Ethics Programs

The educational function of the Ethics Program shall ensure that the staff and partners of CoxHealth have the opportunity to learn about the Ethics Program. The educational function shall provide education regarding ethical practices. The aims of these educational efforts will be to provide the staff and partners of CoxHealth with access to the language, concepts, principles and body of knowledge about ethics that they need. This function will be the responsibility of the Ethics Education Committee. Any ethical educational efforts undertaken by the Ethics Education Committee for the staff and partners of CoxHealth will be coordinated with existing educational efforts as much as possible (i.e. new staff orientation, required reeducation, etc.). The Ethics Education Committee's primary emphasis will be on assisting departments and divisions to incorporate material about the Ethics Program into their existing educational programs and activities.

An important function of the Ethics Program will be its role as a forum for analysis of ethical questions that arise in the care of individual patients. In most circumstances, these ethical questions will concern medical decision making regarding patients with diminished capacity. In order to specifically address such issues through the case review process, a Case Review Committee will be designated by CoxHealth Administration. Not less than 15 people will be designated from a grouping of volunteers interested in working with the Ethics program in this capacity and/or persons identified by CoxHealth Administration to serve. Two of those individuals will be designated as Review Team Leaders. In the event that a formal Case Review is implemented (as detailed below), the responsible Review Team Leader will contact the requisite members of the Case Review Committee to form a Review Team. The Review Team will attempt to provide support and counsel to those responsible for treatment decisions regarding the particular patient at issue (including, but not limited to, health care providers, patients, surrogates and members of the patient's family). The Futile Care Committee is a sub-committee of the Ethics Case Review Committee.

Case review is particularly recommended in three specific categories of decision making:

1. Decisions involving significant ethical ambiguity and perplexity in which case review may provide insight into complex ethical issues;
   
2. Decisions involving differences in opinion between care providers or between providers and patients/families regarding the ethical aspects of a patient's care; or
   
3. Decisions that involve withholding or withdrawing life-sustaining treatment which are not adequately addressed in CoxHealth policies and procedures, likely to be addressed by the Medical Futility policy.
   

In this role, the Case Review Team will not act as a decision-making body, but will attempt to assist and to provide support to those who have decision-making responsibility. The Case Review Team's role in all such cases shall be advisory.

A Case Review Team will be available to respond to requests for a case review as needed. In order to facilitate 24 hour 7 day a week coverage, there are two different contact tracks to follow; one for Monday through Friday 8:00 a.m. to 5:00 p.m. and one for after-hours and weekends.

Monday through Friday (8 a.m.-5 p.m.)

1. Any person wishing to make a request for a case review ("Requester") shall call the Corporate Integrity Department (269-7655) by telephone to request a case review.

2. Corporate Integrity Department shall notify the Vice President of Corporate Integrity (or her/his designee) to inform her/him of the request.

3. The Vice President of Corporate Integrity (or her/his designee) will use her/his best efforts to have an initial discussion with the Requester as quickly as possible under the circumstances. The Vice President of Corporate Integrity will obtain pertinent facts regarding the ethical issue from the Requester (i.e. patient name, family involvement; physician(s) and staff involved in the patient's care; whether patient has a power of attorney or DNR, etc.).

4. The Vice President of Corporate Integrity will contact a Case Review Team Leader to discuss the case. The Vice President of Corporate Integrity and Review Team Leader shall contact at least one other member of the Case Review Committee (such Case Review Committee Member should, if possible, be a person with expertise in the area at issue-i.e. end of life decision making; women and children; etc.).

• Collectively, the Vice President of Corporate Integrity, Case Review Team Leader and the Case Review Committee Member shall determine whether a Formal Case Review would be appropriate. (In order to make this decision, the Vice President of Corporate Integrity, Case Review Team Leader and Case Review Committee Member may consult with the Vice President of Medical Affairs, general counsel, applicable department heads, other Case Review Committee Members and/or may meet with the Requester, treating physician if applicable, and others to help them make this determination). This group will use their best efforts (under the circumstances) to make the determination whether to proceed with a formal case review within 24 hours of the initial request.
  
• If the Vice President of Corporate Integrity, Case Review Team Leader and Case Review Committee Member collectively determine that a formal case review is not appropriate, then they will otherwise handle the issue as appropriate (this may include referring the issue to the appropriate department, such as Human Resources or the Medical Staff office). If the Vice President of Corporate Integrity, Case Review Team Leader and Case Review Committee Member determine that a Formal Case Review is appropriate, then they shall contact the Corporate Integrity Department to set up a Formal Review, as defined below. If the Vice President of Corporate Integrity, Case Review Team Leader, and Case Review Committee Member differ in opinion on whether the Formal Case Review should occur, then the default will be that a Case Review will be undertaken.
  

