In this episode, Tyler and Devan are joined by Dr. Peter DePergola to explore policies addressing non-beneficial treatment requests, medical futility, and inappropriate treatment demands. Dr. DePergola, the Shaughness Family Chair for the Study of the Humanities at Elms College, is an Associate Professor of Bioethics and Medical Humanities with joint appointments in Philosophy, Religious Studies, and Biomedical Sciences. He also serves as Director of the Undergraduate and Graduate Bioethics and Medical Humanities Programs and Executive Director of the Saint Augustine Center for Ethics, Religion, and Culture.

Dr. DePergola shares insights from his recent policy revision work, focusing on refining the concepts and language surrounding non-beneficial treatment, futility, and related ethical challenges in medical decision-making.

In this Episode, Hospital President Dan Carey, Chief Medical Officer Barbara Ducatman, and Clinical Ethicist Jason Wasserman at Corewell Health William Beaumont University Hospital in Royal Oak, Michigan join Tyler and Devan to discuss their action-oriented, complex case committee work and its success.

Transcript

0:01 

Welcome to this episode of Bioethics for the People, the most popular bioethics podcast on the planet according to Grandma Nancy.I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every single day. 

0:18 

And I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here right now, would probably be golfing.Devin, welcome to another episode of Bioethics for the People podcast.Always my favorite time of the week, Tyler.So we're continuing our series of episodes about success stories in clinical ethics and we've got a, we've got a good one today. 

0:42 

OK, I'm excited.I've actually see multiple people on the Zoom today, not just one person.So this must be a Tripoli successful story.Yeah, well, it's one of our very, very few repeat guests on the podcast.So we've got Doctor Jason Wasserman from Oakland University, William Beaumont School of Medicine, who also works in clinical ethics with the Corwell Hospital system, which recently changed its name. 

1:09 

And I don't remember the new name.I apologize.Jason, tell us who you are again.Yeah, So Jason Wasserman, I do.I'm a faculty member in the School of Medicine at Oakland University, William Beaumont School of Medicine and do clinical ethics consultation for Corwell Health East, but primarily at Corwell Health William Beaumont University Hospital where my two favorite administrators of all time work. 

1:33 

And when you, when you guys put a call out for bioethics success stories, it, it struck me that what the relationship that we've been able to build in clinical ethics with our administration at the hospital constitutes not only a success story, but might be something instructive for other people out there doing clinical bioethics and working through their, their systems to kind of build support and change culture. 

2:02 

And I think we've, we've made strides in that.We have, you know, certainly more that we want to accomplish, but we've made a lot of strides.And it really owes to my MY2 colleagues here, Barbara Ducketman and Dan Carey, and I'll let them introduce themselves.Great.Hi.I'm Barbara Ducketman, and I'm the vice president for medical affairs at Caldwell Health William Beaumont University Hospital. 

2:25 

Hello, I am Dan Carey.I'm the president here at Corwell Health William Beaumont University Hospital, and I'm also a faculty member at Oakland University of William Beaumont School of Medicine.Awesome.And Jason, I know you've been there for a number of years, since the, almost the very beginning of the, the medical school there at Oakland. 

2:45 

And just recently went through a transition, like I said, the, the hospital system was acquired by a different hospital system.And that poses a lot of maybe instability, uncertainty within a clinical ethics consultation system because so much of what we do is not at the behest of, but maybe with the, I don't know, with the blessing of administration, right? 

3:10 

Because there are easy, easy shortcuts in order to meet their clinical ethics regulatory requirements.And I think it takes a special system, takes special ethicists to be able to work together and able to to build a clinical ethics practice that not only serves the patients, but is well supported and integrated throughout the system. 

3:32 

So tell us, tell us what you guys are doing out there.Well, so, yeah, let me, I'll start with a little bit of history.Right at the beginning of the pandemic, you know, there were huge financial pressures on the on the system.And the former CEO and CMO decided to sort of decentralize the ethics service at what was then Beaumont Health. 

3:54 

And everything kind of got pushed to the chief medical officers at the individual hospitals.They were told to sort of figure out an ethics process at your different hospital by way of, you know, cutting costs and all that.And that's how Barbara, who was the chief medical officer at the flagship hospital in Royal Oak, ended up sort of reaching out to us. 

4:17 

And I mean, I think there's a, there's a lot of credit owed there because not every CMO at every hospital did so there.There were different ways in which they rebuilt ethics at each of these different places.But I think we've been particularly successful.So I might, you know, not to take over the sort of moderating and hosting duties from Tyler and Devin here. 

4:40 

But I might ask Barbara, you know, just to talk a little bit about why she even reached out to us as in, in, in light of the many other options that you might have had.Well, this was during the pandemic, actually during the first wave of the pandemic. 

4:56 

And it was kind of scary because Royal Oak during the pandemic, our University Hospital took on more COVID patients than any place in Michigan.And we were inundated in this first wave.And actually, we were very concerned that we were going to run out of resources such as ventilators that could support COVID patients. 

5:21 

And right in the middle of this, they decentralized ethics.So I was kind of frightened because I certainly didn't want to make these decisions.And I had met Jason as part of some other work I do for the medical school and other committees and, and positions I serve on for the medical school. 

