Volume 4, Issue 08 - November 2001

Success Is the Journey: The Crossroads Regional Ethics Committee

In this article, we share our journey of building a regional ethics committee in Alberta's Crossroads Health Region. We would like to begin by acknowledging PHEN for the opportunity to do so. We are humbled by this invitation and hope that by sharing some of what we have learned, others may benefit. We have worked passionately to nurture a group of people who care a great deal about ethics, to be champions of this endeavour in our region . . . it is rewarding for them to know their work is being noted beyond our health region.

First Steps

Upon regionalization in 1995, the Crossroads Regional Health Authority (RHA) embarked upon an extensive strategic planning process that identified the need to establish a regional ethics committee. The RHA Board and Chief Executive Officer (CEO) for the region were very supportive of this idea. They believed the need for a regional ethics committee would become very significant as RHAs encountered increasingly complex resource and service issues. The Chief Operating Officer (COO) for Regional Community Services was asked to establish, mentor and coach this committee.

This was new territory for all. After much discussion, it was decided that a different approach for the formation of this committee would be used. The COO for Regional Community Services organized an introductory forum with Dr. John Dossetor and his team from PHEN to present on the whys, hows and roles of a regional ethics committee. Personalized invitations to the forum were sent to about 45 people in the region and community - individuals known to be interested in ethics or thought to have great potential to be valuable members. Of those invited, 29 individuals came. At the end of the forum, the CEO and the COO for Regional Community Services spoke about their vision of what we needed and how this evolutionary work was likely not for the faint of heart, but rather would require a huge commitment. They asked for expressions of interest and commitment and invited those expressing such to a continuation of the session with PHEN in January 1997. And so, our committee was formed. Four years later, 8 out of 16 people who attended the follow-up workshop are still very involved with ethics in the region.

Committee Membership

We have found that it is critical to have people interested and committed to ethics involved with the committee because the work of this group involves a very long journey of education and influencing attitudes. In selecting committee members, we were not primarily concerned with geography or professional discipline (this seemed to self-sort). The only appointment to the committee was the physician member. Today, we do try to ensure that we have a community member and we also have the ability to augment the committee with expert advice when necessary. We have always tried to emphasize that membership is voluntary, and continue to do so.

In terms of recruitment, we have a continual low-grade campaign underway to ensure we always have sufficient members available as contingencies to deal with changes that normally occur in the lives of people. Out of all the strategies we have employed, the best is one-on-one recruitment. Prospective members or individuals expressing interest are invited to observe a meeting before making the decision to join.

Each year we review our Terms of Reference and re-visit membership. The profile of membership over 3 years has included: home care nurse, public health nurse, speech-language pathologist, continuing care manager, pastor, pharmacist, physician, medical library technician, regional placement coordinator, community genetics nurse, executive secretary, mental health therapist, dental health/health promotion program secretary. The COO for Regional Community Services provides corporate liaison and mentoring for the committee and facilitates an annual operational climate scan and goal setting session.

Roles & Functions

Very early on in our journey we decided as a committee that it was important to know what our focus would be, and to establish a framework for how our committee would work. Planning has been key for our committee and we cannot stress this enough. There has been a direct correlation between the time and energy we have spent in planning and the success of, and satisfaction with, our committee. Our planning process has involved all committee members as we believe that the responsibility for the committee's work belongs to everyone on it. The roles and functions of our committee are clearly outlined in our terms of reference. During the early days of our committee, they provided a point of focus for us when we were developing goals and work plans, and continue to guide the work of our committee today. These roles include:

Education

It is probably no surprise that our initial discussions led us to focus on the education of committee members first. To feel comfortable providing consultations and being an ethics resource for our region, we had to be knowledgeable ourselves. Our self-education has included establishing a work plan to follow that gives focus and establishes priority areas for the committee. Key self-educational activities have included: time at each meeting for the review of case studies and ethics articles, attendance at ethics workshops and conferences, inservices on topics such as group facilitation, and development of a standard orientation process and manual for new members.

