Champlain Centre for Health Care Ethics Annual Report:

Transcription

1 Champlain Centre for Health Care Ethics Annual Report:

2 2 Table of Contents Table of Contents Executive Summary Champlain Centre for Health Care Ethics (CCHCE) Clinical and Organizational Ethics Services Regional Capacity Building Other Noteworthy Activities Appendix A Ethics Education Program Overview Appendix B Annual Symposium Event Poster and Agenda Appendix C Regional Funding Proposal... 15

3 3 Executive Summary The Champlain Centre for Health Care Ethics (CCHCE) is now in its fourth year of providing support and integrating robust ethics programming into the daily functioning of partner organizations across the region. The scope of this report will be from 1 st April 2016 to 31 st March With respect to services, CCHCE provided 91 ethics consultations regionally in the noted time period. Requests for consultation support were made by a variety of health care professionals, and addressed an assortment of challenging clinical and organizational issues (see section 3). In addition, education sessions were provided to 121 groups with approximately 2300 participants attending. Capacity-building services are available for nurses, physicians, residents, volunteers, management, administrative staff, and other health professionals in the region. The CCHCE has also continued to pursue alternate funding arrangements to the contractual provisions currently in place with partners, and has made a formal proposal to the Champlain Local Health Integration Network (LHIN) to do so. An alternative funding model is needed to enable timely, cost effective access to ethics services and to ensure equitable access to expert health care ethics services to organizations, providers, and patients and families in the Champlain LHIN. Specifically, a consistent, regional approach to ethics is imperative to address some of the most pressing challenges that face health care today. In order to better serve its affiliated partners, the CCHCE, in collaboration with the Department of Clinical and Organizational ethics and a multi-disciplinary team at the Ottawa Hospital, also led a task force to address the changing legislative and ethical landscape with regard to Medical Assistance in Dying (MAID) in Canada. This team was among the first in the country to develop a robust organizational policy and procedure for MAID, and all materials, as well as personnel contacts, have been shared with partner organizations of the CCHCE. With this information, the CCHCE regional ethicist worked with the partner organization ethics committees and working groups to develop and implement policies and procedures for addressing requests for MAID. In addition, information material for staff/physicians, as well as patients and their families was also created.

4 4 Champlain Centre for Health Care Ethics (CCHCE) Over the last year the Champlain Centre for Health Care Ethics has undergone several significant changes. The placement of the CCHCE within The Ottawa Hospital (the hosting organization) organizational structure has shifted from the Department of Medical Affairs, to now being situated within the purview of Chief of Staff, Dr. Jeffrey Turnbull. The Regional Ethicist now reports directly to Dr. Turnbull. The CCHCE has also continued to pursue alternate funding arrangements, and has made a formal proposal to the Champlain Local Health Integration Network (LHIN) to do so. While the current cost of partnership in the CCHCE is relatively nominal, many smaller organizations in the LHIN have identified partnership fees as a barrier. Such organizations typically do not have access to in-house ethics expertise, and any external support is currently offered at a cost that is also beyond the organization s fiscal constraints. Models of ethics service delivery that are able to provide expertise only to those organizations that can pay present considerable issues of fairness, where those organizations unable to pay are left without support, despite facing the same ethical issues. An alternative funding model is needed to enable timely, cost effective access to these services and to ensure equitable access to expert health care ethics services to organizations, providers, and patients and families in the Champlain LHIN. Specifically, a consistent, regional approach to ethics is imperative to address some of the most pressing challenges that face health care today. Such challenges include: Ensuring a consistent, accessible, and ethically-sound approach to delivering Medical Assistance in Dying (MAID) regionally. Supporting regional policy decisions that require uniformity from an ethical perspective. This is to ensure that, as patients move from organization to organization, they are not subjected to different ethical directions or standards. Needing to heighten ethics capacity at all organizations in the LHIN, including providing support directly to the LHIN to make ethically-defensible decisions for the region it serves.

5 5 In the coming months, the CCHCE will continue to meet with leaders of LHIN-funded organizations to garner support for the formal regionalization of the ethics program. We anticipate that a decision will be made by the LHIN regarding CCHCE funding for the fiscal year. While pursuing alternate funding mechanisms, the CCHCE continues to build-regional capacity and develop partnerships with health care organizations throughout the Champlain LHIN. As of 31 st March, 2017, our current affiliated partners include: The Champlain Community Care Access Centre (CCAC) The Royal Ottawa Health Care Group The Queensway Carleton Hospital VHA Home and Health Support The Perley and Rideau Veterans Health Centre Cornwall Community Hospital Personal Choice Independent Living Seaway Valley Community Health Centre Deep River and District Hospital Primary activities include consultation and education, and these activities have focused on a variety of themes, including: consent/capacity, moral distress, end-of-life care, living at risk, and organizational ethics. Other key CCHCE activities over the last year include delivery of a 10-session, 20-hour Ethics Education Program, and hosting of the third annual full-day symposium on the ethical challenges in prioritization and resource allocation in health care. Both the Ethics Education Program and Symposium will continue in Clinical and Organizational Ethics Services The full range of clinical and organizational ethics services were provided to partner organizations between 1 st April 2016, and 31 st March Other health service providers received either an educational session or ethics consultations on a fee-for-service basis. In total, the CCHCE provided 91 ethics consultations and provided education sessions to 121 groups. a) Consultations Main themes for ethics consultations included consent and capacity, substitute-decision making, and living at risk, among others.

6 6 Regional ethics consultation primary themes can be depicted graphically as: Ethics Consultations by Primary Theme Consent & Capacity 38% 25% Goals/Plan of Care MAID Living at Risk Substitute Decision-Making 11% Fairness 6% 9% 6% 5% Moral distress Other b) Education While education topics varied across organizations generally, the primary topics trans-regionally remained relatively similar and included Medical Assistance in Dying (MAID), consent and capacity, introduction to CCHCE ethics services, and Ethics 101. In total, approximately 2300 participants attended these sessions over the last year. Capacity-building services are available for nurses, physicians, residents, volunteers, management, administrative staff, and other health professionals in the region.

7 7 Capacity building themes across the region can be summarized as follows: Capacity Building Primary Theme 4% 4% 14% 5% 14% 25% 8% Intro to Services Consent/Capacity Ethics 101 MAID Moral Distress 26% Resource Allocation End of Life Care Issues Other c) Policy Review Policy development and review was one of several tasks that fulfilled the CCHCE s organizational ethics mandate. All partner organizations have access to an ethics consultation policy prepared and detailed for the specifics of their institution upon initiation of partnership. These consultation policies included two ethical decision-making frameworks as suggested tools for use within the policy. An abbreviated list of policies that were reviewed or developed is presented below. i) Medical Assistance in Dying (MAID) Policy ii) Quality of Care Policy iii) Goals of Care Policy iv) Ethics Framework Policy v) Governance Ethics Policy vi) Conflict of interest policy vii) Maintaining professional boundaries policy viii) Medical Marijuana Policy ix) Internet Usage Policy x) Advance Care Planning Policy

