By LISA EISENHAUER

At CHI Health hospitals, the Unrepresented Patient Ethics Review Process is activated as soon as a care team member (usually a social worker or care manager) identifies a patient as unrepresented. It runs concurrent with ongoing efforts to find a surrogate spokesperson for the patient or have a public guardian appointed by a court, a process that can take months.

Leslie Kuhnel, the system's vice president of ethics and theology, researched suggestions made by bioethicists and legal experts before collaborating with the chief medical officer at CHI Health Creighton University Medical Center – Bergan Mercy in Omaha, Nebraska, and other colleagues to pilot the process in 2013. The process has since been adopted at all CHI Health hospitals. The system is part of CommonSpirit Health.

When an unrepresented patient is identified, Kuhnel convenes an interdisciplinary committee. The committee's members generally include an ethics consultant and a team from the hospital caring for the patient made up of the chief medical officer, chief nursing executive, attending physician, chaplain, legal counsel, risk management representative and medical social worker or care manager. Palliative care specialists, translators and others with special expertise are sometimes asked to join the committee, depending on the situation.

The committee reviews the proposed treatment plan, evaluates the identified risks and benefits of the options and provides recommendations. When possible, the committee considers as much information as is known about the patient, including conversations from past hospital visits and information from individuals who may have some insight into the patient's values and beliefs, such as case managers at a homeless shelter. It bases its evaluations and recommendations on a long list of questions that include:

• What decisions, if any, does the patient have the capacity to make at this time?
• What are the potential sources of conflict of interest and bias within the review team and how can they be mitigated?
• How is this decision aligned with/informed by the Ethical and Religious Directives for Catholic Health Care Services?
• What if the patient would disagree with this plan even after careful review?

The committee meets in person or by videoconference and makes recommendations as needed until a surrogate is identified, the patient regains the capacity to make his or her own choices or the patient's circumstances are otherwise resolved.

"In a way, the attending physician has this unrepresented case review committee to work with in a similar way they might if they were having the conversation with the patient's surrogate or family member," Kuhnel says. "The review committee is there to wrap around the attending physician and care team as much as the patient in terms of support in this type of unique decision-making circumstance."