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INTER AMERICAN UNIVERSITY OF PUERTO RICO
METROPOLITAN CAMPUS
FACULTY OF SCIENCES AND TECHNOLOGY
SCHOOL OF NURSING CARMEN TORRES DE TIBURCIO
NURS 2351 FUNDAMEMTALS OF PEDIATRIC CARE
Name: _____________________ Student #: __________ Date: _________ DEVELOP AN ESSAY ON A CHRONIC CLINICAL CONDITION OF YOUR INTEREST IN A CLINICAL CONDITION FROM WHICH YOU WOULD LIKE TO EXPAND YOUR KNOWLEDGE OR BASED ON A HEALTH EXPERIENCE OF ANY PERSON.
DUE DATE: January 13,2020
CATEGORY
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Anita Catlin, DNSc, FNP, FAAN ❍ Section EditorEthical Issues in Newborn CareThe Hospital Ethics Committee andthe NurseAnita Catlin , DNSc, FNP, FAANABSTRACTThis article discusses all aspects of the hospital ethics committee. The nurse’s use of the committeeand participation on the committee are delineated. Neonatal examples are given.Key Words: bioethics , ethics committee , ethics consultation , hospital ethics committee , neonatalnurse , nurseIn this article, a review of the hospital ethics committeeis provided. The function of the ethicscommittee or consultation service is reviewed,including the role of the neonatal nurse on the ethicscommittee, preparation for that role, and contributionsthat the neonatal nurse can make.WHAT IS AN ETHICS COMMITTEE?Access to ethics consultation service is a JointCommission regulation. Beginning in 1992, TheJoint Commission required a means for clinicians toaddress troubling issues in medical care. The JointCommission does not distinguish whether theremust be an ethics committee or an ethics consultant,only that clinicians have the access to a format foreducation and resolution. It is estimated thatbetween 80% and 100% of American hospitals havean ethics committee. 1 Those that do not have anonsite committee have access to a consultant by telephone.In this article, the hospital ethics committeewill be the term used to discuss ethics services.Author Affiliation: Ethics Committee, Kaiser Researchand Redesign, Pope Valley, California.The author wishes to acknowledge the hospital ethicscommittee 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 ofNeonatal NursesDOI: 10.1097/ANC.0000000000000151HOW DOES AN ETHICS COMMITTEEWORK?A hospital ethics committee “provides a set of servicesoffered in response to questions from patients, families,surrogates, healthcare professionals, or otherinvolved parties who seek to resolve uncertainty orconflict regarding value-laden concerns that emerge inhealthcare.” 2p2 The committee is usually cochaired bya physician and a nurse with at least master’s preparationor another member of the healthcare team withadvanced education such as a social worker, clinicalpsychologist, philosopher, or chaplain. Committeesfrequently have at least 1 representative from the localcommunity. Both cochairs should have a degree, certification,or special training in the field of ethics.Ethics committee functions follow standards set bythe professional organization for ethicists, theAmerican Society of Bioethics and Humanities(ASBH). Guidelines for consultations are delineated inthe ASBH Manual for Core Competencies. 3The committee meets regularly and is convenedwhen called for a committee consult. A wellfunctioningethics committee contains membersfrom all areas of the organization, and all membersare given training in basic ethical concepts, communicationskills, basic mediation, and conflict resolution.People on the committee must have, as Smith 4writes in the text Guidance for Healthcare EthicsCommittees, “honesty, humility, respect for others,and self-knowledge.”The hospital ethics committee has traditionallyhad 3 main functions within the hospital and clinicssetting: (1) education, (2) policy development, and(3) case consultation. The education and policyAdvances in Neonatal Care Vol. 14, No. 6 pp. 398-402Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.398The Hospital Ethics Committee and the Nurse 399work are often not as well known as the availabilityof the committee for consultation but can lend agreat deal to hospital operations. In recent years,many ethics committees have also contributed additionalfunctions, such as (1) difficult situationdebriefing, 5 (2) participation in ethical operations inthe organization, 6 and (3) ethical work as risk managementand prevention. 