bioethics reference grid - covenant health3-bioethics reference grid page 4 of 5 02/21/02 bioethics...

49
3-Bioethics Reference Grid Page 1 of 5 02/21/02 BIOETHICS REFERENCE GRID Perceived Problem Pertinent Principle Policy Provision Patient’s decision making capability being questioned/challenged Patient is presumed to have decision-making capacity unless clear and convincing facts indicate it is lacking for a particular medical treatment. Administrative Policy Manual, Patient Rights and Organization Ethics: 01-RI, Patient Rights and Responsibilities 02-RI, Patient Self Determination Act Compliance, Advance Directives, Medical Power of Attorney, DNR Policy 03-RI, Resolving Ethical Issues II-C-6 Directive to Physicians “Living Wills” “Competent” means possessing the ability, based on reasonable medical judgement to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to any proposed treatment decision. “Incompetent” means lacking such ability, based on reasonable medical judgement to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to any proposed treatment decision. Patient not receiving adequate information for informed consent. Each person has the moral right to information needed to make informed decisions about his of her life and health Administrative Policy Manual, Patient Rights and Organization Ethics: 01-RI, Patient Rights and Responsibilities 07-RI, Informed Consent I, A, 2. The patient must understand the circumstances to which he/she is consenting to, freely choose to enter into the agreement, and understand the consequences of having or now having the procedure. I, A, 3. The physician is responsible for informing the

Upload: others

Post on 27-Apr-2020

9 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

3-Bioethics Reference Grid Page 1 of 5

02/21/02

BIOETHICSREFERENCE GRID

Perceived Problem Pertinent Principle Policy ProvisionPatient’s decision makingcapability beingquestioned/challenged

Patient is presumed to havedecision-making capacity unlessclear and convincing facts indicateit is lacking for a particular medicaltreatment.

Administrative Policy Manual, Patient Rights andOrganization Ethics:01-RI, Patient Rights and Responsibilities02-RI, Patient Self Determination Act Compliance,Advance Directives, Medical Power of Attorney, DNRPolicy03-RI, Resolving Ethical IssuesII-C-6 Directive to Physicians “Living Wills”“Competent” means possessing the ability, based onreasonable medical judgement to understand andappreciate the nature and consequences of a treatmentdecision, including the significant benefits and harms ofand reasonable alternatives to any proposed treatmentdecision. “Incompetent” means lacking such ability,based on reasonable medical judgement to understandand appreciate the nature and consequences of atreatment decision, including the significant benefits andharms of and reasonable alternatives to any proposedtreatment decision.

Patient not receiving adequateinformation for informed consent.

Each person has the moral right toinformation needed to makeinformed decisions about his of herlife and health

Administrative Policy Manual, Patient Rights andOrganization Ethics:01-RI, Patient Rights and Responsibilities07-RI, Informed ConsentI, A, 2. The patient must understand the circumstances towhich he/she is consenting to, freely choose to enter intothe agreement, and understand the consequences ofhaving or now having the procedure.I, A, 3. The physician is responsible for informing the

Page 2: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

3-Bioethics Reference Grid Page 2 of 5

02/21/02

BIOETHICSREFERENCE GRID

patient/legal guardian of the recommended surgical,diagnostic, or medical procedure and the risks involved,benefits and alternatives and obtaining the patient’sinformed consent.Texas Medical Disclosure Panel.II-C-6 Directive to Physicians “Living Will” Effortsshould be made to discuss/resolve issues and/or conflictsabout the persons directly involved; qualifieddeclarant/agent, attending physician/family members.Discussion should take place between the physician andthe competent adult, legal guardian and/orrepresentatives when no legal guardian has beenappointed.

Patient being misled or deceivedabout treatment alternatives, risks,foreseen suffering, probablefunctional outcome or patient beingpressured by others into making adecision.

The primary responsibility ofhealthcare professionals in theprocess of reaching decisionsabout treatment is to provide thepatient or surrogate with sufficientmedical information and adequatepsychological/social/spiritualsupport to enable a free andinformed choice.

01 RI, Patient Rights and ResponsibilitiesII-C-6 Directive to Physicians “Living Will” If theattending physician determines that a specific treatment(to include CPR) would be futile and declarant/agentdisagrees then physician must make a reasonable effortto transfer care to another physician. Discussion shouldtake place between the physician and the competentadult, legal guardian and/or representatives when nolegal guardian has been appointed.

Patient’s choice beingdisregarded/overridden.

Each patient is the primarydecision-maker for his or hertreatment. In no case may familymembers or healthcareprofessional override the ethicallyappropriate decision of a patientwho has decision-making

Administrative Policy Manual, Patient Rights andOrganization Ethics:01-RI, Patient Rights and ResponsibilitiesThe patient has a right to :I, A, 1. Be provided information and assistance inunderstanding information throughout their stay abut theircondition, rights and responsibilities.

Page 3: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

3-Bioethics Reference Grid Page 3 of 5

02/21/02

BIOETHICSREFERENCE GRID

capability. 07-RI, Informed ConsentII-C-6 Directive to Physicians “Living Will” If theattending chooses not to follow the directive, thephysician must make a reasonable effort to transferresponsibility for the patient’s care to another physician.

Surrogate(s) not being agreedupon.

The surrogate decision-makershould be a person concerned forthe welfare of the patient withknowledge about the patient’spreviously expressed preferencesregarding treatment.

01 RI, Patient Rights and Responsibilities The patientwill make healthcare choices together with the physicianwith respect to the following, the involvement of familyand/or guardian in the care choices throughout the courseof treatment or the exclusion of any or all family membersfrom participating in his/her care decisions.II-C-6 Directive to Physicians “Living Will” Knowingthe incompetent wishes, the family legal guardian maymake those wishes known to the attending physician sothat treatment decisions might be made in accordancewith the patient’s desires.

No surrogate available. When no surrogate is availableand the patient is not known bycaregivers, a treatment decisionshould promote the patient’s wellbeing in accord with respect forhuman dignity.

02-RI, Patient Self Determination Act Compliance,Advance Directives, Medical Power of Attorney, DNRPolicy: Refer to Vernon Texas Statue and Codes, whichstates such incidents are referred to the BioethicCommittee.

Patient’s advance directives notbeing honored or patient’s knownpreferences being disregarded.

The surrogate’s duty is to choosethe ethically appropriate alternativemost in accord with the patient’sexpressed preferences or knowndesires/values.

01 RI Patient Rights and Responsibilities The patienthas a right to the formulation of advanced directives andappointing a representative to make healthcare decisionson their behalf.II-C-6 Directive to Physicians “Living Will” Knowingthe incompetent wishes, the family legal guardian maymake those wished known to the attending physician sothat treatment decisions might be made in accordance

Page 4: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

3-Bioethics Reference Grid Page 4 of 5

02/21/02

BIOETHICSREFERENCE GRID

with the patient’s desiresPatient/surrogate insisting onmedically, i.e, physiologically, futiletreatment

Healthcare givers are not ethicallyobligated to initiate or continuemedical treatment that would beclearly futile.

01 RI Patient Rights and ResponsibilitiesII-C-6 Directive to Physicians “Living Will” If theattending physician determines that a specific treatment(to include CPR) would be futile and declarant/agentdisagrees then physician must make a reasonable effortto transfer care to another physician. Issues and/orconflicts that cannot be resolved maybe referred to theBioethics Committee for advice.

Surrogate or caregivers beingunwilling to stop an existingtreatment.

There is no ethical or legaldifference between withholdingand withdrawing treatment.Considerations that justify notinitiating treatment also justifywithdrawing treatment.

02-RI, Patient Self Determination Act Compliance,Advance Directives, Medical Power of Attorney, DNRPolicy: Refer to Vernon Texas Statue and Codes, whichstates such incidents are referred to the BioethicCommittee.

Patient requests to forgo life-sustaining treatment.

A person may ethically forgodisproportionate means ofpreserving life. Disproportionatemeans are those that in thepatient’s judgement do not offer areasonable hope of benefit orentail excessive burden or imposeexcessive expense on the family orthe community.

02-RI, Patient Self Determination Act Compliance,Advance Directives, Medical Power of Attorney, DNRPolicy 1-b Directive to Physicians and family orsurrogates: a person may instruct his physician not to usemechanical or artificial means of support, artificial nutritionand hydration, life sustaining treatment, when theapplication serves only to postpone the natural process ofdying.

Patient requests to forgo artificialnutrition and hydration.

Since artificial hydration andnutrition are medical treatments,the same ethical principle aboutdisproportionate means ofpreserving life applies. Thereshould be presumption in favor of

02-RI, Patient Self Determination Act Compliance,Advance Directives, Medical Power of Attorney, DNRPolicy 1-b Directive to Physicians and family orsurrogates: a person may instruct his physician not to usemechanical or artificial means of support, artificial nutritionand hydration, life sustaining treatment, when the

Page 5: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

3-Bioethics Reference Grid Page 5 of 5

02/21/02

BIOETHICSREFERENCE GRID

providing artificial nutrition andhydration as long as this is ofsufficient benefit to outweigh theburdens involved to the patient.

application serves only to postpone the natural process ofdying.

