Champlain Centre for Health Care Ethics Annual Report: 2015-2016
2 Table of Contents 1. Executive Summary... 3 2. Champlain Centre for Health Care Ethics (CCHCE)... 4 3. Clinical and Organizational Ethics Services... 5 4. Academic Endeavours... 8 5. Other Noteworthy Activities... 12 Appendix A Ethics Education Program Syllabus... 13 Appendix B Annual Symposium Event Poster and Agenda... 14 Appendix C Conference Abstracts... 16
3 1. Executive Summary The Champlain Centre for Health Care Ethics (CCHCE) is now in its third year of providing support and integrating robust ethics programming into the daily functioning of partner organizations across the region. The last year of service delivery saw Valerie Badro, the first Regional Ethicist of the CCHCE, leave the Centre in January 2015 to accept a position in her native Montreal. As Dr. Badro departed, Mr. Joshua Landry PhD(c) joined the CCHCE as the second regional ethicist, coming from a teaching position at Queen s University School of Medicine. Mr. Landry has helped to grow the program and continue to provide exemplary service to its partner organizations. Due to this transition, the scope of this report will be from 1 st January 2015 to 31 st March 2016. Since Mr. Landry s arrival, the CCHCE has provided 108 formal ethics consultations to affiliated partners. Requests for consultation support were made by patients, families, and a variety of health care professionals, and addressed a number of clinical and organizational issues (see section 3). In addition, 98 capacity-building/education sessions were provided to approximately 1815 participants (see section 3). Capacity building/education activities were presented specifically to organizations throughout the year, regionally through monthly ethics rounds (Sept-Dec. 2015, Feb.-March 2016), at the CCHCE annual Ethics Education Program (10-week, 20 hours), and at the CCHCE annual Symposium (Sept. 2015). Capacity-building services are available for all staff and physicians at partner organizations. In order to better serve its affiliated partners, the CCHCE, in collaboration with the Department of Clinical and Organizational ethics at the Ottawa Hospital (TOH), also engaged in a variety of academic research activities, including publication of several manuscripts in peer-reviewed journals, and presentations at international ethics conferences (see section 4). Research activities have focused on: the ethical appropriateness of providing Ebola patients with an unregistered intervention, the development of an ethics curriculum for critical care trainees, and the ethical and regulatory challenges in policy development around physician-assisted death. Lastly, the CCHCE provided expert consultation to the External Panel on Options for a Legislative Response to Carter v. Canada which looked at legislative options for the regulation of assisteddeath in Canada. This consultation was requested in response to a leading-practice peer-reviewed article published in the journal Health Policy by Joshua Landry, Thomas Foreman, and Michael Kekewich. Other noteworthy activities that the CCHCE has participated in include providing onboarding organizations with an initial institutional scan of ethics resources and corresponding recommendations for improvement. Additionally, the CCHCE assists in the development of ethics consultation policies, in the implementation of ethical decision-making frameworks, and in providing ethics support in the revision of organizational policies.
4 2. Champlain Centre for Health Care Ethics (CCHCE) The CCHCE aims to improve health care services throughout the region by serving as a centralized ethics resource. Sustained and customized ethics services have already proven to be beneficial for those having access to them by increasing patient/client satisfaction, reducing moral distress, improving Accreditation Canada compliance, and enhancing corporate integrity and accountability. 1 A centralized regional and evidence-based model of ethics service delivery has become a prominent approach for less urbanized and more geographically distributed regions in Ontario. 2 As a newly established organization, the CCHCE continues to embark on a process of creating the foundational infrastructure that will serve as a stepping stone to the establishment and future success of partner-organization ethics programs. The CCHCE continues to build-regional capacity and develop partnerships with health care organizations throughout the Champlain region. To date, our current affiliated partners are: The Champlain Community Care Access Centre (CCAC) The Royal Ottawa Health Care Group The Queensway Carleton Hospital VHA Health & Home Support The Perley and Rideau Veterans Health Centre Cornwall Community Hospital Personal Choice Independent Living Seaway Valley Community Health Centre (April 1 st 2016) The CCHCE is now actively providing ethics services to all of these partners, and provided 108 ethics consultations and 98 capacity-building activities from 1 st January 2015-31 st March 2016. These activities have focused on a variety of themes, including consent and capacity, substitutedecision making, living at risk, and privacy and confidentiality. Included in the capacity building of partner organizations and other interested parties in the region, the CCHCE delivered a 10-session, 20-hour Ethics Education Program, and hosted a full day symposium on the ethical challenges in regulating the practice of euthanasia and physicianassisted death in Ontario. Both the Ethics Education Program and Symposium will continue in 2016. 1 As an example, the CCHCE supported three partner organizations in their achievement of success in Accreditation Canada reviews in the fall of 2015. 2 For example, the Hamilton Niagara Haldimand Brant (HNHB) Regional Ethics Network.
