The Healthethics.ca Framework for Supporting Ethical Practice

Dr. Robert Butcherrbutcher@healthethics.ca

rbutcher@healthethics.ca Page 1

Table of ContentsAbout this guide.........................................................................................................4The Framework has the following sections:................................................................4Leadership..................................................................................................................6Mission, Vision and Values..........................................................................................6

Self Reflection.........................................................................................................6Governance Policy Statement....................................................................................7

Self Reflection.........................................................................................................7Organizational, Professional and Clinical Ethics.........................................................7Ethics lead within the organization.............................................................................8

Examples.................................................................................................................8Self Reflection.........................................................................................................8

Organizational structures to support ethical practice.................................................9Ethics Committee....................................................................................................9Self Reflection.........................................................................................................9Inter-professional practice council........................................................................10Self Reflection.......................................................................................................10Services of an ethicist...........................................................................................10Self Reflection.......................................................................................................11Case Consultation.................................................................................................11Self Reflection.......................................................................................................12Case Review..........................................................................................................12Self Reflection.......................................................................................................13

Additional Support for Ethical Practice.....................................................................13Code of Conduct....................................................................................................13Self reflection........................................................................................................14Policy.....................................................................................................................14Self Reflection.......................................................................................................14Policy: Examples of policies intended to support ethical practice:........................15Self Reflection.......................................................................................................15

Education................................................................................................................. 16Self Reflection.......................................................................................................17

rbutcher@healthethics.ca Page 2

Research.................................................................................................................. 18Self reflection........................................................................................................18

Resources.................................................................................................................19Tools......................................................................................................................... 20Other Resources.......................................................................................................21

rbutcher@healthethics.ca Page 3

About this guideThis guide is intended as a template for developing your own organization’s Ethics Framework (or programme) to support ethical practice. In each section there are examples, questions for you and your organization, and suggestions. The guide is linked to Qmentum accreditation standards.

(Leadership 1.7, Governance 1.3, 1.6)

Your organization may well have some (or many) components of the programme already in place in which case your task is to assemble them to create a framework. In other cases the guide will prompt you to identify gaps and to work out how your organization can meet those needs.

Throughout the process, however, it is worth remembering that the provision of health care is an activity grounded in values and governed by ethics. Ethical situations, challenges and choices constantly arise in health care – in all aspects of care -- and the whole point of ethics programmes or frameworks in your organization is to support all members of the health care community as they strive to practice ethically and with integrity.

The Framework has the following sections:Leadership

Mission, Vision and Values Governance policy statement Ethics lead within the organizational structure

Organizational structures to support ethical practice

Committee Services of an ethicist Consultation process

Additional Support for ethical practice

Policy

rbutcher@healthethics.ca Page 4

Educationo Awarenesso Capacity Building

Case Consultation Case Review Research

Tools

Framework for ethical decision-making Ethics primer Pamphlets and brochures Intranet resources Case consultation referral tool Case review referral tool Pocket guide Handbook Planning guide for ethics activities

rbutcher@healthethics.ca Page 5

LeadershipThe leaders of an organization have a critical role in setting the tone and values of the organization. This can be done in formal ways through official statements and published documents, but it is also exhibited in the way in which the organization is led, how it interacts with its communities, what it expects from its staff and how it rewards them.

(Qmentum Standard: Leadership 1.2 Governance, 5.0)

Mission, Vision and ValuesThe Mission, Vision and Values of an organization are intended to be the defining and guiding principles that govern the overall direction and conduct of the entire enterprise. The Mission, Vision and Values should define the scope of activities of the organization and describe the way in which it carries out its business and makes its decisions.

The Mission, Vision and Values should be a living part of the day-to-day activity of the organization. The Mission, Vision and Values should be used. All too often the Mission, Vision and Values of the organization rest in dusty policy manuals or sit unheeded on the boardroom wall (or next to the elevator.)

(Qmentum Standard; Leadership 1.0, 1.1, Governance 5.0, 5., 5.2)

Self ReflectionWhat are your organization’s Mission, Vision and Values?