Page 6: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Revised 1-24-02

ETHICS CONFERENCE WORKSHEET

Person Requesting Consult:________________________________________Reason For Consult:______________________________________________Attending:_______________________Consultants:_____________________________________________________Case Manager____________________Chaplains Consultants:____________________________________________Admitting Diagnosis:______________________________________________Present Condition/Prognosis:______________________________________Advanced Directive for Healthcare: Yes NoIs Document in Chart? Yes NoIf yes, what are patientsdirections?______________________________________________________________________________________1) Medical Power of Attorney forHealthcare? Yes No2) Is Document in chart? Yes No3) Is Patient capable of making thisdecision? Yes No 4) If yes what are patients directions?________________________________________________________________________________________________5)Who has Durable Power of Attorneyfor Healthcare?________________________________6) Who is/are the surrogate decisionmaker(s)?______________________ ________________________________7) If more than one of equal positionare they in agreement? Yes No

8) If No Please Explain:____________________________________________________________________________Surrogate Wishes:________________________________________________________________________________Presenting Ethical Concern________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Values or Principles at stake:(EthicalReligious Directives)______________________________________________________________________________________________________________________________________________Pertinent Covenant Health SystemPolicies_______________________________________________________________________________________________Patient Label

Page 7: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Revised 1-24-02

Summary of Plan for Implementation:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Conference Members Evaluation of Process:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations for Improvements:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Forward completed form to Director of Spiritual Care.

ChaplainsSignature:__________________________________Date:______________

Page 8: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Bioethics Team Consultation Evaluation FormThe members of the Bioethics Committee wish to know if their responses to your consult have been timely,helpful, and effective. In order to constantly improve the service offered, we need feedback. Yourresponse to the following questionnaire is essential. Thank you.

Please fill out the information below and return the form to Director of Department of SpiritualCare, Box 163.Please check the response that most clearly reflects your opinion.

1. The team of consultants who responded to your request:A. Was open to your concerns ( ) Yes ( ) NoB. Asked useful questions ( ) Yes ( ) NoC. Seemed knowledgeable ( ) Yes ( ) NoD. Assisted in the discussion process ( ) Yes ( ) NoE. Clarified issues ( ) Yes ( ) NoF. Was prompt ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

2. As a result of the consult:A. Ethical issues were clarified ( ) Yes ( ) NoB. Decision-making was facilitated ( ) Yes ( ) NoC. You became aware of additional perspectives ( ) Yes ( ) NoD. You had an increased confidence in patient care decisions ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

3. The consultation provided an opportunity for health professionals to express concerns,raise questions, give input and receive explanations ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

4. Were you satisfied with the result/outcome of the consultation? ( ) Yes ( ) No

5. As a result of your experience, are you more likely or less likely to seek the assistanceof the Bioethics/Chaplaincy services again?

( ) Neither ( ) More Likely ( ) Less LikelyComments: __________________________________________________________________________________________________________________________

6. Any suggestions for improving the consult service?Comments: _________________________________________________________________________________________________________________________

Signed: ______________________________ Date: _____________________________ Evaluator

Page 9: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Ethics at A Glance

A Manual for Resolving Ethical Clinical Issues

This manual is provided by the Covenant Health System BioethicsCommittee to assist you in resolving ethical dilemmas that mightarise in the hospital. Please review this manual as needed to beginthe process of resolution when you are aware of a possible ethicalconcern.

You may access help at any time by contacting theDepartment of Spiritual Care, your unit chaplain, or thechaplain on call. This department will help you with ethicalconcerns and arrange team conferences and/or consults asneeded.

Department of Spiritual Care 725-0427On-Call Pager 71-0162

Table of Contents:

Resolving Ethical Issues in Patient Care Flowsheet

Bioethics Reference Grid

Bioethics Committee Members 2002

Ethics Conference Worksheet

Bioethics Team Consultation Evaluation Form

Administrative Policies & Procedures Related to Ethical Concerns

Nursing Policies Related to Ethical Concerns

St. Joseph Health System – Ethical Decision Making

Page 10: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,
Page 11: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Resolving Ethical Issues in Patient CareConfer with immediate supervisor (i.e),Assistant Nurse Manager, Supervisor

Discuss with designated attending physician and attempt toresolve

Specify Policy Provision(See Bioethics Reference Grid - Ethics at a Glance manual)

Impasse Reached

Chaplain to contact Bioethics Committeerepresentative and

Community of Concern,(Bioethics Team Consultation Evaluation Form

completed)

EthicalIssue

Identified?

No Ethical Issueto Address

IssueResolved?

IssueResolved?

IssueResolved

IssueResolved

Contact chaplain in Spiritual CareDepartment for Ethics Conference,

gather Community of Concern(Ethics Conference Worksheet completed)

No

Yes

No

Yes

Yes

No

Community of Concern mightinclude: patient/surrogate, family,members of the medical team,administrative representative

Page 12: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Administrative Policies Related to Ethical Issues

Page 13: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 1 of 7

Revised 1-24-02

Covenant Health System - Lubbock

Standard Policy and/or Procedure Policy # 03 RITitle: Resolving Ethical Issues

Approved By: Executive Management Team: 03/99 Legal/Compliance: 03/99

CMC & CCH Medical Staff: 04/05/99 Board of Directors:

Effective Date: 05/99Revised Date: 01/02

Review Date:Statement of Purpose: To have an identified process through which Covenant Health Systemcaregivers, patients, family members, and employees may raise an ethical concern.

Text:

I. PolicyA. Definition of ethical concern, issue, dilemma:

1. An ethical dilemma arises when there is tension between loyalties; responsibilities, duties,rights, or values, all of which are good in themselves, but all of which can't be satisfied in aparticular situation.

2. In this event, issues arise for which there is no discernible "right" or "best" answer.3. If the attending physician refuses to honor a patient's Advance Directive or a treatment decision

made on behalf of a patient, a Bioethics Committee review is mandatory under state law.

II. ProcedureA. Defining an ethical process:

1. How may ethical dilemma's be approached. Covenant Health System - Lubbock identifies thefollowing steps that may be taken to resolve ethical dilemmas:

2. Most often, the process of working through an ethical issue requires going back and forthbetween steps rather than proceeding in a step-by-step progression.a. Gather the community of concern for a “bedside” ethics conference. The work of this group

will be to facilitate the identification of the problem. The community of concern may becomprised of:1) the attending physician and/or consulted physicians2) nursing staff3) chaplains4) case management/social services representative5) other members of the health care team directly involved in the patient’s care6) patient/patient’s surrogate7) patient’s family members

Page 14: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 2 of 7

Revised 1-24-02

b. Clarify the facts as far as possible. The step involves gathering points of view, querying formissing information, researching for policy and practice guidelines, regulations, availableliterature.

c. Identify key stakeholders. In this step, the group identifies who the people are who will beaffected - directly or indirectly - in the resolution of the dilemma. Attention must also begiven to foreseeable harms and benefits, and there must be a determination of what isimportant to these people.

d. Consider alternative course of action in light of Covenant Health System's values (Dignity,Service, Excellence, and Justice). The group begins the brainstorming process: allalternatives are considered, benefits & harms are identified, comparison of alternatives withour values is done, and the option that best realizes our values is articulated.

e. Make a decision.f. Develop a plan for implementation. The group determines what the steps to implement the

decision need to be and by whom, the communication mechanisms, managing remainingconcerns of those affected by the decision, and a determination of whether or not additionalpolicies/practices need to be articulated or existing ones altered.

g. All medical personnel will provide appropriate documentation in the medical record.h. Evaluate the team process utilizing verbal feedback from all participants in the community

of concern. The chaplain facilitator will document feedback on the Ethics ConferenceWorksheet.

i. Implement the Plan for Implementation.B. Mechanisms available that an employee, caregiver, patient or family member may use to initiate this

process:1. Department of Spiritual Care personnel are contacted.2. Spiritual Care personnel will gather the community of concern for a “bedside” ethics conference

and serves as facilitator of the outlined process, utilizing the Ethics Conference Worksheet as aguide. At the conclusion of the process the facilitation chaplain will lead the team through averbal evaluation of their work together. The completed Ethics Conference Worksheet will besubmitted to the Director of the Department of Spiritual Care.

3. If the chaplain leading the team is unable to resolve the identified ethical problem, the case willbe referred to the Bioethics Committee for review.

4. If the attending physician refuses to honor a patient's Advance Directive or a treatment decisionmade on behalf of a patient, a Bioethics Committee review will be conducted.

5. The chaplain will contact the Bioethics Consultation Team leader. The issue will be reviewedemploying the procedure outlined in A. 2 above.

6. The person requesting the Bioethics Team Consultation will be requested to evaluate thefunctioning of the Bioethics Consultation Team utilizing the Bioethics Team ConsultationEvaluation Form.

7. The team leader will contact the Bioethics Committee Chair with the findings andrecommendations from the consult.

8. The team leader will give a follow-up report at the next scheduled Bioethics Committeemeeting.

References: Federal Patient Self-Determination Act, Texas Health & Safety Code, Chapter 166 -Advance Directives. See also related Nursing Service policy for additional details.