5 3. Clinical and Organizational Ethics Services The full range of clinical and organizational ethics services were initiated and provided to partner organizations. Other HSPs received either an educational session or ethics consultations on a feefor-service schedule or at no charge. In total, the CCHCE provided 108 ethics consultations and 98 educational sessions. a) 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 Queensway Carleton Hospital Hôpital Général de Hawkesbury (Ended Aug. 31/15 due to Financial constraints) 22 16 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
6 Regionally, ethics consultation primary themes can be depicted graphically as: 2015-16 Ethics Consultations by Primary Theme Consent & Capacity 7% 10% 22% WH/WD Treatment Goals/Plan of Care 11% 11% 11% 17% 11% Living at Risk Substitute Decision-Making Fairness Moral distress Other b) Education 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 Consent and capacity, fairness, introduction to services
7 Queensway Carleton Hospital Hôpital Général de Hawkesbury (Ended Aug. 31/15 due to Financial constraints) 20 3 Consent and capacity, introduction to services, fairness 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 7 Consent and capacity, introduction to services, PAD Other Ethics Education Program 18 Various Capacity building themes across the region can be summarized as follows: Capacity Building Primary Theme Intro to Services 4% 3% 3% 15% 23% Consent/Capacity Ethics 101 (inc. frameworks) 2% 11% 17% Assisted Death Living at Risk 22% Moral Distress Resource Allocation End of Life Care Issues Other
8 c) Policy Review Policy development and review was 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 were reviewed or developed is presented below. i) Goals of Care / Resuscitation ii) Consent to treatment iii) Ethics and related issues iv) Terms of admission v) Goals of Care II vi) Code of ethics for support workers vii) Board Code of ethics policy viii) Board Ethics Policy Framework ix) Code of Conduct for the Board x) Ethical Issues Resolution Policy xi) Complaints, Concerns, Compliments, and Recommendations xii) Pet Visitation xiii) Harassment and Discrimination of Employees xiv) Abuse of Visitors xv) Abuse of Volunteers xvi) Employee Internet, E-mail, and Computer Usage xvii) Privacy, Correction of Personal Health Information xviii) Privacy, Resident Access to Personal Health Information xix) Privacy, Breaches of Privacy xx) Immunization Program 4. Academic Endeavours and Regional Capacity Building From 1 st January 2015 to 31 st March 2016, two annual regional capacity-building activities were advertised and offered to all health care service providers within the region. The first was the Ethics Education Program and the second an Ethics Symposium. Both were received with great success. A third academic activity included two presentations at internationally renowned conferences on ethics in Paris, France the Cambridge Consortium for Bioethics Education and Cambridge University International Bioethics Retreat. Fourth, the CCHCE held six monthly regional ethics rounds, which were only made available to partner organizations. Finally, the CCHCE and TOH Department of Clinical and Organizational Ethics worked collaboratively on a number of manuscripts that were accepted for publication in peer-reviewed journals. 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
9 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 for free, and while others may participate, an enrollment fee will apply. By the end of the 2015 program, we have had more than 110 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: Ethical Challenges in Regulating the Implementation and Practice of Euthanasia and Physician-Assisted Death in Ontario. The CCHCE held its second annual full-day symposium on September 30 th 2015. The CCHCE funded all costs associated with this symposium to ensure access to all interested parties across the Champlain region. The symposium was also graciously supported by the Perley Rideau Veterans Health Centre who volunteered to host the day. This year s topic was Ethical Challenges in Regulating the Implementation and Practice of Euthanasia and Physician-Assisted Death in Ontario, and was in response to the recent Supreme Court of Canada decision from February 2015 which struck down the provisions in the Criminal Code that prohibit such practices. Once again, all health care organizations within the Champlain LHIN received invitations to take part in this complimentary day. 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 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
10 topic and how the symposium met their learning objectives very positively (See Table 5). 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. 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 complementary 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). Evaluation of the Physician-Assisted Death Symposium 60% 50% 40% 30% 20% 10% 0% N/A Poor Fair Good Very good Excellent Speaker Quality Relevance of Topic Learning Objective n = 58 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: 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.