5:43 

So I, I called up Jason and we had a very productive conversation.And he brought in his, his partners and colleagues and I set up an ethics contract so we'd have ethics consultation.Actually, they were nice enough to do this for almost a year before we actually got the exact contracted place. 

6:05 

But at the same time, kind of coming out of the 1st wave and 2nd wave of the pandemic, we realized where we had issues with some of our policies that that have difficult decisions in end of life situations. 

6:20 

So I asked Jason and some of the other ethicists to craft new policies for futile and non beneficial care as well As for unrepresented patients.And you know, in the last year or two we've adopted those policies. 

6:39 

We brought it through and actually those ended up in in kind of an imitation is the sincerest form of flattery.These were adopted by all of the Coral Health East institutions.Tell me a little bit, Barbara, about your experience with ethics or like during your training or during during your career and what did Jason and his colleagues present that was appealing or beneficial or you thought that would be useful and with this these particular questions or issues? 

7:09 

Well, I'm going to, I'm going to admit I'm a pathologist so I didn't have to think about some of these end of life issues.I'd see the after end of life issues, but I wouldn't see the pre end of life issues since medical school. 

7:25 

So this is one of the reasons I was particularly kind of concerned when the ethics got got kind of put back in my lap because but I knew Jason from, as I said, other committee work and I was sure he would be a great resource. 

7:41 

So I felt very comfortable reaching out to ask for ethics consultation because, you know, just a little bit we started talking about before this all got decentralized when we had a an ethicist who kind of ran the whole system is I realized I didn't understand, you know, ethical rationale, for example, for rationing healthcare very well. 

8:07 

And we were very concerned at some point we might get there.Fortunately, we actually got within a day or two of running out of ventilators, but that was at the very peak and it started coming down.So we never had to test our, our system.But you know, that was pretty frightening for me as somebody who hadn't really thought about it a lot in a number of years to to deal with. 

8:32 

That's one of the reasons I reached out so quickly.Well, if I could just add, I mean, right there I think is a important piece of the the success story that we've had and that we're continuing to build.Because as you and all of your listeners will know, it's not uncommon to run into people who think that, you know, clinical ethics, even professional clinical ethics. 

8:54 

It's just a matter of, you know, being a good person and having some common sense.And what we know really is that, especially in these difficult dilemma ridden situations, it actually is a, a, a, a discipline that requires a form of expertise.And so I really appreciate that. 

9:10 

And I think that when Dan came on as president, you know that that kind of only got amplified.But Dan has his own sort of background in ethics.And if I recall correctly, Dan, this that was part of your bio when you were announced.We, I remember reading your bio and it said he has a particular interest in ethics. 

9:27 

And I'll admit to you now for the first time as an ethicist, I went, Oh no, I hope this is this is a good and not a bad value added thing.And it turns out it it absolutely was.But I'll let Dan give a little bit of his background as well.Well, sure, Jason.And, and I think I'm smart enough to know what I don't, what I don't know. 

9:44 

And I'm not an expert.I'm a champion for a number of areas, including medical ethics.So my background, I've been a clinical cardiologist for more years than I want to admit.So dealing with critically, I'll patients, dealing with appropriate use of technology, having and encouraging those around me as a chief of service to have the right crucial conversations at the right time for most for the well-being. 

10:15 

You know, following the wishes of the patient and the wishes of the family, but also discerning what those are and appropriate use of technology and, and what is within the scope based on a particular patient's preferences and, and previously stated wishes and and end of life situations was something very, very familiar to me. 

10:37 

I mean, as Jason indicated, I, I did, you know, my undergraduate background.I went to the University of Virginia and I study political and social thought.I always wanted to be a physician.But you know, I, I did graduate work, at least graduate courses while in undergraduate with Jim Childress in bioethics. 

10:56 

And he was one of my readers for my undergraduate thesis on an ethical critique of national service programs.And that's, so I think my contribution has been I, I, I, I have been a clinician. 

11:13 

It's not my primary role.Now I've been in complex situations.I'm not the one having those conversations, but I know the value of them.And I also knew our medical staff, having come through the, the pandemic, could use some extra support of a facilitator, if you will, to enhance and to increase the frequency of those right crucial conversations. 

11:35 

So that I think is where Barbara and I working together, then she working with a number of resources, including that to the committee, put together the complex care committee to really look at these in a systematic fashion. 

11:51 

And again, it is both doing the right care at the right time at the right place for the right reasons.But there isn't an A resource allocation issue here.It it frankly, for lack of a better word, there can be waste in the services that we provide, especially if they're not consistent with the the best practice. 

12:13 

And this is feudal care or care that's inappropriate based on the the circumstances.So wait.Devin, have you been to the University of Virginia?Wah wah yes.Also went to UVA and studied with Jim Childress.So it really sets you up for success I think. 

12:30 

Well, I I'd like to piggyback on what Dan and Jason said and say that actually the idea for what I think has been one of the most successful interventions is the complex care committee.And about a year ago, the ethics spokes brought from OUWB brought in a ethicist who discussed a complex care committee at their institution that dealt with predominantly patients with, you know, social needs who were were just sort of staying in the hospital because there was no Ave. to get them out. 