Attachments:1. Ethics Conference Worksheet2. Bioethics Team Consultation Evaluation Form3. Resolving Ethical Issues in Patient Care Flowsheet

Page 15: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 3 of 7

Revised 1-24-02

ETHICS CONFERENCE WORKSHEET

Person Requesting Consult:________________________________________Reason For Consult:______________________________________________Attending:_______________________Consultants:_____________________________________________________CaseManager____________________ ChaplainsConsultants:____________________________________________Admitting Diagnosis:______________________________________________PresentCondition/Prognosis:______________________________________Advanced Directive for Healthcare: Yes NoIs Document in Chart? Yes NoIf yes, what are patientsdirections?______________________________________________________________________________________1) Medical Power of Attorney for Healthcare? Yes No2) Is Document in chart? Yes No3) Is Patient capable of making thisdecision? Yes No4) If yes what are patients directions?________________________________________________________________________________________________5)Who has Durable Power of Attorney forHealthcare?________________________________6) Who is/are the surrogate decisionmaker(s)?______________________________________________________7) If more than one of equal position are theyin agreement? Yes No

8) If No Please Explain:____________________________________________________________________________Surrogate Wishes:________________________________________________________________________________Presenting Ethical Concern________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Values or Principles at stake:(EthicalReligious Directives)______________________________________________________________________________________________________________________________________________Pertinent Covenant Health System Policies_______________________________________________________________________________________________Patient Label

Page 16: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 4 of 7

Revised 1-24-02

Summary of Plan for Implementation:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Conference Members Evaluation of Process:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations for Improvements:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Forward completed form to Director of Spiritual Care.

Chaplains Signature:__________________________________Date:______________

Page 17: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 5 of 7

Revised 1-24-02

Bioethics Team Consultation Evaluation FormThe members of the Bioethics Committee wish to know if their responses to your consult have beentimely, helpful, and effective. In order to constantly improve the service offered, we need feedback. Yourresponse to the following questionnaire is essential. Thank you.

Please fill out the information below and return the form to Director of Department of Spiritual Care, Box 163.Please check the response that most clearly reflects your opinion.

1. The team of consultants who responded to your request:A. Was open to your concerns ( ) Yes ( ) NoB. Asked useful questions ( ) Yes ( ) NoC. Seemed knowledgeable ( ) Yes ( ) NoD. Assisted in the discussion process ( ) Yes ( ) NoE. Clarified issues ( ) Yes ( ) NoF. Was prompt ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

2. As a result of the consult:A. Ethical issues were clarified ( ) Yes ( ) NoB. Decision-making was facilitated ( ) Yes ( ) NoC. You became aware of additional perspectives ( ) Yes ( ) NoD. You had an increased confidence in patient care decisions ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

3. The consultation provided an opportunity for health professionals to express concerns, raise questions, giveinput and receive explanations ( ) Yes ( ) NoComments: __________________________________________________________________________________________________________________________

4. Were you satisfied with the result/outcome of the consultation? ( ) Yes ( ) No

5. As a result of your experience, are you more likely or less likely to seek the assistanceof the Bioethics/Chaplaincy services again?

( ) Neither ( ) More Likely ( ) Less LikelyComments: __________________________________________________________________________________________________________________________

6. Any suggestions for improving the consult service?Comments: _________________________________________________________________________________________________________________________

Signed: ______________________________ Date: _____________________________ Evaluator

Page 18: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 6 of 7

Revised 1-24-02

Resolving Ethical Issues in Patient CareConfer with immediate supervisor (i.e),Assistant Nurse Manager, Supervisor

Discuss with designated attending physician and attempt toresolve

Specify Policy Provision(See Bioethics Reference Grid - Ethics at a Glance manual)

Impasse Reached

Chaplain to contact Bioethics Committeerepresentative and

Community of Concern,(Bioethics Team Consultation Evaluation Form

completed)

EthicalIssue

Identified?

No Ethical Issueto Address

IssueResolved?

IssueResolved?

IssueResolved

IssueResolved

Contact chaplain in Spiritual CareDepartment for Ethics Conference,

gather Community of Concern(Ethics Conference Worksheet completed)

No

Yes

No

Yes

Yes

No

Community of Concern mightinclude: patient/surrogate, family,members of the medical team,administrative representative

Page 19: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 03 Resolving Ethical Issues 1-02 Page 7 of 7

Revised 1-24-02

Affected Departments: All Departments

Responsible Parties:Department Directors, Bioethics Committee, Department of Spiritual Care,

Consutation Teams

JCAHO Standard: RI.1, RI.1.2, RI.1.2.2, RI.1.2.3

Comments: In collaboration with Patient Rights and Organization Ethics Functional Subcommittee, ExecutiveManagement Team, Compliance, Medical Staff, Bioethics Committee

...........................

Page 20: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 01 Patient Rights & Responsibilities Page 1 of 4

Covenant Health System - Lubbock

Standard Policy and/or Procedure Policy # 01 RITitle: Patient Rights & Responsibilities

Approved By: Executive Management Team: 03/99 Legal/Compliance: 03/99

CMC & CCH Medical Staff: 04/05/99 Board of Directors: 04/12/99

Effective Date: 05/99Revised Date: 09/99

Review Date: 01/01

Statement of Purpose:The health care professionals at Covenant Health System - Lubbock recognize that each patientis an individual with unique health care needs. We respect the dignity and worth of every personand continually strive to provide considerate, respectful care focused upon the patient'sindividual needs. We believe that a person's health is affected by environmental and emotionalstresses, and that being able to communicate concerns with the health care team is important tothe healing process as well as being a primary right of the patient. Our organization assistspatients in exercising rights and informs patients on admission of any responsibilities incumbentupon them in the exercise of those rights. We provide education for our staff about patient rightsand responsibilities.

Text:

I. Policy

Patient Rights:A. Our patients have the right to exercise these rights without regard to sex, nationalorigin, race, age, economic status, educational, or religious background or the source ofpayment for care:1. Be provided information and assistance in understanding information throughouttheir stay about their condition, rights and responsibilities.2. Have a written copy of the patient's rights and responsibilities upon admission inthe patient's primary language, or have an appropriate translator.3. Receive a reasonable response to requests and needs for treatment and/or service.4. Impartial access to medically appropriate treatment which promotes continuity ofcare.5. Considerate and respectful care that recognizes psychosocial spiritual, and culturalvariables, preserving human dignity.

Page 21: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 01 Patient Rights & Responsibilities Page 2 of 4

6. Access to pastoral care and other spiritual services.

7. The right to be free from all forms of abuse or harassment, including verbal, physical,psychological, sexual or emotional while under the care of the hospital.

8.Access to protective services, including guardianship and advocacy services,

conservatorship, and child or adult protective services.

9. The right to be free from seclusion or restraints of any form that are not medicallynecessary or are used as a means of coercion, discipline, convenience, or retaliation bystaff.10. The opportunity to voice complaints about his or her care, and to have thosecomplaints reviewed, and when possible, resolved (see also Administrative Policy #11-RI, Patient and Family Requests/Complaints). Patients and family members areencouraged to call the Guest Request Line at extension 40625) If a patient or familymember wishes to lodge a formal complaint with the Texas Department of Health, theymay do so either by phone, fax or mail to:

Health Facility Compliance DivisionTexas Department of Health1100 W. 49th StreetAustin, TX 78756FAX (512) 834-6653Complaint Hotline 1-888-973-0022

11. Personal privacy and confidentiality including:a. Being interviewed, examined, and treated in surroundings designed to givereasonable visual and auditory privacy. Giving consent to any photographic techniquesthat would allow or be used in such a way that personal identification is possible.b. Restricting access to the medical record to only individuals directly involved in thepatient's care, or monitoring the quality of care, or authorized by law/ regulation, orauthorized by permission of the patient or legal representative.c. Having access to the information in the patient's hospital record by the patient ordesignated representative.12. Care of the dying which provides comfort and dignity to the patient througheffective pain management, and acknowledgment of the psychosocial and spiritualconcerns of the patient and the family regarding dying and the expression of grief.13. To express their spiritual beliefs and cultural practices as long as these do not harmothers or interfere with treatment.14. Make healthcare choices together with the physician with respect to the following:a. The acceptance of care and/or refusal of treatment and to be informed of themedical consequences of such refusal.b. Formulation of advance directives and appointing a representative to makehealthcare decisions on their behalf.

Page 22: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 01 Patient Rights & Responsibilities Page 3 of 4

c. The involvement of family and/or guardian in the care choices throughout thecourse of treatment or the exclusion of any or all family members from participating inhis or her care decisions.15. Be informed of any research/ educational projects involving their care or treatmentand to understand that refusal to participate in a research project will not affect theirtreatment or care.16. Have their guardian, next of kin or legal representative exercise their rights if thepatient is deemed legally incompetent, medically incapable of understanding theproposed treatment or procedure, unable to communicate health care choices, or is aminor.

17. Have a family member or representative of the patient's choice and his/her physiciannotified promptly of his/her admission to the hospital.18. Know the professional status of persons providing care and services, and anyprofessional relationships of persons providing care.19. Reasonable personal and environmental safety.20. Request another health care practitioner or consultant from another facility.21. Transfer to another facility or organization if the patient is medically stable, hasbeen completely examined by a physician, the need for transfer established andcommunicated to the patient and an accepting physician and facility have been secured.22. Request and receive a detailed explanation of a bill for services rendered.23. Patients have the right to communication (mail, visitors, phone calls) unless thepatients chooses to restrict communication.24. If it becomes necessary to restrict a patient's visitors, mail, telephone calls or otherforms of communication, the restrictions are evaluated for their therapeuticeffectiveness and are fully explained to the patient and are determined with theirparticipation.

B. Ethical Issues: The Bioethics Committee at Covenant Health System serves as theadvisory body to deal with ethical issues that arise in the case of treatment choice. Thepatient or designated representative can bring ethical issues to the committee bycontacting Covenant Health System Pastoral Care Ministries.

