New! Collaborative Health Care Ethical Decision Making Model for Interprofessional Teams

Joanna Sturhahn Stratton, Ph.D., L.P., LMFTRegis University, Professor, Masters of Marriage and Family Therapy

University of Colorado Denver School of Medicine, Assistant Clinical Professor

•Session E5

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.

OR

The presenters of this session currently have or have had the following relevant financial relationships (in any amount) during the past 12 months.

Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Identify cases in which professional ethics may collide when working in interprofessional teams

• Identify the ethics related to each profession’s legal, professional and virtues

• Learn new model of ethical decision making that connects each profession to unifying themes

• Discuss how to implement this model in real clinical encounters

Burning Bridge•More and more medical providers are feeling the deluge of patients who have complex needs can be best met by a well-functioning interprofessonalteam.

•We are working in multidisciplinary teams without a clear way in which to make ethical decisions about patient care. Each profession’s codes of ethics and foundational principles may guide us toward conflicting resolutions.

Kuzel, A. J. (2011). Keys to high-functiong office teams Family Practice Management, 18 (3) 15-18.

Burning Bridge•High functioning interprofessional teams deliver care in such a way that all team members work to the top of their ability and license, play a role in delivering preventive services and manage chronic diseases.

•We need a unifying model of ethical decision making in order to effectively and efficiently treat patients.

Kuzel, A. J. (2011). Keys to high-functiong office teams Family Practice Management, 18 (3) 15-18.

The solution•At the core of Inter-Professional Practice is the importance of learning about, from, and with other professions (Johnson, 2016).

•We propose a new model of ethical decision making that can be taught to all health care professionals early in their respective programs to increase collaborative learning and practice.

•Ultimately, this unified model benefits future patients as health care teams will have similar language and model in which to make prudent decisions.

We need to keep working in teamsU.S. has highest per capita healthcare costs in the world

However, The U.S. ranks 37th in the world in standard health outcomes, lower than all other industrialized nations.

70% of all healthcare dollars go to managing patients with chronic conditions◦ Chronic conditions are complex and multifactorial in nature

Chronic condition are best treated by a highly communicative healthcare team (cite here)Chelminski PR, et al. A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic and non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Services Research. 2005, 5:3. doi 10.1186/1472-6963-5-3. http://www.biomedcentral.com/1472-6963/5/3. Accessed on 9/24/2017.

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Interprofessional teams support patient outcomes

•70% of the symptoms seen in primary care do not have an identifiable organic cause

•66% of primary care patients either meet criteria for a DSM diagnosis or have social/contextual issues that impair their functioning—most prevalent in patients with chronic illness

•60-70% of psychotropics are prescribed by primary care providers

•Underserved populations have the worst health outcomes.

•Inequities in the distribution of health resources has a detrimental impact on the whole population

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Mental Health Ethical ScenarioPatient is 72 year old male with Type II Diabetes, neuropathy, nerve pain in his extremities and a new diagnosis of a mass on his liver. His medical provider has stated that he has less than 6 months to live. He has seen a physical therapist for neck and shoulder pain and has a good relationship with his pharmacy provider. Patient has discussed end of life issues with medical provider and has decided not to continue to live with pain, medical treatments or future hospitalizations. The patient has discussed his decision to end his life with his family. Their preference is to end his life through the use of medication under the supervision of a physician and obtain the medication from his trusted pharmacist. The patient sees me for mental health treatment. In the past six months, I have diagnosed the patient with chronic depression, severe, recurrent and has been receiving evidenced based psychotherapy and antidepressant medication. You have observed some decline in cognitive functioning over the last six months. What is the ethical next step?

Mental Health Guiding EthicsConfidentiality: Protect patient confidentiality above all else except when mandated to report specific information

Safety: Clients should be evaluated for safety. Intervention may be necessary to keep self and others from harm.

Autonomy: Patient should be able to make decisions that are best for one’s own life

Non-maleficence: The impact on family members should be discussed and addressed with the system as a whole.

