20 May 2016
Clinical nurse manager
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Patient (F 80) had motor accident earlier in week. Fractured jaw & broken elbow. Pt. has dementia. Daughter doesn’t want anything done. No surgery to her jaw and was taken off oxygen. Has DNR. Attending put her back on oxygen because she was struggling to breathe. Nurses feel she would be fine with surgery and food (pt. was taken off food because she had been scheduled for surgery) in a nursing home.
In this situation, the clinical ethics committee must first obtain a comprehensive picture of the situation, before taking any action to address the issue.
From her chart, the committee members learnt that Mrs. Corbett, the patient, had been admitted five days previously with minor injuries resulting from a car accident – a fractured wrist, dislocated elbow, broken rib, and a fractured mandible. All of her injuries, bar the mandible fracture, had been repaired, and an operation to fix the jaw fracture had been scheduled for the previous afternoon. The morning before the surgery, she went into respiratory distress and had to be intubated. She was extubated that same evening, but the surgeon postponed the surgery indefinitely and placed a DNAR order in her chart. In the chart, Mrs. Corbett was described by the surgeon as ‘a woman with a poor quality of life following injury and arrest’. The following morning, Dr. Boyd, the surgeon, met the patient’s daughter and legally-appointed decision-maker to discuss Mrs. Corbett’s care. Dr. Boyd noted in the chart that Mrs. Corbett ‘requires extensive surgery, placement of a feeding tube, and nursing home care’. The patient’s daughter, Breda, was documented as stating that her mother had said that she would not want to be in a nursing home long-term. She also stated categorically that she was not able to look after her mother at home. The social worker noted in the chart that Breda was ‘concerned about her mother’s declining mental status’. A decision was made not to operate but to keep Mrs. Corbett as comfortable as possible.
Armed with this information from the chart, two committee members met with Elizabeth, the clinical nurse manager who had contacted the committee, two of the nurses looking after Mrs. Corbett, and the social worker responsible for Mrs. Corbett’s case. For the nurses, the main issue was the abruptness of the decision to forego the option of surgery. The social worker maintained that Breda, Mrs. Corbett’s daughter, was making the wrong decision. All three felt that she didn’t seem interested in what was going to happen to her mother. She seemed cold and they had overheard her arranging to meet friends for lunch just after the decision had been made to opt for comfort care for Mrs. Corbett. The committee members were unable to speak to Mrs. Corbett herself, who continued to stare straight ahead without looking at them and could not be engaged in conversation.
Later in the day, the committee chair spoke to Dr. Boyd on the phone. Dr. Boyd said that he found Breda to be a devoted daughter and he made it clear that he believed that resetting Mrs. Corbett’s fractured jaw was not in her best interests. Although fixing her jaw would be relatively straightforward, the recovery process would be complicated. Mrs. Corbett would need full-time nursing care for up to six months. Breda would not be able to provide this and her insurance didn’t include a home care option, so Mrs. Corbett would have to go to a nursing home against her wishes. She would need to have a PEG tube inserted since her jaw would have to be wired shut and, according to Dr. Boyd, it was likely that she would develop pneumonia and require a tracheostomy, possibly leading to long-term dependence on nursing care. For Dr. Boyd, the choice was between fixing Mrs. Corbett’s jaw and condemning her to the nursing home and a slow death, on the one hand, or keeping her comfortable and allowing her to die with dignity, on the other.
Because Mrs. Corbett seemed unable to communicate, a capacity assessment was carried out the following day which found her incapable of making treatment decisions. Breda could not be reached by phone and didn’t return to the unit. The nurses watched Mrs. Corbett deteriorating and felt that they had failed her. Some nurses felt strongly that, if they allowed her to die, they would be complicit in her death.
