Chaplains and Clinical Ethics Consultation: Roles, Skills, and Knowledge
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1 Chaplains and Clinical Ethics Consultation: Roles, Skills, and Knowledge The Rev. Steven S. Ivy, Ph.D. Sr. Vice President Clarian Health Partners September 23, 2009
2 Contact Information Values, Ethics, and Pastoral Services Fairbanks Hall 6107 Clarian Health Indianapolis, IN
3 Objectives To outline the purposes, roles, and skills associated with clinical ethics consultation. To recommend ways that chaplains can enhance a hospital s clinical ethics consultation process. To provide next steps for participants who wish to develop knowledge and skills related to ethics consultation.
4 Outline Clinical ethics Chaplains and clinical ethics Next steps Life is not a spectacle or a feast; it is a predicament. -- Santayana
5 A Teaching Case 74 year old, married, two adult children, Protestant Post-surgery for brain stem tumor, nonmalignant, recurrent Problem: wants to stop life sustaining interventions, family disagrees Competent, living will
6 What is clinical ethics? The analysis, study, or consideration of morality (right or good action) in the care of patients. (Fletcher) Key Components Policy review Education Clinical consultation Organizational responsibility Medical staff Mission leader Pastoral care
7 What is clinical ethics consultation? Health care ethics consultation is a service provided by an individual or a group to help patients, families, surrogates, health care providers, or other involved parties address uncertainty or conflict regarding values-laden issues in health care. (ASBH)
8 What is clinical ethics consultation? Typical issues Communication confusion or failure End of life (withholding and withdrawing curative or life-sustaining therapies) Beginning of life (abortion, genetic and reproductive technologies) Policy clarification Other: organ transplantation concerns, genetic testing and counseling, various concerns regarding sex and sexuality
9 Who is a clinical ethics expert? Core competencies Ethical assessment skills Facilitation skills Interpersonal skills Core Knowledge Ethical theory Current literature on common health care ethics concerns Current applicable health law Institutional context including policies and procedures Cultural contexts of patients and staff Per ASBH
10 How does clinical ethics consultation focus? Medical indications Beneficence and Nonmaleficence Quality of life Beneficence and Autonomy Patient preferences Respect for autonomy Contextual issues Justice (fairness)
11 Institutional requirement Joint Commission Standard on Patient s Rights and Responsibilities RI : The hospital respects patient rights. RI : The hospital respects the patient's right to receive information in a manner he or she understands. RI : The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services. RI : The hospital honors the patient's right to give or withhold informed consent. RI : The hospital honors the patient s right to give or withhold informed consent to produce or use recordings, films, or other images of the patient for purposes other than his or her care. RI : The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials. RI : The hospital respects the patient's right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services. RI : The hospital addresses patient decisions about care, treatment, and services received at the end of life. RI : The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse. RI : The patient has the right to an environment that preserves dignity and contributes to a positive self-image.
12 Outline Clinical ethics Chaplains and clinical ethics Next steps "Character is that which reveals moral purpose, exposing the class of things a man chooses or avoids." -- Aristotle
13 Chaplains engaging clinical ethics 1. Assessment of Need Identify situations of values uncertainty or conflict Identify situations of conflicting assumptions or life perspectives Identify communication failures
14 Chaplains engaging clinical ethics 2. Referral to experts Identify with cogent ethical terms Conflict of interest Beneficence / Nonmalefisence Autonomy -- Informed consent Confidentiality Best interest Futility Justice Encourage and support patients, family, nurses, staff, physicians Foster compassion, cooperation, curiosity
15 Chaplains engaging clinical ethics 3. Participation with experts (What actually happens?) Gather relevant data (clinical, relational, psychological, spiritual, cultural) Identify and distinguish interpretations medical, legal, ethical Identify core values that various involved persons bring Offer an interpretation and direction from an ethical perspective
16 Chaplains engaging clinical ethics 4. Learn expert skills in Mediation Stimulate the moral imagination and relational imagination Evaluation of arguments for and against various perspectives and interpretations Facilitation of respectful and insightful conversations in the face of severe disagreements about really important matters Engage varying perspectives that discovers common ground and allows for a decision owned by all key stakeholders Tolerate conflict and ambiguity Management of conflicting ideas, emotions, and worldviews
17 Chaplains Natural Expertise 1. Knowledge Areas Well-being -- health, disease, sin, sickness, good life, miracles Sexuality -- procreation, conception, relationships Life passages -- birth, youth, adulthood, aging, dying Dignity -- soul, sanctity of persons, autonomy, respect for life Caring -- duty, priority for sick and poor, prolonging life, commitment to future generations Suffering -- pain, embodiment, God and the present Dying -- finitude, mortality, resurrection, immortality, meaning, God and the future
18 Chaplains Natural Expertise 2. Skills Listening skills, empathy Recognize and ameliorate relational barriers Respect for varying world views Sensitivity for cultural and religious differences Institutional connections Formation in moral / ethical perspectives Analysis and application of abstract concepts Analysis of situations of uncertainty and conflict
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20 Outline Clinical ethics Chaplains and clinical ethics Next steps Knowing is not enough; we must apply. Willing is not enough; we must do. -- Goethe
21 Chaplains Natural Expertise Expanded Continuing education plan Institutional engagement plan
22 Bibliography Articles in Health Progress American Society for Bioethics and Humanities, Core Competencies in Health Care Ethics Consultation, Association for Professional Chaplains, Guidelines for the Chaplain s Role in Health Care Ethics, J. Fletcher, et.al., Fletcher s Introduction to Clinical Ethics, L. Post, et.al., Handbook for Health Care Ethics Committees, A. Jonsen, et.al., Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 2002.
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