Ethics Facilitation

Part 1

Philip Boyle, Ph.D.

Vice President, Mission & Ethics

www.CHE.ORG/ETHICS

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Goals for today’s conversation

• House keeping & review of course

• Part 1: The nature of ethics facilitation

• Part 2: Responsibilities of those engaging in ethics facilitation

• The nature of ethics

• The nature of ethics facilitation

• Are you tracking your self- understanding?

Who is providing consultations?

• ASBH study

• 35,000 are involved in 15,000 annually– 36% MDs– 30% RN– 11% LSW– 10% Chaplains– 10% Administration

• The nature of ethics

• The nature of ethics mechanisms– Promoting appropriate moral agency

• Distinctions– Consultation– Facilitation– Mediation

Case

• 82-yr-old found disoriented at home unattended, septic, breathing problems

• Placed on vent

• 3 day woman requests to be extubated

• MD refuses—”Its assisted suicide”

• Ethic facilitation identifies her rights under the law

What is healthcare ethics consultation?

• A service provided by individual or groups to help patients, families, surrogates, healthcare providers to address uncertainty or conflict regarding value-laden issues.

What’s the goal of facilitation?

• “The proper role of ethics consultation is to advocate for an unbiased robust process and not to privilege the needs and agenda of any one part.” ASBH, 2007

Commonly performed tasks• Navigating clinical setting• Gathering information• Evaluating, interpreting, and analyzing info• Facilitating meetings, understanding each

perspective, assessing options for moral acceptability

• Promoting ethically acceptable plan of action• Implementing quality assurance measures

“Qualified facilitation model”• Identify and analyze nature of value

uncertainty– Gather relevant data– Clarify relevant conceptual issues– Clarify related normative issues– Help identify range of morally acceptable options

• Resolve value uncertainty by building consensus– Ensure concerned parties have voices heard– Assist in clarifying values– Help build morally acceptable share commitment

Core competencies

• Skills of ethical assessment– Identify the nature of the value uncertainty– Analyze the value uncertainty

• Process and interpersonal skills

Developing skills

• Apprentice model

• Simulation model

• Opportunities to practice

• Method to evaluate performance

• Feedback on performance

The consultationAbility to facilitate meetings• Introducing oneself properly, explaining what an ethics

consultation is and what a person taking the lead does, the purpose and limitation of the consultation and his or her recommendations, and the relationship between the ethics consultation mechanism and institution.

• Ensure that all relevant parties have been invited and encouraged to participate.

• Ensure that all parties are introduced and explain their perspective roles

• Explain the goals and process of meeting and what can be expected.

• Elicit medical facts• Elicit views and values of principles regarding issue• Facilitate reflective listening, clarifications, summarizing

interests.

The consultation

Ability to build moral consensus

• Help individuals to critically analyze their underlying assumptions

• Negotiate between competing moral views

• Recognize possible areas of conflicts between personal moral views and one role in consultation

Practical considerations

• Focus on “interests” not arguments

• Bioethics facilitator is not a judge!– No constraints on evidence– But some statements are more useful in

resolution

Practical considerations

• Summarizing—most critical aspect– Lets the parties know facilitator is listening– Lets the mediator test her understanding– Helps parties organize thoughts– Helps parties to hear what others are saying– Shows areas of common interest– Provides order to discussion– Lets facilitator remind parties of progress– Repeat in nondestructive language– End with question: “Have I missed anything?”

Practical considerations

• Questioning – To obtain a broader view– To obtain information– To clarify abstract ideas/generalizations– To focus discussion– To introduce hypothetical– To generate new options– To encourage participation

Practical considerations• Generating movement

– Asking problem solving questions– Reframing– Raising issues– Hearing proposals– Stroking– Allowing silence– Holding caucuses– Reality testing– Reversing roles– Normalizing

Practical considerations

• Packaging proposals– Loss aversion– Reactive devaluation-leads parties to view

the one proposing as “enemy”– Attribution theory—what really is motivating

the one who is proposing

– Holding caucuses and allowing facilitator can avoid these barriers

Limits to consensus

• People do not give up political rights– Patient’s autonomy– Employees’ conscientious objection

Place of personal views

• Cannot remain value neutral

• Do you offer your personal views?

• How to attend to sociological power and authority?

Evaluation

• Videotape simulations ad self-assess performance

• Keep track of feedback

• Conduct case conference to evaluate

• Use existing check lists to see if pertinent information has been asked

• Debrief parties

Evaluation• http://www.meddean.luc.edu/depts/bioethics/online_masters/ethics%20

consult/ethics_consult_eval.html• Q1: Does the ethics consultant do an adequate job of gathering the

facts of he case from the physicians? What kinds of things must the ethics consultant gather in advance of facilitating a conference?

•  • Q2: Does the ethics consultant give the physicians an adequate idea

what they might expect from an ethics case consultation, in general, and in this case, in particular?

•  • II. The Case Conference

 • Q3: Does the ethics consultant do an adequate job of introducing

himself and explaining what he does or what the goal of the conference is? Should he have said anything else?

•  • Q4: Does the case conference result in the patient’s surrogate decision

maker, understanding the medical facts of the case adequately?   

•  • Q5: Does the case conference result in the patient’s attending physician

understanding the patient’s values and wishes adequately? Does he adequately understand the surrogate decision maker’s understanding of the situation?

•  • Q6: Does the ethics consultant do a reasonable job of “supporting” the surrogate

decision maker through the conference? That is, does the consultant reinforce the notions that the surrogate’s understanding of the case is welcome in the discussion and that the patient’s legitimate rights will be respected?

•  • Q7: Does the conference “flow” well or should the consultant have redirected it

at points? If so, please be specific regarding when.•  • Q8: Does the consultant help to summarize and delineate the acceptable

options? Is it clear what will happen next and how matters will proceed?•  • Q9: Are the options highlighted within ethically acceptable norms?

Conclusion

• Bioethics Mediation: A Guide to Shaping Shared Solutions, Nancy Dubler and Carol Liebman, United Hosptial Fund, 2004.

• Mediation Information Resource Websites

• Http//www.meidate.com

• http://www.crinfor.org/narrative_new _developments.cfm