8 8 Regional Capacity Building From 1 st April 2016 to 31 st March 2017, two annual regional capacity-building activities were advertised and offered to all health care service providers within the region, in addition to the Regional Ethics Rounds held monthly. The first was the Ethics Education Program and the second an Ethics Symposium. Both were received with great success. The Ethics Education Program (EEP) This program consists of a 20-hour curriculum designed to educate healthcare providers and administrators on identifying and managing ethical issues. Specific topics addressed in this program include consent/capacity, end-of-life care, moral distress, and Accreditation Canada requirements related to ethics. Each partner organization may send one attendee to the education program at no cost, and while others may participate, an enrollment fee will apply. By the end of the 2016 program, we have had more than 125 participants from throughout the region complete the course. Feedback demonstrated great appreciation for the content and quality of the program. For the complete syllabus, see Appendix A. Regional Ethics Symposium: Ethics and Resource Allocation in Health Care Can We Choose Wisely? The CCHCE held its third annual full-day symposium on September 29 th This year, the event took place at St. Elias Conference Centre in Ottawa. This year s topic was Ethics and Resource Allocation in Health Care: Can We Choose Wisely? and was in response to the ongoing challenges that organizations face in the current resource-limited health care climate. Many organizations deal with surging (over-) capacity and waitlist issues, and this event addressed some of the particular ethical challenges that present due to such issues. Once again, all health care organizations within the Champlain LHIN received invitations to take part in this day. The topic of appropriate allocation of resources was well received and was identified as a chief concern amongst providers across the region. The day was introduced by Regional Ethicist Joshua Landry, and followed by guest speakers from various health sectors. These included: Dr. Rakesh Patel, Assistant Professor & Program Director, Adult Critical Care Medicine Training Program, Department of Medicine, University of Ottawa & Department of Critical

9 9 Care, The Ottawa Hospital Catherine Butler, Vice President, Clinical Care, Champlain CCAC Nathalie Cadieux, Executive Vice-President of Finance and Business Development, The Ottawa Hospital Cal Martell, Sr. Director, Health Systems Improvement, Champlain LHIN Participants were very engaged and evaluated the quality of the lectures, the relevance of the topic and how the symposium met their learning objectives very positively (See Table below). Overall the symposium represented an excellent venue for different participants to meet and network, discuss similar ethical challenges, and increase understanding of what challenges regarding appropriate resource allocation were being experienced across the region. Given the success of the event, it is the CCHCE s intention to continue hosting an annual symposium as many participants expressed the importance of having access to such regional ethics education. Participants also provided general feedback on what they wanted the CCHCE to do for them in the coming year. (For agenda and event poster, see Appendix B). 30 Evaluation of Resource Allocation Symposium N/A Poor Fair Good Very Good Excellent Speaker Quality Relevance of Topic Learning Objectives n = 43

10 10 Regional Ethics Rounds The CCHCE is pleased to hold regularly scheduled Regional Ethics Rounds throughout the year that can be accessed by partner organizations. These rounds began in September 2015, regularly attract participants from all partner organizations, and have presented the following topics: April 2016: Consent to Treatment: The Law is the Minimum Ethic, ~100 attendees. May 2016: Legislating MAID: Considerations on Bill C-14, ~40 attendees. October 2016: Assisted Death and Lessons from the Dutch Experience Dr. Gerrit Kimsma (the Netherlands), ~100 attendees. November 2016: Ethical Issues in Sexuality and Intimacy in Long-Term Care, ~50 attendees. December 2016: Responsible Resource Allocation in Health Care: A community nursing perspective, ~40 attendees. February 2017: Disagreements in Care Planning: Whose Wishes Prevail?, ~40 attendees. March 2017: Professional Boundaries and Behaviour: In Practice and on Social Media, ~40 attendees. Other Noteworthy Activities Proposal for Alternate Funding The CCHCE has continued to pursue alternate funding arrangements to the annual-contract model currently in place, and has made a formal proposal to the Champlain Local Health Integration Network (LHIN) to do so. While the cost of partnership in the CCHCE is relatively nominal, many smaller organizations in the LHIN have identified partnership fees as a barrier. Such organizations typically do not have access to in-house ethics expertise, and any external support is currently offered at a cost that is also beyond the organization s fiscal constraints. Models of ethics service delivery that are able to provide expertise only to those organizations that can pay present considerable issues of fairness, where those organizations unable to pay are left without support, despite facing the same ethical issues. An alternative funding model is needed to enable timely, cost effective access to these services and to ensure equitable access to

11 11 expert health care ethics services to organizations, providers, and patients and families in the Champlain LHIN. Specifically, a consistent, regional approach to ethics is imperative to address some of the most pressing challenges that face health care today. Such challenges include: Ensuring a consistent, accessible, and ethically-sound approach to delivering Medical Assistance in Dying (MAID) regionally. Supporting regional policy decisions that require uniformity from an ethical perspective. This is to ensure that, as patients move from organization to organization, they are not subjected to different ethical directions or standards. Needing to heighten ethics capacity at all organizations in the LHIN, including providing support directly to the LHIN to make ethically-defensible decisions for the region it serves. In the coming months, the CCHCE will continue to meet with leaders of LHIN-funded organizations to garner support for the formal regionalization of the ethics program. We anticipate that a decision will be made by the LHIN, regarding CCHCE funding, for the fiscal year. For the full funding proposal, see Appendix C.

12 12 Appendix A Ethics Education Program Overview Week (1) Introduction to Ethics Week (2) Ethics in Practice I: Models of Ethics Service in Health Care Settings Week (3) Ethics in Practice II: Models of Ethics Service in Health Care Settings (Continued) Week (4) Ethics in Practice III: Introduction to Clinical Ethics Consultation Week (5) Ethics in Practice IV: Consent, Capacity, and Substitute Decision Making I Week (6) Ethics in Practice V: Consent, Capacity, and Substitute Decision Making II Week (7) Ethics in Practice VI: Ethical Issues in End-of-Life Care Week (8) Ethics in Practice VII: Moral Distress Week (9) Ethics in Practice VIII: Accreditation Canada Standards Week (10) Ethics in Practice IX: Special Topics Physician-Assisted Death

13 13 Appendix B Annual Symposium Event Poster and Agenda

14 14

15 15 Appendix C Regional Funding Proposal The Champlain Centre for Health Care Ethics A Regional Approach to Clinical and Organizational Ethics Regional Funding Proposal and Strategic Plan Mr. Joshua T. Landry, MSc, CCE, PhD(c) Regional Ethicist, Champlain Centre for Health Care Ethics Dr. Jeffrey Turnbull Chief of Staff, The Ottawa Hospital Dr. Virginia Roth Senior Medical Officer, The Ottawa Hospital on Twitter

16 16 Table of Contents Executive Summary Background Opportunity Regional Health Care Ethics Model Program Expansion with Base Funding Introduction Health Care Ethics Model Regional Model Service Delivery Plan Alternatives Team/Activity Highlights Impact of Recent Activities Clinical and Organizational Ethics Services Program Expansion with Base Funding CCHCE Strategic Plan Objective: Regional Clinical and Organizational Ethics Objective: Regional Ethics Capacity Building Objective: Integration and Sustainability Objective: Equitable Access Appendix i Ethics Support Services Appendix ii Ethics Symposium on Ethical Resource Allocation Appendix iii Ethics Symposium on Physician-Assisted Death Appendix iv Regional Ethics Rounds Appendix v Sample of Recent Publications Appendix vi Ethics Consultations Appendix vii Ethics Education and Capacity Building... 44