The committee chair convened a meeting and invited all staff members involved in Mrs. Corbett’s care to exchange their perspectives on the situation. During the meeting, Dr. Boyd was surprised by the nurses’ reaction and admitted that he should have consulted them before making the decision not to reset Mrs. Corbett’s jaw. He learnt that the hospital had a new DNAR policy mandating that resuscitation decisions should be made collaboratively rather than unilaterally. In turn, he was able to inform the nurses that Mrs. Corbett’s husband had died a year previously after a long illness and that, even though she had no written advance directive, she had stated repeatedly that she did not want to go to a nursing home or be ‘tied up to tubes’. He also told them that Breda was the single mother of a teenage son with autism and that she had been struggling in recent months to cope with his behaviour. A colleague whom Dr. Boyd consulted for a second opinion agreed that recovery from the jaw operation would be complicated for Mrs. Corbett. After the meeting, staff felt that they had a fuller picture of the situation and most of the nurses accepted Dr. Boyd’s rationale. They also came to understand that they had judged Breda too hastily, and a family meeting was organised to offer Breda a respite package. Mrs. Corbett was kept comfortable until her death the following week and Breda was able to be present at her death. Afterwards a debriefing session was held to provide nursing staff with an opportunity to explore the difference between ‘passive’ euthanasia and the justification for withholding of treatment in cases like Mrs Corbett’s.
What this case illustrates is the importance of examining contested decisions and making underlying values explicit, providing a non-threatening forum where differences in perspective can be explored, and facilitating communication between clinical disciplines. Beyond addressing this impasse at the ‘micro’ level within the clinical setting, the responsibilities of the clinical ethics service include briefing staff in relation to new policy initiatives and building ethics capacity among staff by facilitating discussions of controversial topics such as euthanasia. Discharging these responsibilities effectively requires that the clinical ethics service is proactive, visible within the organisation, and supported by senior management.
The Growth of Organisation Ethics
As indicated above a clinical ethics service is more likely to function optimally within the context of an organisational ethics framework. The concept of organisation ethics was imported into the healthcare domain from the field of business ethics during the last quarter of the twentieth century. Business ethics is concerned with the ethical implications of business practices and commercial activity and it came to prominence as an academic discipline following a number of corporate scandals in the 1970s and 1980s. Although business ethics may be narrowly viewed in terms of compliance – avoidance of activities which violate laws and regulations – it also addresses a range of other issues, including fair competition, employment relations, managerial practice and corporate social responsibility. In resource-rich countries, recent decades have witnessed an inexorable move towards an institutionalised, market-oriented approach to healthcare provision (Shale 2012, p. 13).
Radical changes in the delivery, management, structuring and reimbursement of healthcare have resulted in the ‘corporatisation’ or ‘industrialisation’ of healthcare provision (Shale 2012, p. 12). These changes have led to greater external scrutiny of the organisational and managerial practices of healthcare organisations, mirroring the increased attention paid to compliance in the corporate and financial sectors (Rorty et al. 2004, p. 76). Organisation ethics programmes in healthcare institutions were put in place partly in response to demands for greater transparency and accountability in healthcare management, and partly to support the effective delivery of care in an increasingly complex social, financial, and regulatory environment.5
Organisation ethics in healthcare represents a shift from thinking about how decisions are made at the level of individual patients and clinicians to identifying ethical tensions in the larger system within which the clinical encounter takes place: the structures which govern how healthcare is administered, rationed, purchased, and paid for (Childs 2000, p. 235). In this context, organisation ethics can be described as an attempt to understand and address the ethical issues associated with the financial and managerial operation of healthcare organisations, including the business, professional, and contractual relationships which underpin the daily running of these institutions (Spencer et al. 2000, p. 212). Otherwise put, organisation ethics addresses the ethical issues faced by those who manage and govern healthcare organisations and analyses the “[effects] of their decisions and practices on patients, staff and the community” (Gibson et al. 2008, p. 243).
