By BETSY TAYLOR
When medical resident Junad Chowdhury took part in orientation at Mercy Health System of Southeastern Pennsylvania, there was plenty to learn about the system's hospitals and caring for its patients. But he said the new residents were flat stumped when Fr. Peter Clark, a Jesuit bioethicist, started asking them questions about medical ethics and state law, questions like: What is competency?
Three ethics teaching rounds team members educate medical residents and a student at Mercy Philadelphia Hospital. The team members are Patrick O'Connor, left, the hospital's rehab director, and Fr. Peter Clark, SJ, and Sr. Suzanne Gallagher, RSM, both center right. Fr. Clark directs the Institute of Clinical Bioethics at Saint Joseph's University. Sr. Gallagher is Mercy Philadelphia Hospital's vice president of mission services.
"No one really knew the answers," Chowdhury said. The prevailing sense among the residents was: "What is he talking about?"
Now they know, Chowdhury explained, since he and other residents and nurses routinely take part in ethics teaching rounds to learn about ethical and legal issues. The ethics rounds are conducted by an interdisciplinary team at three hospitals within the health care system: Mercy Philadelphia Hospital, Mercy Fitzgerald Hospital in Darby, Pa., and Nazareth Hospital in Philadelphia. (Nazareth isn't a teaching hospital and doesn't have medical residents; ethics teaching rounds were adapted to train the nursing staff there.)
Rounding is the practice of gathering clinicians and students together to discuss patient care. Ethics teaching rounds at Mercy Health System hospitals complement medical teaching rounds and are conducted separately. The ethics teaching rounds are held once a week at each hospital.
According to an article Fr. Clark co-authored in Medical Science Review, ethics teaching rounds help equip participating students, residents and fellows to make better decisions and to provide quality care. Participants learn about the interdependency among medicine, law and ethics and become better equipped to handle thorny issues when they arise. The rounds have reduced the number of ethics consultations requested within the health care system. Fr. Clark is a professor and director of the Institute of Clinical Bioethics at Saint Joseph's University in Philadelphia, and is a bioethicist consultant for the Mercy Health System.
Holistic view
An interdisciplinary team leads the ethical teaching rounds; its members vary from hospital to hospital. They may include the vice president of mission, the chief medical officer, a bioethicist, a pharmacist, a nutritionist, pastoral care staff, physical and occupational therapists and social workers. There's much more to patient care than treating a medical condition, and the cross-disciplinary approach allows the team to competently discuss any social or legal issues, past medical history or family medical history, and a patient's religious and personal beliefs that they need to be sensitive to in caring for a patient, said those who take part in the rounds.
Sr. Donna Watto, RSM, an ethics teaching rounds team member, said, "Part of our purpose is to treat patients holistically and look at the whole situation." She is the vice president of mission integration for Mercy Fitzgerald Hospital.
Shades of gray
During the ethics teaching rounds, the interdisciplinary team meets with a group of residents and/or nurses in a hospital conference room. The participating residents and nurses provide a medical synopsis of each patient, but don't use the patient's name, outlining the medical reasons why each patient is at the hospital and highlighting any ethical or legal concerns that have arisen related to the patient. Members of the interdisciplinary team often ask questions of the resident or nurse presenting information, such as the patient's religion. They inquire about family members who play a role in the patient's care and ask if the patient has a health care proxy.
Chowdhury said team members sometimes create scenarios that include an ethical dilemma to help the residents understand what information can be shared with a patient's spouse or family, what cannot, and how to communicate effectively with patients and their loved ones, particularly on sensitive topics. Separate from the ethics teaching rounds, residents complete a core curriculum related to ethics, and meet monthly to discuss those topics, said Fr. Clark.
The ethics teaching rounds are designed to make participants feel more competent and comfortable when ethical issues arise with their patients. The frequent communication also means clinicians feel more at ease approaching a member of an ethics committee when they have a question or think a consultation would be helpful. Fr. Clark said, "Our residents see us, and our ethics committees, as an advocate, as a source of support."
Clearing a path
Chowdhury recalled one case in which a patient was on a ventilator and gravely ill. One of the patient's children thought it was time to take the patient off the ventilator, the other wanted the parent to remain on the ventilator and be transferred to a long-term care facility. Chowdhury said because the children couldn't agree, and the patient wasn't able to communicate her wishes, the ethics committee and a hospital lawyer indicated the matter should go into court where a judge determined which child got to be the medical proxy for the patient. The parent was transferred to a long-term care facility, as he recalled. While the situation wasn't an easy one, ethics teaching rounds, in that case, provided guidance on steps to take, which Chowdhury found helpful, he said.
The ethics teaching rounds aren't just about education related to Catholicism, though employees learn at length about the Ethical and Religious Directives for Catholic Health Care Services. Fr. Clark explained the rounds allow for discussion, and often solutions, for aspects of medical care that relate to other religions. For instance, a patient who is a Jehovah's Witness wouldn't receive a blood transfusion for religious reasons, and Mercy would respect the patient's beliefs. However, an attending physician can contact another hospital that has a center for bloodless products, focused on reducing or eliminating the need for blood transfusions. A physician from there could be given privileges to the Mercy Health System hospital to administer a synthetic blood product acceptable to the patient, Fr. Clark said. A Muslim patient in need of an anticoagulant would be informed that heparin is pork-based, and an alternate medication would be suggested for a patient concerned about abstaining from pork for religious reasons, he said.
The Medical Science Review article co-authored by Fr. Clark, then-resident Dr. Rajiv Bhattarai and research fellow Dr. David Temme Jr., said surveys given to ethics rounds participants and the teaching team found both groups agreed that some form of the ethics teaching rounds should be implemented in all teaching hospitals. Of the more than 50 residents and interns who responded to the survey, nearly 53 percent agreed and an additional 35 percent strongly agreed that the ethics teaching rounds enabled them to handle ethical issues without needing to schedule an ethics consultation.
Since the article's publication, Fr. Clark said he's received inquiries from other hospitals, including one in Poland and another in Nicaragua, about ethics teaching rounds and how the rounds are conducted. "Our hope is that it could become a paradigm for other teaching hospitals," he said.
Copyright © 2016 by the Catholic Health Association of the United States
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