17 17 Executive Summary Background Health care ethics services have proven to be beneficial for those having access to them by improving decision making, reducing staff distress, providing alternatives to ethically challenging situations and improving the quality of care. The Champlain Centre for Health Ethics (CCHCE) is the leading health care ethics support system in the Champlain region. The CCHCE provides a regional approach to the provision of health care ethics services to a diverse group of organizations across the continuum of care (hospitals, long-term care homes, community health services) through annual contracts/partnerships based on an organization s budget size. Opportunity The CCHCE is continuing to grow. While the cost of partnership in the CCHCE is relatively nominal, many smaller organizations in the LHIN have identified partnership fees as a barrier. Such organizations typically do not have access to in-house ethics expertise, and any external support is currently offered at a cost that is also beyond the organization s fiscal constraints. Models of ethics service delivery that are able to provide expertise only to those organizations that can pay present considerable issues of fairness, where those organizations unable to pay are left without support, despite facing the same ethical issues. An alternative funding model is needed to enable timely, cost effective access to these services and to ensure equitable access to expert health care ethics services to organizations, providers, and patients and families in the Champlain LHIN. Specifically, a consistent, regional approach to ethics is imperative to address some of the most pressing challenges that face health care today. Such challenges include: Ensuring a consistent, accessible, and ethically-sound approach to delivering Medical Assistance in Dying (MAID) regionally. Supporting regional policy decisions that require uniformity from an ethical perspective. This is to ensure that, as patients move from organization to organization, they are not subjected to different ethical directions or standards. Needing to heighten ethics capacity at all organizations in the LHIN, including providing support directly to the LHIN to make ethically-defensible decisions for the region it serves. Regional Health Care Ethics Model The vision of the CCHCE is to centralize ethics expertise and services, make them available to all, and build an adaptable, resource sensitive, region-wide approach to ethics that can address systemic and interrelated ethical issues that all health service providers in the Champlain region face. Currently, the CCHCE offers a wide array of ethics support services to nine organizations in the region via expert ethics consultation, capacity building, policy development and support, accreditation compliance, and other activities.

18 18 The primary roles of the CCHCE are ethics consultation and ethics capacity building/education. In 2015, the CCHCE provided 108 ethics consultations, and 98 educational sessions to its nine partner organizations. Both consultation and education themes included: consent and capacity, substitute decision-making, care planning, and others. In addition to clinical ethical issues, the CCHCE frequently facilitates the exploration of challenging organizational issues relating to governance, scarce resource allocation, or procedural fairness. The CCHCE also serves as expert advisors, and provides support in meeting Accreditation Canada s ethics standards. Program Expansion with Base Funding The Champlain Centre for Health Care Ethics demonstrates great promise for continued growth and success. Sustained LHIN funding is required to hire an additional 2.0 FTE ethicists, and a 1.0 FTE administrative assistant in order to have the capacity to provide robust ethics support to the Champlain Region. This will enable the CCHCE to address clinical and organizational issues, and build capacity among staff, leaders, and governance within organizations. CCHCE services are currently offered through a partnership-fee model. Presently, only nine of approximately 200 health service providers funded by the LHIN are partnered with the CCHCE. These nine organizations contribute $115,000 in partnership fees, compared to the estimated funding of $450,000 required to provide services to all health care organizations in the LHIN. The total funding of $450,000 is requested annually for a five-year period, during which the region s capacity for ethics will be enhanced and a formal review initiated to support continued regional ethics funding beyond this point. With sustained LHIN funding the CCHCE will also be equipped to support the provision of high quality, compassionate, and patient-centered care to all in the region by fulfilling its 5-year ( ) strategic plan. The strategic plan focuses on the following high-priority objectives related to quality ethics programming: Regional Clinical and Organizational Ethics: Provide high-quality support services to both clinical and organizational stakeholders across the Champlain region. Regional Ethics Capacity Building: Develop and deliver robust ethics capacity-building initiatives on topics affecting the region. Integration and Sustainability: Work toward the integration of ethics services into standard operating procedure where possible, and support a model of ethics service delivery that is sustainable in the geographically-vast, and culturally diverse Champlain region. Equitable Access: Ensure funding, geography, or other factors do not impede equitable access to high-quality ethics services available within the region.

19 19 Introduction It has become imperative to have access to ethics expertise to address increasingly complex issues in many areas of health care, such as: end-of-life care, consent to care/treatment, and substitute decision-making. Health care ethics services have proven to be beneficial for those having access to them by improving decision making, reducing staff distress, providing alternatives to ethically challenging situations and improving the quality of care. Based on a survey conducted at the CCHCE inaugural symposium in September 2014 on Living at Risk, and needs assessment surveys completed at the beginning of each of the Centre s partnerships, it is clear that needs for ethics services exist throughout the Champlain LHIN, and that these needs are not generally felt to be addressed adequately outside of the CCHCE program. For example, the 2014 survey revealed that when excluding responses from hospitals, ethics committees were the main ethics resource available to health-care providers, but at many as 33% had no ethics services available to them, and 42% had not used or had access to any services in the last 6 months. Of the 300+ survey-respondents from partner organizations, greater than 85% believed that ethics resources and ethics education were either important or very important to patient care, demonstrating a perceived need for the service. Difficult patient demands, as well as issues with substitute decision-making and moral distress were identified as significant challenges encountered across the continuum of care. Also, the need to address ethical issues collaboratively and from a regional perspective is more apparent when preliminary data demonstrated that 53% of respondents had issues with other health service providers in their region, and 70% had discharge issues. In addition to clinical ethical issues faced by health care providers, organizations also struggle with difficult ethical questions. Organizational ethical issues are of concern when approximately 29% of participants perceive a lack of transparency with medical errors, work in an environment that does not allow for honest discussion of ethical issues and do not have enough support from their superiors. Making the Case The current funding model of the CCHCE is highly restrictive to its growth as a regional ethics program, and has significantly impacted an ability of the program to provide support to all who need it. At present, only a small number of organizations in the Champlain LHIN are partnered with the CCHCE and pay annual fees toward its operation, and therefore, few patients, families, and health care providers, have access to an expert ethics service. Regionalizing ethics services is critical in order to: - Ensure a consistent, accessible, and ethically-sound approach to delivering Medical Assistance in Dying (MAID) regionally. The implementation of MAID policies and

20 20 procedures in the region has been inconsistent thus far, and has relied heavily on the work done by a multidisciplinary task force, which included representation from the Champlain Centre for Health Care Ethics, at The Ottawa Hospital. The CCHCE has also been integral to the dissemination of information done by this task force, and has played a key role in connecting regional partners with personnel and resources related to MAID. - Support regional policy decisions that require uniformity from an ethical perspective. This will ensure that, as patients move from organization to organization, they are not subjected to different ethical directions or standards. - Heighten ethics capacity at all organizations in the LHIN. As demonstrated by the frequently-occurring themes of ethics consultations found in Appendix F, health care providers and organizations face similar ethical issues, regardless of the location of service delivery. Having an ability to heighten ethics capacity regionally will not only have the potential to decrease staff moral distress and turnover, but also positively impact the quality of patient care, and increase safety and compliance. - Support the LHIN to make ethically-defensible decisions for the region it serves, especially in light of forthcoming changes to health service delivery. Perhaps now more than ever before, the LHIN itself faces great ethical challenges that could be supported by a regional approach to ethics service delivery. Supporting the regionalization of ethics services will demonstrate to organizations in the region that ethics is a priority for the LHIN, and that the decisions made at that level have undergone careful ethical examination. In addition, regionalizing ethics services will enable the CCHCE to: - Increase equity: ensures that all organizations, patients, and families served are able to access ethics expertise when required. - Positively impact the management of wait lists. - Ensure that organizations have access to ethics guidance when allocating scarce funds. - Support organizations in Accreditation compliance: Currently the Champlain Centre for Health Care Ethics holds a 100% success rate in facilitating partner organization achievement of Accreditation Canada ethics standard compliance. - Provide support and create linkages between and among organizations to ensure that there is a coordinated and consistent approach to addressing common concerns and issues. - Ensure the delivery of ethics services is sustainable; something not realizable under the current pay and play model. The following report explicates various aspects of the Champlain Centre for Health Care Ethics program at present time, and provides additional support to the stated benefits that sustained LHIN base-funding would bring to the region.

