Ascension's Clinical Ethics Intensive (CEI) was created to address the desire among ethics committee members for education and a greater understanding of the Catholic bioethics tradition in the context of clinical ethics case consultation. It is a one-day training session, designed to be delivered in person by at least two Ascension ethicists. At the conclusion of the CEI, participants should be able to discuss the Ethical and Religious Directives for Catholic Health Care Services and apply the Directives to commonly encountered case situations; identify skills and knowledge required to provide competent clinical ethics case consultations as Embedded Ethics Resources (EERs) utilizing the Clinical Ethics Deliberation Process; demonstrate opportunities for proactive ethics integration in the context of the participant's respective service line and/or unit within the health ministry; and perform continuous quality improvement in ethics initiatives through ethics case consultation documentation in the electronic health record and in Ascension's Ethics Integration Database. Ideally, participants are given a full day's release time or RVU relief in order to participate fully in the Clinical Ethics Intensive.

Covid-19 has changed the face of health care, perhaps indefinitely. Lessons learned from the pandemic and our response, including how to adapt to new learning and teaching environments, and how to take advantage of both the scale and scope of our resources (as well as how to steward these resources more wisely), represent a paradigm shift in how we deliver care and how we do business. Although Covid-19 has presented health care with myriad challenges, it has also created some opportunities. This includes the development within Ascension of a Virtual Clinical Ethics Intensive. The goal, scope and process of delivering the virtual CEI are outlined below.

GOAL

To provide tools and resources to assist Ministry Market ethicists in the delivery of the Clinical Ethics Intensive (CEI) virtually in a manner that uses technology to take advantage of scalability and the depth of experience and expertise of the Ethics Advisory Community (EAC) while preserving, as much as possible, the dynamic, interpersonal team-building that is an inherent part of the in-person CEI.

SCOPE

The virtual CEI is intended to be used across Ascension and is customizable to the needs of individual Ministry Markets. The tools and resources include three foundational videos, three didactic videos, a live Q and A session, and three, live, case-based sessions facilitated by Market Ethicists with support from additional EAC members if desired. The three foundational videos and three didactic videos are designed to be "conversational" in nature and were facilitated by an Ascension ethicist who navigated a discussion on the topic with her/his colleagues, and possibly "veteran" ethics committee chairs or EERs. A slide deck facilitator guide is provided for use in each case-based session, and Market ethicists may choose from a bank of seven prepared cases, based on Market needs.

We wanted to make delivery of the Virtual Clinical Ethics Intensive as customizable as possible based on the local ethics team's understanding of the needs of their committees, member feedback, the impact of Covid-19 on their Market(s) and their own pedagogical style. At the same time, we wanted the Virtual CEI to be an "intensive" with all or most of the essential elements of the in-person model. So, we developed the following process:

PROCESS

Individual Market ethicists determine when to offer a CEI in their Market, and who will attend. An invitation letter is sent to participants, which includes links to the foundational and didactic modules on myLearning, the date of the follow-up Q and A session for the foundational modules, instructions on how to download the myEthicsRx app (an Ascension in-house ethics app), and other market-specific information. Market ethicists may choose to schedule the live, case-based sessions (which include small group breakouts where participants apply Assess, Analyze, Act to the specific case) in one, three-hour session, or in individual one-hour sessions. Information on these sessions could also be included in the invitation letter.

Market ethicists can track attendance for the CEI and completion of the foundational modules through myLearning; participants can earn CME/CEU credits by scanning a QR Code at the end of each module. It is expected that the foundational modules and didactic modules have been completed prior to participation in the live, case-based sessions. The process flow to complete the Virtual CEI is as follows:

AGENDA

The three, 30-minute foundation modules are:

1. An overview of Ascension's Proactive Ethics Integration Model
2. An overview of the ERDs and Foundational Bioethical Principles
3. An overview of the Clinical Ethics Deliberation Process (Assess, Analyze, Act)

The three, 30-minute didactic modules, which provide a framework for the case-based discussion, are:

1. The Professional-Patient Relationship: ERDs Part III and Key Principles
2. Issues in Care at the Beginning of Life: ERDs Part IV and Key Principles
3. Issues in Care for the Seriously Ill and Dying: ERDs Part V and Key Principles

Three, one-hour each, case-based discussions chosen from the following:

1. "Just Let Her Die" - Provider-Patient Relationship, Best Interest,Substituted Judgement and Surrogate Decision-Making
2. "Consent and Mental Illness" - Provider-Patient Relationship: Capacity and Mental Illness
3. "Try and Save My Baby"- Ethical Issues at the Beginning of Life: MFVC
4. "Our Faith Does Not Allow That" - Ethical Issues in the Seriously Ill and Dying: Non-indicated Medical Interventions and Cultural Considerations
5. "She Said She Wanted Everything Done" - Ethical Issues in the Seriously Ill and Dying: Goals of Care and End of Life
6. "Baby Sima" - Pediatrics
7. "RQ" - Provider/Patient Relationship and Goals of Care
8. "It Doesn't Look That Bad to Me"- Patient Refusal of Beneficial Medical Interventions

The total time for the delivery of the Virtual CEI is 6-7 hours, with 3 hours devoted to didactic content, 3 hours to case-based discussions, and possibly an hour for additional discussion, clarifications, and review of next steps.

The verdict is still out on the success or failure of our efforts to create a virtual Clinical Ethics Intensive. Even though we have seen the roll-out, at least to some degree, of the Covid-19 vaccine, our hospitals are still overrun by the virus. Our health care providers, many of whom serve on our ethics committees, are tired and have little time to devote themselves to even self-directed learning. Those who do have the time often report that this endeavor is a welcome respite from their day to day reality, and a chance to be with their colleagues in a different way. We will continue to solicit feedback and advice from those that utilize the virtual CEI resources, and will pivot as necessary to meet the needs of those we serve.

Matthew R. Kenney, Ph.D., HEC-C
Vice President, Ethics Integration and Education
Ascension
[email protected]