A few key points that our committee likes to emphasize about education and member attitudes are: 1) members do not need to start with a knowledge of ethics, but they do need to start with an interest in how consumer/client/patient and professional values are lived out in daily acts; 2) members need a tolerance for ambiguity and a willingness to commit time to learn more about the field of bioethics; 3) they need to acknowledge what they do and do not know; and 4) committee leaders must make conscientious efforts to provide learning opportunities for committee members throughout their time with the committee.

Clinical Consultation

It was critical for our committee to adopt a model for dealing with clinical consultations and case reviews, as well as a decision-making framework that would guide our process for thinking about the complex issues we would face. This identification was central in that it provided us with a concrete base from which to move in consultations. Our committee follows an educational model for doing clinical consults. Key elements of this model are: providing opportunities for people to talk through issues; clarifying the problem/issues at hand within the situation; discussing explicitly the ethical issue(s) of concern and principles involved; exploring options for resolving the issues; and assisting the individual(s) in making a decision.

Connections

What makes an ethics committee an exciting and interesting group to belong to is the sense that what members are doing is valuable. One important step in becoming a valuable resource is letting people know about the work we do. To this end, we developed brochures about the committee and distributed them to staff and physicians, and also made them available to the public. We also developed a display board to promote ethics within and outside the region. The display is put up at various events, such as inservice sessions, conferences, workshops, and during bioethics week.

Dialogue/Reflection

When an ethics committee is doing its job well, it will be seen not as a group of "ethics experts" but rather as a community where issues concerning human dignity and respect can be safely discussed, and where those responsible for making decisions can receive assistance in making those decisions for themselves. To ensure this, it has been important for our committee to make the time and space for critical reflection. It is the richness of the conversation about ethical issues that is generated in this space that draws most people to ethics committees. Building upon this, our current and future work now focuses on developing committee expertise around common issues such as resuscitation orders, truthtelling and withholding information, insertion of feeding tubes and various end of life issues.

Cooperation

One key role for ethics committees is observing where practices, policies and missions of organizations have become disconnected. After careful thought, we decided our role would be in an advisory/consultative capacity regarding policies and policy writing. We have consulted on several policies and letters (e.g., concerns resolution policy, personal directives, protection for persons in care, anonymity issues, and recommendation 46 of the Broda Report).

Barriers & Successes

One of the primary challenges our group faces is getting the resources necessary to support the committee - especially replacement for shift workers. Another continual challenge is promoting the role and value of the committee throughout the region. And, of course, a key challenge is the extraordinary personal time commitment that working on an ethics committee requires. Notwithstanding these barriers, our committee has met with some success. We believe that some of the reasons why our journey has been fruitful include:

• the support we have received from and the continued liason we have with the RHA and Senior Management
• the keenly interested, highly committed and self-motivated committee members we are so fortunate to have - members with a passion for ethical principles and practices
• our celebration of small successes
• the relationship building that continues to happen among our members that spins into other relationships and places where people live, work and play
• the fact that we have a small region where all programs are planned and managed using a regional approach.

Several meetings ago, one of our valued members brought back learnings from a workshop she had attended. It is something that she personally exemplifies in all of her daily work and reflects the general understanding and global outcome we as a committee desire. We would like to leave you with it...

"Each of us plays a part in making our region ethically value laden."

Thank you for inviting us to share a bit of our journey.

Announcements

• Bioethics Distance Education
  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 28, 2002 and conclude with a final in-person session to be held on May 23, 2002. Information and application materials can be obtained from the PHEN website (www.phen.ab.ca) or the Network's Northern Alberta office.

• Bioethics Week 2002
  Alberta's Second Annual Bioethics Week is set to run from March 4 - 10, 2002. This initiative is meant to provide opportunities for hosting events aimed at raising awareness of and facilitating discussion around ethical issues concerning health and health care. For information on how PHEN or one of our partner organizations might assist with the planning of your event, please contact either Network office.

• Articles Database
  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 website at www.phen.ab.ca/articles. For more information, or to obtain articles, please contact PHEN's Northern Alberta office or e-mail info@phen.ab.ca.

• General Announcements
  
  • The seventh annual PHEN conference will be held at the Westin hotel in Edmonton on May 24th, 2002. Watch In Touch and the PHEN website 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.

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