Patient Responsibilities:A. Our patients have the responsibility to :1. Provide accurate and complete information relating to their health and medical care.2. Ask questions if they do not understand their plan of care or expectations, and tomake decisions regarding their medical care.3. Follow the recommended treatment plan and be responsible for actions andoutcomes from refusing services/instructions.4. Assure prompt payment for financial obligations for services rendered.5. Follow hospital policies, procedures, rules, and regulations as these affect patients,their families, their visitors.6. Respect individuals and property of other patients, health care workers, visitors, andthe hospital.B. It is the responsibility of the patient who wishes to make an advance decisionregarding his/her medical or surgical treatment, including the withholding or

Page 23: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 01 Patient Rights & Responsibilities Page 4 of 4

withdrawal of life-sustaining procedures if he/she should become unconscious,incompetent, or otherwise incapable of personally making a decision, to clearly indicatehis/her desires to Covenant Health System and his/her attending physician.

Affected Departments: All Departments

Responsible Parties:Department Directors

JCAHO Standard: RI.1, RI.1.1, RI.1.2-RI.1.2.3, RI.1.3 - RI.1.3.6.1.1, RI.1.4, RI.1.5, RI.3-RI.3.1, PF 1.9

Comments: In collaboration with Business Services, Patient Rights and Organization Ethics FunctionalSubcommittee, Compliance, Legal, Executive Management Team, Medical Staff

...........................

Page 24: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 02 PSDA, Advance Direct, Med Pwr Atty, DNR Page 1 of 4

Covenant Health System - Lubbock

Standard Policy and/or Procedure Policy # 02 RITitle: Patient Self Determination Act Compliance, Advance Directives, Medical Power of Attorney, DNR Policy

Approved By: Executive Management Team: 03/99 Legal/Compliance: 03/99

CMC & CCH Medical Staff: 04/05/99 Board of Directors:

Effective Date: 05/99Revised Date: 09/99

10/01

Review Date:Statement of Purpose: To provide guidelines for the Covenant Health System - Lubbock tocomply with the Federal Patient Self-Determination Act; Texas Health & Safety Code, Chapter166 - Advance Directives. Texas law regarding informed consent; and a patient's/patient's agent'sright to refuse medical or surgical treatments, which includes the right to have life-sustainingprocedures withheld or withdrawn.

Text:

I. PolicyA. Medical Power of Attorney for Health Care allows a person to designate a third party as his agent

for purposes of making any health care decision should the patient become incapable of making suchdecision for himself.

B. Directive to Physicians and family or surrogates: a person may instruct his physician to administer,withhold, or withdraw, life sustaining treatment in the event of a terminal or irreversible condition,including artificial nutrition and hydration and other life sustaining treatment when the applicationserves only to postpone the natural process of dying, unless pregnant.

C. Advance Directives: an advance directive or similar instrument validly executed in another state orjurisdiction shall be given the same effect as an advance directive validly executed under the law ofthis state.

C. Adult patients will be informed in writing, about their right, under state law, to make health caredecisions and execute advance directives.

D. A patient within the Covenant Health System has the right to make decisions involving his/herhealth care in collaboration with his/her physician, including the right of the patient to:1. Accept medical care or refuse treatment and to be informed of the medical consequences of suchrefusal;2. Formulate, in compliance with Texas law, advance directives (Directive) and/or appoint asurrogate to make health-care decisions on his/her behalf (Medical Power of Attorney) should he/shebecome mentally or physically incapable of communication.

Page 25: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 02 PSDA, Advance Direct, Med Pwr Atty, DNR Page 2 of 4

3. A Directive will not become effective until the patient has been diagnosed and certified in writingto have a terminal or irreversible condition by the attending physician.4. A Medical Power of Attorney

a. before executing the Medical Power of Attorney , the patient must sign a statement that he/shereceived a disclosure statement, and read and understood its contents.b. allows a person to designate a third party as his agent for purposes of making any health caredecision should be the person become incapable of making such decisions for himself.c. is effective only if the patient's attending physician certifies in writing and files thecertification in the patient's medical record that based on the attending physician's reasonablemedical judgment, the patient lacks capacity to make health-care decisions.

5. Request his/her attending physician do nothing (Do Not Resuscitate) if he/she experiencescardiac arrest and/or respiratory or ventilator arrest. Comfort care will be provided for both physicaland spiritual needs, however medical interventions will not be done to stop or slow the dyingprocess. The patient will be allowed to die without intervention by Covenant Health System or thepatient's attending physician.6. Have his/her guardian, next of kin, or a legally authorized responsible person (an agent) exercise,to the extent permitted by law, the rights delineated on behalf of the patient if the patient: a. Has been adjudicated incompetent in accordance with the law, b. Is found by his/her physician to be medically incapable of understanding the proposed treatment or procedure, c. Is unable to communicate his/her wishes regarding treatment (temporary or permanent), or

d. Is a minor.e. An agent cannot make a health-care decision:

1) If the patient objects, regardless of whether or not the patient has the capacity to make thehealth-care decision, except if declared incompetent by a court of law.

2) For voluntary inpatient mental health services. 3) For convulsive treatment. 4) For psychosurgery.

5) For abortion.6) For the discontinuance of care intended to provide for the comfort of the patient.

f. If the agent and the physician disagree regarding the patient's treatment and the patient'swishes are not known, an ethics consultation may be facilitated by the unit Chaplain or anotherSpiritual Care Ministries representative. Advice from legal counsel may be requested. If theattending physician refuses to honor a patient's Advance Directive or a treatment decision madeon behalf of a patient, a Bioethics Committee review is mandatory under state law.

II. Procedure

A. When admitting personnel conduct pre-registration phone calls, patients will be asked if they have an advance directive, and if so, will be asked to bring a copy when they are admitted.B. Upon admission the adult patient will be asked if he/she has prepared a living will or executed a

Medical Power of Attorney. If patients have directives, they will be asked to provide a copy, and acopy will be placed on the medical record.

C. If the patient does not bring a copy of the directive at the time of admission and a current copy is noton file in the Medical Records Department, Admitting will advise the patient to arrange for thedirective to be brought in and then ask the patient to fill out an Advance Directive AcknowledgmentForm and give it to their nurse.

D. If the patient has a directive from previous admission, Medical Records will be contacted to retrievethe directive. A copy will be sent to the unit and put on the patient's medical record. If the computerhas no date for the Advance Directive, Medical Records will write the visit (date Advance Directivereceived) on the face sheet and return it to the Admitting Manager to enter into computer database.If Medical Records is unable to locate the directive from a previous admission, the patient will be

Page 26: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 02 PSDA, Advance Direct, Med Pwr Atty, DNR Page 3 of 4

asked to arrange for a copy to be brought in and then asked to fill out an Advance DirectiveAcknowledgment form.

E. Patients who are not admitted through the Admitting Department and who indicate on the PatientHealth History form they have executed an advance directive but have not brought it with them willbe asked by nursing staff to arrange for a copy to be brought in and then asked to fill out an AdvanceDirective Acknowledgment form.

F. Advance Directive Acknowledgment forms will be placed under the Advance Directive tab in themedical record. The Advance Directive Acknowledgment form is not intended to replace, modify,or cancel existing directives, and is only applicable until the actual directive is physically available.When a copy of the actual directive is obtained, the Acknowledgment form will be replaced in themedical record.

G. At the time of admission as an inpatient and on request, the patient will receive literature and haveaccess to education regarding1. His/her right to accept or refuse medical or surgical treatments, including the withholding orwithdrawal of life-support;2. His/her right to formulate an Advance Directive;3. Policies of the Covenant Health System respecting the implementation of such rights.Departmental responsibility for presenting Patient Self-Determination Act information to a patientwill depend on the route by or through which a patient is admitted to the Covenant Health Systemand at what point the patient expresses a desire to make a health-care decision or formulate adirective.4. Spiritual Care Ministries or Case Management/Social Services will be contacted to assist anindividual with directives and should document in the multidisciplinary/ancillary notes. The patientmay consult with their physician regarding advance directives.

H. It is the responsibility of the patient who wishes to make an advance decision regarding his/hermedical or surgical treatment, including the withholding or withdrawal of life-sustaining proceduresif he/she should become unconscious, incompetent, or otherwise incapable of personally making adecision, to clearly indicate his/her desires to his/her attending physician and Covenant HealthSystem.

I. The Covenant Health System - Lubbock will document in each adult patient's record whether or notthe patient has executed an Advance Directive, or other type of advance health-care decision.

J. An advance health-care decision may be revoked at any time by oral or written notification by thepatient/agent.

K. Neither this health system nor the attending physician may require a patient to execute a Directive,a Medical Power of Attorney or other advance health-care decision as a condition for admittance orreceiving treatment in this hospital.

L. The Health System will provide educational opportunities to its staff and the community on issues concerning Advance Directives/advance health-care decision choices.M. While Covenant Health System - Lubbock supports the involvement of the family and/or guardian in the decision making process throughout treatment, it is the right of the patient to choose those persons to be excluded, unless otherwise specified by law.N. The physician will be contacted for orders concerning the implementation of the healthcare

decision/document as needed.O. Health-care decisions that affect the delivery of care to the patient by members of the health care

team must be entered into the patient's chart as an order by the attending physician, or the staff maytake a verbal order which is to be authenticated by the physician or his/her designee within 24 hours.