21 21 Health Care Ethics Model There are three primary models of health care ethics delivery: 1) Ethics committees: A group of individuals from across the organization meets routinely (monthly, quarterly) or on an ad-hoc basis to discuss and address ethical issues. 2) Individual ethics consultants (ethicist): An individual ethics expert, specifically trained in health care ethics issues, is responsible for addressing ethical issues as they arise, and for delivering education and capacity building on ethics-related topics. 3) Hub and spoke model: The hub and spoke model builds on a core capacity of an ethics expert (the hub) while building capacity and strengths through leaders and ethics integration teams in an organization (the spokes). Many organizations without a dedicated ethicist rely on ad-hoc ethics committees, or a person in a different role (e.g. Quality and Risk) to address ethical issues, despite a lack of ethics-specific training to do so. The Champlain Centre for Health Care Ethics operates within a hybrid (modified) individual consultant and hub-and-spokes model, in order to provide ethics expertise to its regional partners, while also developing capacity within those organizations to integrate and sustain a successful ethics program. The goal of the regional ethics program is to allocate 1.0 FTE ethicist the task of developing and maintaining education material, patient and staff literature, model policies, and other standardized documentation, while 2.0 FTE ethicists will be integrated into organizations, providing consultation and education support at the front line in collaboration with ethics champions at those organizations. The modified hub-and-spokes model is represented graphically as:

22 22 Ethics Champion - Board of Directors Ethics Champion - Nursing Champlain Centre for Health Care Ethics Central Hub Partner Organization Ethics Committee and CCHCE Ethicist contact Regional Spoke / Organizational Hub Ethics Champion - Medicine Ethics Champion - Patient Council Ethics Champion - Social work Regional Model As of August 31 st, 2016, nine health care organizations are partnered with, and are receiving services from the CCHCE: 1- Champlain CCAC 2- Royal Ottawa Health Care Group 3- Queensway Carleton Hospital 4- Cornwall Community Hospital 5- The Perley Rideau Veterans Health Centre

23 23 6- VHA Home HealthCare 7- Seaway Valley Community Health Centre 8- Deep River and District Hospital 9- Personal Choice Independent Living While significant progress has been made to date, the CCHCE is continuing to grow. The nine partner organizations represent a small percentage of the total number of health care organizations in our LHIN. While the cost of partnership in the CCHCE is relatively nominal, many of the smaller organizations in the LHIN have identified partnership fees as a barrier. For example, the following organizations have requested services, but due to resource limitations or other factors are not able to access or continue receiving services: Hawkesbury General Hospital, Prescott Russell Residence, Carleton Lodge, Almonte General Hospital, Renfrew Victoria Hospital, Saint Francis Memorial Hospital, and Winchester District Memorial Hospital. Service Delivery Plan The vision of the CCHCE is to centralize ethics expertise and services, make them available to all and build a participatory, adaptable, resource sensitive, regional-wide approach to ethics that can address systemic and interrelated ethical issues that all health service providers in the Champlain region face. Currently, the CCHCE offers a wide array of ethics support services which may include: Identification of ethical needs, clinical and organizational ethics consultation services, capacity building and ethics education, support in meeting Accreditation Canada requirements, prevention and support groups, and others. Robust descriptions of available services are found in Appendix A. Alternatives Currently there are no viable available alternatives to developing a robust and integrated regional ethics program to the services offered by the Champlain Centre for Health Care Ethics. The reason for choosing the CCHCE model as the only viable option is multi-faceted. First is that no alternative regional model exists, and thus, no other group is offering similarly structured services. Second relates to an issue of need and resource constraint. The CCHCE was created because of a gap in expert ethics service availability for well over 90% of health care organizations in the Champlain LHIN. While needs continue to exist across the continuum of care, a requirement for a full-time ethicist, or the ability to pay for that full-time support at each individual organization, does not exist. The CCHCE is able to provide expert ethics services, help develop and support robust ethics programs, and ensure access to ethics resources when it would be unrealistic or impossible

24 24 for organizations to adequately staff such a resource on their own. While it may be a possibility for very large health care organizations to staff such support, the majority of organizations in our LHIN do not have the financial capacity to do so. An additional barrier to organizations securing ethics expertise individually is the lack of a core group of trained professional health care ethicists within the Champlain LHIN. As a result, organizations would have to import this expertise from other regions at additional expense. These services are extremely valuable to staff, patients, and families, and are becoming increasingly embedded in Accreditation Canada standards for Leadership and Governance. Many organizations are struggling to meet these standards of practice in a meaningful way, and the CCHCE represents an accessible and costeffective means for providing professional ethics support. The most common approach to addressing and resolving ethical issues in the absence of a dedicated ethics consultant or regional approach seems to be the ethics committee model. Ethics committees can be beneficial in addressing policy and organizational issues that may arise as a result of a clinical consultation, and since they are multidisciplinary, offer a diversity of viewpoints that can broaden the perspective of the review process. Unfortunately, not all members of such committees (if any) are ethics experts 1 and may not understand the ethical foundations of issues that arise. In addition, organizing large groups to provide clinical consultation support can be difficult and time consuming, and such consultations may need to occur quickly. A diversity of viewpoints may be better suited for organizational decisions where process, rather than consequence, can be agreed upon. Other organizations may choose to have an individual ethicist available on a fee-forservice basis. Unfortunately, those who offer this service often live outside of the Champlain region, and are unable to be onsite frequently. An inability to be present can hinder the development of a robust ethics program, and makes it difficult for organizations and their staff to accept ethics services as a necessary part of their organizational culture. Additionally, fee-forservice is not cost effective. Based on data collected from activities conducted for partner organizations, the cost to provide services on a fee-for-service basis would grossly exceed the cost currently associated with an annual partnership fee. 2 Rather than either of these options being sustainable, LHIN base-funding would cost all organizations less than what they would pay on either annual partnership, or fee-for-service models, and result in a cost savings for the entire region. A cost savings that could reasonably result in funds being used elsewhere. In addition, the current inequity in being able to access expert ethics support would be resolved. 1 By expert we mean a professional with extensive training in medical ethics. At minimum, ethicists typically require a Masters degree with special interest in ethics, bioethics, moral philosophy, theology, or other related specialty. 2 In some instances, the fee-for-service cost would be in excess of double an annual partnership cost. For example, if an organization paid an annual $20, partnership fee, the services they received on a fee-forservice model would have cost $40,

