Stop passing the buck
Last year I took a new job as a clinical nurse educator in a hospital and was invited to join the ethics committee. I'm one of three nurses on this committee; the other members are physicians and hospital administrators.
After serving in this role for 9 months, I've seen a pattern: The committee never takes any action on its own. Instead, it passes the buck to medical staff committees for further action. The other two nurses, who are long-term committee members, say, “This is how it's always been.”
Maybe so, but it doesn't seem good enough to me. How should I proceed?—T.S., CALIF.
A strong ethics committee is an asset to the entire organization. Besides helping hospitals meet accreditation standards, it also helps healthcare professionals, patients, and families work together to improve care.
Keep in mind that the ethics committee doesn't make the tough decisions. Rather, it offers a forum for all involved parties to examine and weigh various approaches and options. The resolution of a sensitive issue is always left to the healthcare team, patient, and family.
By better understanding the committee's purpose, you can present a strong case for improving the process of case consultation at your facility. But before you can bring about change, you need to do your homework. One approach would be to form a small subcommittee of concerned committee members, including your nurse colleagues, to share the workload and get more buy-in for change. Investigate the structure and functions of other hospital ethics committees in your area. Perform a literature search on the organization and purpose of ethics committees nationwide to get a baseline of best practices. You can also solicit information and feedback from listservs and blogs to help you identify institutions that have high-functioning ethics committees that you might want to use as models.
Share the results of your fact-finding with the full committee in the spirit of performance improvement, and brainstorm ideas to enhance the committee's value to patients and families. For example, committee members might benefit from a conference call with members of a best-practice institution to learn more about how they function. An on-site visit and face-to-face interviews with ethics committee members from other facilities is another way to gain insights on how a great ethics committee functions in the real world. Contact with others who are making a difference in their hospitals can help reset expectations and kindle enthusiasm for giving your ethics committee a more active and meaningful role.
Posting poses problems
I'm caring for a 53-year-old patient, Mr. N, who has amyotrophic lateral sclerosis. He's cognitively intact but physically disabled. He has no family and has been living in a long-term-care (LTC) facility for 2 years. A few months ago, my hospice was contracted to provide care for him in the same facility.
One of Mr. N's few joys in life is maintaining his personal Facebook page, and he's “met” many people through Facebook that he'd have never gotten to know otherwise. At the LTC facility, nurses and other staff frequently take pictures of him (at his request) and post them on Facebook for him because he can't physically do so. They use their personal cell phones to take the photos because Mr. N doesn't have one.
My agency adheres strictly to the Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules. Agency policy forbids us to use personal cell phones to photograph patients or to post on patients' Facebook pages. But the LTC facility staff does this all the time and he's come to expect this, so hospice caregivers feel like we're letting him down when we refuse to participate. How should I handle this?—N.J., OHIO
When two agencies share responsibilities for a patient's care, they must have a clear contractual relationship. Share your concerns with the hospice nurse manager. Together you can review the contract terms with the LTC facility. If your agency has strict HIPAA standards for employees, it's likely that the LTC facility has the same standards, and these should be spelled out in the interagency contract.
The real problem then becomes how to handle a sensitive situation in which employees with the best of intentions are, nevertheless, potentially violating HIPAA standards and/or facility policy. Your hospice manager should discuss this with her counterpart at the LTC facility and with legal counsel. Potential confidentiality violations must be addressed ASAP since both the facility and its employees could share liability.
But even more important, staff from both facilities can begin to work together to find appropriate ways to help this patient continue an activity he enjoys without violating confidentiality and policies pertaining to personal cell phone use. For example, could a cell phone or digital camera be procured for the patient so he doesn't have to rely on staff members' devices? Could volunteers post for him? Can a policy be created to allow staff members to take and post photos with the patient's consent? Get risk managers for both facilities involved to come up with creative solutions.