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Presented at the 12th World Congress of Bioethics organized
by National Bioethics Commission of Mexico held in Mexico City 25-28 June 2014,
by Professor Omar Hasan Kasule Sr. MB ChB (MUK),MPH (Harvard), DrPH (Harvard), Faculty of Medicine King Fahad Medical City,
Chairman of the Ethics Committee and the Institutional Review Board, Riyadh,
Saudi Arabia.
The role of the
hospital bioethicist: pro-active vs reactive
- This paper describes the author’s experiences of proactive engagement of the ethicistsin hospital procedures
- The ethicists in all these scenarios play multi-facetted roles: patient advocate, a mediator between practitioners and patients, problem solver, and educator.
- This represents a paradigm shift from waiting to be called to solve ethical problems to being there before and when problems arise.
- This approach has been found to be very satisfying to both the ethicists and the clinicians
Areas of proactive involvement
- Quality Council
- Clinical / ethical ward rounds
- Clinical ethics consultations
- Risk management programs
Quality Council
·
Ethicist is a member of this
council chaired by the CEO
·
Many committee are represented:
patient safety, environmental safety, risk management, nursing and other
quality improvement committees
·
The bioethicist is exposed to
reports of adverse and sentinel events several of which involve ethical issues
and gives his/her opinion
Clinical / ethics ward rounds
·
The ethicist can attend ward
rounds in departments most vulnerable to ethical dilemmas: Intensive Care
Units, Emergency Rooms, Obstetrics and Gynecology
·
The ethicist would anticipate,
observe and resolve ethical problems as they arise
·
We also had envisaged purely
ethical ward rounds in the target wards
·
The project was hampered by lack
of manpower; we are training more ethicists to undertake this in the future.
Corporate Policy and Procedure on ethical consultations: clinical (CPP
No 1432-81)&
non clinical (1435–54)
·
To explain procedural details to
be followed by heads of department and consultants in seeking ethical advice
·
24 hr. /7
day Clinical Ethics Consultationis available and is treated like any other form
of clinical consultation according to the hospital regulations.
·
An ethical
problem exists when it is not clear what is the ethically sound action or
course of action or when people disagree about what is best for a patient.
CPP on Clinical Ethical Consultations 2
·
An Ethics
Consultation is advisory. Ethics consultantsshall act as professionals giving
specialist ethical advices and their role will be advisory and non-binding. All
final decision making will by heads of department, the attending consultants,
and the patients or their families.
·
Bioethics consultants shall take
turns being the consultant on duty and while on duty, will receive all urgent
consultations through special email ethics@kfmc.med.sa,
intranet portal and/or special pager no. 5556
CPP on Clinical Ethical Consultations 3
·
Clinical
consultants, patients, and families can request ethics consultation by email,
telephone, or pager
·
Response to emergency
consultations is immediate by the ethicist on duty; routine consultations are
attended to within 24 hours
·
Ethicist visits the ward, review
patient charts, talk to the physicians (if needed) and to the patients and
their families (if necessary).
·
Gives an electronic or telephonic
opinion to the consulting physician with a follow-up letter. Signs the
consultation report.
CPP on Clinical Ethical Consultations 4
·
Complicated cases encountered
during ward rounds and consultations are referred to the clinical ethics
committee that recommends long-term policy-related solutions.
·
In practice over 80% of these
consultations turned out to be mediating between the patient, the family, and
the healthcare workers to reach a joint decision. The patients and families
trusted the ethicist as an unbiased outside authority
Examples of clinical consultations 1: amputations of
septic diabetic foot
·
Patient in 6th decade
first refused toe amputation and maintained refusal when the foot and lower leg
were involved
·
He had signed the consent for his
sister who had late below knee amputation and later above knee and eventually
died
·
Bioethicist convinced the
physicians to decrease sedation and talked to the patient who authorized his
son to decide as a proxy
·
Disputes within the family no
decision and patient was discharged against medical advice
Examples of clinical consultations 2: amputations of
septic diabetic foot with cardiac complications
·
6th decade diabetic
had authorized his son as proxy decision maker and the son had signed the
consent to amputation
·
The father made the son swear
that he would never allow any of his organs to be amputated so the son revoked
the consent
·
Ethicist discussed with the
family the benefits and risks of general anesthesia for a patient with cardiac
complications
·
The family was willing to accept
the 14% mortality risk but the son could not go against the father’s will.
