Interprofessional Ethics and Team Approaches to Brain Injury Rehabilitation

Transcription

1 Interprofessional Ethics and Team Approaches to Brain Injury Rehabilitation Woodford A. Beach, PhD, CCC/SLP Daniel W. Klyce, PhD, LCP Shawn E. Soper, PT, DPT, MBA Nathan D. Zasler, MD, FAAPM&R, FACRM, FIAMIME, DAIPM, CBIST May 4, 2018 Williamsburg, VA

2 Course Objectives 1. Participants will be able to identify common issues relevant to individual providers, care teams, and organizations that affect ethical decision-making in rehabilitation settings. 2. Participants will be able identify common elements of models for ethical decision-making shared across rehabilitation disciplines. 3. Participants will be able to apply an understanding of interprofessional ethics to common clinical issues through discussion of sample cases. 2

3 Course Overview Ethical principles shared across rehabilitation professions Common ethical tensions related to brain injury rehabilitation Defining the interprofessional workspace Inclusive Model of Ethical Decision Making (McAuliffe & Chenoweth, 2008) Applying the model to example cases 3

4 Ethics in Clinical Practice 4

5 A (Very) Concise Review of Ethical Theories 1. Deontology: Kantian, duty-based, non-consequentialism Humans are rational actors, guided by categorical imperatives But reconciling absolute moral rules is tricky, depending on the context 2. Teleological Theory: Utilitarianism, consequentialism Maximize good and minimize bad to the benefit of the most But may not always serve the marginalized and vulnerable 3. Virtue or Character Ethics Aristotelian and Platonic pursuit of our best, most virtuous self But it s one thing to be virtuous and another to be effective 4. Ethics of Care and Relationships Emphasizes interdependence and exploring mutual benefits But may be tricky to reconcile with responsibilities to systems 5

6 Biomedical Ethics: Principles and Rules Beauchamp & Childress (1979, 2001) Autonomy Honesty Beneficence Focal Principles Respect for Persons Nonmaleficence Justice 6

7 Biomedical Ethics: Principles and Rules Beauchamp & Childress (1979, 2001) Substantive Rules Privacy Confidentiality Fidelity Informed consent Procedure Rules Allocation of resources Recourse when aggrieved Authority Rules Who can perform actions Who can make decisions 7

8 Common Ethical Dilemmas in Brain Injury Rehabilitation 8

9 Common Challenges in Brain Injury Rehabilitation Privacy and Confidentiality Promoting Autonomy Equal Access to Care Adequate Record Keeping Provider Burnout Cultural Competence Clinical Competence Questionable Conduct of Colleagues Managing Boundaries Medicolegal and Forensic Issues 9

10 Interprofessional Workspaces 10

11 Framework for Ethics in Interprofessional Teams Clark, Cott, and Drinka (2007) Factors of Interprofessional Framework 1. Principles General guidelines for behavior 2. Structures Shared knowledge and patterns of behavior 3. Processes Procedure aspect, how things get done Levels of Interprofessional Framework 1. Individual 2. Team 3. Organization 11

12 Factor 1 Principles: General Guidelines for Behavior Individual Develop bases for respect among team members Understand norms and standards for team members Master knowledge and skills required for teamwork Team Promote ethical virtues within the team Address communication and conflict issues Understand differences between team members Share responsibility for decisions and outcomes Organization Respect relationship between team and patient Understand basic principles of teamwork Provide resources for team to function effectively Clark, Cott, and Drinka (2007) 12

13 Factor 2 Structures: Knowledge and Patterns of Behavior Individual Develop standards for personal and professional relationships Acquire insight into practice of other professions Establish structure of teaching others about one s profession Team Integrate professional knowledge with other team members Integrate structure for assessment and care planning Promote and protect team as distinct structure Organization Provide resource foundation for team Establish structure for evaluating team s work Clark, Cott, and Drinka (2007) 13

14 Factor 3 Processes: How Things Get Done Individual Practice respectful and responsible communication Discuss controversies and problems Assimilate new team members into processes Team Cultivate open communication and dialogue Arrive on time for meetings Develop and implement integrated care plans Organization Support team development and function Appoint facilitator to address ethical issues and mediate conflicts Clark, Cott, and Drinka (2007) 14

15 Inclusive Model of Ethical Decision Making (McAuliffe & Chenoweth, 2008) 15

16 Inclusive Model of Ethical Decision Making McAuliffe & Chenoweth (2008) 16

17 Essential Dimensions of Ethical Decision Making 1. Accountability Articulate and justify a decision Openness, honesty, transparency 2. Consultation Seek the wisdom and counsel of others Promote integrity within/between professions 3. Cultural Sensitivity Honor worldviews and community norms Practice inclusivity and promote justice 4. Critical Reflection Subject decision making to scrutiny Recognize personal values and influence McAuliffe & Chenoweth (2008) 17

18 Step 1: Defining the Ethical Dilemma A. Define the competing principles Do I need to consult a colleague/expert? Are there cultural aspects to the conflict? B. Determine your role Is this my decision to make? Who else is accountable? C. Appraise the situation Can I reflect on a similar situation? Do I need to seek new knowledge/skill? McAuliffe & Chenoweth (2008) 18

19 Step 2: Mapping Legitimacy A. Determine the stakeholders Clients, families, communities? My team, agency, profession? B. Clarify stakeholders relation to dilemma Who should be included/excluded? What is culturally normative? C. Define the scope of the dilemma Who do I need to consult? Who else will be accountable? McAuliffe & Chenoweth (2008) 19

20 Step 3: Gathering Information A. Consult the relevant guidelines What are the ethical principles, standards? Are there legal or regulatory issues? Who will be holding me accountable? B. Clarify tensions or conflicts Have I reflected on my personal values? Do my values align with the guidelines? C. Identify other sources of knowledge Should we consult a risk manager? Would a cultural mediator be helpful? McAuliffe & Chenoweth (2008) 20

21 Step 4: Alternative Approaches and Action A. Delineate course(s) of action What options fit the current set of facts? How will this decision be implemented? B. Justify the decision What is the ethical/moral/legal basis? How will I respond when held accountable? C. Anticipate consequences Will the action be culturally insensitive? Have I reflected on potential outcomes? McAuliffe & Chenoweth (2008) 21

22 Step 5: Critical Analysis and Evaluation A. Reflect on the situation What can I learn from this experience? Did we act in a cultural sensitive manner? Did we consult appropriately? B. Identify opportunities to improve Are institutional polices adequate? Do we need different resources? C. Advocate for change Who is accountable in the debrief? Who should be consulted prior to advocacy? McAuliffe & Chenoweth (2008) 22

23 Case Applications 23