1. building an ethics service | components | new questions and models | physician capacity | empirically driven

2. “To educate and hope is a futile strategy.” - Jack Glaser

3. systems | a different dilemma

4. capacity | mentors and aces

5. | Relationship | Culture | Meaning

6. spread | early adopters

7. Engaging Physicians  Education  Integration

8. Medical Resident Roundtables Bioethics Grand Rounds Bioethics focused CME Mandatory ethics conferences (ICU)

9. Building an Ethics Service | metrics

10. Context for Ethics Consultation n Columbia St. Mary’s Health System –Four Acute Care Hospitals ~700 beds –35+ physician clinics with ~240 employed physicians –FY 2008: 342,182 outpatient visits; 69,346 ED visits; 25,891 inpatient admissions –Ethics Consultation Service: Two Medical Staff Ethics Committees One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model –Advisement: ERD Clarification; Ethics Policy Elaboration; family care conference attendance –Consultation: all non-advisement matters –Ethics Consultation for Database: 278 consults from January 2003 through December 2008 Cases: –Identified ethical reason for consultation –Identified discipline requesting –CSM Ethics consultation service engaged –Ethics consultation documented –Ethics recommendations made to case

11. Ethics Consultation Intake: Requestor Info

12. Clinical Ethics Consultation: Columbia St. Mary’s Health System n CSM Ethics Consultation for Database: –278; January 2003 - September 2008 No. of Consults/Literature: 255; Swetz, et al. Mayo Clinic Proceedings 2007; 82(6): 686-691. 150; Schenkenberg. HEC Forum 1997; 9;147- 158. 104; La Puma, et al. JAMA 1988;260: 808-811. 31; Forde & Vandvik. J Med Ethics. 2005; 31:73-77. 39; Waisel, et al. Mil Med 2000; 165:528-532.

13. Clinical Ethics Consultation: Quantitative Measures of Ethics Integration Mean Days Consult from DoA

14. Clinical Consultation Changing Organizational Practice n Ethics Tracker Database –August 2006-October 2006 –3 consults related to Intra/peri-operative Code Status n Physician Association Guidelines –American College of Surgeons: ST-19 Statement on Advance Directive by Patients: “Do Not Resuscitate” in the Operating Room –American Society of Anesthesiologists: Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders n Goal: Initiate opportunity within existing pre-precedure processes for MD to address with patient or designated surrogate(s) existing directives to limit the use of resuscitation procedures n Dept of Surgery follow-up re: Ethics Case Consultations n Grand Rounds follow-up with CME Accountabilities for CIP

15. Clinical Consultation Changing Organizational Practice Medical Staff Pre- Procedure Checklist Adopted: Dept Anesthesiology Dept Surgery Dept Orthopedic Surgery Dept of Medicine (Exec Council)

16. action points