25 25 Team/Activity Highlights Accreditation Canada The CCHCE is pleased to have supported three of its partner organizations in successfully completing their Accreditation Canada evaluations in Cornwall Community Hospital received Accreditation in September 2015, while the Royal Ottawa Mental Health Centre and the Queensway Carleton Hospital achieved Accreditation with Exemplary Standing in October and November respectively. In preparation for accreditation visits, the CCHCE ensures partner organization preparedness by creating and distributing ethics literature, attending program meetings to review standards, assisting in the development of mechanisms for tracking ethical issues and trends, and providing on-site support during the Accreditation Canada visit, among other activities. Implementation of Curriculum The CCHCE had also been working diligently with Critical Care physicians Rakesh Patel and Sabira Valiani since 2014 to complete a 6-session intensive Ethics Curriculum for Critical Care Trainees. This curriculum was completed, published in the International Journal of Ethics Education, as will be noted below, and implemented, all in Of the six sessions, two have been offered at Critical Care Academic Half days by the end of the fiscal year. The remaining four sessions will be provided in the forthcoming months. Expert Consultation Of particular importance in the fall of 2015 was an invitation to the CCHCE and Department of Clinical and Organizational Ethics from The Ottawa Hospital to provide expert ethics consultation to the federally appointed External Panel on Options for a Legislative Response to Carter v. Canada. The External Panel greatly valued this consultation, and made considerable mention of CCHCE/TOH input in their final report of recommendations. This report was used by the Federal Government as part of their process for developing the current Medical Assistance in Dying legislation. Medical Assistance in Dying Policy/Process Development The CCHCE liaised with The Ottawa Hospital s policy and procedure working groups in early 2016 to prepare for the implementation of physician-assisted death, which is now

26 26 alternatively termed Medical Assistance in Dying (MAID) in the legislation. The participation by the CCHCE in these working groups has allowed the dissemination of information across organizations in the region, and the connection of resources between groups. The CCHCE has been integral in the push for a regionalized, patient-centered approach to MAID, and partner organizations have been most appreciative of this contribution. Ensuring a consistent, accessible, and ethically-sound approach to delivering MAID regionally is imperative. The implementation of MAID policies and procedures in the region has, unfortunately, been inconsistent thus far, and has relied heavily on the work done by the aforementioned working groups at the Ottawa Hospital. While the CCHCE has been integral to the dissemination of information done by this working group, and has played a key role in connecting regional partners with personnel and resources related to MAID, those not connected to the regional ethics program have not had this opportunity. Sustained LHIN funding is essential to ensure that an ethically sound, regional approach to MAID is operationalized, and that organizations and providers are able to supply patients with the information they need to make informed choices at the end of life. In doing so, the CCHCE will play a key role in the development of capacity-building tools for organizational leaders, providers, patients, and families, and in the provision of ethics education related to MAID for these groups. The CCHCE will also assist those organizations who may need to clarify or explore their values in order to better support all who may have concerns with, or any who wish to request, MAID. Finally, the CCHCE may be required to play an integral administrative role if a central intake mechanism is developed for the Champlain region. Such a role may include the development of an ethicallysound triage process, and of a tracking mechanism to ensure sufficient reporting regionally, and provincially. Ethics Education Program (EEP) This program consists of a 20-hour curriculum designed to educate healthcare providers and administrators on identifying and managing ethical issues. Specific topics addressed in this program include consent/capacity, end-of-life care, moral distress, and Accreditation Canada requirements related to ethics. Currently, each partner organization may send one attendee to the education program at no cost, and while others may participate, an enrollment fee applies. By the end of the 2016 program, we have had more than 125 participants from throughout the region complete the course. Feedback demonstrated great appreciation for the content and quality of the program.

27 27 Regional Ethics Symposium 2016: Ethics and Resource Allocation in Health Care: Can We Choose Wisely? The CCHCE held its third annual full-day symposium on September 29 th, The symposium was held at St. Elias Conference and Banquet Centre in Ottawa, and welcomed nearly 100 guests. This year s topic was Ethics and Resource Allocation in Health Care: Can We Choose Wisely, and was in response to many of the current financial challenges that providers and organizations face in the region. All health care organizations within the Champlain LHIN received invitations to take part in this day. For more information relating to this and the 2015 symposium, see Appendices B and C. Regional Ethics Rounds The CCHCE is pleased to hold regularly scheduled Regional Ethics Rounds throughout the year that are available exclusively to partner organizations either in person, or via OTN. These rounds began in September 2015, and regularly attract participants from all partner organizations. Sustained LHIN funding would allow the CCHCE to offer these Ethics Rounds to all organizations in the region. For a list of Regional Ethics Rounds held to-date, see Appendix D. Academic Development and Publication The CCHCE continues to engage in a variety of academic activities and original research in order to better serve its affiliated partners. A retrospective chart review project that began several years ago was concluded in This project examined documentation of end-of-life care preferences for in-patients, with the results being published in the journal Cambridge Quarterly of Health Care Ethics. This, along with a publication on the ethical permissibility of the use of unregistered interventions against Ebola Virus Disease, led to an invitation to Regional Ethicist Joshua Landry to participate in the 2015 Cambridge Consortium for Bioethics Education in Paris, France, as well as the 2015 Cambridge International Bioethics Retreat at the same location. These events provide a forum for academics from around the world to meet and discuss issues in health care ethics. For a sample of recent publications, see Appendix E. Impact of Recent Activities The CCHCE is now actively providing ethics services to its current partners, and provided 108 ethics consultations and 98 (formal and informal) capacity-building activities from 1 st January st March These activities have focused on a variety of themes,

28 28 including consent and capacity, substitute-decision making, living at risk, and privacy and confidentiality. Clinical and Organizational Ethics Services The full range of clinical and organizational ethics services were initiated and provided to partner organizations. Other health service providers received either an educational session or ethics consultations on a fee-for-service schedule or at no charge. In total, the CCHCE provided 108 ethics consultations and 98 capacity building sessions. Major themes of ethics consultations included: consent and capacity, substitute-decision making, living at risk, and care planning. More detailed information relating to clinical and organizational ethics consultation may be found in Appendix F, and relating to Education in Appendix G. Policy development and review was also one of several tasks that fulfilled the CCHCE s organizational ethics mandate. All partner organizations had an ethics consultation policy prepared and detailed for the specifics of their institution upon initiation of partnership. These consultation policies included two ethical decision-making frameworks as suggested tools for use within the policy. An abbreviated list of policies that have been reviewed or developed is presented below.

29 29 Goals of Care / Resuscitation Pet Visitation Consent to treatment Ethics and related issues Terms of admission Goals of Care II Code of ethics for support workers Board Code of ethics policy Harassment and Discrimination of Employees Abuse of Visitors Abuse of Volunteers Employee Internet, , and Computer Usage Privacy, Correction of Personal Health Information Board Ethics Policy Framework Code of Conduct for the Board Ethical Issues Resolution Policy Complaints, Concerns, Compliments, and Recommendations Privacy, Resident Access to Personal Health Information Privacy, Breaches of Privacy Immunization Program Program Expansion with Base Funding The Champlain Centre for Health Care Ethics demonstrates great promise for continued growth and success. Sustained LHIN funding is required to hire an additional 2.0 FTE ethicists, for a total of 3.0 FTE ethicists, and a 1.0 FTE administrative assistant in order to have the capacity to provide robust ethics support to the Champlain Region. This will enable the CCHCE to address clinical and organizational issues, and build capacity among staff, leaders, and governance within organizations.