13:07 

So they were meeting once a month.I formed a complex care committee.I didn't know how often we'd meet and what we'd do.But when I, when I did this and I sent out invitations, a number of people said, well, you know, we had one in the past and all we did is discuss a couple cases. 

13:25 

And I said, no, this is an action oriented committee.So every week we discuss somewhere between 8:00 and 10:00 cases.And these are patients who have family issues, who have guardianship issues, who have end of life issues and where things are not progressing. 

13:46 

And we, we the the complex care committee offers recommendations to physicians.We often ask to get a palliative care consult to discuss goals of care because we have patients who are in end of life situations and the family is demanding everything be be done without any idea kind of where the illness is going. 

14:10 

So the palliative care folks are very good.Sometimes we need ethics issues when the families push even further for things that's basically futile or non beneficial care.We need actually every week and we have a broad representation with leadership. 

14:30 

We have an ethicist always there.We have the head of surgery, the head of medicine, the head of the MICU, We have the that's the medical intensive care unit.We have a palliative care specialist, we have a psychiatrist, we have care management, we have nursing. 

14:50 

So nursing refers a lot of these patients to us.Sometimes these people are abusive.They need some kind of contract and they need somebody to go in.Sometimes the families are very difficult.And we also also invite the attending physician when we can see they're struggling. 

15:09 

So I think what it's done is we always have action items for each patient of things we're going to do to sort of help the process move along.And you know, often times the complex care committee will write a letter kind of reining inpatient demands. 

15:27 

And I'll, I'll give you like one or two examples.So we had a patient who came into the hospital, the emergency center at least, you know, once a week and they would be admitted because they failed dialysis. 

15:44 

They would go to dialysis and they would not, they'd skip it.They would go, she would go for an hour, an elderly lady, she would go for an hour when she needed three hours.And then of course, she would have issues because she needed dialysis and she came in the hospital and then she was admitted. 

16:03 

She'd stay 5 or 6 days, she'd be discharged and within three or four days she would come back.So we, she was discussed.We discussed her broadly palliative care saw her, we wrote a letter, ethics was involved.It was a joint intervention. 

16:20 

I went down with the chief of medicine and the palliative care physician and we had a discussion with her and we told her that basically what she was doing was was short starting her own life and you know, we were not going to admit her. 

16:35 

She had some secondary gain from an admission.So I then have to like watch the emergency center.We would not admit her if she came in because she skipped dialysis.We dialysed her and send her home.She really didn't need a hospitalization. 

16:51 

She needed dialysis.So after we did this a couple of times, actually, she she stopped coming to our hospital.She went elsewhere.I don't know what she did there, but you know, we basically made her just stop abusing our system because she didn't want to do this. 

17:13 

It's really encouraging to hear that your complex care meetings in this committee, which I, I, I want to get into the details of a little bit more, is not just looking at difficult discharge planning because I think that's where it often defaults is this is a complex case because we can't get them out of our doors and they're stuck, right. 

17:31 

If there's so much more difficulty and complexity that goes into some of these types of cases that I had imagined would come before the committee like this.Jason, what was your experience standing up this committee like working on it from an ethics perspective?So, so just going back, we have an endowed lecture, the, the Jerry Weintraub ethics lecture that Stone has an internal medicine grand rounds. 

17:55 

And since I became involved in planning it, I, I try to think about what, what kinds of issues are we seeing on the floors that, that we can then bring a speaker in to talk about from an ethics point of view, but that it's also responsive to the kinds of things that are happening within the system.And of course, one of the things that was really complicated and we were experiencing a lot of as, as all systems do were were difficult discharges. 

18:18 

Again, not just from the standpoint of how do we get this person out, but from the standpoint of how do we provide the best care, the most effective care, you know, And what are our our ethical responsibilities when the social system and this the sort of network of resources in society is highly deficient. 

18:34 

And then it pushes back obligation on us, but that we're not the best place or well positioned to meet those social needs.And how do we coordinate and what and what are the, you know, what are the boundaries that are created in those types of situations from an ethical social point of view, really tough issues. 

18:50 

And so we actually invited Kehan Parsi, who I believe is on been on your podcast and also former president of American Society for Bioethics and Humanities.He had written a piece on this and and we brought him in to speak on that topic exactly.And then Barbara was in the audience and he mentioned their complex care committee and what it does. 

19:08 

Again, just another maybe take away for the audience is that when you have administrators who value clinical ethics and are also action oriented, these are the kinds of things that can happen within your system.Because at the end of that talk, it was 9:00 when it ended.And I remember Barbara in the aisle of the auditorium said we're going to stand back up to the complex care committee and said, Oh yeah, that sounds great. 

19:30 

By 3:00 PM that day, everybody had appointments on their calendars.The entire roster was populated and we were it was a go.And that's that's what happens, I think when you have advocates that are that are in upper administration, they see the value of something and they act on it. 

19:47 

And then as Barbara pointed out, this iteration of the complex care committee has been highly actually oriented and, and that's where it drives its success because there is high level administrative involvement and support.There's a lot of brains in the room, but there's also a lot of people with, with resources and connections within the system. 

