HealthManagement, Volume 10, Issue 4 / 2008
Authors:
Prof. Dr. Stella Reiter-Theil,
area of studies: medical and health ethics,
Faculty of Medicine/University Hospital
Basel, Switzerland
Dr. Barbara Meyer-Zehnder,
area of studies: medical and health ethics,
Faculty of Medicine/University Hospital
Basel;
Department of Anaesthesia, University Hospital Basel, Switzerland
Email: [email protected]
Bibliography is available upon request at [email protected]
Having to deal with limited resources is an unavoidable part of day-to-day hospital work. What measures are appropriate in each case and what criteria apply?
Ethical
Focal Points at the Sick Bed - and Support
Current studies show that most doctors experience ethical difficulties at the sick bed. Studies which we carried out with different methods and in different countries 1, 2, 5, 7, 8, 9, 10, 11, 14, 15 point to the following focal points:
Therapy decisions with patients whose decision-making ability is temporarily or permanently impaired: if no clear patient will can be established Decision as to whether a vital measure such as cardiovascular resuscitation is appropriate or should not be performed Lack of agreement among the various persons involved as to therapy decisions. Having to work with limited resources at the sick bed represents a major problem area: There are reports both of inadequate provision (e.g. waiting lists) and of unequal treatment (discrimination against certain groups), and also of overtreatment (so-called futility). If we add further attendant findings from these studies to the effect that the quality of decision-making is not infrequently inadequately structured and explicit, we can assume a considerable need for offers for ethical assistance in everyday clinical activities.
Clinical ethical advice or ethical counselling (clinical ethics consultation) is - alongside rather informal internal case discussions, qualification measures or orientation assistance such as directives and guidelines – one of these possibilities12, 3.
In Europe it is in the grip of a highly dynamic development and expansion, which has also en compassed the German-speaking area. We take as our starting point the prerequisite that different forms of ethical support are meaningful and - de pen ding on institutional framework conditions - possible 13.
A further source of ethical support that has received little systematic investigation is the setof directives or guidelines withthe emphasis on Clinical Ethics4;pioneering work remains to becarried out here to provide astronger scientific backgroundfor such rules and to make themmore readily applicable.
The METAP Project at the University Hospital Basel
To help clinical staff and those involved in such difficulties through structural and scientifically well-founded measures and to promote ethically appropriate therapy decisions, we created the clinical-ethical cooperation project METAP (Modular Ethical Treatment Allocation Process), in which clinical areas such as intensive care, geriatrics and palliative care cooperate.
The evidence for the (sometimes simultaneous) occurrence of inadequate provision, overtreatment and unequal treatment and therefore also the everyday of clinical staff is based on the fact that patient care is occasionally experienced as unfair.
Over time, this experience can cause moral distress among staff and lead to burnout. Interestingly, the experience of not handling ethical questions such as the sense and usefulness of measures competently can also contribute to this: if ethical decisions are experienced as simply arbitrary (e.g. as dependent on who happens to be on duty), motivation and work satisfaction are adversely affected - not to mention the consequences for the patients themselves. We have developed a set of instruments which provides the cooperating departments with bases founded on research and literature, as well as “tools” for a structured decision-making, precisely for difficult ethical questions, e.g. if patient will is unclear or if there are differences of opinion as to the correct level of treatment:
What medical measures are appropriate in each individual case, in what intensity and duration, and what criteria are to be taken into account during reevaluation? When is it defensible to restrict treatment, and when not? How is a patient’s risk profile asses sed so that he or she receives too much or too little treatment, i.e. is not cared for “appropriately”?
How is the procedure for taking difficult decisions to be formulated: when is an internal ethical case discussion appropriate, and when should use be made of extra specialist help such as a clinical ethics consultation?
Outlook
The METAP set of instruments, which includes a full and abridged version, recommendations or guidelines, manuals and other tools, is currently in the pilot implementation phase. After an initial evaluation and corresponding modification, implementation will take place in various departments.
There are also plans to expand the clinical spectrum, which currently covers operative intensive care, acute geriatrics and palliative care.
Problem cases such as those formulated above can be tackled in various ways with the help of METAP.
Specifically prepared (empirical and ethical) bases pertaining to various relevant questions are available which contain criteria and re commendations.
Insofar as the treating staff who are seeking guidance cannot yet reach a workable decision and agreement in the specific situation by consulting this material, further steps and procedures are indicated: the use of methodical “tools”, an ethical case discussion with internal moderation or - as further support – a clinical ethics consultation with appropriate independent experts.
The use of METAP is systematically assessed and modified. Beyond individual case analyses, insights from this are also assessed for the institutional development of the cooperating departments.