P. Patients for whom a DNR order has been written should have a strip of blue tape on the outside ofthe chart and on the armband.

Q. When no surrogate is available and the patient is not known to caregivers, any treatment decisionsshould promote the patient's well being in accord with respect for human dignity; refer to Vernon'sTexas Civil Statutes which states to consult the Bioethics Committee for assistance with decisions.

R. When the surrogate or caregivers are unwilling to stop an existing treatment, refer to Vernon's TexasCivil Statutes which states to consult the Bioethics Committee for assistance with decisions.

Page 27: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 02 PSDA, Advance Direct, Med Pwr Atty, DNR Page 4 of 4

References: Federal Patient Self-Determination Act, Texas Health & Safety Code, Chapter 166 -Advance Directives. See also related Nursing Service policy for additional details.

Affected Departments: Medical Records, Admitting, Patient Care Units, Business Services,

Medical Staff, Spiritual Care Ministries, Case Management/Social Services

Responsible Parties:Medical Records, Admitting, Medical Staff, Nursing Service, Department of

Spiritual Care, Case Management/Social Services, Ethics Committee

JCAHO Standard: R1 1.2.4 – RI. 1.2.8

Comments: In collaboration with Patient Rights and Organization Ethics Functional Subcommittee,Compliance, Legal, Executive Management Team, Medical Staff

...........................

Page 28: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 1 of 6

Covenant Health System - Lubbock

Standard Policy and/or Procedure Policy # 07 RITitle: Informed Consent

Approved By: Executive Management Team: 03/99 Legal/Compliance: 03/99

CMC & CCH Medical Staff: 04/05/99 Board of Directors:

Effective Date: 05/99Revised Date: 09/99

10/01

Review Date:Statement of Purpose: To assure that the patient has been provided with adequateinformation to make a decision to consent to a procedure or treatment. To assist the physician incomplying with Article 46901, V.A.T.S., and amended Title 25, Texas Administrative Code,601. Informed consent required disclosures for medical and surgical procedures.

Text:

I. PolicyA. Proper consent must be obtained before administering medical treatment or special procedures.

1. To be valid, the consent obtained must be an informed consent.2. Securing the patient's signature on a form is not sufficient; the patient must, in addition

a. understand the circumstances to which he/she is consentingb. freely choose to enter into the agreement.c. understand the consequences of having or not having the procedure.

3. The physician is responsible for informing the patient/legal guardian of the recommendedsurgical, diagnostic, or medical procedure and the risks involved, benefits, and alternatives andobtaining the patient's informed consent.

4. This consent must be in writing and on the proper form.5. This obligation may not be delegated to other hospital personnel.6. If the patient/legal guardian has questions relating to the procedure, the consent will not be

signed and the physician will be notified.B. An emergency is presumed to exist if the physician determines that there is an immediate threat to

life or limb.1. If immediate treatment is required to prevent deterioration or aggravation of the patient's

condition.2. Consent by emergency will be effective until that point at which delay in treatment does not

increase the hazard to the patient.

Page 29: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 2 of 6

II. ProcedureA. To obtain an informed consent, to the following conditions must be met by the physician:

1. Advise the patient (or legally responsible representative) of:a. The nature of the proposed procedure;b. Alternative methods of treatment, if any;c. The seriousness of the procedure;d. The expected and possible results;e. Any significant risks involved; andf. Possible results of nontreatment

2. The physician will document that he/she has informed the patient of the risks, benefits and alternatives on either the History and Physical, the Physician's Progress Notes, the label provided, or elsewhere in the medical record.

3. It should be noted that the amount of information given to the patient regarding risks involved inthe proposed procedure is a medical decision within the sound discretion of the physician, anddue consideration should be given to the patient's condition.

4. If two different physicians do two procedures at the same time, two consent forms should beobtained.

5. Before the consent form is signed, the patient or guardian will be asked to:a. read the formb. ask questionsc. verbalize an understanding of the risks and hazards on the consent form and the procedures

to be performed.6. Consent forms will be read to patients who are unable to read or who are visually handicapped:

a. The form will be translated into the patient's language if the patient does not read orunderstand English.

b. Documentation of translation should be in the nurse's notes.B. Disclosure of Risks and Hazards: the Texas Medical Disclosure Panel.

1. Pursuant to Article 45901, V.A.T.S., the Texas Medical Disclosure panel was created todetermine the risks and hazards related to medical care and surgical procedures which must bedisclosed by attending physicians prior to treatment of patients in order to obtain a valid andbinding consent. The panel was authorized to identify and make a thorough examination of allmedical treatments and procedures in order to determine which of these treatments andprocedures do and do not require disclosure of the risks to the patient and to establish thegeneral form and substance of such disclosure.

2. The Panel was required to place each treatment/procedure on one of two lists; (1) thoserequiring written disclosure or List A, (2) those not requiring written disclosure or List B.a. A current list of procedure on Lists A and B will be maintained on all nursing units.b. Procedures that do not require disclosures (List B) may have:

1) "Does Not Require Disclosure" entered in the space provided for recording risks andhazards.

3. If the Panel's approved consent form is correctly utilized it will be presumed that the physicianhas complied with the statute and that the patient has been adequately informed of all risks andhazards involved with the procedure to be performed.

C. Disclosure and Consent: Medical and Surgical Procedure forms are available for physicians fromthe hospital Medical Record Department and on the patient care areas.

D. The physician is requested to use the Disclosure and Consent forms provided by the Hospital whichhave been preprinted with the required disclosures for the procedures/treatments on List A.

E. The physician is requested to have the form signed by the patient at his office, and send the consentto the hospital prior to admission or with the patient at the time of his/her admission.

F. If the physician telephones (verbal), or writes specific orders as to:1. The condition requiring treatment2. The specific procedure or treatment

Page 30: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 3 of 6

3. Any specified risks and hazards or those in List A, Nursing personnel may then transcribe thisinformation to the Disclosure and Consent form.

G. If the nursing personnel assist the physician in securing the patient's signature on the Disclosure andConsent form:1. The consent form should be spelled accurately, written legibly and without abbreviations.2. Enter the name of the physician(s) responsible for the procedure.3. Transcribe the condition requiring treatment in the appropriate space.4. Cross through "do", "do not", or "not applicable" to this procedure as appropriate.5. Enter "not applicable" or "none required" in spaces as appropriate.6. Secure the signature of the patient or his legally responsible representative, prior to any pre-

medication.a. If a patient is physically or educationally unable to sign his/her name, an "X" is legal.b. The witness will write "patient's mark" beside the "X" before signing as a witness.c. Patients who are unable to make an "X" will give verbal consent and the next of kin or legal

guardian will be allowed to sign the consent.7. Secure the signature of as least one competent adult witness. The "witness" signature confirms

only the signature of the patient and does not verify that the information was actually given.8. Enter the date and time patient signed consent.9. Stamp the form with the patient's addressograph card or label with the patient's identification

sticker.10. All appropriate spaces on the consent form must be completed. The consent form must not

contain any blank spaces.H. Physicians may wish to briefly summarize in the progress notes or other appropriate sections of the

medical record the explanations given to the patient which constituted the informed consent, and todocument the fact that the patient appeared to understand and agree to the procedure.

I. If the patient voices questions or lack of understanding about the procedure to be done and the risksinvolved the consent will not be signed and the physician will be notified. The patient should not berequested to sign the form until he/she expresses understanding. All questions should be referred tothe physician and not answered by hospital personnel.

J. All consent forms will be checked by a licensed nurse for accuracy and completeness before a pre-operative medication is administered. The nurse has a responsibility to notify the physician if thisform is incomplete or has not been completed. The nurse's note should reflect:1. a call (or calls) was placed to notify the physician for the purpose of advising him/her with

regard to the consent2. the physician was advised regarding the status of the consent form (incomplete/not completed at

all) and;3. the physician's response to this information.

K. An obvious error in Disclosure and Consent will be reported to the physician:1. If pre-operative medications have not been given a corrected consent will be obtained by the

physician or by order.2. If pre-operative medications such as sedative or hypnotic drugs have been given, the patient

may sign a permit if an assessment is done and the patient is found to be oriented to person,place, time, and verbalizes an understanding of the procedure to be done.

L. Who May Consent: the following persons are legally authorized to consent:1. Adults-

a. An adult is any person 18 years or older or any person male or female who is or has beenlegally married and has not been legally declared incompetent or insane with a guardianappointed.

b. Common law marriage is legal anytime two persons publicly state they are man and wife.Hospital personnel must take the word of the man and woman involved.

c. For adult patients who are comatose, incapacitated or incapable of communication, thefollowing persons in order of priority are deemed surrogate decision-makers:1) Spouse (or parent if not married)2) Adult child who has the waiver and consent of all other qualified adult children

Page 31: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 4 of 6

3) A majority of the patient's reasonably available adult children4) Parents5) Majority of available adult brothers and sisters6) Patient's nearest living relative7) An explanation of the person's relationship to the patient should be written on the

consent form when someone other than the patient has signed the form.d. Exemptions to the above list include:

1) A durable power of attorney for health care2) An Advanced Directive under the Natural Death Act3) Consent to medical treatment for minors under Chapter 35 of Family Code4) Hospital patient transfers under state law5) Patient's legal guardian with decision-making authority for medical treatment6) Consent for emergency care under state law regarding emergency services7) In the event of a life-threatening emergency in which the patient is unable to give

informed consent, and the legal guardian cannot be reached, the attending physicianwill obtain written concurrence of two physicians, not involved in the case, or a courtorder may be obtained.