ConfidentialityConfidentiality can be understood as a special obligation that mental health professionals incur when they enter into a relationship with a client (Kitchener, 2000). Client confidentiality is the requirement that therapists, psychiatrists, psychologists, and most other mental health professionals protect their client's privacy by not revealing the contents of therapy. The fundamental intent is to protect a client's right to privacy by ensuring that matters disclosed to a professional not be relayed to others2.7.Marriage and family therapists, when consulting with colleagues or referral sources, do not share confidential information that could reasonably lead to the identification of a client, research participant, supervisee, or other person with whom they have a confidential relationship unless they have obtained the prior written consent of the client.Hohmann-Marriott (2001) explains that disclosing sensitive information is likely to bear greater risks than disclosing less sensitive information.This has implications when a “secret” is shared in therapy that may be important to convey to the rest of the healthcare team. Even when a disclosure has been signed, our ethics are to share as little as necessary.

Safety: Informed Consent2.1 Disclosing Limits of Confidentiality.

Generally, when does a therapist have to break confidentiality with a client?

1. If the client may be an immediate danger to himself or others2. If the client is endangering a population that cannot protect itself, such as the case of child or elder abuse3. To share diagnosis information as necessary to obtain payment for services4. As required by federal or state laws (subpoena)

Including if a client has suicidal intent with a plan and means to carry out the activity. This involves assessing if a client is competent to make decisions about their own safety.

Autonomy: Multiple Roles1.3 Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation.

This is pertinent to having a relationship with the patient’s healthcare team and learning about the patient from these professionals or the Electronic Medical Record (EMR).

Non-Maleficence1. Who is the patient? As a family therapist, my patient may actually be the family. Even if I am treating the patient individually, it is my responsible to contextualize the patient and understand the impact of the family on his decision making and the impact of his decision making on the family.

2. Potential for Harm: underestimating the influence of family members on his decision to die (potentially undermining his autonomy)

3. Potential for Harm: overestimating the preparedness of the family for the patient’s possible impending death which may create many psychological impacts on the family members

Physical Therapy Scenario

Pete is a 56 y.o. male who sought care at a local community health clinic due to persistent shoulder pain. He is covered under Medicaid health plan. Pete has worked in construction since he was 16 and reports he has incurred multiple physical injuries causing him to be in and out of work for long periods of time while he healed. He requested a consult with the NP and Pharmacist to receive medication for the pain so he can return to work and not lose his job to “younger, healthier workers”. Under the NP’s encouragement, Pete did meet the Physical Therapist and Counselor for a brief screen.

Ethical ConsiderationsPete’s examination revealed the following “red flags”◦ Long term use of narcotic and non-narcotic pain medications◦ History of depression (untreated)◦ History of high blood pressure (untreated)◦ High stress associated with work and family life ◦ Bilateral shoulder pain with impairments in overall upper extremity strength and range of

motion◦ Loss of strength in both hands◦ History of Illicit drug use

Ethical ConsiderationsPete requires extensive medical care from various healthcare providers. (financial hardship and loss of work time)

Pete depends on daily narcotic/opioid medication to function (new laws restricting the use of opioid medications)

Pete has a history of depression and high stress that has never been managed (needs to be addressed to optimize patient’s health)

Pete refuses provision of health care due to limited time and resources to access care based on his insurance plan

Pete is fearful that he will lose his job if he takes time to attend to his medical needs

Potential lack of agreement on plan of care for Pete

Ethical MattersPotential misuse of narcotic/non-narcotic medications and illicit drugs

Patient’s wellness goals differ from healthcare providers wellness goals

Potential biases from healthcare providers

Patient’s mental health status and his impact on decision-making

Relationships involved access to care ◦ Patient to healthcare providers◦ Healthcare providers to the Health clinic ◦ Healthcare providers to patients Health insurance◦ Healthcare provider to healthcare provider◦ Healthcare provider to society

Ethical PrinciplesHighlighting a few Code of Ethic Principles for Physical Therapist◦ Act in the best interest of the patient/client over the interest of the physical therapists.