7 In all situations, the ethicscommittee is not a decisional body, but a reflectivebody, which opens and widens discussion and offersethically based recommendations. The committee isopen to issues brought from every part of the healthcarecommunity, such as patients, families, nurses,physicians, leadership, and others. The committeeoften reports to the medical executive committee ofthe hospital.WHAT IS THE COMMON WORK OF THEETHICS COMMITTEE?Before the advent of palliative care committees, mostethics committee consultations were related to endof-life issues. This may still be the case in some organizationsand is often the case when the adult palliativecare services do not extend to children andinfants. The text Palliative Care for Infants, Childrenand Adolescents, 2nd Edition, edited by Carteret al, 8 is a handbook to enhance pediatric expertisewith life-limiting conditions. Trained palliative careclinicians who understand neonatal issues can be atremendous help to the neonatal community.In the neonatal area, many ethics cases are relatedto complexly ill neonates. Dr Brian Carter, an ethicsconsultant and neonatologist, and his colleagues 9recently wrote about a typical ethics consultation/patient situation. In the article, “Four Wishes forAubrey,” he discusses how an end-of-life situationcan go smoothly and without conflict when the teamworks together to honor the values of the family andstaff.The ethics committee often intersects with workdone 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 ethicalis not always legal” and that “ethics begins wherethe law ends.” Healthcare law determines policy, butthe implementation and nuances of the policy is thepurview of ethics. In addition, the hospital spiritualaffiliation is important. If this is a secular hospital,the ethics recommendations will stand. If this is ahospital owned by a religious community (and it isestimated that 25% of US hospitals are), the hospital’sreligious mission may override recommendationsmade by the ethics committee. This was seen inArizona in a maternal child situation, in which anethics committee approved ending a pregnancy of acritically ill woman to save her life, and the religiousauthorities did not agree (see case of Sister MargaretMcBride 10). The hospital’s mission statement mostoften guides the ethics committee in their work.It is the within role of the committee to offer educationabout ethical issues. For the neonatal community,examples may include education on religiousand cultural family practices impacting care,palliative care barriers, 11 and protocols, 12 and theuse of Resolve Through Sharing Bereavement trainingfor care of families who lose an infant. 13 Thecommittee might introduce the use of Penticuff andArheart’s Family Medical Record 14 for families touse to assess their infant’s progress. Conflict overblood refusal in the maternal child department is anexample of an ethical issue needing education. Theethics committee might provide a house-wide educationprogram with the local Jehovah’s WitnessesEducation Committee. A video called “Transfusion-Alternative Strategies—Simple, Safe, Effective” 15teaches new information on alternatives for transfusionand updated information is available from theJehovah’s Witnesses deacons on which componentsof blood products Jehovah’s Witnesses might nowaccept.On occasion, the issue that is brought to the committeeis not really ethical in nature. This might be ahuman resources issue or risk management issue.But ethics committee members never turn colleaguesaway. Moral distress is always acknowledged, andthen referral to the appropriate resource or an offerto call someone on the person’s behalf is offered.Facilitators of a Good Ethics CommitteeGaudine and colleagues 16 from Canada have studiedbarriers to and effective qualities of a wellfunctioningethics committee. Characteristics of awell-functioning committee include ethics supportavailable within the hospital and clinics, informationabout the committee freely distributed, easyaccess to committee members, ethics education inthe form of rounds or learning sessions, speedy consultationwhen asked, expertise of committee members,and an organizational setting that is interestedin and supportive of the ethics committee. Nelson, 17from the American College of Health CareExecutives, recognizes the committee’s ability to usemoral reasoning, incorporate individual culturalvalues, keep a focus on healthcare law, and providean ethical compass for the institutional mission. Asthe work of the committee becomes known throughoutthe organization, trust in the committeeincreases.THE NURSE AND THE ETHICSCOMMITTEENeonatal nurses may interact with the ethics committeein several ways. The neonatal nurse may wishto refer a case to the ethics committee, attend anAdvances in Neonatal Care Vol. 14, No. 6Copyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.400 Catlineducational session by the ethics committee, ask forsupport from the ethics committee, participate in adebriefing by the ethics committee, or the nurse maywish to serve as a member of the committee. Each ofthese roles will be discussed.Asking for a ConsultThe neonatal nurse should have access to the ethicscommittee directly. In some institutions, one mightneed permission to contact