1. The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

2. Goals for today’s conversation Is the role of the chaplain any different than ethics facilitation? Boundaries The nature of ethics & facilitation Responsibilities of those engaging in ethics facilitation –Common risks

3. Cases The curbside consult Religious ethical differences Interpreting the ERDs Looking for moral approval

4. Case Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.

5. NACC Standards 302.4 Incorporate a working knowledge of ethics appropriate to the pastoral context –302.41 Demonstrate an understanding of the ERDs

6. Who is providing consultations? ASBH study 15,000 consults annually –36% MDs –30% RN –11% LSW –10% Chaplains –10% Administration

7. The nature of ethics The nature of ethics mechanisms –Promoting appropriate moral agency Distinctions –Consultation –Mediation –Facilitation

8. What is ethics facilitation? A service provided by individual or groups to help patients, families, surrogates, healthcare providers to address uncertainty or conflict regarding value-laden issues.

9. What’s the goal of facilitation? “The proper role of ethics facilitation is to advocate for an unbiased robust process and not to privilege the needs and agenda of any one part.” ASBH, 2007

10. Commonly performed tasks Navigating clinical setting Gathering information Evaluating, interpreting, and analyzing info Facilitating meetings, understanding each perspective, assessing options for moral acceptability Promoting ethically acceptable plan of action Implementing quality assurance measures

11. “Qualified facilitation model” Identify and analyze nature of value uncertainty –Gather relevant data –Clarify relevant conceptual issues –Clarify related normative issues –Help identify range of morally acceptable options Resolve value uncertainty by building consensus –Ensure concerned parties have voices heard –Assist in clarifying values –Help build morally acceptable share commitment

12. Core competencies Skills of ethical assessment –Identify the nature of the value uncertainty –Analyze the value uncertainty Process and interpersonal skills

13. The facilitation Ability to facilitate meetings Introducing oneself properly, explaining what an ethics facilitation is and what a person taking the lead does, the purpose and limitation of the facilitation and his or her recommendations, and the relationship between the ethics facilitation mechanism and institution. Ensure that all relevant parties have been invited and encouraged to participate. Ensure that all parties are introduced and explain their perspective roles Explain the goals and process of meeting and what can be expected. Elicit medical facts Elicit views and values of principles regarding issue Facilitate reflective listening, clarifications, summarizing interests.

14. The facilitation Ability to build moral consensus Help individuals to critically analyze their underlying assumptions Negotiate between competing moral views Recognize possible areas of conflicts between personal moral views and one role in facilitation

15. Practical considerations Focus on “interests” not arguments Ethics facilitator is not a judge! –No constraints on evidence –But some statements are more useful in resolution

16. Practical considerations Summarizing—most critical aspect –Lets the parties know facilitator is listening –Lets the facilitator test her understanding –Helps parties organize thoughts –Helps parties to hear what others are saying –Shows areas of common interest –Provides order to discussion –Lets facilitator remind parties of progress –Repeat in nondestructive language –End with question: “Have I missed anything?”

17. Practical considerations Questioning –To obtain a broader view –To obtain information –To clarify abstract ideas/generalizations –To focus discussion –To introduce hypothetical –To generate new options –To encourage participation

18. Practical considerations Generating movement –Asking problem solving questions –Reframing –Raising issues –Hearing proposals –Stroking –Allowing silence –Holding caucuses –Reality testing –Reversing roles –Normalizing

19. Place of personal views Cannot remain value neutral Do you offer your personal views? How to attend to sociological power and authority?

20. Case Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.

21. Potential risks Scope & limitation of role Conflicting interests Challenges of the role Responding to unethical practice Evaluation & accountability

22. Role Limitations Institutional role v. ethics facilitation Misperception & misuse of role Explaining the role Appearance, comportment, interpersonal skills Power & ethics consultations

23. Role Limitations Role confusion –Primary institutional role Administrator Chaplain Lawyer Nurse Physician Social worker –How could there be role confusion? –How do you avoid role confusion?

24. Role Limitations Misperception & misuse of role –Should ethics facilitators be held to a higher standard of comportment? –Common presumptions: Moral police Exemplar Fixing the institution –Common requests that are inappropriate? –How do you or institution describe ethics facilitations?

25. Role Limitations Appearance, comportment, interpersonal skills –Implications of wearing white coat, scrubs, stethoscope, clericals –How does appearance of gender, ethnicity influence facilitation? Can you name a time that appearance, gender or ethnicity influenced a facilitation?

26. Role Limitations Power & ethics consultations –Expertise as power –Negotiator as power –Insider as power What are the reasons why judgments & actions of ethic facilitator be misinterpreted and misunderstand and lead to abuse of power? How do you limit the abuse?

27. Conflicting interests What situations would be considered conflicts of interest? –Under what set of circumstances would you recuse yourself? Competing obligations –Name primary obligations What ways to avoid –Individually –By all members of team –During the actual consultation

28. Challenges to the role Boundaries & moral weight of consultations Distinctions among –Moral uncertainty: is there a dilemma, which values apply –Dilemmas: good reasons for opposing actions –Distress: discomfort & unable to act Experience of marginalization –Silencing –“Obviously unethical”

29. What does it mean to incorporate ethics? Case of Fr. Dave –Place ERD 58 302.4 Incorporate a working knowledge of ethics into pastoral context –Help parties apply theory to case –Help RN with moral distress and issues of conscientious objection

30. Directive 58 As a general rule, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically-assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.”

31. Directive 58 For instance, as the patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore, not obligatory in light of their very limited ability to prolong life or provide comfort.

32. Conclusion Dual agency: –Ethics facilitator & pastoral counselor At minimum: qualified facilitation Religious interpretation Helping patients in religious coping over values disputes –Feeling at odds with religious norms Clarity about what you are being asked and transparency in what you can & cannot do

33. Evaluation http://www.meddean.luc.edu/depts/bioethics/online_masters/ethics%20 consult/ethics_consult_eval.htmlhttp://www.meddean.luc.edu/depts/bioethics/online_masters/ethics%20 consult/ethics_consult_eval.html Q1: Does the ethics facilitator do an adequate job of gathering the facts of he case from the physicians? What kinds of things must the ethics consultant gather in advance of facilitating a conference? Q2: Does the ethics facilitator give the physicians an adequate idea what they might expect from an ethics case consultation, in general, and in this case, in particular? II. The Case Conference Q3: Does the ethics facilitator do an adequate job of introducing himself and explaining what he does or what the goal of the conference is? Should he have said anything else? Q4: Does the case conference result in the patient’s surrogate decision maker, understanding the medical facts of the case adequately?

34. Q5: Does the case conference result in the patient’s attending physician understanding the patient’s values and wishes adequately? Does he adequately understand the surrogate decision maker’s understanding of the situation? Q6: Does the ethics facilitator do a reasonable job of “supporting” the surrogate decision maker through the conference? That is, does the consultant reinforce the notions that the surrogate’s understanding of the case is welcome in the discussion and that the patient’s legitimate rights will be respected? Q7: Does the conference “flow” well or should the facilitator have redirected it at points? If so, please be specific regarding when. Q8: Does the facilitator help to summarize and delineate the acceptable options? Is it clear what will happen next and how matters will proceed? Q9: Are the options highlighted within ethically acceptable norms?

35. Resources Bioethics Mediation: A Guide to Shaping Shared Solutions, Nancy Dubler and Carol Liebman, United Hosptial Fund, 2004. Mediation Information Resource Websites Http//www.mediate.com http://www.crinfor.org/narrative_new _developments.cfm