JCB Partners:
Toronto Rehabilitation Institute, Ethics Program
People and Roles:
Director, Ethics and Spiritual Care: Ann Heesters
Research Ethicist: Marleen Van Laethem, MHSc (Bioethics)
Ethics Facilitators: Debbie Driver (Complex Continuing Care), Martha Gibson (Education), Jim Huth (Geriatric Rehab), Lynn Keats (Spinal Cord Rehab), Rhoda Lordly (Quality, Safety & Risk Management), Pam Young (Cardiac Rehab), Karen Sasaki (Neuro Rehab), Trish Unruh (Musculoskeletal Rehab)
Program Description:
Toronto Rehab has implemented a decentralized "hub-and-spokes" strategy to improve the delivery of clinical ethics consultation, education and research. This decentralized strategy was developed in collaboration with the Joint Centre for Bioethics in response to Toronto Rehab’s needs and patient populations. In 2004, our "hub-and-spokes" strategy for clinical ethics service delivery was designated a Leading Practice by CCHSA under Leadership & Partnerships theme "Ethics, Client Rights and Consent".
A local Ethics Facilitator is in place for every clinical program and for services such as quality/safety/risk, education and research. The Ethics Facilitators are the local ethics contacts and work with Leader, Clinical Ethics and the Ethicist to provide ethics consultations and regular ethics rounds for each patient care area. The "hub" and "spokes" come together via monthly Ethics Forum meetings to undertake quality peer review of complex case consultations, develop core knowledge and skill competencies, and work on joint ethics projects. The Ethics Program establishes operating initiatives each year and uses an Ethics Scorecard with measurable milestones for each quarter.
The program is now in Phase 2, expanding to include "Spokes for the Spokes". Ethics Contacts will be appointed for each patient care unit as first contact for ethics questions or requests thereby serving as "spokes" for the Ethics Facilitators who, in turn, serve as "spokes" for the ethicists.
Consultation:
The ethics consultation service is a resource that can help clarify ethical issues, review options, make recommendations, and/or facilitate decision-making. Staff, physicians, volunteers, administrators, patients and families are invited to use the ethics consultation service. Some of the issues we've been consulted about include:
- patient decision-making capacity and informed consent
- substitute decision-making
- discharge planning and placement
- advance care planning
- patient autonomy and risk-taking
- safety of patients, families and staff
- privacy and confidentiality (including new legislation)
- staff involvement in forensic investigations
- moral distress of staff in complex clinical ("difficult") relationships
- alleged abuse of staff and patients
- least restraint
- patient intimacy and sexuality
- palliative and end-of-life care
- withholding or withdrawing artificial nutrition hydration
- research ethics (particularly informed consent, privacy)
- gift-giving and receiving in professional-patient relationships
- commercial sponsorship of continuing professional education
- resource allocation and priority setting
Education:
We provide staff, physicians, students and volunteers with opportunities to find out about ethics issues and processes available to support ethics decision-making through:
- monthly Ethics orientation for all new staff (summarizing key ethics issues as well as available ethics resources and processes)
- the Bioethics intranet site
- a monthly e-bulletin listing free clinical ethics and research ethics presentations in Toronto
- regular ethics rounds and in-services in all patient care areas
- a quarterly ethics grand rounds series
Members of the Ethics Forum meet monthly to continue to develop core knowledge and skill competencies that support not only ethics consultation but also ethics education, research ethics, and organizational ethics. Recently Ethics Facilitators provided input into the development and delivery of new core ethics education modules developed by members of the Joint Centre for Bioethics Clinical Ethics Group. In addition to helping pilot these modules, they completed a 3-hour module on Ethics Imagination and Awareness and a 4-hour module on Introduction to Ethical Assessment and Reasoning along with the "Bridging" Tool and Exercise session.
Policy Development:
The Leader, Clinical Ethics has led an initiative to revise and update our policy on Advance Care Planning (ACP) to bring it in alignment with rehabilitation and complex continuing care and the relevant literature on best practice. To support compliance with this policy, we have:
- developed process tools including an ACP decision tree, scripted ACP form, ACP discussion guide for physicians, and brochures for patients and families on Advance Care Planning and Substitute Decision-Making
- supported implementation through an on-going collaborative process, and education (e.g., through ethics rounds and in-services, one-on-one consultation)
- monitored compliance through regular chart audits, including communicating results and key areas for improvement
Other recent initiatives include collaborating to help develop a Toronto Rehab Code of Conduct and to draft Corporate Sponsorship Guidelines. For 2007-08 we will be leading an organizational initiative on decision-making capacity and informed consent.
Research:
In collaboration with the Joint Centre for Bioethics, Barbara Secker led a multidisciplinary group research project producing:
- a white paper Ethics of LHINs: Implications for People with Disabilities and Chronic Illnesses (targeting our MOHLTC and Local Health Integration Networks [LHINs] leadership
- a highly-accessed peer reviewed article "Just Regionalisation: Rehabilitating Care for People with Disabilities and Chronic Illnesses" in BMC Medical Ethics
- a CIHR grant application "There's no place like home: What constitutes an 'adequate' home environment for younger adults with chronic mobility disabilities?"
Another research cluster focuses on ethics, patient autonomy and decision-making capacity. Barbara Secker has been conducting research that examines the ethics of patient autonomy and decision-making since 1991. Her master's thesis is titled Mental Competency and the Autonomy of Patients. Her doctoral research provided the first philosophical constructionist analysis of incapacity/incompetence grounded in clinical experience, including a typology of the causal construction of incompetence that focuses on the excess risks faced by particular vulnerable patient populations in relation to competence assessments (Medico-Legal Jurisdiction over Human Decision-making: A Philosophical Constructionist Analysis of Mental Competence). She is also co-investigator on a research project recently funded by the Canadian Patient Safety Institute exploring patient and family perspectives on safety, risk-taking and autonomy (Partnering with Patients and Families to Address Potential Conflicts between Patient Safety and Patient Autonomy in Rehabilitation and Complex Continuing Care).
Website:
Toronto Rehabilitation Institute
Contact Information:
Ann Heesters |