How were they developed?

How are they used?

How does the leadership of your organization use the Mission, Vision and Values?

How could you help improve how they are used?

Governance Policy StatementIn addition to the Mission, vision and Values some organizations have a statement of organizational commitment to ethics and ethical practice. These governance

rbutcher@healthethics.ca Page 6

policy statements set out the formal commitments to ethics and values and expectations for staff that govern all aspects of the organization’s activities. In some cases these governance statements can be linked to policies such as Codes of Conduct and standards of professional behaviour.

(Qmentum Standard Leadership 1.7, Governance 1.3, 1.6, 5.0, 5.1)

Self ReflectionWhat statement of commitment to ethics and values does your organization have?

Organizational, Professional and Clinical EthicsHealth care is a “value-rich” enterprise. First, health care is full of situations where choices and expressions of ethics and values are required. Health care organizations have traditionally approached these questions of ethics of care at the bedside under the heading of “clinical ethics” or “bioethics.” But ethics in the health care organization extends beyond care at the bedside. Second, health care professionals are all subject to their own professional codes of ethics and each health care organization has an obligation to support its professionals as they practice ethically. Third, health care organizations are organizations with all the demands of organizational ethics. Your organization`s ethics framework needs to support these three aspects of ethical practice.

(Qmentum Standard: Leadership 1.7)

Ethics lead within the organizationExamplesVP Patient Services,

Chief Nursing Executive,

Director of Quality,

Director of Risk Management,

Chief of Staff

Spiritual Care

rbutcher@healthethics.ca Page 7

In Long Term Care Facilities it is often the Director of Care.

Interested staff member with appropriate authority and support.

(Qmentum Standard: Leadership 1.9)

Self ReflectionWho has the lead within your organization to ensure the ethics programme/framework exists, and is used effectively?

Is this role reflected in his or her job description?

Is this role reflected in the person’s performance appraisal?

Is there adequate administrative/budget support for the ethics programme?

rbutcher@healthethics.ca Page 8

Organizational structures to support ethical practiceEthics Committee

Many organizations have an ethics committee, but those committees vary widely in their functions and usefulness. Far too often an ethics committee exists merely because it is thought to be necessary, while all it does is meet, conduct small “p” politics as usual then schedule another meeting. Before developing an ethics committee or before revising the terms of reference of your current ethics committee, ask yourself what you want your ethics committee to do? What functions will it fulfill? For example, it is very difficult to have an ethics committee function as a case consultation body (though its members may perform that role as part of a team outside of committee meetings.) Ethics committees meet infrequently and case consultation needs to be timely for it to be effective. Some organizations have their ethics committees fulfill the role of a “wise-persons” advisory body, making recommendations to the organization on high level corporate values issues. Others have their ethics committees act more as working committees, charging the committee with the duties of overseeing development or review of policy on ethics issues, planning education events, hosting or facilitating case reviews and supporting case consultation in some form or another.

Reflection on the role of the ethics committee will provide guidance on the composition of the committee and its reporting structure. It is difficult to do case consultation on an ethics committee with outside or “lay” members, but it is also difficult to act as a high-level advisory body to the governance team without outside representation.

Self ReflectionWhat does your ethics committee do?

How does it support ethical practice?

Does it plan/host education events?

Does it develop or review ethics related policies?

Does it hear case reviews?

Does it support case consultation?

Does it act as a venue for discussion of ethical issues?

Does it advise the governance of the organization of ethical issues of strategic importance?

rbutcher@healthethics.ca Page 9

Inter-professional practice councilSome organizations have an inter-professional or inter-disciplinary practice council to co-ordinate issues of practice. These bodies are often used to develop practice guidelines on issues that have an ethical or values component. In such cases it is important to ensure that ethical discussions and considerations are incorporated in policy development and are documented.

Self ReflectionDoes your organization have an inter-professional practice council?

If so, how does that council incorporate and document ethical reflection and discussion?

