IntegratedEthics™
Improvement Forum Call
Life-Sustaining Treatment Decisions Initiative
April 24, 2017
Slide 1 - Welcome to Ethics Consultation Coordinators
This is Marilyn Mitchell. I am the IntegratedEthics Manager for Ethics Consultation at the National Center for Ethics in Health Care and I will be moderating today’s IE Ethics Consultation Improvement Forum call. Thank you for joining us today. Our topic today is: The Life-Sustaining Treatment Decisions Initiative
If you did not receive a reminder email for this EC Improvement Forum call, it is possible you are not signed up for the IE listserv. You can do so easily by going to the National Center’s website and under the Integrated Ethics portion of the website you will find it. The link will be available in the minutes:
The call schedule and summary notes are posted on the IntegratedEthics website at:
Before I continue I want to mention that other staff from the Ethics Center typically join the call and you may be hearing from them.
Presentation shown on the call:
Slide 2 – Life Sustaining Treatment Decisions Initiative – We are joined today by two guest presenters, Dr. Ashby Sharpe and Dr. Jill Lowery. Welcome to you both. First allow me to open this call with a few announcements.
Slide 3 - This meeting is a multimedia presentation requiring both audio and visual access.
- Audio will be available through VANTS: 800-767-1750 Access: 89506# and Online Meeting
- Visuals will be accessed through the Lync online meeting: Join online meeting
Please call the usual VANTS line AND join the Lync online meeting.
If you are having technical difficulties, please contact your local IT department to assist you.
Slide 4–Participating in this Meeting –
I need to briefly review the overall ground rules for these calls:
- PLEASE do not put the call on hold.
- We ask that when you speak, you please begin by telling us your name, location and title so we can continue to get to know each other better.
- As you may know the Ethics Center does not audiotape these calls; instead, we provide minutes. In the field some VHA facilities are audiotaping the calls to make it possible for their colleagues to hear the full text of the discussion. As a result, this is not the venue for reporting violations, talking about individual case information, or disclosing identifiable patient information.
Slide 5– Announcements – TheNCEHC is pleased to announce two upcoming virtual EC Beyond the Basics programs which are available for registration. Registration is available through TMS.
- May 12 from 3:00 – 5:00 pm ET – Getting Off to the Right Start in a Formal Ethics Consultation Meeting – (Module 6) TMS # 33106
- June 23 from 2:00 – 4:00 pm ET – Managing Common Misconceptions about the Role of an Ethics Consultant – (Module 1) TMS # 33107
Slide 6 – Focus Topic – So now I’d like to introduce our focus topic, the Life-Sustaining Treatment Decisions Initiative. Welcome again to Dr. Ashby Sharpe and Dr. Jill Lowery.
Slide 7 – New LST Handbook VHA Handbook1004.03 - Life-Sustaining Treatment Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences
Slide 8 – Multidisciplinary Committee –
- Required to review proposed LST plans for patients who lack decision-making capacity and do not have a surrogate
- Appointed by the Director – this means the Director approves the make-up of the committee
- The Director does not have to appoint specific individuals to the multidisciplinary committee
- The Director’s approval is documented through signature on the MCM specifying the composition of the committee
Slide 9 – Multidisciplinary Committee Membership –
- Comprised of three or more different disciplines
- Include at least one member of the Ethics Consultation Service
- Not include members of the primary treatment team
- The Ethics Consultation Service, IntegratedEthics Council, subcommittee of the IE Council or an independent standing or ad hoc group may serve this function.
- See Handbook 1004.03, page 12, paragraph 8
Slide 10 – Multidisciplinary Committee –
In your facility’s MCM:
Specify composition of the Multi-Disciplinary Committee (MDC)
Specify mechanism for contacting the MDC
Specify how MDC will document results of review
Recommended MDC Consult template provided:
Slide 11 – Template: Multidisciplinary Committee Consult:
This slide is an example of a template for obtaining a multidisciplinary committee review.
Slide 12 – Reason for Request:
This slide is a continuation of the example of a template for obtaining a multidisciplinary committee review.
Slide 13 – Process Map for Life-Sustaining Treatment Decisions
Slide 14 – Next Steps:
- Review Handbook 1004.03
- Work with Life-Sustaining Treatment Decisions Initiative Implementation Coordinator and Advisory Board to propose:
- MDC membership
- Process for contacting MDC when appropriate
- MDC documentation processes
Slide 15 – Questions? - Now I’d like to open it up for comments and questions. Please do not hesitate to speak up.
Q:If there is an advance directive (living will) but no surrogate do we still have to consult a special committee for decisions or can we simply follow the AD?
A:The MDC is for patients who lack capacity and have no surrogate. So, a living will would not be sufficient as a basis for treatment planning for these patients.
Q: In the above case of no capacity/no surrogate but does have Living Will, then would it be correct to say that the Living will would be useful information for the MDC to use in their decisions?
A: Yes, it would be useful. Any existing living will (instructional directive) -- whether it is a VA living will or state living will or a SAPO -- should be reviewed by the treatment team as a basis for its recommendations for the patient. The MDC can also review those documents as part of its role to ensure that the plan reflects the patient's known wishes (or best interests). A living will does not speak for itself, but needs to be interpreted by a surrogate or if there is no authorized surrogate, the MDC is engaged to play this interpretative role.
Q: Will this new process for consulting the MDC when patients lack decision making capacity, have no surrogate and have no active LST orders in essence replace the need for consulting the local Ethics consultation service?
A: It is expected that at least one member of the MDC is an ECS member.
Q: Will the language change on the VA AD; it currently states, "I want my preferences, as expressed in this Living Will, to be followed strictly, even if the person making decisions for me thinks that this isn't in my best interests"?
A: No - we will not be changing the language in the VA AD - this will continue to be an option for Veterans - and the choice they make will help guide those who need to make decisions. However, for high-risk patients (who have a serious life-limiting illness) and have NOT lost capacity - a goals of care conversation is key to understanding and documenting the patient's goals and consent for a treatment plan before a crisis. Advance Directives, as Jill said are still key - they are the way to designate a health care agent and are appropriate for individuals of any health status to document preferences.
Thank you everyone for those questions & comments. We will have a summary of the call up on the website in a short while for you to review as needed.
Before you leave the call, please indicate on our anonymous poll how helpful you found this call:
“I found this call helpful and useful to the work I do in IntegratedEthics”
Slide 16–Upcoming Ethics Consultation Improvement Forum Call -
The next EC Improvement Forum call will be on May 8th to celebrate ten years since IntegratedEthics was rolled out. On May 22nd the EC Improvement Forum Call will be on two topics – Introducing IEWeb and Patient Recording Encounters. I hope to see you then.
Please remember, that like the rest of my New York colleagues, my door, my email, and my phone (212-951-5477) are always open to hear from you.
Take care – and thank you for everything you do to deliver excellent care to our Veterans.
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