, Schonfeld T, eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012.
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402 7.
8.
9. 10.
11.
12. 13.
14.
15.
16.
Catlin
Parsi K. Education as prevention. In: Hester DM, Schonfeld T., eds. Guidance for Healthcare Ethics Committees. New York, NY: Cambridge University Press; 2012. Carter BS, Levetown M, Friebert SE, eds. Palliative Care for Infants, Children and Adolescents. 2nd ed. Baltimore, MD: Johns Hopkins Press; 2011. Carter BS, Brown JB, Meyer EC. Four wishes for Aubrey. J Perinatol. 2012;32:10-14. Ryan Z. Excommunicated sister finds healing. National Catholic Record Online. http://ncronline.org/news/people/excommunicatedsister-finds-healing. Published 2011. Accessed October 29, 2014. Kain V, Gardner G, Yates P. Neonatal palliative care attitude scale: development of an instrument to measure the barriers to and facilitators of palliative care in neonatal nursing. Pediatrics. 2009;123(2): e207-e213. Catlin AJ, Carter BS. Creation of a neonatal end of life palliative care protocol. J Perinatol. 2002;22(3):184-195. Gundersen Lutheran. Resolve through sharing bereavement services. http://www.gundersenhealth.org/resolve-through-sharing . Published 2014. Accessed October 30, 2014. Penticuff JH, Arheart KL. Effectiveness of an intervention to improve parent-professional collaboration in neonatal intensive care. J Perinat Neonatal Nurs. 2005;19(2):187-202. Watchtower. Transfusion-Alternative Strategies—Simple, Safe, Effective. Jehovah’s Witnesses Watchtower Online Library; 2000. http://wol.jw.org/en/wol/d/r1/lp-e/1200276918 Gaudine A, Lamb M, LeFort SM, Thorne L. Barriers and facilitators to consulting hospital clinical ethics committees. Nurse Ethics. 2011;18(6):767-780.
17. 18. 19. 20. 21. 22.
23. 24.
25.
26. 27.
28.
Nelson WA. Necessary competencies for ethics committees. Health Care Exec. 2013;28(4):46-48. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 7th ed. New York, NY: McGraw Hill; 2010:8. Catlin A. Doing the right thing by incorporating evidence and professional goals in the ethics consult. JOGNN. 2013;42:478-484. Clark PA. Building a policy in pediatrics for medical futility. Pediatr Nurs. 2001;27(2):180-184. Cantor MD, Braddock CH, Derse AR, et al. Do-not-resuscitate orders and medical futility. Arch Intern Med. 2003;163(22):2689-2694. Catlin A, Armigo C, Volat D, et al. Conscientious objection: a potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept. Neonatal Network. 2008;27(2): 101-108. Savage TA. The nurse’s role in ethics committees and as an ethical consultant. Semin Nurse Manag. 1994;2(1):41-47. Cusveller B. Nurses serving on clinical ethics committees: a qualitative exploration of a competency profile. Nurse Ethics. 2012;19(3): 431-442. Rubinstein D, Tabak N. Nurses’ knowledge, attitudes and willingness to participate officially in workplace healthcare ethics committees (HEC). Med Law. 2012;31:163-176. Dalby J. Nurse participation in ethical decision making in the clinical setting. AWHONN’s Clinical Issues. 1993;4(4):606-610. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010. Englebright J, Perlin J. The chief nurse executive role in large healthcare systems. Nurs Adm Q. 2008;32(3):188-194.
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