20:05 

There's a lot of opportunity in that room to make things happen.And that's how things have, that's how it's, it's been successful and ethics has been grateful to be a part of that.And I think we've we've contributed to that, but it it really is.It what it it owes to the way that administration has put this sort of committee together, involved ethics and valued ethics, but also this interdisciplinary approach and also high level administrative support. 

20:30 

And that's the recipe for success.And I think I'll add to what Jason said, because that again, just the feedback that I've gotten from Barbara and from Jason and from other clinicians that said, you know, when you start getting involved in complex care where patients and families have very strong feelings, you, you know, they're going to be complaints. 

20:50 

There may be legal action taken.There may be, you know, bad mouthing of a hospital And it, I didn't think it was that big a deal.I said, if you do the right thing and you have solid process, I, I, I got your back.I don't, you know, if they write a letter to the head of the health system, you know, I, if we do the right thing, if we use good process. 

21:12 

And again, I'm not a medical ethicist, but I, I, I've been involved in cases and I, I know what it looks like if we do good stuff and good process, even if there's friction, if patient, you know their complaints, there's letters, there's what have you. 

21:27 

What we we will, we will stick to it and we will have your back and I think.And I'll say from a on the ground perspective that's that's been absolutely critical.As Barbara mentioned, we redid our A policy on futile and potentially inappropriate interventions. 

21:45 

We, we worked that through the, you know, appropriate channels and adopted it.But on the ground, we would still hear quite a bit of well, I'm not willing to do that.I'm not willing.If the family wants futile CPR, that's what we're going to do.I mean, they wouldn't quite put it that way, but that's what they were saying.Because I don't think that administration will have my back. 

22:03 

And So what we realized is after getting the policy online that we needed to take it on a tour for for educational purposes.But what made it, I think effective in at least starting in in to change the culture and in very tangible way, we've seen real success with this, although we still have a little ways to go with some folks. 

22:21 

We've really made strides is that when we took it on this tour, when we did it at internal medicine grand rounds, for example, we explained the new policy, the underlying ethical considerations underneath it.Both Barbara Dan were there and they stood up and said, if you use this policy appropriately and you know, everybody's involved, the way that the policy calls for, we have your back and this is what you should do. 

22:42 

And that makes all the difference, right?And ethics, if you can tell a clinician to use it and that it's ethical all they want.But if the clinician's worry is that administration doesn't have their back when the president and the chief medical officer stand up and say we do have your back.Yeah, and even with that, sometimes clinicians are still reluctant to go through it as well. 

22:59 

But I mean, we can only do so much as we can do.So since I've got, since we've got Barbara and Dan with us today, what about Jason and Jason's group as ethicists do you guys find valuable not just in their role in this committee, but what characteristics, what skills, what expertise does a high level competent professional ethics consultation service? 

23:21 

What does that do for your hospital?And I can log off if you guys want.To say it, just just just mute yourself.I would say Barbara probably has more of the nuts and bolts, but from a high level, I think there's credibility.Jason, you and your two or three partners have credibility. 

23:40 

People listen to you.You're just, you're kind and incredibly articulate.And also you understand what it's like to be in the trenches, you know, with, you know, docs and nurses and therapists where it's, you know, it's not always clear, right, what the right next thing to do is. 

24:01 

And I think it's that credibility that that likely was there before I got here, that was earned in the, the history that you and Barbara shared.So I think there's that.And two, you don't go down rabbit holes, you know, and I think that often happens with legal, legal involvement is that you're, you're going down this rabbit hole that's not going to lead to a clear, a, a clear path in which everyone can, can feel good despite the sadness of whatever the situation. 

24:32 

So credibility, competency, communication, I'd say those three elements is true not just for you, but your partners as well.I agree with everything Dan said.And I'd add they're very pragmatic.So, you know, these aren't sort of pie in the sky kind of ethics conversations. 

24:50 

They're very concrete.You know, here's what the family believes, here's what you know the patient wishes were, you know, here's how we do this.They're willing to always they're very responsive.They come quickly when asked to do an ethical consult and they're happy to have a meeting with the family. 

25:10 

They're happy to meet with the clinicians.They explain in a in a very clear and concise way what you know the ethical issues are and what should be forward.They're very, they're very helpful when people want to invoke our non beneficial and futile care policy in that, you know, they'll, they'll, they'll walk people, they'll walk a clinician who's never done it before through all the steps in getting to, for example, changing a full code to ADNR in, in a futile setting, for example, for CPR, because that's part of our futile care policy. 

25:51 

And there's a very clear process and they know it extremely well.So they're very helpful to the clinicians in doing so.And anyone at our hospital can order an ethics consult.So nurses can order an ethics consult and occasionally clinicians will be upset that somebody you know not be attending ask for an ethics consult. 

26:14 

And then when that happens, I'll sometimes call up the clinician and explain that anyone can can recommend an ethics consult and order one.And I'll often also go through how they can support the clinician.If you know if the clinician's dead set against it, we're not going to overrule them. 

26:32 

But often with conversation, you know they're willing to change their minds.Just along the lines, to return to one of the examples Barbara mentioned before, you know, we had at that younger patient with AML and was intermittently he's sort of non compliant in a way that was disrupting her own care and the effectiveness of it. 