2. Minors- A minor is generally defined as a person under 18 years of age who is not and has notbeen married or who has not had his disabilities of minority removed for general purposes.a. A parent or legal guardian will sign the consent form for minor childrenb. A written consent for treatment signed and dated by an absent parent or guardian will be

accepted in emergency situations.c. The divorced parent who has legal custody of a minor may sign. The parent without

custody has the right to consent to medical treatment of the child to the same extent as theparent with custody.

d. Divorced parents of minors who have joint custody will both sign the consent form.e. Any of the following persons may consent to medical treatment of a minor when the

parents or legal guardians cannot be contacted and actual notice to the contrary has not beengiven by that person:1) A grandparent2) An adult brother or sister3) An adult aunt or uncle4) An educational institution in which the minor is enrolled that has received written

authorization to consent as otherwise provided by law.5) Any adult who has care and control of the minor and has written authorization to

consent from the person having the power to consent as otherwise provided by law6) Any court having jurisdiction of the child.

3. When Minors May Consent: Minors may consent to their own treatment under any of thefollowing conditions without the consent of the parents:a. The minor is legally married.b. The minor is on active duty with the armed services of the United States of America.c. The minor is 16 years of age or older and resides separate and apart from his parents,

managing conservator, or guardian, whether with or without the consent of the parents,managing conservator, or guardian and regardless of the source of his/her income.

d. The minor consents to the diagnosis and treatment of any infectious contagious, orcommunicable disease which is required by law or regulation adopted pursuant to law to bereported by the licensed physician or dentist to a local health officer.

e. The minor is unmarried and pregnant, and consents to treatment, other than abortion,related to the pregnancy.

f. The minor consents to examination and treatment for drug addiction, drug dependence, orany other condition directly related to drug abuse. Under the above conditions the hospitalmay rely on the written statement of the minor containing the grounds on which the minorhas the capacity to consent to his own treatment.

g. A married minor may consent to the treatment of his/her minor child.

Page 32: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 5 of 6

h. The physician may (with or without the minor's consent) advise the parents of the treatmentgiven or needed by the minor, except in case of drug abuse and in the case of alcohol abuse.

i. In the case of examination and treatment for drug abuse and in the case of alcohol abuse, noinquiry can be made of the parents' financial responsibility, and no bill or any othercommunication in respect to service rendered may be transmitted directly or indirectly tothe parents without the express written consent of the minor patient.

j. In the case of drug abuse and in the case of alcohol abuse, when a minor applies forservices, the fact of such application may not be disclosed without consent of the applicantto the applicant's parent, guardian, or other person authorized under State law to act onbehalf of the applicant, unless the applicant lacks capacity for rational choice.

M. Refusal to Submit to Treatment:1. Occasionally a patient who is conscious, obviously in full possession of his/her faculties and

other wise authorized to consent to treatment or a special procedure, may refuse to submit totreatment.

2. In addition to documenting the fact that the nature and necessity of the procedure was explainedand the consequences of the refusal, the physician should document the medical indicationsjustifying the necessity for the procedure or treatment, the fact that the patient understood thisinformation, the fact that the patient refused to consent to and the reason.

3. If the responsible physician doubts the mental competency of a conscious patient who isotherwise authorized to consent and who refuses to consent:a. If the treatment in question is emergent in nature, the responsible physician may rely on his

own medical judgment relative to the competency of the patient.b. If the treatment in question is not emergent in nature and there is sufficient time to

implement necessary incompetency procedures, or to secure a court order authorizingtreatment, the physician should contact Hospital Administration.

N. Patient In Police Custody:1. The rules listed above apply to patients in police custody.2. The fact that a patient is in police custody does not change the responsibility to obtain the proper

consent.O. Telephone Consents:

1. Ordinarily, telephone consents should not be taken. If the next of kin or legal guardian is notpresent and the patient's condition will not allow delay of treatment, a telephone consent will beobtained.

2. The telephone consent will be made by a hospital employee with a second employee listening inon a conference connection or by stating the consent to two employees separately if aconference connection is not available.

3. Full documentation is required. An entry should be made in the medical record denoting thedate, exact time of the call, telephone number called, name of person giving the consent,relationship to the patient, reason for the telephone consent, name and title of witnesses, andsignature and title of person making the note.

4. The consent form will be read to and explained to the person giving consent.5. The consent form will state "Telephone consent of (name of consentor)" and "(relationship to

name of patient)." Both hospital employees who heard the consent given will sign as witnesses.6. Consents obtained by FAX machine may be accepted as valid.

P. Consent Via Power of Attorney:1. Any patient may transmit his/her power to consent to his/her agent through the use of power of

attorney. There are several requirements before such a transmission of power is consideredvalid.a. First, the agreement must be in writing, and must either specifically grant the power to

consent for medical purposes or grant a general and unlimited power to consent.b. There are two issues where a power of attorney is involved:

1) The scope of the power to consent must be sufficient to encompass the situation.2) The grant of power must be a valid grant.

Page 33: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 07 Informed Consent Page 6 of 6

Q. Duration of Consents:1. A consent is not valid after the patient has been discharged from the hospital.2. The consent obtained from the patient upon admission will generally cover medical treatment

received during the entire period of hospitalization, excluding those procedures/treatmentsrequiring specific disclosures and consent on List A.

3. If the patient is admitted for a specific course of treatment/procedure and the anticipatedprocedure changes it is necessary to obtain a new consent form for the changed procedure.

R. Disclosure and Consent for Blood Transfusion:1. A signed disclosure and consent form for blood transfusion must be obtained with the

physician's order for type and cross-match.2. This consent form is valid during the patient's entire hospitalization unless the patient or

patient's agent notifies the hospital personnel of their desire to refuse administration of blood.3. If the physician orders "No disclosure for blood" or "no blood permit" the administration of

blood will not be discussed with the patient and the consent form will be marked not applicableto this procedure.

4. When the patient has not given consent to receive blood or blood products on the previouslycompleted Disclosure and Consent, but wishes to authorize such treatment a new separateconsent should be signed.

5. If the patient or patient's agent refuses administration of blood, the physician will be notified,and the patient will sign a "Blood Refusal" form.

Affected Departments: Clinical Departments, Nursing Service, Medical Staff

Responsible Parties: Department Directors listed above, Medical Staff

JCAHO Standard: RI 1.2.1, TX.5.2-TX.5.2.2

Comments: In collaboration with Patient Rights and Organization Ethics Functional Subcommittee, ConsentsTeam, Executive Management Team, Medical Staff, Legal, Compliance. Refer to Administration Policy: Autopsy & FormRecord of Death with Request for Organ/Tissue Donation

...........................

Page 34: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 06 Management of Dying Patient Page 1 of 2

Covenant Health System - Lubbock

Standard Policy and/or Procedure Policy # 06 RITitle: Management of the Dying Patient

Approved By: Executive Management Team: 03/99 Legal/Compliance: 03/99

CMC & CCH Medical Staff: 04/05/99 Board of Directors:

Effective Date: 05/99Revised Date: 09/99

Review Date:Statement of Purpose: Our goal in caring for the dying patient is to assist in making thedying phase of life as full and meaningful as possible. Patients and their families should receivecare and attention specific to their individual wishes and needs. Care should be provided withrespect, and in a manner that uphold their dignity. In addition to providing the best care possible,we should facilitate the movement of the patient back into the community through referrals tosuch agencies as hospice and home health.

Text:

I. PolicyA. The care of the dying is an interdisciplinary collaborative effort involving physicians, nursing staff,

Spiritual Care Ministries, and other members of the Health Care Team.1. Since death is such a multi-faceted stage of life, the involvement of caregivers from a variety of

departments will usually be required. Caregivers include, but are not limited to: Nursing,Medical Staff, Spiritual Care Ministries, Case Management/Social Services and Food andNutrition.

2. There are several related hospital policies which may be utilized at appropriate times in the careof the dying patient.

3. Appropriate care of the dying means that a dying person can expect:a. To be treated as a living human being until death.b. To be cared for by compassionate, sensitive, knowledgeable people who will attempt to

understand the needs of the dying and who will be able to gain some personal satisfaction inhelping the patient face death.

c. To express feelings and emotions about approaching death.d. To participate in decisions concerning care and not to be judged for such decisions, which

may be contrary to the beliefs of others.e. To die in peace and dignity and not alone.f. To have every effort made to keep them free from pain.g. To have questions answered honestly and not to be deceived.h. To expect their families will be able to be as supportive as possible.i. That the sanctity of one's body will be respected after death.

Page 35: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

RI 06 Management of Dying Patient Page 2 of 2

II. ProcedureA. Respect the patient's right to make decisions about care. Abide by the patient's advance directive,

including Directive to Physicians and/or Medical Power of Attorney for Health Care.B. Offer pain management, consultation and techniques, including medication, as ordered.C. Position for comfort allowing for decreased pressure on bone prominence.

