Volume 4, Issue 07 -September 2001

Ethics in Long Term Care?

The atmosphere of the long-term care (LTC) environment is changing in Alberta as the population ages and the acuity of LTC residents rises. This change in atmosphere has included a recent popular move towards establishing ethics committees in long-term care. In what follows, I will offer a few thoughts about ethics committees, point out two distinctive features of LTC, and offer two reasons why ethics committees can be helpful in responding. I will then give several examples of the unique clinical situations that arise in LTC.

Ethics Committees

In the LTC setting, I view ethics committees as organized groups of people who have varied backgrounds related to the delivery of long-term care. These backgrounds may range from training in philosophy to healthcare, and include related life experiences. I see the evolution of a successful committee as having three aspects: self-education at both the initial and ongoing stages of committee operation, advertisement of the committee's services, and the offering of consultation services. The committee plays a specific and invited role in the discussion of an ethical issue. There is no role for "policing" in this mandate. I do not believe that every LTC facility needs to maintain an ethics committee, but each does need access to consultation and educational services, perhaps on a fee-for-service basis.

LTC: A Changing World

One might wonder what is special about LTC such that access to an ethics committee is required. I would indicate two distinguishing features of this environment.

First, residents of LTC are currently able to choose from a variety of invasive procedures previously available only in acute care settings. This is part of the "down-loading" of services from the acute care to the community care setting. These choices raise complex questions around care options. Examples of such treatment options include cardio-pulmonary resuscitation (CPR) and intra-venous therapy. Whereas in the past, staff may not have been required to have the skills to offer these services, now proficiency in these areas are expected of LTC workers. Inclusion of these treatments in the LTC setting raises questions about who should receive these services, who should offer the services, and who should pay for these services.

While an ethics committee may not have answers to these questions, the committee can resolve discussions about them into segments that are more easily understood and relate them to the implicit ethical premises on which they are based. In my view, an ethics committee should never take on the role of "problem solver" as this would assume greater knowledge than the care team and resident: a situation that can only lead to committee failure. Thus, issues in LTC are becoming more complex and often involve principles of ethics that an ethics committee can help clarify.

The second distinguishing feature of the LTC environment that I wish to call attention to involves the problematic decision-making that can sometimes arise due to the situation in which many patients find themselves. Residents remain in the LTC setting for extended periods, generally with a contract for care services. Furthermore, the population is large and many residents no longer possess the mental faculties necessary for making personal health decisions. Families and other parties want to play a role in the health care decision-making of residents, while health professionals are in close attendance and often focus on a medical model of care. Although personal directives are widely discussed, very few residents actually have a personal directive or an appointed agent. All of this can make determining the right course of action in certain cases difficult.

Ethics committees can assist with such situations by providing an organized framework for the discussion of the ethical aspects of the situation at hand. Some complex issues may be beyond the care team's training and ability to resolve. When this occurs, an ethics consultation team can be helpful, together with the input of a bioethicist, in bringing to light the ethical features of a discussion.

Examples from LTC

Having provided a flavour of the LTC context, I will now try to identify, using examples, the types of complex cases that arise in LTC. I will also try to highlight some of the more important considerations in these examples that an ethics consultation service would need to bring to attention. The point of this exercise is to further illuminate the nature and complexity of the LTC environment.

My first example involves the non-communicative resident without a personal directive who has a stroke and requires nutritional support such as a feeding tube. Important considerations in this situation include the potential benefit of continued treatment to the patient, the quality of life expected, the impact of life duration on the family, and the costs of maintaining the tube.

My second example involves the LTC resident who is a long-time smoker who is considered not to be safe with smoking materials. Questions of personal freedom and the assumption of personal risk are important and need to be weighed against the safety and health of other LTC residents. Other issues may include the ability of LTC staff to supervise the safe use of smoking materials and regional policies that prohibit smoking on all properties under its management, including LTC sites.

Example three includes the LTC resident known to have been non-compliant with medication in the community and who now objects to the medications offered by health professionals. Issues in this type of example include the right of a compus-mentus patient to accept or reject health advice, the change in the perception of the resident when the medication is delivered on a schedule by a health professional, and the need to review medication effects and overall health plan. The needs of health professionals to meet licensing requirements are another factor to be considered here.