the ethics committee. Butthis is not the most common or appropriate methodology.Anyone in the healthcare community feelingmoral distress over an issue should be able to contactthe ethics committee. When the nurse contacts thecommittee, it is courteous to let the attending physicianand nurse manager know. Often it is the nursewho identifies an ethical issue 18 because of his or herskill at problem identification at the bedside. Thenurse can simply say “I’m not feeling comfortablewith what we are doing; I need some support oradvice.” The case may come to the ethics committeeboth formally or informally. There should be a designatedphone line for an ethics consultation and thehospital operators should have a method to notifywhoever is on call after hours or in an emergency. Amember of the committee will be available to set upan appointment to speak with the nurse informally.Often the initial conversation will include only 1 or2 committee members. And often the initial conversationmay be enough to resolve the angst that isbeing experienced. For the nurse, this may resolvethe issue, but the ethics committee members maywish to discuss the situation at a regular meeting fortheir own learning.Alternatively, the nurse’s call may be evaluatedand lead the ethics committee members to say “Yes,this is a complex situation. We need more information,to meet with additional stakeholders, and toreally think this over.” The “case,” whether patientrelated, provider related, or policy related, needs awider examination. The nurse is thanked and thecommittee goes to work, setting up a whole committeediscussion to come to some recommendations.The committee in this case may organize a meetingof the stakeholders, inviting clinicians, family, andother involved parties, and may use an organizedformat for conducting the meeting. (The Four SquareMethod of case consultation is most popular—seeJonsen et al. 18 Also see Catlin’s added componentsfor consultations. 19) The goal of the consult is toidentify and analyze the nature of the value conflictor uncertainty or to facilitate resolution of conflictsin an atmosphere respectful of all involved. 2Unfortunately, ethics consultations are occasionallycalled at a point late in the decision-making process.So although this case may not be able to besolved to everyone’s liking, the ethics committee isthinking proactively with the stakeholders abouthow to prevent such a dilemma from occurring inthe future. The nurse who consulted the committeeshould leave the meeting feeling hopeful that supporthas been found.Support DesiredSometimes it is enough for the neonatal physician ornurse to talk things over with a member of the ethicscommittee. For physicians, support from the ethicscommittee often provides “permission” to do whatthey feel is the right thing to do. If, for example,parents do not wish to go along with medically providedadvice, the ethics consultant may help the physicianto define for himself or herself acceptablealternatives. If, for example, the issue is related toparental request for nonbeneficial care, this mayinclude exploring an established protocol to impedeescalation of treatment, such as that written byClark, 20 or considering transferring care to anotherprovider as suggested by Cantor and colleagues. 21The nurse may find guidance from Catlin andcolleagues 22 on the provision of conscientious objectionto nonbeneficial care in neonatal nursing.Debriefing for a Hard OccurrenceOccasionally, activities take place in practice thatleave a significant “mark” on providers of care. Thismight be, for example, the unexpected death of apreviously healthy, growing preemie. Nurses andphysicians may experience guilt, anger, denial, and ahost of other imposing feelings. Although a morbidityand mortality review may assess the medicalcomponents of the event, the ethics committee offersa safe place to just discuss feelings, offers assurance,and allows providers to build resilience. Maloney 5delineates the steps in an ethics debriefing, whichincludes the introduction phase, fact phase, thoughtphase, reaction phase, symptom phase, teachingphase, and reentry phase.Serving as a Member of the CommitteeEthics committees should have nurses or physiciansfrom multiple areas within the organization. Usually,the commitment is not more than once per month.As with other hospital committees, persons attendingshould be paid for their time by salary or anhourly rate. Membership on the committee allowsfor learning and growth as a nurse. A wellfunctioningethics committee has no hierarchy andall members have equal voice. Ethics committeesexplore all areas of a designated problem, and whileone might enter the meeting with 1 set belief, membersoften leave with many fresh ideas. Hearing theopinion of the member services staff member, thecommunity liaison, the chaplain, social worker, orrespiratory care provider may open avenues ofthought not previously considered. The committee’swork is confidential, and members should feel free towww.advancesinneonatalcare.orgCopyright © 2014 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.The Hospital Ethics Committee and the Nurse 401express thoughts without judgment by others. Theneonatal nurse offers a unique perspective 23 as his orher continuous relationship with the family, trainingin communication, and reflective and perceptive attitude24 adds to the collective ethics committeewisdom.Joining the CommitteeNurses may be unaware of the potential contributionsthey could make to the ethics committee. 