1. Keep patient clean.2. Provide good skin care.3. Consider special beds as appropriate for care and comfort.

D. Consult Spiritual Care Ministries or Case Management/Social Services as needed.E. Provide patient and family with opportunity to verbalize feelings.F. Help to alleviate anxiety and fear by allowing significant other, clergy, or staff to be present, except

when privacy is required by patient.G. Offer frequent oral care, ice chips, or hard candy as indicated for comfort.H. Support the patient and/or significant other in their individual spiritual or cultural dying rituals.I. Allow significant others to participate in the patient's care to their own abilities and desires.J. Permit significant others to remain with patient twenty-four hours a day if appropriate.K. Provide a calm, soothing environment:

1. light low2. music, as desired3. curtain and door closed4. avoid harsh stimuli

L. Support and facilitate patient and/or significant other's communication with medical staff.1. continue to speak to patient2. encourage family to talk to patient

M. Evaluate patient's response to interventions for pain management and to control other systems asnecessary and document in nurses' notes at least once per shift.

N. Document inclusion of patient and family in development of the plan of care on Care Plan.O. Document referrals to Spiritual Care Ministries, Case Management/Social Services or Dietitian in

Care Plan.P. Document patient/family visits in nurses' notes.

Affected Departments: Clinical Departments, Medical Staff, Department of Spiritual Care

Responsible Parties: Clinical Department Directors, Medical Staff, Department of

Spiritual Care

JCAHO Standard: RI 1-RI.1.2, RI.1.2.7

Comments: In collaboration with Patient Rights and Organization Ethics Functional Subcommittee, ExecutiveManagement Team, Medical Staff

References to other Policies & Procedures: Management of Pain, Positioning of Patient, Patient Self-Determination Act.

...........................

Page 36: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Bioethics Committee Members 2002

Beth PrattBarbara CoxDarla HowardDiane McIntire, MDEd GeorgeElizabeth MartinEvelyn QuigleyFr. Anthony EmeritoJohnny CoxJoyce BrommLinda McMurryMelanie Oblender, MDMichelle PruittPam HillisPaulett RozneckRonnie Agnew, JDRoxie TaylorSister Claire OliverSusan WarnerTed Allen, MDTed DottsTom McGovernWilliam Shaver, MD

Page 37: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

St. Joseph Health System

Ethical Decision Making

Page 38: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

1

Recognizing and Managing Ethical Concerns

By their very nature, questions about what should be done, rather than simply whatcan be done have no easy answers. Taking time to reflect together can shed light onwhat approach to a given situation might best protect human dignity.

I. Understanding EthicsA. Ethics is concerned with activity and identity:

1. Activity - choices - what we do.2. Identity - character - who we are.

B. Each person's worth is the keystone of ethical responsibility:1. Fundamental rights address the basic needs required for persons to live

together with dignity.2. Discrimination, exploitation, manipulation violate human worth.

II. Ethical Problems occur in two main formsA. Ethical Dilemmas:

1. Some evidence indicates that act x is morally right, and some evidenceindicates that act x is morally wrong, but the evidence on both sides isinconclusive.

2. An agent believes that, on moral grounds, he or she both ought andought not to perform act x.

B. Ethical Distress occurs when one knows the right or fitting thing to do butinternal or external constraints are preventing one from doing it:1. Disagreement about which action is right or fitting exists among

patient/family or caregivers (conflict of conscience).2. Individual organizational or societal forces hinder doing the right or fitting

thing.

III. Analyzing Ethical ConcernsA. Knowing our personal values enhances our professional choices:

1. Recognizing and naming value concerns is usually difficult.2. Responding to differences and conflicts requires confidence and good will.

B. Gathering data is just as important as evaluating:1. Questions individuals ask can lead to insights about key concerns.2. Ethical analysis considers four essential components of choices:

alternatives available, specific circumstances, probable consequences, motivations.

C. Evaluating alternatives reveals hidden assumptions:1. Uncover values and concerns of each of the stakeholders.2. Consider them with ethical principles and organizational conscience.3. Discuss together to determine optimal alternative.

Page 39: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

2

Recognizing and Managing Ethical Concerns Page 2

IV. Enhancing Ethics ResourcesA. Ethics committee and/or Ethics Resource ServiceB. EducationC. Policy supportD. Open communicationE. SJHS Ethics Staff: Johnny, Barb, Jack

Page 40: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Barb & Johnny CoxEthics at a GlanceA:/Consult3docJune 2000

3

ETHICS CONSULTATION/CASE REVIEWS

What are they?♦ An opportunity to focus upon and think through the ethical issues in particular

cases.

When are they appropriate?♦ When the ethical dimensions of a case are puzzling or disturbing♦ When decision-making is at a stand-still♦ When the proper decision-making cannot be identified♦ When there is disagreement among patient, family and/or caregivers

Who can initiate a consultation/case review?♦ Patients♦ Families♦ Physicians♦ Employees

What can a consultation/case review accomplish?♦ Clarify issues♦ Promote reflection♦ Facilitate decision-making♦ Enhance communication and understanding♦ Provide support with difficult decisions♦ Resolve disagreements♦ Support primary decision-maker(s)♦ Promote dignity♦ Avert crises♦ Manage resources♦ Identify the benefits and risks of intervention♦ Lead to the best solutions-best interest of the patient

Page 41: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Barb & Johnny CoxEthics at a GlanceA:/Consult3docJune 2000

4

Page 42: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

A M ethod for M akingEthical Decisions

An ethical dilemma arises when there is tension between loyalties,responsibilities, duties, rights, or values, all of which are good inthemselves, but not all of which can be satisfied in a particular situation.Both in our personal and our professional lives, we often struggle withissues for which no “right” answer seems available. In these situations it isimportant to think through as carefully as possible the many factors that areat stake.

The following method lists six steps that will trigger consideration ofcritical areas.

While there is a logical progression to these steps, the process of decisionmaking will usually involve going back and forth among them.

The six steps are:

1. Gather the community ofconcern

2. Clarify the facts as far aspossible

3. Identify key stakeholders

4. Consider alternative course of action in light of our values

5. Make a decision

6. Develop a plan for implementation

Community of

Concern

Implementation

Facts

Stakeholders

EthicalDecision

Alternatives

Page 43: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

St. Joseph Health System Values

DignityWe respect each person as an inherently valuable member of the human

community and as a unique expression of life.

• We respect the inherent dignity and worth of every individual.

• We share needed information and encourage decision making,responsibility, and accountability at all levels.

• We communicate openly with each other and provide timely, honestfeedback.

• We provide recognition - formal and informal - to individuals and workgroups for their contributions.

• We recognize the importance of a balance between work and personallife.

ServiceWe bring together people who recognize that every interaction is a unique

opportunity to serve one another, the community, and society.

• We respond to the needs of the whole person: body, mind, and spirit.

• We foster an environment characterized by hospitality, trust, and a spiritof community.

• We design and evaluate our organizational systems and structures toassure that they meet the needs of those we serve.

• We value the opportunity to be of service beyond our organization bycontributing to the well-being of our communities.

• We work with others - public and private agencies, associations andindividuals - to improve the delivery and quality of health services.

ExcellenceWe foster personal and professional development, accountability,

innovation, teamwork, and commitment to quality.

• We foster personal and professional development, free exchange ofdiverse ideas, innovation, and teamwork.

• We expect accountability for excellence in performance and foradherence to professional and organizational standards.

• We work together to be effective and efficient in the use of resourcesand to provide a safe environment.

• We require a reasonable financial return in order to fulfill our mission.

• We develop programs and processes to measure and continuallyimprove quality in everything we do.

JusticeWe advocate for systems and structures that are attuned to the needs of the

vulnerable and disadvantaged and that promote a sense of communityamong all persons.

• We advocate at local, state, and national levels for health care policiesthat provide universal access to basic benefits, distribute burdens andbenefits equitably, and promote the responsible allocation ofresources.

• We dedicate resources to the care of the medically poor.

• We develop systems and structures that attend to the needs of those atrisk of discrimination because of age, gender, lifestyle, cultural orethnic background, religious beliefs, or socioeconomic status.

• We conduct our business ethically, with integrity, honesty, andconfidentiality.

• We develop a work environment that promotes mutual respect,participation, equitable compensation, growth, and effective use oftalents.

• We recognize that individual, institutional, and societal interests areoften in tension; in every case we strive to discern how the good ofthe whole can best be served.

1. Gather the community of concernAn essential first step in the process is to gather the appropriategroup to discuss the issues. The best solution will emerge only ifthe dilemma is defined and the questions are considered from ascomplete a perspective as possible.Even though not everyone concerned can be present for thediscussion, it is important to get their perspectives in some way.When key stakeholders have been identified in Step 3, additionalmembers of the community of concern may need to be added.

2. Clarify the facts as far as possiblea. Does everyone agree on the facts of the situation?b. Are there key facts we do not know? How can we find these

facts?c. Are there regulations, policies, or practices that apply?d. What has been the practice in the past, in this or similar

situations?3. Identify key stakeholders

a. Who are all the people who will be affected, directly orindirectly, in the resolution of this dilemma?

b. What are the foreseeable harms and benefits to these individuals and/or groups?

c. Is there priority among stakeholders?

4. Consider alternative courses of action in light of ourvaluesa. What are all the possible options for resolving the dilemma?

(Be expansive here; don’t judge or limit yet.)b. What are the likely benefits and harms to those who will be

affected by each option?c. What values are at stake (and possibly in conflict)?

(See Values listed above.)d. Which option best realizes our values?

5. Make a decision6. Develop a plan for implementation

a. What next steps need to be taken? By whom?b. How will the decision be communicated?c. What process will be used to handle remaining concerns of

those affected?d. Are there policies/practices that need to be altered as a result

of this decision?