26:54 

Very treatable form of cancer and she was going to cause her own death with these refusals.She is judged to have capacity and the, you know, and able to refuse.And she wasn't refusing outright, just sort of intermittently.And it was unclear what she meant and or what what she wanted.Her parents were really permissive of her problematic behavior. 

27:12 

It was a really tough case because she was basically decompensating in that bed over a period of months, getting sicker in all sorts of ways, and yet seemed said she wanted treatment and then would interfere with it.A a a really tough case.And so we, you know, ethics was consulted on that case multiple times. 

27:32 

What solved it was when we got that interdisciplinary complex care committee involved with high level people who could bring a lot of thought but also resources to that.And just to describe the scene to you for, because I think people that do ethics consultation will be fascinated to see or to, to imagine what this was like when we, the complex care committee authored this letter to the patient saying that if you refuse any more care, we're going to respect that because you have capacity, but we're also going to discharge you from this hospital because we cannot effectively care for you if you're going to intermittently refuse these things. 

28:05 

She had been served on a very high, high cost treatment that then she was starting to refuse.And it was, that was going to be net harmful to her if she did that.And so we, we had this, a letter authored by the committee, signed by Barbara, but it wasn't just a letter from Barbara. 

28:22 

Barbara went up to the floor with Mark Navin and I and we with the psychiatrist, with a nurse, with the oncologist, and we we all walked down the hall together and into that patient's room.And Barbara very compassionately explained what the letter said to the patient. 

28:39 

She actually told some, you know, empathize with the patient quite a bit about following medical advice.And it was a highly effective intervention that was multidisciplinary, came from the top, that ethics was there to support. 

28:55 

But it, it wouldn't have happened if it hadn't been for that kind of administrative support.And I'm not exaggerating when I say that it saved that woman's life.I see why you wanted to bring this, Jason, because like Barbara, having your back like that, Dan, having your back like that is, is so huge. 

29:12 

I worked at a hospital once where we had a patient and this was years before I got there.A patient had been declared brain dead and the all the clinicians wanted to remove all treatment as you would for a dead patient and got to the place where they figured it out loud.They used the the futility policy, although I don't think they needed to because again, this patient was dead and administration would not back them up in removing the ventilator and other kinds of medical treatments. 

29:37 

And every time we tried to then invoke our non beneficial treatment policy, all everybody would say they didn't back me up 10 years ago when we had a dead patient.They're not going to back me up now.And this was the mythos.This is like the lore in the background of.So the policy would never work because one time administration wouldn't back up what seems like a really reasonable route to overriding a family who didn't want care removed for their dead loved one. 

30:02 

And the administration wouldn't let the clinicians remove that treatment.And then we just couldn't ever use the policy because they just refuse to use it because of this background.So having the support of of the people in your institution is just so important to making this work.And then having somebody so responsive as Barbara saying, you know, I'll talk to the clinician who didn't want the ethics council ordered. 

30:23 

That's huge.I've never heard of any administrator doing that before.It's usually the clinical ethicist who's having to push like here, here's what our policy is, here's how we do ethics consults, and that's a hard place to be in.So having somebody in upper administration backing you up all the time and being responsive in the situation is so crucial. 

30:40 

It's been an amazing environment to do what we do.It really has.Over on that side of the state, you guys are well, well provisioned with really high quality ethicists there to help support you.So Wasserman, Navin Brummett, these individuals bring not just a, a robust expertise, which I think a lot of clinical ethicists can bring, but also some, you know, diplomacy skills, be able to provide practical, real advice in ways that don't offend and ostracize people, but also individuals who really care. 

31:12 

And I think that that is increasingly rare in the world that there are people who really at, at their, at their heart, they care about what's good and what's right and what's helpful for people.So.I think Barbara and I both understand what how, how fortunate we are indeed.And, and we are indeed quite grateful to have Jason and his team and the impact that they have and the improvement we're seeing because of it. 

31:36 

We realize how fortunate indeed we are.We're so grateful for you all to come this morning and talk about all the great work that you're doing.And I hope and expect that it will inspire a lot more work and clinical ethics that works well with administration.So thanks for being here this morning.Yeah.Thanks so much.Thanks for tuning into this episode of Bioethics for the People. 

31:55 

We can't do it alone.So a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork.If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music. 

32:12 

Or wherever you listen.And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch. 

In this episode, Stephanie Van Slyke helps us to understand DNR orders and her success in helping clinical staff understand what they mean.

Transcript

0:00

Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy. I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing. And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.

0:28

All right, so Tyler, we have a fellow Michigander in the house. I prefer the term Michigan gangster. Oh well, that sounds like a bumper sticker but OK. Yeah, good friend of ours from up north as as we say here in Michigan, right.

0:44

So Stephanie is a clinical ethicist up north in one of the health systems around the very tip of the mitten, as we say.So, Stephanie, do you want to introduce yourself, please?Thanks, Ty.Good to see you both.And Devin.So yes, I am a nurse by practice, I guess, if that's what you want to call it.

1:02

But most of my nursing career has been in a hospital as an ICU nurse, which just kind of naturally drew me down the path of ethics because of a lot of the complexities that we find as an as an ICU nurse.And I've since kind of moved away from the bedside and now leader ethics consult service here at at the hospital.