Services of an ethicistAn “ethicist” can bring a body of knowledge and professional training to bear on decision-making, case consultation, policy development and organizational structures. In Canada there are no formally required courses of instruction, training or preparation for people who call themselves “ethicists.” Many people accept the American Society of Bioethics and Humanities “Core Competencies for Health Ethics Consultation” as a starting point for professional standards.

The ethicist could be directly employed by your organization, on contract, accessible through another organization, shared and so on.

Self ReflectionDo you have access to an ethics specialist, ethicist or ethics consultant?

What services does the ethicist provide?

How do you use your ethicist?

How do staff gain access to the ethicist?

Does your ethicist`s credentials and training meet appropriate standards of professional practice?

rbutcher@healthethics.ca Page 10

Case Consultation Case consultation is designed to facilitate decision-making in particularly difficult or troubling situations as they unfold. It must therefore be timely, responsive, and helpful. Case consultation is intended to improve decision-making, increase consistency and share the burdens of care.

Case consultation supports ethical practice by facilitating decision-making as the decisions are being made. There are a variety of methods for delivering case consultation services: through the use of an ethicist or ethics consultant (either in person or by teleconference) through the use of an ethics consult team, or other means. The case consultation process should be easily accessible to staff (and often to clients/families too). The case consultation process may use a Framework for Ethical Decision Making to facilitate discussion. On some occasions a case consultation may give rise to the development of ethics related policy.(Qmentum Standard: Leadership 1.8, Governance 3.0)

Self ReflectionDo you have an ethics case consultation process?

How does that consultation process facilitate decision-making?

What is the structure of the process? (How does it work?)

Does the process use a decision-making framework?

What is that framework?

How are staff trained or led through the decision-making framework?

How do you record consultations and recommendations?

How do you collect feedback on staff consultations?

How do you track results of consultations?

How do you identify trends or common issues?

(Qmentum Standard, Leadership 1.11, 1.12)

rbutcher@healthethics.ca Page 11

Case ReviewCase review occurs after the situation and is intended to provide an opportunity for staff to share the burdens of care and learn from experience. Case reviews can be performed on the unit with the staff concerned, or before an ethics committee or other review group. Case review can be facilitated by an ethicist or led by trained team members. Case review may give rise to policy development.

Self ReflectionDo you have an ethics case review process?

What is the structure of the process? (How does it work?)

Does the process use a case review framework?

What is that framework?

How are staff trained or led through the framework?

How do you record case reviews?

How do you collect feedback on case reviews?

How do you track the outcomes of case reviews?

How do you identify common trends or issues?

(Qmentum Standard, Leadership 1.11, 1.12)

Additional Support for Ethical PracticeOrganizations support ethical practice in a variety of ways. What follows are examples of some of the more common supports that are offered.

Code of ConductCodes of Conduct outline and prohibit unacceptable behaviour. They align with the organization’s values and the ethics framework. They are usually enforceable as disciplinary codes.(Qmentum Standard: Leadership 2.4, Governance 1.4)

rbutcher@healthethics.ca Page 12

Self reflection

Do you have a Code of Conduct?

To whom does it apply?

How is it used?

PolicyMany ethically difficult situations are not unique in the principles or values that are at play (though each situation will be unique in its circumstances) so it is often useful to develop policy to deal with similar situations in a similar fashion and to guide practitioners in their deliberation and action.

Many organizations have a “policy on policies” which lays out the process to be followed when developing policy. Sometimes those policies will include a statement that instructs policy developers to consider the ethical and values base of the policy they are writing:

Self ReflectionDoes your organization have a formal process for developing and approving policies?

