ASPR PowerPoint Slide Template

Application of Healthcare Ethics:

Consults, Cases, & Choices

Brigid Herrick, M.P.H., M.S., C.P.X.P.

Chief Experience Officer

Healthcare Ethics Committee Co-Chair

Walter Reed National Military Medical Center

Bethesda, Md.

Army Chaplain Maj. Vincent Bain, Ph.D., M.Div., M.B.E.

Bioethics Advisor

Healthcare Ethics Committee Co-Chair

Walter Reed National Military Medical Center

Bethesda, Md.

May 9, 2024

0815 – 0915 ET

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Presenters

Brigid Herrick, M.P.H., M.S.,

C.P.X.P.

Chief Experience Officer

Healthcare Ethics Committee

Co-Chair

Walter Reed National Military

Medical Center

Bethesda, Md.

Army Chaplain Maj. Vincent

Bain, Ph.D., M.Div., M.B.E.

Bioethics Advisor

Healthcare Ethics Committee

Co-Chair

Walter Reed National Military

Medical Center

Bethesda, Md.

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Brigid Herrick, M.P.H., M.S., C.P.X.P.

Ms. Brigid Herrick serves as the Chief Experience Officer and Hospital

Ethics Committee Co-chair at Walter Reed National Military Medical

Center (WRNMMC). She is a health care industry leader with over 20

years of experience in change management, healthcare process

improvement, and program design.

Ms. Herrick formerly ran the Patient Experience program at Inova

Health System. While there, she was a subject matter advisor to C-suite

executives, senior-level nursing leaders, physicians, and other

healthcare staff. She conducted over 10,000 direct clinical

observations and consultations within the adult inpatient hospital units,

women’s and children’s, ambulatory surgery, emergency department,

and outpatient services.

Ms. Herrick earned a Master of Public Health from George Washington

University and a Master of Science in Bioethics from Creighton

University.

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Army Chaplain (MAJ) Vincent Bain, Ph.D.

Chaplain (Major) Vincent Bain is a native of Illinois

and now calls Minnesota his home of record. He was

commissioned as a chaplain in the United States

Army in 2009. CH Bain has served units at Fort

Cavazos, TX, Fort Leonardwood, MO, and Fort

Campbell, KY. He has deployed twice. He earned a

Master of Bioethics from Harvard Medical School in

May 2022. He presently serves as the Bioethics

Chaplain – Hospital Ethicist at Walter Reed National

Military Medical Center (WRNMMC) at Bethesda, MD.

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Disclosures

• Ms. Brigid Herrick and CH Vincent Bain have no relevant financial or non-

financial relationships to disclose relating to the content of this activity.

• The views expressed in this presentation are those of the authors and do

not necessarily reflect the official policy or position of the Department of

Defense, nor the U.S. Government.

• This continuing education activity is managed and accredited by the

Defense Health Agency, J-7, Continuing Education Program Office (DHA, J-7,

CEPO). DHA, J-7, CEPO and all accrediting organizations do not support or

endorse any product or service mentioned in this activity.

• DHA, J-7, CEPO staff, as well as activity planners and reviewers have no

relevant financial or non-financial interest to disclose.

• Commercial support was not received for this activity.

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Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Summarize the purpose of a healthcare ethics consultation.

2. Identify ethical concerns within medical cases.

3. Discuss the implications of responses to ethical concerns.

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Polling Question #1

 Does your facility have a

healthcare ethics consultation

service?

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Polling Question #2

 Have you ever requested a

healthcare ethics consultation?

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Healthcare Ethics Consult

“A set of services provided by an individual or

group in response to questions from patients,

families, surrogates, healthcare professionals, or

other involved parties who seek to resolve

uncertainty or conflict regarding value-laden

concerns that emerge in health care.”