11 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 2014. 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 the CCHCE Director, Dr. Thomas Foreman, and 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 conference abstracts, see Appendix C) A sample of recent publications by the CCHCE team and colleagues are listed below. 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, 366-9. 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. 1490-1498. 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. 57-68.
12 5. Other Noteworthy Activities Accreditation Canada The CCHCE is pleased to have supported three of its partner organizations successfully complete their Accreditation Canada evaluations. Cornwall Community Hospital received Accreditation in September 2015, while the Royal 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, and providing onsite 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 noted above, and implemented, all in 2015. 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 12-16 months. Expert Consultation Of particular importance in the fall of 2015 was an invitation to the CCHCE and Department of Clinical and Organizational Ethics of 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. (The Report) Medical Aid in Dying Policy/Process Development Finally, 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 alternatively termed Medical Assistance in Dying (MAID) in proposed legislation. The participation by the CCHCE in these working groups has allowed the dissemination of information across organizations in the region. The CCHCE has been integral in the push for a regionalized, patient-centred approach to MAID, and partner organizations have been most appreciative of this contribution.
13 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
14 Appendix B Annual Symposium Event Poster and Agenda
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16 Appendix C Conference Abstracts Cambridge Consortium for Bioethics Education - June 24, 25, 26 2015 Development of an Ethics Education Curriculum for Critical Care Trainees in Canada: From Knowledge Synthesis to Bedside Application. Intensivists require a specialized approach to learning and managing complex bioethical issues due to the immediacy, uncertainty and gravity of medical decisions made when caring for the critically ill. A systematic examination of the literature and solicited feedback from experienced Intensivists has demonstrated that the knowledge and skill required to understand and navigate complex bioethical dilemmas is not often taught with the rigor necessary for independent clinical practice. This prompted us to design a bioethics curriculum for adult critical care medicine trainees to fill a significant void in ethics knowledge and reasoning within critical care training. The curriculum consists of six self-learning, online, case-based modules, and interactive group discussions. It is to be integrated into an existing Critical Care Academic Half Day schedule and completed over a 1-2 year period. This paper presents a detailed explication of the problem, and puts forward our developed solution a comprehensive bioethics curriculum. Cambridge University International Bioethics Retreat - July 1, 2, 3 2015 Reconsidering the Ethical Permissibility of the use of Unregistered Interventions against Ebola Virus Disease. Ethical considerations for the use of unregistered interventions for Ebola virus disease have sparked considerable debated among academic and clinical ethicists. Recently the World Health Organization (WHO) convened a panel of experts to discuss approaches to the outbreak in West Africa, with the goal of determining "whether it is ethical to use unregistered interventions with unknown adverse effects for possible treatment or prophylaxis. The panel concluded that there would be an ethical imperative to provide such unregistered interventions if the following specific criteria could be met: 1) transparency about all aspects of care, 2) informed consent, 3) freedom of choice, 4) confidentiality, 5) respect for persons, 6) preservation of dignity, and 7) involvement of the community.