24However, serving on the committee can bring to thehospital and clinics community increased respect forthe nursing profession. Nurses have indicated a willingnessto obtain additional ethics training, 25 andthose who serve on ethics committees can offer supportto their colleagues. 26 The nurse desiring to jointhe committee should put this request in writing tothe committee chair. A sample letter might containthe following:Dear , My name is _. I am a nurse in the neonatalintensive care unit. I have a bachelor’s degree and acourse in healthcare ethics was included in my program.(If this is the case, put each item from the curriculumin this letter; if you have not taken a specialcourse, say that material was included in each nursingclass and list class numbers). I work the nightshift. I believe that I can contribute to the ethicscommittee by representing nurses who work at nightand those who care for critically ill newborns. We donot have a palliative care consultant who works inour area and often experience ethical issues in thecare of our infants. I am also interested in the areasof informed consent and research we do in our unit.I am willing to attend additional training and attendeducational seminars in the ethics field. Currently,we do not have a nurse representing my constituencyon the ethics committee. My manager supports thisrequest. Please respond to .Thank you very much,Nurses who are invited to join the committee canfind direction from their professional nursing organizations,associated medical organizations, and theAmerican Nurses Association (ANA). The NationalOrganization of Neonatal Nurses, the NationalPerinatal Association, the American Academy ofPediatrics Ethics Committee, and the AmericanCollege of Obstetrics and Gynecology EthicsCommittee all provide position papers that areinstructive when considering neonatal ethical problems.The ANA has an Ethics Advisory Board thatdeliberates on ethical issues that impact the nursingprofession, writes position papers, and is availableto answer questions of an ethical nature. In addition,there are several journals specifically related tohealthcare ethics, such as Nursing Ethics, Journal ofClinical Ethics, American Journal of Bioethics, theHealth Ethics Committee Forum, and CambridgeQuarterly of Healthcare Ethics.How Can a Nurse Be Trained in Ethics?Nurses serving on committees can attend the annualASBH conference. At this conference, training sessionsfor new ethics committee members occur andupdates are provided on healthcare policy, law, andconsultation practices. There are sessions on ethicalramifications of new advances in medicine, such astechnology or genetics. The ASBH also has a robustarea of interest groups, such as rural ethics, dentalethics, palliative care, mental health, instructors inmedical schools, nurse ethicists, and more. TheNursing Ethics Subsection has an annual meeting atthe ASBH conference to update nurses on currentissues in ethics. The ANA director for the Center onEthics and Human Rights also gives a report on ethicsissues that have come in to the ANA that year.For nurses desiring more advanced ethics education,such training can be obtained through variousuniversities in masters or certificate programs orweek-long seminars. Such schools as the Universityof Washington, Seattle; Georgetown University inWashington, DC; University of Wisconsin,Milwaukee; Albany Medical Center in New York;and Loyola University or Rush University in Chicagooffer in-person and online programs.SUMMARYNursing can benefit from and contribute to the ethicscommittee. The ethics committee can provide a venuefor working through conflict or moral distress. Theethics committee can provide education on issuesimportant to neonatal nurses. As nurses continue tobe recognized as partners in the interdisciplinaryteam, as they are encouraged to perform at the highestlevel of their education, 27 and as more and morenurses are accepting executive operations roles, 28 theethics committee offers 1 more opportunity for problemsolving and professional enhancement.References
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