30 30 Budget CCHCE services are currently offered through a partnership-fee model. Presently, only nine of nearly 200 health service providers funded by the Champlain LHIN are partnered with the CCHCE. These nine organizations contribute a total of $115,000 in partnership fees, compared to the estimated required base funding of $450,000 to provide services to all health care organizations in the Champlain region. An estimated breakdown of the total funding can be expressed as follows: Resource Cost 3 x 1.0 FTE Regional Ethicist 3 x $115,000 annually (inclusive of benefits) 1 x 1.0 FTE Administrative support 1 x $60,000 annually (inclusive of benefits) Annual travel (Mileage, etc ) $5,000 Office costs/overhead Up to $30,000 *Dependant on cost of office space, if any. Misc. and Inflation $10,000 Total $450,000 Impact of Regionalization on Consultation and Education Under our current service delivery model, we provided approximately 100 ethics consultations to partner organizations in the last year. With sustained LHIN base-funding, we would increase the number of organizations we provide service to, and therefore increase the number of consultation requests we receive exponentially. It is for this reason that the CCHCE will transition its model of service delivery from the current individual ethicist model, to a modified hub-and-spokes model as presented earlier. We would expect an estimated % increase in consultation requests (i.e consultation requests annually) if we were to provide services to all organizations in the LHIN under the modified hub-and-spokes model. This increase is based on the role of Ethics Champions in an organization addressing issues that may not require full ethicist support, and the fact that our current consultation figures represent those attained by providing services to some of the larger organizations in the region. Since a majority of those organizations that would receive services with LHIN funding would be smaller than those currently serviced, we expect that they will require less consultation support than those larger organizations. We would therefore not expect the number of consultations to increase by the same factor as number of organizations (i.e. 20x more organizations will not result in 20x more consultations), thus, we would also not require additional FTE ethicist support in this amount. If base funded,

31 31 information from consultations would continue to be used to identify trends, and explore areas that require additional education and capacity building. In supporting the entire Champlain LHIN, additional support will also be required to adequately develop and maintain education and capacity building initiatives. We have provided approximately 40 formal education sessions this year, which could reasonably translate to an estimated sessions for all LHIN organizations based on presentations being available and shared between organizations via OTN. For example, the CCHCE may offer 8 capacity-building activities focusing on issues found in long-term care. These presentations will occur on site at organizations on a rotating basis, and will be available via OTN for others who do not attend on site. We will also continue to offer regional ethics rounds, and an annual ethics symposium. It is estimated that 2.0 FTE will be required to carry out ethics consultations and regional capacitybuilding initiatives on site at organizations. As is currently being realized, an ability to heighten ethics capacity at all organizations in the LHIN can not occur in the absence of sustained funding. We demonstrated that the frequently-occurring themes of ethics consultations (as found in Appendix F) that health care providers and organizations face, are similar in nature, regardless of the location of service delivery. An inability to pay for such ethics capacity building is a visible cause of inequity. With sustained LHIN funding, having an ability to heighten ethics capacity regionally will not only have the potential to decrease staff moral distress and turnover, but also positively impact the quality of patient care, increase safety and compliance, and eliminate the inequity that currently exists. Part of the role of the final 1.0 FTE ethicist will be to create patient and staff literature that is standardized for dissemination across organizations, in order to support a regional approach to addressing many of the challenging ethical issues in health care. Some of these issues would include: understanding consent and capacity, navigating requests to live at risk, and explicating challenges involved with Medical Assistance in Dying. This role will also make use of the aforementioned ethics consultation trends as they are required for compliance with Accreditation Canada standards. In addition, this 1.0 FTE ethicist will be required to ensure organizational information relating to legislation and professional regulatory college guideline compliance is continually reviewed and kept up-to-date. The CCHCE will ensure review of the regional ethics program s feasibility by collecting data regarding number of requested consultations, ability to fulfil consultations, requests for capacity-building, need for additional services. Such a review will be completed in the first 3-5 years in order to ensure the full functioning of the program before such a review is undertaken. With sustained LHIN funding the CCHCE will also be equipped to support the provision of high quality, compassionate, and patient-centered care to all in the region by fulfilling its 5- year ( ) strategic plan. Full details of the strategic plan are presented next.

32 32 CCHCE Strategic Plan The strategic direction of the Champlain Centre for Health Care Ethics (CCHCE) for the period has been informed by the following: The vision of the Champlain LHIN; The Mission and Vision of the Champlain Centre for Health Care Ethics; The results of organizational scans completed at current Partner Organizations between January October 2016; Longitudinal data on consultation and education services collected by the Champlain Centre; for Health Care Ethics in the period from ; Partner organization (Stakeholder) feedback To achieve success as a regional program, the Champlain Centre for Health Care Ethics has aligned itself with the vision of the Champlain LHIN, and endeavors to provide high-quality, accessible ethics support to all in the region. Consultation data collected over the past 22 months has highlighted specific trends related to the types of issues that front-line staff and leaders struggle with that have the potential to negatively impact both the patient experience as well as the delivery of better quality care at a lower cost. Despite differences in the location of care provision, and type of intervention provided at these locations, collected data demonstrate consistency in the ethical issues that individuals and organizations face. In addition, the results of organizational scans have provided valuable information regarding staff and leadership perceptions on a number of important issues, including: barriers to accessing ethics support, primary ethical issues faced in one s work, and others. This data has enabled the CCHCE to provide pro-active regional ethics support that addresses actual and perceived issues in a manner that is consistent with preferred capacity-building methods. With sustained LHIN funding the CCHCE will be equipped to support the provision of high quality, compassionate, and patient-centered care to all in the region. To do so, the CCHCE Strategic Plan focuses on the following high-priority objectives related to quality ethics programming: 1) Regional Clinical and Organizational Ethics: Provide high-quality support services to both clinical and organizational stakeholders across the Champlain region. 2) Regional Ethics Capacity Building: Develop and deliver robust ethics capacity-building initiatives on topics affecting the region. 3) Integration and Sustainability: Work toward the integration of ethics services into standard operating procedure where possible, and support a model of ethics service delivery that is sustainable in the geographically-vast, and culturally diverse Champlain region.

33 33 4) Equitable Access: Ensure funding, geography, or other factors do not impede equitable access to high-quality ethics services available within the region. 1. Objective: Regional Clinical and Organizational Ethics Overview To achieve the goal of supporting ethical decision-making across the region, the CCHCE must provide high-quality support services to both clinical and organizational stakeholders. These services are critical in addressing issues that have significant potential to impact patient satisfaction, resource utilization, length of stay, and quality of care. In addition to ensuring the quality of clinical consultation services, the CCHCE will pursue a regional focus on supporting the development and implementation of Medical Assistance in Dying programming.