Weekends and After Hours (5 p.m. Friday through Monday morning at 8 a.m.)

1. Requester shall contact the Director of Nursing on call.

2. The Director of Nursing (or her/his designee) will use her/his best efforts to have an initial discussion withthe Requester as quickly as possible under the circumstances. The Director of Nursing will obtain pertinent facts regarding the ethical issue from the Requester (i.e. patient name, family involvement; physician(s) and staff involved in the patient's care; whether patient has a power of attorney or DNR, etc.).

3. The Director of Nursing shall contact the Vice President of Corporate Integrity as soon as possible to informher/him of the request for a case review. If the Vice President of Corporate Integrity is not available, theAdministrator on-call may be contacted to initiate a discussion with a Case Review Team Leader and the Director of Nursing. If a determination is made that a Case Review must occur on the weekend, those individuals should follow the steps under Monday through Friday above beginning at Paragraph 4 with the Administrator on-call functioning in the role of the Vice President of Corporate Integrity's designee

Following a decision that a Formal Case Review is warranted, the Case Review Team Leader will direct the Corporate Integrity Department (or the Nursing Administration Secretary) to assemble a Review Team. The Review Team will be formed by calling members of the Case Review Committee until at least six (6) members are available at a specific time to meet (the Review Team) and review the case. A Review Team shall not be considered formed unless at least one physician, one case manager, one nurse is available to meet at the designated time and place. If at all possible, the team will reflect the multidisciplinary composition of the entire team.

Absent special considerations, the caregivers, the patient or the patient's family or surrogate decision makers, as the case may be, should also be notified that the formal case review will be taking place, and should be invited to participate. A family or surrogate decision-maker's decision not to participate or his/her objection to the formal case review in general, shall not prevent a formal case review from taking place (assuming the consult is otherwise determined to be appropriate as noted above.) Similarly, the refusal of a patient's attending physician to participate in a formal case review (or objection to the formal case review in general) shall not prevent a formal case review from taking place.

If the patient's attending physician believes that formal case review is not appropriate, or otherwise refuses to participate in the case review process, this conflict should be discussed with the Vice President of Medical Affairs for possible solutions. It will be up to the Team Leader, Vice President of Corporate Integrity and other Committee member discussing the need for review, working with the Vice President of Medical Affairs to determine if peer action should be requested.

Members of the Review Team may determine that it is appropriate to invite other participants to some or all of the meetings in which the Review Team discusses the case (such as department heads or additional members of the professional staff who are directly involved in providing care to the patient and resource personnel with special expertise).

The results of the case review and any recommendations will be communicated to the individual who requested thecase review; to the attending physician; to other members of the staff; and, to the patient/family as appropriate. Following these discussions, and with the concurrence of the attending physician, the Review Team Leader will record the results of the ethics case review in the patient's medical record.

Membership of the committees will be multidisciplinary, including representatives from clinical departments. Members will be appointed by CoxHealth Administration for the organizational group and first meetings. After that initial appointment process, replacement members will be approved by each committee.

Education Committee

The Education Committee shall consist of at least 7 members, one of which shall have a background in education, others should include a representative from nursing services, Corporate Integrity Department, Pastoral Care, and Case Management. The Education Committee shall meet as needed.

Case Review Committee

The Case Review Committee will consist of at least 15 members. The committee should have representation from interested physicians, Case Management, Nursing Services, other Ancillary Service Departments, and Pastoral Care. The committee will have at least one representative from the Corporate Integrity Department. The Case Review Committee shall meet as needed.

An agenda for all committee meetings, with the exception of the Case Review Team meetings when a case review is being conducted, will be developed by the Chair and distributed one week prior to the meeting, if at all possible. Meetings that do not involve discussion of specific case material will be open to any member of CoxHealth. Guests and other interested parties will be allowed to attend at the discretion of the Chair. For purposes of conducting business, a majority of the committee members shall constitute a quorum, with the exception of the Case Review Team. A quorum will be considered present if at least 7 members are present for a case review. Actions of the committee shall be taken by the vote of a majority of the members attending the meeting. Each member will be required to attend at least two-thirds of the committee's meetings each year.

Failure to do so can be considered to constitute a resignation and the vacancy shall be filled by appointment of a new member.

Each committee will maintain minutes of all of its meetings, including summaries of all case reviews and recommendations. Minutes will not include identifying information about specific patients, family members, or identify the individuals requesting case review (if asked to keep confidential). These minutes will be maintained in accordance with hospital policy and applicable law governing the confidentiality of records of medical review committees.