Does that process include directions for ethical reflection?

rbutcher@healthethics.ca Page 13

Policy: Examples of policies intended to support ethical practice:

Conflict of Interest

(Qmentum Standard: Governance 5.5)

Sponsorship / Donation / Corporate Relations

Workplace Respect

Conflict resolution

Harassment

End of Life Care

Withdrawing and Withholding Treatment

Feeding Tube / Feeding

Resuscitation and Do not attempt resuscitation, Allow natural death

Advance Directives

Patient Rights and Responsibilities

Disposition of Human remains

Matters of conscience (opt-out provisions for staff)

Definition of “Death” and organ Donation

Self ReflectionWhat policies does your organization have that support ethical practice?

rbutcher@healthethics.ca Page 14

Education One of the most direct ways of supporting ethical practice is through education. Typically, ethics education can be thought of under two main headings: awareness education; and capacity-building education. Awareness education is general, typically targeted at all staff, and is intended to familiarise staff with the values and ethical issues and policies that affect their own practice. Capacity building education is generally intended to improve the capacity of the organization to identify and work through ethically challenging situations as they arise. Capacity building education normally focuses on a smaller group of people who are trained to play the role of “first responder,” or act as part of a team to conduct case consultations. (Qmentum Standard: Leadership 1.10, Service Excellence 3.6)

Awareness

Lunch and learns

Ethics Rounds/Grand Rounds

Team meetings

Unit-based education

MAC

Quarterly staff meetings

Journal Clubs

Workshops

Capacity Building

Workshops

Conferences

On-line/distance learning

rbutcher@healthethics.ca Page 15

Courses

Self ReflectionWhat education events on ethics and values do your offer staff?

How do you support staff who wish to develop their ethics skills?

rbutcher@healthethics.ca Page 16

ResearchResearch conducted on human subjects in Canada needs ethics oversight. The document that governs this ethical oversight is the “Tri-Council Policy Statement on Ethics and Human Research (TCPS2)”

http://www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/Default/

In practical terms this means that your organization needs a process to approve and oversee research conducted in your facility. Often, the research that comes before you will already have gone through a process of research ethics review by a recognised Research Ethics Review Board. These Boards are often affiliated with academic centres, though some are private and stand alone. In addition you will need a process to determine not only whether the research meets ethics standards but also to decide whether your organization wishes to have the research conducted there at all. (Qmentum Standard: Leadership 1.13, 1.14)

Self reflectionDoes your organization have a research oversight and approval process?

Does that process include opportunity for both ethical oversight and a determination that the organization wishes to have the research performed?

Is the process consistently followed?

How is research tracked and reviewed?

ResourcesProfessional Codes of Ethics

World Medical Association: WMA International Code of Medical Ethics

https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

rbutcher@healthethics.ca Page 17

International Council of Nurses: Code of Ethics for Nurses

http://bioetika.sam.lt/get_file.php?file=bnBTYXk1V2hZcVdkbTJWbXlKZVpsWjFrYk1PVXltdlR4cHh3MnBtZHg2UnZ4cDJTblo5a1oyNmprcGFYbTUyWm1LRnF4bWZVYlpPYXJuSE1rcDNHcFclMkZLbHRhZFlaV2ViWiUyQlhvNWVhYW1USGFwdVNsNCUyQlYxSm1ibmN6RWI4U0NtclBKcHNlUmFaMXRwR21leDZHZG1jaW9iTWxuajVuVXg1dWJ6Slp2bW5Sdw==

Universal Declaration of Ethical Principles for Psychologists

http://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Islamic Code of Medical and Health Ethics

http://applications.emro.who.int/docs/EM_RC52_7_en.pdf

rbutcher@healthethics.ca Page 18

Tools:Accountability Framework

Conflict of Interest

Ethics primer

Framework for ethical decision-making

IDEA : Trillium Health Partners Framework for ethical decision- making

Handbook

How do I access case consultation or review services?

Intranet resources

Pamphlets and brochures

Pocket guide

Planning guide for ethics activities

Sample content for the governance policy statement

Sample Research Committee Terms of Reference

Sample policy on policies

rbutcher@healthethics.ca Page 19

Other Resources

Joint Centre for Bioethics : Home (Canada)

National Center for Ethics in Health Care Home (US Veteran`s Affairs)

National Council on Ethics in Human Research (Canada)

Nuffield Council on Bioethics - Nuffield Council on Bioethics (UK)

www.healthethics.ca

rbutcher@healthethics.ca Page 20