Example four is about the health professional who doesn't believe that medical orders need the permission of a patient. Questions of professional expectations, patient autonomy, and how to handle conflicts arising over care plans; all must be considered here.

In example five, the LTC administrator reduces unit funding, thus lowering the staffing ratio. Questions of how to best benefit the most people and yet fulfill obligations to serve the entire LTC population as well as the ethics of workplace stress require attention in this type of example. While questions at this level may be beyond the mandate of ethics committees, ethics resources should be available to assist these types of issues.

Personhood

Threaded throughout this review of the role of an ethics committee in LTC is the concept of the "personhood" of the resident. We can define "personhood" as the fulfillment of the human potential to accept the rights of an adult within this society. This highlights a common issue in LTC wherein residents may no longer have the capacity to make informed choices with regard to their personal well-being. When a person moves from the community to LTC, there is a potential decrease in personal freedom and privacy that is exchanged for services and health benefits. The overall role of LTC and an important role for an ethics committee is to preserve as much of a resident's "personhood" as possible. This means where possible to make use of personal directives, respect agent's roles, and strive to attain the community of care that a resident would choose if able.

I believe that by acting as an educational resource to itself and those it serves, and by offering sound ethical information in consultation with the care team, an ethics committee has a justified existence in LTC. It needs to be recognized that no committee functions without expenditures for operation and education, but when weighed against the costs of disrupted healthcare delivery and the attendant frustration, there is a balance in favour of ethics committee existence. As we try to move the mandate of superior long-term care forward, the need for clearly thought-out care based on ethical principles and for moral assistance and support for care providers becomes increasingly acute.

Ethics committees will likely not provide answers to the types of complex problems identified in this article, but will hopefully help to crystallize the questions that can aid discussion. In my opinion, the ultimate reason for the pursuit of quality in LTC is the preservation of "personhood." I have introduced this concept briefly, and believe it should be the guiding concept in LTC. "Personhood" raises numerous ethical issues as my examples indicate. Without a functioning ethics committee in LTC, I believe that the "personhood" of residents is in jeopardy.

Announcements

• The Network's staff are pleased to announce that PHEN's distance education course: An Introduction to Bioethics, will be offered again this year. The course is scheduled to begin January 21, 2002 and conclude with a final in-person session to be held on May 23, 2002. Information and application materials will be available shortly. Please consult the PHEN web site for more details.
• PHEN has put together a collection of articles that touch on a number of issues in health ethics as a resource for Albertans. The index for these articles is available on the PHEN web site at www.phen.ab.ca/articles. The articles will be available, free of charge, until November 1, 2001. For more information, or to obtain articles, please contact PHEN's Northern Alberta office or e-mail info@phen.ab.ca.
• The seventh annual PHEN conference will be held at the Westin hotel in Edmonton on May 24th, 2002. Watch In Touch and the PHEN web site for further details regarding the conference program.
• A reminder that the next deadline for submitting applications to PHEN's User Fund is November 15, 2001. For more information, please contact PHEN's Northern Alberta office or e-mail info@phen.ab.ca.
• Copies of In Touch for the months of July and August have been published on PHEN's web site. To access these articles, please visit www.phen.ab.ca/materials/intouch.html. If you do not have access to the Internet, please contact the Northern Alberta office to have a copy of these issues faxed or mailed to you.
• Staff Changes:
• Colette Mooney, PHEN's Executive Assistant, has accepted a new position elsewhere and will be leaving the staff as of September 28, 2001. Colette has been a member of the PHEN staff almost since the Network's inception and has provided much of the glue that keeps the disparate parts of the organization together. Her dedication to the Network has clearly been instrumental in its rapid growth and various successes. She will be sincerely missed by her fellow staff members and is wished the very best of luck in the new chapter of her life experiences.
• Marika Warren and Rose Muto, summer research assistants working with the Northern Alberta office, have completed their time with PHEN and have returned to their academic pursuits. PHEN thanks them for their valuable contribution to the Network's activities and wishes them prosperity in their studies.
• The Northern Alberta office is pleased to welcome Maria Tchir to the PHEN team. Maria will be assisting the Northern Alberta office on a part-time basis for the coming months.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.