1:21

A nurse ethicist?I'm trying to think I know a few, but it's actually not the more common path.It makes total sense to me that as a nurse at the bedside, you're seeing a lot of ethics issues and it would move you that way.And yet I haven't met a ton of clinical ethicists who also practice or at one point practiced as a nurse.

1:40

So you're this wonderful Unicorn in our space.Oh, thank you, Devin.I prefer gangster.Oh, right, right, right.Sorry.Come on, Devin, keep up.OK.So Stephanie, you're going to talk about a success story, right?

1:56

And so often in our world, we deal with the the difficult and the heavy and the dark kind of side of healthcare.But we wanted to highlight some things that have gone well or successes that people have had in their clinical ethics space.So tell us what you got from up north.

2:13

Thanks Ty.So this really stems from circumstances when I was still at the bedside.This goes way back to like 2014.I'll never forget this patient.I'll never forget this situation where the patient had ADNR order and I had interpreted it one way.

2:31

And come to find out there were other colleagues of mine who had interpreted what that meant differently.And she experienced a medical emergency and we didn't know what to do.We didn't know how to intervene.And it's kind of haunted me ever since that did I do the right thing?

2:49

Even though I called the provider and described what was going on, there wasn't a clear understanding of how far do we intervene and what does her do not resuscitate order mean.And so it really led me to ever since then dig deep into the literature that's out there.

3:08

And thankfully I found a whole bunch of it.But more importantly, just within my organization, we did just a survey of staff to say how do you interpret DNR?And at that time, what was interesting is we had a long list of options that people could choose from around code status, which I think was another complicating factor.

3:29

So we had a limited code option.We're essentially code status was presented to patients and families as a menu of options to choose from.Which isn't it?Which I don't think was really that uncommon during that time.

3:45

I think a lot of the other healthcare systems that I've worked with or worked for also had similar, like you said, a menu where it's, and let's talk through some of the options that somebody might have in this menu, right?So the obvious one is compressions for cardiac arrest, right?

4:01

Do you want that or do you not want that?So what are some other ones that people could choose?Yeah, whether or not you wanted to be intubated, whether or not you wanted a central line or transferred to a higher level of care, ours also included, do you want to be defibrillated?

4:16

Do you want to be given meds?You know, so this just madding, if you will, assortment of options for one particular procedure that really encompasses all of that.So it really put the nurses and staff in a tough position of, you know, what do I do and what don't I do?

4:36

It might be helpful to take like just one step back and say, OK, so ADNR order is a physician order.So it's not something that the patients elect outside of, you know, a situation in which the doctor orders this for them.But it's really if your heart stops, if you have a cardiac arrest, what do you want us to do?

4:54

Do you want us to let you die?You know, your heart stops, you are dead.Do you want us to try to revive you or do you not want that?And if you say yes, there's a whole lot of things that go into that because the protocol says that you have to.All those things you just named on that menu have to happen for a resuscitation attempt to be successful.

5:15

It's very unusual for CPR to work at all.Right.So do you know the current stats on in hospital cardiac resuscitation?Yeah, from some of the studies that I read for in hospital cardiac arrest, the success rates have been shown to be anywhere between 20 and 40%.

5:33

Outside of a hospital, it's much lower, 10 to 15%.But I think that the the key thing here is how do we define success?Is it merely just getting a heartbeat back?Because we know there are a lot of other kind of ailments that occur because of CPR itself.

5:52

And are, are those acceptable ways of living for some people, some of the conditions that they're that they're left in the loss of independence, so on and so forth.So you know, I think there's, there's a lot to be said about how do we define success?Because yes, if we're thinking about was CPR successful?

6:09

And if it did return a heartbeat, then yes, it was successful.But is that truly what we're looking for?Right.Most people will say it's only successful if, like, then they can get out of the hospital, right?They're not thinking I'm going to be intubated for the rest of my life.I might be unconscious for the rest of my life.

6:25

Those might be unacceptable successful outcomes.So even in that kind of small percentage, because you watch, you know, Grey's Anatomy and everybody just like gets resuscitated and they bounce out and they go, thank you so much.And they leave the hospital immediately.That doesn't happen.It's very violent.

6:40

We're breaking ribs often, So.And even then, even if success is only just getting it back, it's still pretty low.And as far as I know, if you don't do all the things that are required for cardiac resuscitation, there's no chance it works even getting your heartbeat back.

6:56

So you know, offering people like menu options doesn't make a lot of logical sense because it only works if you do all of it.Yeah, that certainly is the way that I approach it, much like you would a surgery, right?We're never going to offer somebody open heart surgery and then give them a list of options to choose from that are part of that surgical procedure, right?

7:17

It just, it's illogical and why CPR is kind of morphed into this menu of options is just fascinating to me.But the other piece I did want to add that that I think is a contributing factor to this.It's not only the list of menu options, but the wide range of code status options that I see among healthcare systems.

7:35

It's not all the same.So if a patient is taken care of in my health system, we have one particular policy that says these are your options.But if they go to a, a hospital, you know, downstate, it's very different.And so we're creating this confusion not only among the community, but also within our own profession of, of people really that should know what this means and should know how to intervene when somebody experiences cardiac arrest.