(American Society for Bioethics and Humanities, 2014)

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Foundational Principles of Medical Ethics

• Autonomy

• Beneficence

• Nonmaleficence

• Justice

(Beauchamp & Childress, 2019)

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Military and Medical Ethics

Theories, principles, and norms related to morally right

and wrong decisions and actions in health care. This

includes decisions and actions of individuals involved in

health care (including patients, families, surrogate

decision makers, healthcare personnel, or other involved

parties), as well as hospitals, healthcare delivery

systems, healthcare insurers, and other institutions

involved in the provision of health care.

(Defense Health Agency, 2021)

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Healthcare Ethics Consultation: Valid Purpose - Yes or No?

• Investigate an allegation of a serious ethics violation.

• Conduct a medical evaluation.

• Make a treatment plan.

• Never report anything to authorities.

• “Clean up a mess.”

• Give legal advice.

• Tell the requester what to do.

• Talk to the family so the requester does not have to.

• Take the decision out of the hands of the family or out of the hands of the staff.

• Rubber-stamp what the healthcare team wants or what the patient/family wants.

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Healthcare Ethics Consultation: Purpose

The purpose of a healthcare ethics

consultation is to review a case and

provide ethically supportable

recommendations for patient care.

(Wiesen, 2022)

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Healthcare Ethics Consultation: Focus

• Shared decision making with patients

• Informed consent

• End-of-life care

• Beginning of life care

• Privacy and confidentiality

• Professionalism and building trust

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Healthcare Ethics Consultations

Growth over the last 20 Years:

• 6% increase in the prevalence of healthcare ethics

consultation (HEC) services.

• 14% increase in the percentage of hospitals with active HEC

services.

• 94% increase in the estimated annual number of case

consults performed in U.S. hospitals.

• 100% of hospitals allowing anyone involved in a case to

request an HEC.

Fox, E., et al (2022)

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One – two ethical

dilemmas

per week brought to co-

chairs for evaluation

Two to

three

family

meetings

per month

Four - six

significant

cases per

year

Healthcare Ethics Consultations at WRNMMC

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Healthcare Ethics Consultation: End of Life

• 82-year-old Female, retired service member was hospitalized in the military treatment

facility (MTF) intensive care unit with multiorgan failure, cardiovascular failure, and

sepsis. The medical team had provided the appropriate standard of care for each of the

patient’s issues. Unfortunately, the interventions did not provide any positive therapeutic

value and the prognosis was extremely poor. They suggested comfort care would be a

possible next step with code status moving to Do not Resuscitate (DNR)/Do not Intubate

(DNI).

• The patient was unresponsive and not did not have an advance directive. The eldest

daughter was now responsible for medical decisions. She had a strongly held belief her

mother would recover and should remain “full code” and all interventions continue to be

employed to sustain her life, because she had “always been a fighter.”

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Healthcare Ethics Consultation: End of Life

Ethical Perspectives

 Patient Autonomy

 Surrogate Decision Maker

 Patient’s Best Interests

 Beneficence v. Nonmaleficence

 Withdrawal or Withholding Treatment

 Futile or Non-Therapeutic Treatment

(Dressler et al, 2021; Tanaka et al, 2023; Weisen et al, 2021)

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Healthcare Ethics Consultation: Abandonment

• 91-year-old male, retired service member living outside the contiguous United States (OCONUS) for

over 30 years was escorted to a CONUS MTF for treatment. The patient was seen in the Emergency

Department (ED) for an infection which required admission for treatment, lasting seven days. While in

the ED, the patient’s escort departed, leaving only limited information about the patient’s extended

family.

• The patient was medically ready to discharge after seven days but while inpatient had been assessed

to not have decision making capacity for his medical care. Placement in a long-term care facility was

the recommendation. The eldest daughter, who was now his decision maker, was contacted and

agreed her father should be in a long-term care facility, but never followed through on her

responsibilities to complete this process.

• The VA was also not an option because the patient had never established service with the VA prior to

relocating OCONUS. Eventually a step-daughter was identified and contacted who agreed to begin the

VA enrollment process. Before this could be initiated, the daughter learned of this course of action

and prevented it from being completed. The patient remained in the MTF and medically ready to

discharge for a period exceeding nine months while viable solutions for his long-term care were

explored.