34 34 Key Tactics Enhance the quality of consultation services Proactively address ethical issues regionally Support development and operationalization of high quality MAID programming Ensure organizational compliance with relevant legislation (Health Care Consent Act, Substitute Decisions Act, and others) Key Performance Indicators (KPIs) On-going quality improvement via consultation satisfaction surveys with a 5-year goal of at least 80% satisfaction. Trend and track regional consultation themes as evidence-based clinical and organizational indicators. Act as a regional contact for MAID resources (clinical & organizational) and programming, in collaboration with the Ottawa Hospital 2. Objective: Regional Ethics Capacity Building Overview As a primary function of the CCHCE, education and capacity-building is essential to providing staff with the tools necessary to engage in ethical decision-making. The CCHCE aims to empower regional health care staff and leaders with both the knowledge and tools to understand, and address ethical issues. Various avenues will contribute to this goal: monthly regional ethics rounds, an annual symposium, unit/program based education, corporate orientation, and the introduction of ethical decision-making frameworks. Increased knowledge of ethical concepts and decision making may result in better patient-centered care, more ethically justifiable resource allocation decisions, and a decrease in moral distress. Key Tactics Increase the number of regional ethics rounds, ethics in-services, and other education sessions provided regionally by adding to current capacity to address education requests. Develop high-quality resources for patients, families and staff on issues related to consent, capacity, substitute decision making and MAID, and have these available online for access regionally. Act on trends identified through consultation service data and accreditation activities

35 35 KPIs Increase frequency of capacity building events by at least 25% compared to current numbers. Increase availability of education resources by at least 50% compared to current numbers. Review capacity building activities in relation to trends identified through consultation to ensure themes are being addressed. 3. Objective: Integration and Sustainability Overview To positively influence decision-making in clinical and organizational decisions across the region, the CCHCE aims to better integrate ethical decision-making frameworks and resources to all. This will be achieved through regional capacity building, an ability to provide model-policy templates on topics requiring heightened ethical oversight, and an ability to offer ethics frameworks that have received Accreditation Canada s Leading-Practice Standard designation. The CCHCE will also provide on-going regional capacity-building and support with the goal of creating organizational Ethics Champions to act as on-site resources, better able to address ethical issues that organizations and teams face. In addition, by increasing the number of ethicists available to provide consultation and capacity building support, there will be an ability by the CCHCE to adequately service the geographically-vast Champlain region. Key Tactics Act as regional hub for ethics service delivery and capacity-building resources by liaising with organizational leaders and regional committees. (Create Ethics Champions ) Provide comprehensive policy and process models to organizations for wide-reaching access to ethics services. Offer dual ethical decision-making framework model (Clinical & Organizational) Support successful accreditation review of ethics-related standards. (Accreditation Canada and others) Increase number of ethicists to ensure capacity to deliver effective and timely service. KPIs Facilitate regional communication for ethics resources Increase presence on organizational and regional committees and leadership venues

36 36 Ensure access to leading-practice standard ethics frameworks to enable organizational success with accreditation review. Ensure success of CCHCE model of service delivery by measuring ability to respond quickly and effectively to consultation requests. (Via satisfaction survey tool) Increase number of ethics-education resources available to organizations regionally, measured against past numbers. 4. Objective: Equitable Access Overview Currently, access to expert ethics support is not available to all organizations in the Champlain region, in part, due to inability to pay. Sustained LHIN funding would remove ability to pay as a barrier for organizations, and also eliminate the burden of higher cost of services from those organizations that are current regional partners. In addition, such funding would enable the CCHCE to better serve rural, francophone, and indigenous populations by increasing expertise in these areas. By ensuring access to all, the CCHCE and LHIN visions to ensure equitable access to health services will be fulfilled. Key Tactics Acquire direct LHIN funding in order to provide exemplary service to all, without regard for an organization s ability to pay. Expand the use of emerging technologies to ensure access to consultation and education support for rural communities in a timely manner. Increase capacity to deliver services regionally in both official languages, and to indigenous populations by expanding ethics team. KPIs On-going quality improvement via consultation, and capacity building satisfaction surveys with a 5-year goal of at least 80% satisfaction. Ensure OTN or teleconference is available for all regional activities. Grow CCHCE team to include additional ethicists, and administrative support

37 37 Appendix i Ethics Support Services 1. Identification of Ethical Needs In the spirit of promoting the culture and mission of each organization, part of the ethics support available is sustained assistance in the identification of an organization s ethical needs. This is to develop integrated ethics programming that meets the needs of individual organization and is reflective of their reality and available ethics support resources (e.g. spokes ). The identification of ethical needs is multilayered from individual patient/client/resident and staff ethical concerns, to organizational ethical concerns. 2. Ethics Consultation Services (ECS) The ECS aims to help patients/clients, families, employees and other stakeholders resolve ethical concerns in the organizations it services. All health care organizations should support and ensure timely access to ECS. This recommendation aligns with Accreditation requirements. The goal of ECS is to improve health care quality by facilitating the resolution of ethical concerns. One feature of the ECS is ethics consultations. The level of support will depend on the needs of the organization and the circumstances of the requested consultation If necessary, support can be provided to help organizations develop an ethics committee. The Regional Ethicist can serve as an advisor to that committee or serve on the committee A Regional Ethicist can provide ethics consultation as an individual ethics consultant on a case-by-case basis. 3. Organizational Ethics Support Effective mechanisms for addressing ethical concerns depend on leadership support, expertise, time, resources and formal policies Support can be provided for the development or revisions of an organization s ethics related policies including, for example, policies pertaining to the terms of references of an ethics committee or the process of how to request an ethics consultation Support can be provided on how an ethics consultation should be documented, tracked or made available for educational purpose.

38 Support can be provided to revise, develop, implement and make known an organization s clinical and organizational ethical framework; again, an Accreditation recommendation Support can be provided to revise or develop an organizational approach to ethics that is responsive and meets standards of access and accountability Support in refining the values and mission statement of the organization can be provided. 4. Capacity-Building and Ethics Education To positively impact the environment and culture of any organization, capacity-building and ethics education must be planned and ongoing Education sessions can be provided on a case-by-case basis on different topics such as moral distress, community ethics, end-of-life issues, living at risk, boundaries setting, value-centered care, ethics and elderly care, and organizational ethics. Additional topics can be identified in collaboration with the organization Out-reach sessions and introductions to ethics can be organized to make the ECS known throughout the organization The existence of and instructions on how to use the clinical and organizational ethical framework can be organized Support in the preparation of educational materials can be provided (e.g. ethics services brochures). 5. Accreditation Support Expertize and support in meeting Accreditation Canada s ethics standards can be provided. The goal with sustained LHIN funding will be to create material to be distributed to organizations that focus on ethics-specific standards. The ethicist will work with Ethics Champions in the organizations and support their implementation of these materials. 6. Prevention and Support Groups With the identification of ethical gaps by different mechanisms that can collect and review ethical concerns, additional support can be provided to address recurrent problems. Additional ethics programming and bridges will also come from the identification of similar regional ethical concerns that affect different organizations (e.g. advance care planning, ALS, waiting lists, etc.). Lines of communication and support can be developed.