8:02

Something else I've seen in hospitals it worked in that creates confusion is some people think that if you're DNR, it means you don't want aggressive treatment in general, right?So if you're not willing to be resuscitated, if your heart stops, you're not willing to undergo other kinds of aggressive procedures.

8:18

And that is not true typically.So you can have in our hospital system somebody who says, OK, if my heart stops, that's the end of it.You can stop treating me.But until that time, I want you to try to do everything you can to keep me alive.It's just like, at that point, I want to stop.

8:35

If my heart stops, let it be stopped.But I want chemotherapy, and I want maybe to be ventilated or intubated if I need that.I might want all sorts of things unrelated to cardiac arrest, but that's my stopping point.Whereas other people might be at the point where they're saying I don't want anything aggressive.

8:51

I want to be able to die a natural death and CPR is not part of that.So make me DNR and make me what sometimes you call AND allow natural death versus others who might say I don't want you to try to restart my heart, but I do want everything else that you think might keep me alive, which we call COT or continue on treatment.

9:09

So we have to have a DNRCOT or a DNRAND, and all the folks at the bedside have to know the distinction between those two options.Yeah.And that's fascinating to hear you say that, Devin, because that that to me, I think is the problem that that we as a healthcare industry have not come to a place where we all define it the same.

9:32

And it's just creating mass chaos.And unfortunately, it's causing a lot of really difficult circumstances for our patients and their families.It seems to me that it's also creating this a scenario in which the burden of deciding what is a coherent medical treatment plan is put on the family or the patient.

9:52

Like how?How could anybody not with healthcare training understand the difference between the necessity for Defibrillation and pressors and like all these other things that are integrally entwined with each other and you can't, like you said, you can't stop 1 without the other.

10:08

But we're giving this family almost like it's their responsibility to tell us how to practice medical, Not us, but but tell the healthcare system how to practice medicine.Right.I and I wonder if it's a lot of that kind of massive pendulum shift that we've seen around patient autonomy, right?Super important that that's happened.

10:25

But to now kind of apply that same logic to code status and CPR administration, I think we've we've really messed that up as a profession.Yeah.So you saw this situation that's that's kind of stuck with you.

10:40

It's really common when we've been talking with individuals who have like a policy change that they've been in charge of or a Seminole case that's changed practice at their hospitals where it's something from a personal experience that really kind of gives them that motivation.So tell us what happened after this case.

10:57

So yeah, I really just did a lot of digging and a lot of just back finding.I was super curious, how did my, my, you know, my fellow ICU nurses interpret what DNR meant?How did some of my providers, our respiratory therapist, you know, a wide range of professions who, who come to a code, right?

11:16

And if you're not all on the same page, it can be quite messy.And So what we really dug into is first of all, our, what does our policy say?And is it clear?And we, we easily identified, wow, we have a lot of opportunity here to do some better work.

11:32

And of course, our Ethics Committee really dug into the policy.We're fortunate to have our palliative care medical director as our chair.And as you know, that profession usually does a good job of having these great conversations.So we really wanted to first start to look at when is code status really applicable, right?

11:53

Because we were worried we were seeing it used as more of a goals of care forum to kind of Devon's point where if somebody has ADNR order, somehow it's now kind of morphed into they can or can't have surgery that can or can't have chemotherapy.And that's, that's really not what code status does.

12:10

It tells us if you experienced cardiac arrest, do you want us to do CPR?So really simplifying that.But then we had to take it a step further because we do know there are those situations too, where someone may say, hey, if my heart stops, you know, let me go, let me just die a natural death.But what about severe respiratory failure?

12:28

And I think that's where a lot of the difficulty came with, well, do you have a DNRDNI or just a DNI or you know, and, and because of course this person still has a heartbeat it, but if we don't intervene when they're experiencing severe respiratory failure, it will eventually lead to no heartbeat.

12:47

So how do we do that?So we really started there like first of all, what does code status mean?And I think it's important to acknowledge too, the difference between code status and an out of hospital medical order, right, which commonly fall under the umbrella of advance directives.I know at my organization, we ran into some situations where if a person had checked the box no CPR in an advance directive, that was somehow interpreted as ADNR order for code status.

13:15

And so we had to dig into that as well to say code status is a little bit different.While it falls into the same vein of CPR, it's not applied in the same manner that an advanced directive is.So that's kind of where we started.And then once we, you know, narrow it down to it's really only applicable in these two clinical settings and that's it, period.

13:37

It doesn't impact whether or not somebody can have a surgical procedure, undergo chemotherapy, anything else.Really it's only two clinical scenarios, which is cardiac arrest and severe respiratory failure.And I think that helped a lot.I think 1 important thing for listeners to hear, I hear this all the time is that we, when we're talking about code status, patients will say, oh, I have that paperwork and you say, no, no, no, Code status is not your advance directive.

14:04

So you do not elect your own code status.It has to be a physician.And so if you don't want CPR, you have to tell your physician.So just for our broad listenership, please tell your physician if you don't want CPR because that will not necessarily follow from the paperwork that you filled out.

14:21

Great point of it.And I'd even add even if you're hospitalized, you say you don't want CPR and you do well and you go home and then you come back whether it's months or years later, you have to make the decision again every time It doesn't because you can change your mind, right?