Principles: 1A,1B( core value: compassion, integrity) ,2A-E(Altruism, compassion, professional duty)

◦ Provide information necessary to allow patients to make informed decisions about participation in physical therapy Principles 2A,2C

◦ Use of professional judgment guided by best evidence and standards of practice, experience and patient values Principle 3 (core value: excellence, integrity) 5A (core value: professional duty, accountability) Principle # 6 (core value: excellence) 6A,6B,6C,6D

◦ Shall provide pro bono care or support organizations that meet the health needs of individuals that are underserved, uninsured or underinsured Principles # 8 (core value: social responsibility) 8A, 8C

◦ Advocate to reduce disparities in provision of health care Principles 8A , 8B

◦ Educate the public about the benefits of physical therapy Principle 8DCode of Ethics for the Physical Therapist. American Physical Therapy Association. www.apta.org

Example 49 YEAR OLD PATIENT RECEIVING

DIABETES EDUCATIONPharmacist provides medication therapy management and diabetes education

Pharmacist requests lab values from provider to help evaluate current drug regimen safety and diabetes status of control

DILEMMA

Pharmacist denied lab values from provider based on provider’s perception that this was confidential information and should not be shared with a pharmacist.

Pharmacist unable to provide patient-centered preventative care

Pharmacist Ethical Dilemmas

A pharmacist respects the covenantal relationship between the patient and pharmacist.

CODE OF ETHICS

A pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.

DILEMMA

A pharmacist ensures optimal benefit of medications when they are provided with a holistic view of a patient, including patient health history, lab values, patient perception and health literacy for both the conditions being treated and the medications being prescribed.

A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.

CODE OF ETHICS

A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner.

DILEMMA

Pharmacists are not always provided confidential information that is necessary to provide quality care for their patients.

Pharmacist Code of EthicsA pharmacist respects the covenantal relationship between the patient and pharmacist.

A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.

A pharmacist respects the autonomy and dignity of each patient.

A pharmacist acts with honesty and integrity in professional relationships.

A pharmacist maintains professional competence.

A pharmacist respects the values and abilities of colleagues and other health professionals.

A pharmacist serves individual, community, and societal needs.

Ethical Dilemmas in the Community PharmacyA pharmacist serves individual, community, and societal needs.

◦ Recommendations and assessments provided in the community pharmacy for OTC medications is at the pharmacist’s discretion.

◦ Many pharmacists may be hesitant to provide recommendations for OTC medications if they do not feel as thought they have a sufficient health history.

◦ How can we serve the margins? Those that are hesitant to receive care and rely solely on self-care products?

SolutionPharmacists are trained to save lives by preventing adverse drug outcomes.

Providing pharmacists with key information such as lab values and patient health history is ideal for improving patient care transitions and preventing poor health outcomes.

Pharmacists should not be siloed practitioners, but team-members on an interprofessional healthcare landscape.

Together, with other healthcare professions, we can provide the best care and prevent poor outcomes.

Nursing Ethical situations#1: A patient is threatening a provider for more pain medication. The patient has a history of aggressive behavior. The nurse has the duty to treat the patient and care for the patient with respect (#1) but also must be sure she is safe ( #5). She also has a duty to provide high quality care.

#2: A Nurse Practitioner works in an on-campus clinic. One of her new patients is a student in her undergraduate nursing course. She has a duty to the patient to provide high-quality care, but there may also be a conflict of interest (#2) in seeing the patient and being able to uphold the relationship boundaries with that patient as a student. There is also a potential conflict with (#3) for patient confidentiality.

Ethical situations (cont.)#3: In a NP’s new role, she is working with a medical assistant who she is uncomfortable with. She feels the MA might be making up vital signs. She is being asked to delegate procedures, medications and phone calls to this person due to a need for her to see more patients. (Principles, 2,3,4, 6, 8)

#4: Nurse in Utah who will not allow a law officer draw blood on a patient who has not provided consent (Principles 2, 3, 5, 6)

Fowler, M. D. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application. Silver Spring, MD: American Nurses Association.