39 39 Appendix ii Ethics Symposium on Ethical Resource Allocation, 2016 The 2016 Regional Ethics Symposium titled, Ethics and Resource Allocation in Health Care: Can We Choose Wisely? was well received and was identified as a chief concern amongst providers across the region. The day was introduced by Regional Ethicist from the Champlain Centre for Health Care Ethics, Mr. Joshua Landry, and was followed by guest speakers from various health sectors. These included: Dr. Rakesh Patel, Assistant Professor, Adult Critical Care Medicine Training Program, Department of Medicine, University of Ottawa & Department of Critical Care, The Ottawa Hospital Catherine Butler, Vice President, Clinical Care, Champlain Community Care Access Centre (CCAC) Nathalie Cadieux, Executive Vice-President of Finance and Business Development, The Ottawa Hospital Cal Martell, Sr. Director, Health Systems Improvement, Champlain Local Health Integration Network (LHIN) Participants were very engaged and evaluated the quality of the lectures, the relevance of the topic and how the symposium met their learning objectives very positively. Overall the symposium represented an excellent venue for different participants to meet and network, discuss similar ethical challenges and have a greater understanding of what challenges currently exist at all levels of care and service delivery with regard to ethical resource allocation. Reflections on the day were provide in evaluations, and included the following: Very interesting to hear about the innovations happening at the LHIN. Excellent presentations, very thought provoking, well informed, honest and open. Great exchange of information, identification of need for change, and raise consciousness of need for questioning traditional methods. Given the success of the event, it is the CCHCE s intention to continue hosting an annual symposium as many participants expressed the importance of having access to ethics education.

40 40 Appendix iii Ethics Symposium on Physician-Assisted Death, 2015 The topic of Physician-Assisted Death was well received and was identified as a chief concern amongst providers across the region. The day was introduced by Mr. Akos Hoffer, CEO of the Perley and Rideau Veterans Health Centre, and was followed by guest speakers from various health sectors. These included: Dr. Thomas Foreman, Director, Department of Clinical and Organizational Ethics at TOH and the Champlain Centre for Health Care Ethics "Dr. Gigi" Dr. Andrew Mai, Assistant Professor, University of Ottawa and Medical Director, Hospice Care Ottawa Dr. Ben Robert, Physician, Perley and Rideau Veterans Health Centre Vivian Stang, Chaplain and Registered Psychotherapist, the Ottawa Hospital Participants were very engaged and evaluated the quality of the lectures, the relevance of the topic and how the symposium met their learning objectives very positively. Overall the symposium represented an excellent venue for different participants to meet and network, discuss similar ethical challenges and have a greater understanding of what challenges were expected to be in the implementation of Physician-Assisted Death practice in Ontario. Reflections on the day were provide in evaluations, and included the following: Great day. Very thought provoking and stimulating. I gained a greater understanding of physician conflict/moral/ethical concerns surrounding PAD. The day highlighted the need for discussion/planning in my own organization. The range of professions giving their personal perspective helped to give an good understanding of the topic.

41 41 Appendix iv Regional Ethics Rounds September 2015: Ethical issues arising in consent, capacity, and the sharing of personal health information; ~50 attendees. October 2015: Clarifying the role of SDMs, and thinking about mandatory influenza vaccination; ~60 attendees. November 2015: Carter v. Canada and the ethical challenges we now face; ~40 attendees. December 2015: Ethical challenges in managing police requests for non-medically necessary interventions; ~40 attendees. February 2016: The ethical challenges with resource allocation and system reform; ~45. March 2016: Moral distress and moral courage; ~30 attendees. April 2016: Consent to Treatment: The Law is the Minimum Ethic; ~60 attendees May 2016: Medical Assistance in Dying: Proposed Legislation and Ethical Issues; ~60 attendees October 2016: Regional Ethics Grand Rounds - Assisted Death and Lessons from the Dutch Experience; ~100 attendees. November 2016: Let s Talk About Sex: The Ethics of Sexuality and Intimacy in Dementia; ~40 attendees. Appendix v Sample of Recent Publications Landry JT, Foreman TC, Kekewich MA. (2015) Reconsidering the Ethical Permissibility of the Use of Unregistered Interventions Against Ebola Virus Disease. Cambridge Quarterly of Health Care Ethics, 24:3, Landry, JT, Foreman, TC, and Kekewich, M. (2015). Ethical Considerations in the Regulation of Euthanasia and Physician-Assisted Death in Canada. Health Policy. 119, Pg Landry, JT, Valiani, S, Foreman, T, and Patel, R. (2015). Development of an Ethics Education Curriculum for Critical Care Trainees in Canada: From Knowledge Synthesis to Bedside Application. International Journal of Ethics Education, 1:1, Pg

42 42 Appendix vi Ethics Consultations Main themes for ethics consultations included consent and capacity, substitute-decision making, and living at risk, among others. ( ) Health Service Providers Ethics Consultations CCAC 34 The Royal Ottawa Health Care Group 22 Queensway Carleton Hospital 16 Hôpital Général de Hawkesbury (Ended Aug. 31/15 due to Financial constraints) VHA 7 Perley and Rideau Veteran s Health Centre 7 15 Major Consultation Themes Consent and capacity, fairness/equitability, living at risk Withholding/Withdrawing (WH/WD) treatment, goals of care, substitute decision making Goals/plan of care, consent and capacity, WH/WD treatment Consent and capacity, best interests, living at risk Plan of care, consent and capacity, conflict of interest Living at risk, consent and capacity, goals of care Primary Requestor Care co-ordinator Nursing Physician Nursing Executive Director Nursing PCIL 1 Fairness, justice Leadership Cornwall Community Hospital 6 Consent and capacity, fairness/justice, moral distress Leadership

43 43 Regional ethics consultation primary themes can be depicted graphically as: Ethics Consultations by Primary Theme Consent & Capacity 10% WH/WD Treatment 15% 39% Goals/Plan of Care MAID 9% 9% 17% Living at Risk Substitute Decision-Making Fairness Moral distress 1%

44 44 Appendix vii Ethics Education and Capacity Building While education topics varied across organizations generally, the primary topics transregionally remained relatively similar and included consent and capacity, introduction to CCHCE ethics services, and Ethics 101. ( ) Health Service Providers Capacity Building Events Examples of Topics CCAC 8 Resource allocation, Smart pills, PAD The Royal Ottawa Health Care Group 18 Queensway Carleton Hospital 20 Hôpital Général de Hawkesbury (Ended Aug. 31/15 due to Financial constraints) Consent and capacity, fairness, introduction to services Consent and capacity, introduction to services, fairness 3 Consent and capacity, informed refusal, PAD VHA 5 Ethics 101, ethics frameworks Perley and Rideau Veteran s Health Centre 16 Consent and capacity, introduction to services, living at risk PCIL 3 Ethics 101 Cornwall Community Hospital Other Ethics Education Program 7 Consent and capacity, introduction to services, PAD 18 Various

45 45 Capacity building themes across the region can be summarized as follows: Capacity Building Primary Theme Intro to Services 3% 4% 2% 3% 15% 11% 23% 17% Consent/Capacity Ethics 101 (inc. frameworks) Assisted Death Living at Risk 22% Moral Distress Resource Allocation End of Life Care Issues Other Capacity building and ethics education activities have been well received to this point. Participants in such activities continually rate learning objectives, presenters, and content of presentations well, and have specifically commented that: The facilitator was excellent - he had great knowledge of the subject matter, very good speaker, very interesting. Obtained much more knowledge out of the session than expected and very useful and relevant to my area of work. Thank you - Great course. Very worthwhile and well instructed. Fits well with overall objectives of the CCHCE, which itself appears to be a very productive and high-impact program. I really appreciated networking with the group, it is very beneficial. the subjects are great to make us reflect. I really appreciated participating in this learning experience.