Humber River Hospital, Ethics Program
Humber River Hospital (HRH) is a hospital with three sites with close to 600 beds. The hospital serves very diverse linguistic, religious, cultural and socio-economic communities. We are currently in the process of building a new hospital combining three sites into one state of the art facility in which to provide patient care. We will be taking our fist patients’ in the new facility in October 2015. The bioethics program at HRH was founded in 2005 and continues to integrate throughout the hospital. Presently, there is one Bioethicist whose work is supplemented by Clinical Ethics Fellows and MHSc Bioethics students. The program at HRH is also aided by people in specialized roles who function as resources. In this context, HRH has an active ethics consultation service which serves both staff and patients directly.
One of the goals of the program is to try and ensure that those service areas which generally do not have an engagement in bioethics have a forum for discussion of their concerns. Additionally the bioethics program at HRH strives to identify and be involved in emerging areas of service delivery like the care of bariatric patients.
HRH is also active in doing research in a wide variety of areas meets monthly to review new protocols and review research that is ongoing.
The ethics consultation service is a resource which is easily available to help identify ethical issues, review options, make recommendations and facilitate decision making. All staff, physicians, social workers, nurses, rehabilitation team members, administrators, and staff who provide diagnostic information are invited to use the ethics service. Most importantly patients and their families are also invited use ethics consultation. Some of the issues which the ethics service has been consulted include:
- Consent and Capacity
- substitute decision-making
- end-of-life care decisions: resuscitation & withdrawal of life support
- preparing for Consent and Capacity Board Hearing
- guidance with making treatment decisions
- nephrology (dialysis)
- organ and tissue donation
- transitions in care planning
- patient autonomy and risk-taking: going home where they may be at risk
- use of least restraints
- artificial nutrition and hydration
- moral distress
- resource allocation
- elder abuse: neglect and financial
- privacy and confidentiality
- infection control and public health issues
- religious faith and treatment decisions
From the creation of the ethics service at HRH along with the involvement of staff, clinical ethics fellows and MHSc Bioethics students, we have been able to contribute to the education of staff at all levels through the participation in monthly orientation, rounds, teaching on patient care units as well as presentations at seminars and workshops. Some of the areas of education have been:
- Advance Care planning workshops
- The clinical and public health issues related to hoarding
- Case Studies in Public Health Ethics
- History and Development of HRH's DNR Policy
- When Is Enough - Enough: Responding to unreasonable demands from SDMs
- Do we have a moral duty not to infect others?
- Emerging Issues in Bioethics: Ethics issues from Mental health, Medical Imaging, Respiratory Therapy, Bariatrics etc.
- Workplace Violence from an Ethical Lens
- Moral Distress: What's that Uncomfortable Feeling I Have: Humber River Hospital's Mental Health Clinic Day (2007)
- Bioethics and the Challenge of Technology
- The Need for Pandemic Influenza Planning
- Consent and Capacity
- Bioethics from a faith based perspective
- A Foretaste of the Pandemic
- Infection Control at the Intersection of Clinical and Public Health Ethics
- Diagnostic Imaging and Ethics: Respecting the Best Interest of the Incapable Person
- Guideline for Evaluating Capacity
- Bioethics in End of life Care Planning and Moral Distress
- Using Professional Ethics as our Guiding Compass
- Complementary Medicine Use in an Acute Care Hospital
- Patient Safety in Hospital Emergency Unit and Endoscopy Suite
- Responding to the Increasing Demand for Dialysis
With the help of Mark Handelman formerly of the Ontario Consent and Capacity Board, who is also a MHSc Bioethics graduate, a booklet on substitute decision making was created for patients, families and staff to provide knowledge about the decision making process and what to do if there is conflict. Issues related to consent and capacity are an ongoing element of staff education which is addressed by the Bioethicist either as a presenter or through inviting experts to speak on specific issues related to this topic.
Working with the infection control team to provide staff education is also an ongoing educational endeavor as we explore areas of practical concerns and interest such as the duty not to infect others, vaccinations, pandemic influenza planning and duty to care.
With HRH team members we researched and significantly revised our DNR policy (Resuscitation Code Status Policy) to reflect current best practices. We also surveyed hospital staff, including our doctors to determine what improvements they would like to see with our resuscitation orders, advance care planning documents and substitute decision makers information. The primary feedback we received was to make orders and information about who is the person's substitute decision maker easier to find. We also got feedback that we should begin the advance care planning process earlier. This was a collaborative process internally and with external partners in Alberta and Winnipeg. The outcome of surveys, research and collaboration was the creation of our goals of care order form, an Advance Care Planning workbook and other tools to improve communication of wishes between points of care. This has been a rewarding project that continues to evolve as we use this new process and receive feedback from those involved in our work or using it like patients and families.
With the assistance of a Clinical Ethics Fellow, HRH team members created and developed a guideline for evaluating a patient's capacity to make decisions for long term care placement. This guideline was created to help clinicians do capacity evaluations on patients whose capacity is uncertain. To help with this, an enhanced capacity evaluation questionnaire is included in the guideline as well as algorithm to ensure that due diligence is done in the evaluation process. As part of the process, assessing patients to determine and respond to any communication barriers that might hinder an accurate evaluation is also addressed.
Working with HRH's Risk Management team, a policy on resolving conflict with substitute decision makers about treatment decisions was developed and passed in July 2007. This policy includes information about the Health Care Consent Act, who can be decision makers, the principles for decision making, a framework for dispute resolution and the process to apply to the Consent and Capacity Board if a disagreement between the health care team and substitute decision makers cannot be resolved.
Working with the HRH's Trillium Gift of Life steering committee all the policies, procedures and protocols with respect to organ and tissue donation were revised and brought in line with the Trillium Gift of Life Act and the procedures and protocols of the Trillium Gift of Life Network.
Accomplishments and Ongoing Projects:
Making the everyday ethical. Over the past year thanks to HRH and JCB colleagues, the goal to heighten the awareness of the ethics involved in the quotidian, everyday things we do such as in transitions in care planning, medical imaging, communicating with capable non-verbal patients, infection control and responding to the moral distress staff experience has been enhanced. This will be an ongoing area of interest and work.
A significant accomplishment which was achieved with the help of a patient's family member, MHSc student and volunteers was a series of presentations about end of life care for patients with implantable cardioverting defibrillators (ICDs). Lessons learned from a specific case have taught us the importance of deactivating an ICD when someone is dying to ensure a comfortable death.