Page 44: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

Nursing Policies Related to Ethical Issues

Page 45: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

IN HOSPITAL DO NOT RESUSCITATE (DNR) ORDER(Implementation of a Health-care Decision)DEPT: NursingSECTION: Basic CarePOLICY #: II-C-6aPAGE 1 of 5APPROVED BY: Nursing AdministrationEFFECTIVE DATE: June 25, 1999

REVISION/REVIEW DATE: August 2001

DEFINITIONS: 1. An in hospital DNR order is implementation of a patient's/patient's agent'sauthorization to reject life sustaining or death prolonging treatment or towithhold or withdraw life-sustaining treatment, even if death results and evenin the absence of a written directive or medical power of attorney for healthcare.

2. Attending physician is the physician who has primary responsibility for thetreatment and care of the patient.

3. Agent for the purpose of this policy is a minor's parents, legal guardian,managing conservator or spouse(if an adult.) For the incompetent adult theagent is the legal guardian or the designated decision maker under the directionof the Medical Power of Attorney. If there is no legal guardian or decisionmaker the agent(s) will be one of the following individuals (if available) in thefollowing order:a. the patient's spouse;b. patient's reasonably available adult children;c. the patient's parents; ord. the patient's nearest living relative.e. if the patient does not have any relatives, the attending physician and

with concurrence by a non-treating physician or physician on the ethicsor medical committee can issue a DNR order in the patient’s behalf.

GUIDELINES/STATEMENT OF PURPOSE:1. Covenant Hospital System, Lubbock, Texas has a standing policy to initiate life sustaining procedures

for all patients who do not have a physician's order to withhold resuscitative efforts.2. Level of resuscitation will be defined as follows:

a. Full cardiopulmonary resuscitation efforts will be initiated and continued until otherwiseordered by a physician.

b. Cardiopulmonary resuscitation efforts will not be initiated as per physician's order.c. DO NOT RESUSCITATE orders with restrictions and/or limitations will be clearly defined

by a physician.POINT: A "Medications Only" order is not recognized as a level of resuscitation.

Medications will not be given unless accompanied by cardiopulmonaryresuscitation.

3. The patient's right to reject treatment, even if it may lead to death, will be respected and supported.

DNR Patients should beidentified by placing bluetape on their ID bands andcharts.

Page 46: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

DNRPage 2 of 5

POINT: The rights of a pregnant patient to accept or refuse medical or surgical treatments, aresubordinate to the rights of the unborn child. Life sustaining treatment may not bewithdrawn/withheld.

4. The patient will continue to receive appropriate nursing care for any primary and secondarysymptoms, according to the wishes of the patient or the patient's agent.POINT: 1. Staff should deliver care to the patient and/family or significant other (SO)

that demonstrates respect for the patient's values, religion andphilosophy.

2. It is important to provide nursing care that promotes patient comfort andprovides for patient privacy/confidentiality and dignity.

3. Meeting the patient's/family's/SO's physical, psycho social, and spiritualneeds is best accomplished through collaboration with the attendingphysician, nursing and other healthcare professionals/services.

5. A competent, adult patient can issue a verbal DNR request.6. If the patient is comatose, incompetent or otherwise incapable of communication, a DNR order

to withhold or withdraw life-sustaining procedures will be accepted if agreed upon by theattending physician and the patient's agent(s). Refer to definitions page one.

7. A DNR request will be accepted on behalf of a minor from the patient's parents, legal guardianor managing conservator.POINT: The desire of a competent minor supersedes the effect of a DNR request issued by

or on behalf of the patient.8. A patient's/agent's verbal DNR request will be documented in the physician's progress notes by

the attending physician or his/her designee within 24 hours and should include the following:a. Date, time and description of verbal DNR request issued by the patient/agent;b. Restrictions and/or limitations of DNR order;c. Relationship and signature of agent(s) , if applicable; andd. Assessment of patient's decision making capacity at the time the verbal DNR order was

issued.9. The attending physician will write a DNR order or the staff may accept a verbal order from the

physician.POINT: The physician's verbal order must be authenticated within 24 hours.

10. A DNR order is effective until revoked. It can be revoked at any time without regard to thepatient's mental state or competency.

11. A DNR order will become void with a verbal or written order under the following conditions:a. The attending physician may rescind an order at any time.b. Expressed desires of the patient/agent.c. Upon transfer into the hospital from another facility.d. Upon admission to the surgical department.e. Upon transfer to Covenant Health System, Lubbock, Texas Skilled Nursing Facility or

the Rehabilitation Institute.12. The desire of a competent patient will supersede the effect of any request made on behalf of the

patient when the patient's desire is communicated to attending health care professionals.

Page 47: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

DNRPage 3 of 5

13. Conflicts involving decision-making and or implementation of a DNR order will be resolvedthrough the following means:a. DNR orders issued by competent patients or agents acting on the patient's behalf should

be followed to the extent they are consistent with the patient's wishes, written directive,Medical Power of Attorney, polices and procedures of Covenant Health System,Lubbock, Texas/Covenant Children's Hospital.

b. If the attending physician or health care provider can not follow a request, the physicianwill make a reasonable effort to transfer responsibility for the patient's care to anotherphysician or health care provider. The patient or patient's agent will be informed assoon as is reasonably possible. The refusal will be reviewed by the ethics committee andthe patient will receive life-sustaining treatment during review.Note: Ask a Pastoral Care Representative to contact the Ethics committee. See

Administrative Manual.c. If the attending physician determines that a specific treatment ( including CPR) would be

futile and the patient/agent disagrees, then the physician must make a reasonable effortto transfer care to another physician. The position of the physician will be reviewed bythe ethics committee and the patient will receive life-sustaining treatment during review.See note above.

d. Efforts should be made to discuss/resolve issues and/or conflicts with the persons directlyinvolved, e.g. competent patient/agent/family member and the attending physician.

e. Issues and/or conflicts that cannot be resolved may will be referred to the EthicsCommittee for advice.

14. The charge nurse is responsible for verifying the DNR order on the chart, identifying the patient andplacing a piece of blue tape on the patient’s ID arm band and chart. Should the DNR status berescinded the charge nurse is responsible for verifying the order, identifying the patient and removingthe blue tape from the patient’s arm band and chart.

Purpose: To provide guidelines to allow patients, or their agents, if applicable, to reject life-sustaining ordeath prolonging treatment, to withhold or withdraw medical treatment even if death resultsand even in the absence of a written directive or durable power of attorney for health care byrequesting the attending physician to issue a do not resuscitate order.

PERFORMED BY: Physician, Nursing Staff

PROCESS:1. When a patient or his agent makes known his desire to issue a DNR request, the attending physician is

to be contacted.2. The attending physician should discuss the possible results of non-treatment and any significant

alternatives with the patient/agent by the attending physician.3. Documentation is to be entered into the physician's progress notes as described in policy statement (8)

eight.4. Nursing staff may receive either a written or verbal order from the attending physician on the patient's

DNR status.5. Unit secretary or charge nurse: Enter DNR status to Patient Profile screen in computer.

Page 48: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

DNRPage 4 of 5

NOTE:1. This action will cause code status to print on charge nurse Shift Report .2. Code status will also print on patient Kardex.

6. Charge nurse:a. Enter patient's code status into Charge Nurse Report Book.b. Enter patient's code status on Patient Census Sheet for supervisors. 1. Identify patient and place blue tape on the identification band and chart.

7. Charge nurse/primary care nurse : Inform next shift of patient's code status during change of shiftreport.

8. Documentation:a. Discussions with patient/agent regarding DNR.b. Actions taken, i.e. notification of attending physician, consult for clergy etc.

SHOULD THE DNR STATUS BE REVOKED:Charge nurse/primary care nurse:1. Obtain an order from the attending physician.2. Remove DNR status from computer, Charge Nurse Report Book, and Patient Census Sheet.3. Inform staff of change of status.4. Report change of status in change of shift report.5. Charge nurse identifies patient and removes blue tape from the identification band and chart.6. Documentation:

a. Discussion preceding revocation of DNR.1) Time2) Persons involved3) Patient condition at the time.

b. Actions taken.1) Time attending physician notified.2) Orders received.3) Computer status change.4) Notification of other staff.

OTHER DEPARTMENTS AFFECTED:Medical Staff

JCAHO STANDARDS: Patient Rights and Organization Ethics, RI.1, RI.1.1, RI.1.2, RI.1.2.2, RI.1.2.3,RI.1.2.4, RI.1.2.5, RI.1.2.6, RI.1.2.7Management of Information, IM.7.2Education, PF.1-PF.1.8 IntentContinuum of Care, CC.4

LITERATURE REFERENCES: Texas Health and Safety Code, Chapter 166, Advance Directives, 1999.

Important Choices, Helping You Better Understand Medical TreatmentDecisions, Covenant Health System, Lubbock, Texas

Code of Federal Regulation, Title 45-Public Welfare. Chapter XIII, Part

Page 49: BIOETHICS REFERENCE GRID - Covenant Health3-Bioethics Reference Grid Page 4 of 5 02/21/02 BIOETHICS REFERENCE GRID with the patient’s desires Patient/surrogate insisting on medically,

DNRPage 5 of 5

1340 Child Abuse and Neglect Prevention and Treatment, Sec.1340.15

Texas Bill 1260, Chapter166, Sub-chapter B Directive to Physicians,Sec. 166.049

Combined: May 1999Revised: April 2001(Reviewed by legal)Reviewed: August 2001