Publicly-funded healthcare organisations, unlike corporations, whose primary goal is to maximise shareholder profit, have a social mandate to provide healthcare – regarded as a universal or primary ‘good’ – to a given population (Door Gould 2001, p. 28). Because healthcare provision is rooted in an ethical tradition, many healthcare organisations have mission statements, codes of ethics or terms of reference which emphasise this legacy (Reiser 1994, p. 28). The tension for such organisations is that they must discharge their public responsibilities in an environment dominated by market forces and fiscal constraints. As such, healthcare organisations have a number of competing obligations. They are accountable for the quality of the care they provide to members of the public, but they must also ensure competence and promote professional excellence among their employees and, as financial entities, they must engage in effective stewardship of resources in order to maintain economic viability (Rorty et al. 2004, p. 88). An effective organisation ethics programme must ensure that management practices enable both individual employees and the organisation as a whole to “do the right thing” (Pearson et al. 2003, p. 26). Ultimately, the goal of organisation ethics is to enable an organisation “to conduct itself with integrity in the full range of its activities” (Pearson et al. 2003, p. 32).
Mission and Values: Avoiding ‘Institutional Dissonance’
Values permeate healthcare provision at every level and the nature of healthcare delivery is such that healthcare organisations are required to devise a set of core values which meet ‘societal expectations’ (Graber and Kilpatrick 2008, p. 179). The values espoused by healthcare organisations are articulated in mission statements – values such as respect, inclusiveness, compassion – are often ‘aspirational’ and aligned with the professional values which govern clinical practice (Boyle et al. 2001, p. 75). Organisation ethics programmes represent an organisation’s efforts to define its mission and devise core values which are appropriate to its mission. They enable the organisation to identify situations in which important values come into conflict and to devise processes for the resolution of these conflicts. Perhaps most crucially, they monitor the relationship between the values espoused by the organisation and its behaviours and practices (Pearson et al. 2003, p. 32). A successful organisation ethics programme should avoid what Reiser terms ‘institutional dissonance’: it should ensure that there is no contradiction between “the behaviours organisations urge and the actions they take” (Reiser 1994, p. 28). Certain fundamental ethical obligations follow from this understanding of organisation ethics: key stakeholders must be involved in identifying the values by which the organisation’s conduct will be guided, the organisation must commit itself to a clear and ‘forceful’ statement of these values and it must make these values known to its entire staff (Pearson et al. 2003, p. 33). In a sense, this means giving staff ‘ownership’ of the organisation’s values. Reiterating core values and incorporating them into organisational activities may over time “allow them to become internalised by the organisation’s directors and employees” (Boyle et al. 2001: 75), and this support at the level of senior management should be visible throughout the organisation (Childs 2000, p. 237). Finally, the organisation must ‘walk the walk’ by ensuring that it acts on the values it has espoused (Pearson et al. 2003, p. 33).
The most direct way for an organisation to ‘enhance and maintain’ its espoused values is for it to ensure that the content of its policies and procedures reflects these goals and values; the principal role of an organisation ethics programmes is to make this coherence explicit (Chen et al. 2007, p. S14). Policies and procedures allow the organisation both to reinforce its mandate and to ‘filter’ external influences. Procedural transparency is vital: the organisation must be open about the process by which priority-setting decisions are made and it must specify steps for individuals to follow if they disagree with organisational decisions (ibid.). In organisations as complex as healthcare institutions, legitimate conflicts of roles and expectations arise; however, the potential for conflict can be reduced if the organisation has a “strong and positive ethical climate and culture”, namely, a set of beliefs, practices, and ways of thinking which is shared by individuals within the organisation (Chen et al. 2007, p. S14). The creation of a positive ethical climate requires the organisation to develop processes and structures “which can address these conflicts while maintaining organisational cohesion” (Rorty et al. 2004, p. 92). On this view, ethical leadership of an organisation involves an ability to “[resolve] the tension between competing values and goals when such tension is capable of being resolved, and containing the tension when the conflict is not capable of resolution” (Shale 2012, p. 15).