Examples of clinical consultations 3: stroke and
gastric feeding tube
·
A foreign maid with no family
needed a gastric tube to replace the nasogastric tube that could not maintained
for very long
·
Ethicist called the son in a
foreign country and the son said that he will leave it to the doctors to
decide.
·
The son later refused any further
telephone contact and the surgeons could not operate without informed consent
·
Eventually patient was evacuated
to home country
Risk management programs 1
·
The DATIX (risk management
reporting system) has 32 codes; 6 were selected as being HIGHLY RELATED to ethics to be reported to
the Chair Ethics Committee and investigated: (Code blue,
Confidentiality, Consent, Death, Diagnosis, failed or delayed, IV infiltration
/ extravascation)
·
15 codes were possibly related to ethics reported to the
Chair Ethics Committee if there is patient injury or near-miss
Risk management programs 2
·
11 codes
were remotely relatedto ethics not reported to the Chair Ethics committee
unless there are repeated associated adverse patient outcomes
·
The Chair of the ethics committee
will decide to: take action (investigate and resolve), refer to the ethics committee
members, or note for training purposes
·
A total of 367 events were
reported January-June 2014 analyzed as shown below:
Training of hospital personnel in ethics
·
Not enough bioethicists problem
cannot be resolved in near future
·
We decided to make basic ethical
issues as part of the general culture and knowledge
·
Ethics days to train clinical
staff at first voluntary but will become required in due course
·
Ethics Training day every 2
months certificate given after covering all modules
Training of hospital personnel in ethics: curriculum
1
·
Introduction:
Principles of western & Islamic approaches to bioethics, How to resolve
ethical issues in clinical practice?
·
Professionalism:
Doctor’s professional relationships and duties, Truth telling and breaking bad
news, Health practitioner relationships with pharmaceutical industry & COI
Training of hospital personnel in ethics: curriculum
2
·
Patient rights:
Patient’s rights and responsibilities, Patient autonomy and consent to
treatment, Privacy & confidentiality
·
Issues at the start and
of life: reproductive ethics, terminally incurable diseases and eol
decisions, Organ transplant and donation
Training of hospital personnel in ethics: curriculum
3
·
Errors: Medical
malpractice and medical errors, ethico-legal issues of medication errors
·
Public health issues;
Resource allocation, Ethics of public health and health promotion, Ethics of
disaster and emergency medicine
Ethics related
events per month
number
|
%
|
|
Jan 2014
|
12
|
3.27
|
Feb 2014
|
54
|
14.7
|
Mar 2014
|
85
|
23.16
|
Apr 2014
|
94
|
25.61
|
May 2014
|
57
|
15.53
|
June 2014
|
65
|
17.71
|
Total
|
367
|
Severity of
reported events
N
|
%
|
|
None
|
267
|
86.13
|
Moderate
|
19
|
6.13
|
Severe
|
24
|
7.74
|
Total
|
310
|
Initial Risk grading of reported events
N
|
%
|
|
Low
|
149
|
45.29
|
Moderate
|
148
|
44.98
|
High
|
32
|
9.73
|
Total
|
329
|
Result of the
incident
N
|
%
|
|
None
|
206
|
62.61
|
Near miss
|
61
|
18.54
|
Harm
|
62
|
18.84
|
Total
|
329
|
Type of incident
N
|
%
|
|
EOL
|
195
|
62.10
|
IV Cannula
|
42
|
13.38
|
Consent
|
35
|
11.14
|
Communication
|
13
|
4.14
|
Surgical site
|
6
|
1.91
|
Other
|
23
|
7.32
|
Total
|
314
|