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Healthcare Ethics Consultation: Abandonment

Ethical Perspectives

 Patient Autonomy

 Surrogate Decision Maker Responsibilities

 Patient’s Best Interests

 Beneficence

 Nonmaleficence

 Justice: Allocation of Limited Resources

Ethical Responses; Fulmer & Paveza; Karlawish, J., et al;

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Key Takeaways

• Anyone involved in a patient’s care may request a HEC.

• The purpose of an HEC is to review a case and provide ethically

supportable recommendations.

• Ethically supportable recommendations may be along a spectrum

from good to bad.

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References

American Society for Bioethics and Humanities (2014). Code of Ethics and Professional Responsibilities for Healthcare Ethics

Consultants. asbh.org/uploads/publications/ASBH Code of Ethics.pdf

Beauchamp, T.L. & Childress, J.F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Defense Health Agency, Procedural Instruction Number 6025.39 (2021), Medical Ethics in the Military Health System.

https://health.mil/Reference-Center/DHA-Publications/2021/08/20/DHA-PI-6025-39

Dressler, G., Garrett, S. B., Hunt, L. J., Thompson, N., Mahoney, K., Sudore, R. L., Ritchie, C. S., & Harrison, K. L. (2021). "It’s

Case by Case, and It's a Struggle": A Qualitative Study of Hospice Practices, Perspectives, and Ethical Dilemmas When

Caring for Hospice Enrollees with Full-Code Status or Intensive Treatment Preferences. Journal of palliative

medicine, 24(4), 496–504. https://doi.org/10.1089/jpm.2020.0215

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References

Ethical Responses if Family Abandons Loved One at Hospital (2023, February 1). https://www.reliasmedia.com/articles/ethical-responses-if-family-

abandons-loved-one-at-hospital

Fox, E., Danis, M., Tarzian, A. J., & Duke, C., (2022). Ethics Consultation in U.S. Hospitals: A National Follow-Up Study, The American Journal of

Bioethics, 22:4, 5-18, DOI: 10.1080/15265161.2021.1893547

Fulmer, T., & Paveza, G. (1998). Neglect in the Elderly Patient. Nursing Clinics of North America 33(3), 457-466.

https://doi.org/10.1016/S0029-

6465(22)02611-1

Karlawish, J., Peterson, A., Clapp, J. T., & Largent, E. A. (2022). A Case of Patient Abandonment, or an Abandonment of Patients?. The American journal

of bioethics : AJOB, 22(7), 86–87. https://doi.org/10.1080/15265161.2022.2075961

Tanaka Gutiez, M., Efstathiou, N., Innes, R., & Metaxa, V. (2023). End-of-life care in the intensive care unit. Anaesthesia, 78(5), 636–643.

https://doi.org/10.1111/anae.15908

Wiesen, J., Donatelli, C., Smith, M. L., Hyle, L., & Mireles-Cabodevila, E. (2021). Medical, ethical, and legal aspects of end-of-life dilemmas in the

intensive care unit. Cleveland Clinic journal of medicine, 88(9), 516–5 27. https://doi.org/10.3949/ccjm.88a.14126

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Questions?

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How to Obtain CE/CME Credits

2024 MAY CCSS: Bridging Gaps and Building Resilience in Primary Care

Complete the course evaluation and posttest for the session(s) you attended by 11:59 PM ET on Thursday, May 23, 2024, to

receive CE/CME credit or a certificate of attendance.

1. Log in to your account.

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3. On the session page, click TAKE COURSE under the TAKE COURSE tab.

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5. Complete the evaluation and pass the posttest with a score of 80% or above to select your credits and download

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All completed courses and certificates are available in your account. Refer to your Pending Activities for sessions you have yet

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Questions? Email DHA J7, CEPO at dha.ncr.j7.mbx.cepo-cms-[email protected].