Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. They should not replace the dialogues of interprofessional team members with patients, families, or each other.
There’s been a recent uptick by case managers of their patient referrals to hospital ethics committees. This topic is near and dear to me, especially having served as the chair or co-chair of several acute care-based ethics committees over the years. The industry demand for decreased hospital utilization and length of stay has meant a shift in how ethics committees are viewed and often utilized. We’ve gone from traditional referrals, as in defining a treatment plan when practitioners define care as futile or a patient lacks advance directives, to when an individual refuses to accept a discharge plan. I’ve heard of situations where ethics committee consults are tapped should a patient be “non-compliant” with their treatment; this is language that I challenge at every opportunity and my recent blog on this topic reveals just how much. But I digress….
Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. The Joint Commission standard is clear: “Healthcare organizations must have a mechanism in place to develop and implement a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.” Yet, the details of that mechanism are left to the discretion of each organization and therein lies the conundrum and challenge!
The Power of Ethics Committee
The requirements for ethics committees were driven by increasing patient situations that involved a lack of clarity between patient and family wishes, expectations for treatment, the provider’s prognosis, and/or the patient’s treatment plan. The case of Karen Ann Quinlan is often viewed as a legal landmark to set the precedent for formalization of bio-ethics and ethics committees in hospitals. In April 1975 at the age of 21, Ms. Quinlan became unconscious after consuming Valium with alcohol while on a crash diet. She lapsed into a coma, followed by a persistent vegetative state. After a lengthy legal battle, the New Jersey Supreme Court allowed Ms. Quinlan’s parents to disconnect the respirator, affirming the choice she would have made; Karen lived until 1985. Other patient situations would follow and continue to appear, Terry Schiavo to Brittany Maynard and David Adox. The real-life experiences of these individuals have bolstered the vital role of ethics committees as one firm pillar of today’s healthcare process, leveraging the industry’s ethical principles of autonomy, beneficence, fidelity, justice, and non-malfeasance.
Misconceptions Run Amuck
Despite clear guidelines for ethics committees, organizations can have a varied understanding of their moving parts. Among these points of confusion can be what members of the interprofessional team should be involved, how many persons should serve and for how long, the amount of onboarding required, and the scope of each member’s role. Even the amount of work expected can prompt a moment of pause. Ethics committees are too often developed haphazardly and without a formal plan. The consequences of these actions yield an Ethics Committee in name only, which devalues the role of this critical resource for patients, their families, and the interprofessional teams that care for them.
One of the largest misperceptions of ethics committees lies in their true function. Despite recent popular belief, ethics committees are not used to tell patients, their families, and members of the interprofessional team what to do. Ethics committees review the clinical nuances of individual patient situations and documentation from interprofessional team members to make sure the wishes of the patient and/or their legal representatives are acknowledged. This may be specific to end-of-life decision-making, reviewing futility of care determinations by practitioners, or recognizing the rights of patients to refuse care or treatment.
Ethics committees play a vital role is reviewing that the care rendered is done in accordance with all Federal and State laws and regulations. One of my physician co-chairs used to say, “Ethics Committees step in when the treatment team has employed their due diligence to engage, assess, and communicate with the patient and family, whether through informed consent, shared decision-making, or other collaborative efforts (e.g., team and/or family meetings, care coordination rounds). Anything less reflects incomplete work by the team.”
Functions of Ethics Committees in a Changing Practice Climate
It might seem optimal to involve the ethics committee’s objective lens for the review of discharge planning processes, such as when a patient refuses to go to a particular nursing home in deference to another facility or plan. However, that can also be a misuse or critical resources. Ethics committees should not replace the dialogues of interprofessional team members with patients, families, or each other.
Ethics Committees have three basic functions:
- Ensure training and support for committee members and consultants.
- Provide consistent subject matter expertise for cases requiring formal ethics evaluation and recommendations.
- Develop and implement evaluation metrics to ensure quality improvement, and,
- Develop appropriate reports, publications, and presentations for both internal personnel and external strategic partners.
- Promote ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision-making.
- Assure knowledgeable ethics committee members.
- Provide appropriate education to the organization (e.g., training, journal articles, reports, available literature on professional resource training and conferences).
- Policy review and development
In recent years, ethics committees affiliated with academic institutions and large healthcare systems have advanced into comprehensive ethics programs. A growing number of healthcare organizations integrate ethics from the bedside to the boardroom (University of Washington, 2023). Others provide consultations in response to non-clinical ethics questions, such as identifying and remedying systems-level factors that have the potential to induce or exacerbate ethical problems and/or impede their resolution, as in staffing issues from workforce shortages. A valuable article recommends key foundational principles to:
- Strengthen the position of ethics committees in hospitals,
- Ensure continuous supervision over committee formation and meetings, operations and decision-making processes, and
- Define how committees’ decisions are shared with involved hospital stakeholders and staff.
Case managers can find out more about ethics committees, the seminal cases that drove them, and innovative ways to engage with them in Chapters 2 and 4 of The Ethical Case Manager: Tools and Tactics available on Amazon.
Dr. Ellen Fink-Samnick DBH, MSW, LCSW, ACSW, CCM, CCTP, CRP, FCM is an award-winning industry entrepreneur whose focus is on interprofessional ethics, holistic health equity quality, trauma-informed leadership, and competency-based case management. She is a content developer, professional speaker, author, and educator with academic appointments at Cummings Graduate Institute of Behavioral Health Studies, George Mason University, and the University of Buffalo School of Social Work. More information can be found on her website and LinkedIn profile