Guiding Ethical Principles in Nursing#1: Nightingale Pledge (respect for persons) : The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. (ANA, 2010, p.3)

#2: The nurse’s primary commitment is to the patient, whether an individual, family, group or community. (ANA, 2010, p. 11)

#3: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. (ANA, 2010, p. 23)

#4: The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. (ANA, 2010, p. 41)

Guiding Ethical Principles in Nursing (cont.)#5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. (ANA, 2010, p. 55)

#6: The nurse participates in establishing, maintaining and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. (ANA, 2010, p. 71)

#7: The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. (ANA, 2010, p. 89)

Guiding Ethical Principles in Nursing (cont.)#8: The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. (ANA, 2010, p. 103).

#9: The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. (ANA, 2010, p. 121).

Interprofessional Ethical ConsiderationsDifferences in ability to see students or develop relationships with patients

Differences in whom we identify as our patient(s)

Legal responsibilities to share and report information

Differences between professions with what they hold highest in the ethical code

Whose ethical code is the most important when providing team-based care?

Discrepancies in professional ethics exist

Mental health foundational ethics emphasize patient confidentiality, avoiding dual-roles and assessing for safety .

Nursing has identified the protecting the medical rights of the patient and respecting the uniqueness of the patient’s health goals.

Pharmacy emphasizes patient autonomy and providing patient comprehensive information.

Physical therapy privileges providing patient with sufficient information, conveying professional opinion regarding treatment and promoting the benefits of the profession.

Principles of Team-Based Health Care

• Clear Roles

• Mutual trust

• Effective Communication

• Shared Goals

• Measurable Processes and Outcomes Mitchell et al., 2012

New! Interprofessional Ethical Decision Making Model

Nonmaleficence- Do no harm to patient/patient system. Consider the patient’s ability to make clear decisions without immediate intrapersonal or interpersonal bias or impairment.

Beneficence- Do some good for patient’s health and well-being. Consider the impact of the patient’s health on their family and community .

Optimization of Life goals- otherwise stated as autonomy. Expands to consider that each patient and patient family can define “maximum health outcomes” according to their own culture, context and social identity.

Social Justice Advocacy- consideration of the resources available to a community, membership in underrepresented class, universal right to access high quality services, and potential conflicts with established legislation. Advocate for rights and pro-social society impact.

Social Justice

Beneficence Nonmaleficence Whole-Person Health Goals

Social Justice Motivation“How ought we live.” “Magis”

Regis Jesuit principles

The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.

Franklin D. Roosevelt

The path out of poverty begins when the next generation can access quality healthcare and a great education.

Bill and Melinda Gates

"The owners and players are focused on how we can work together to promote positive social change and address inequality in our communities,"

The NFL and the NFL Players Association said in a joint-statement.

How will this change our decision making?

We will always consult with the team regarding the impact of our care, changes in care or termination of care.

We will consider how the decisions we make about type, duration, cost and course of treatment impacts their family, their community and the ability of others to access services.

We will think about how to best use the interprofessional team in order to act in accordance with the patient’s definition of health.

Recognize our professional bias and knowledge base may be impacting our treatment of the patient

In summaryWorking within an integrated health care model requires clinicians move away from the traditional expert role towards a more collaborative approach to clinical decision making. Collaboration with other team members and patients has implications for the power distribution between clinician and patient, and how health is defined (Blackwell Publishing Ltd.)Re-framing the clinician’s role in collaborative clinical decision making has tremendous implications as each professional attempts to integrate and honor their distinct codes of ethics and discipline-specific decision making model (Franziska, Trede, GradDip & Higgs, 2016).

Session EvaluationUse the CFHA mobile app to complete the evaluation for this session.

Thank you!

Alice M Davis, PT, DPT

Leticia Shea, Pharm D

Courtney Duggan, NP

Bobbi J. Miller, Ph.D., LMFT