14:37

And so just because you had ADNR one time doesn't mean that that's a forever thing.It's you get to choose every time and even as you, you know, go from, let's say the ICU to a step down unit again, you have to revisit, you know, are your have your goals changed?

14:55

And if you're in surgery, right, so we have this big problem at our hospital right now is that people say that they want to be DNR, but they want the surgery.And we know that if you're in surgery and your heart stops, it might be because of something the surgeons did in the process of that surgery.And it would be very easy for them to get your heartbeat back.

15:13

And that seems like a different scenario than having a spontaneous cardiac arrest.And so it's possible and actually preferable that if you're going to get surgery, you suspend the DNR just while you're in surgery and then it gets re enacted as soon as you leave the surgery.But that is also widely misunderstood amongst our clinicians as well as our patients.

15:34

Well, and I'd even argue that I don't think every patient should have to suspend their DNR for a surgical procedure.I really don't because if that's not in alignment with their goals, especially because we're seeing more and more palliative type surgeries, right?And if that person says, hey, if I die on the table, let me go.

15:52

But we're not finding many surgeons or anesthesiologists that are very comfortable with that concept.And so how can we ensure, again, patients have a right to participate in their treatment decisions and that includes whether or not they want to be resuscitated at all stages.

16:07

And if it is such a thing that the procedure is such a high risk that there is concern that this individual may experience cardiac arrest, for example, open heart surgery, that is a good example of a procedure where if the patient is very adamant that they wouldn't want to be resuscitated, they may not be a candidate for that procedure, period.

16:27

And are we, are we really kind of approaching those types of situations in that way?So what did you guys, what did you do with, with with this situation like so, so you, you, you did some review what is what is everybody think about this saw that your policy or maybe your documentation was at least contributing to the issues of misunderstanding.

16:49

And so where do you go from there?So what we did is we modified the options for code status.So we first we got rid of the limited code option.So what we narrowed it down to is the options include full code, which I think everybody understands what full code is.We also have the option of do not resuscitate.

17:06

And within our new policy, we specified how that is defined and what that means that in the event of cardiac arrest, so again the patient has lost their pulse, staff should not initiate CPR and instead allow the patient to die natural death.But if the patient were to experience severe respiratory failure, the patient still has a pulse and we would treat that patient, right.

17:27

So many times we hear DNR does not mean do not treat.And so if a patient has ADNR order and they experience severe respiratory failure, step should intervene, which includes endotracheal intubation with mechanical ventilation for those patients.

17:43

And then we also have 1/3 option of the DNRDNI.So do not resuscitate and also do not intubate.Now I think it's important to acknowledge though that that doesn't mean that somebody has a comfort care plan in place because that was another code status option that we had in our prior policy, which again that's a that's a goals of care, that's not a code status.

18:04

And so in my opinion, the three that we have now have have significantly clarified a lot of the confusion around that.So again, if a person has ADNR, DNI, cardiac arrest or respiratory failure, staff would not initiate CPR or endotracheal intubation, but of course, they could provide, you know, an escalation of therapies from a respiratory perspective.

18:26

So bi pap, you know, heated high flow, so on and so forth with the intention of prolonging life.But again, that's where those goals, those patient goals are going to be really important because a patient with a DNRDNI order could have a comfort care plan in place.

18:43

So we worked on a lot of education, patient identification, arm bands, patient alert signage outside of the doors so that staff knows kind of what the what the plan is.Because you know, in those situations you have to go act so fast and staff needs to know in what way they have to respond in those situations.

19:05

That's so interesting.We had in, I think this is all over Texas, banned the use of these arm bands because they were so often being interpreted as do not treat at all.And that they were like sort of signaling.People thought that if they had such a band, even if it only meant don't resuscitate my heart when it stops, that it also would mean that people wouldn't be as quick to treat them at all.

19:27

And so they've been totally banned.I think they're they're really wise.And it was just a response to like a practical like concern that patients were having about the use of that kind of signage.Well, and I and there's studies that show too patients that do have that DNR order are under treated.

19:43

And so I can certainly see why an organization would say, let's just get rid of the bans to maybe kind of mitigate any kind of risk for misunderstanding.But it doesn't address the underlying problem, right, that that there is a misunderstanding of what it means.And so our, our primary, primary focus was really to to provide the staff with this education to clarify and spell out what each code status option means and what the expectation is for them to respond in those situations.

20:14

What type of format did that education take?So in other episodes we've talked about sometimes the struggles that ethics education has and trying to find a foothold and trying to find timing, trying to find the right format to live deliver the information.So what was helpful for you guys?

20:30

So one, we have like an electronic, it's called health stream and electronic education, you know, platform that you create a PowerPoint, you assign it to people.But we knew that that wasn't going to be enough.And I have to tell you, I have to give a ton of credit to, like I said, the head of our Ethics Committee, Doctor Barraza, he and I really dedicated our time for about 3 months before the policy went live because this impacted more than one hospital in my healthcare system.

20:57

So this was multiple hospitals.So we knew this was going to be quite an endeavor.But we we really dedicated our time to have face to face meetings with staff.So staff meetings, we were invited to multiple meetings to meet with staff and allow them to ask questions.

21:17

We received a ton of questions, as you can imagine, on, well, what about the patient who wants CPR but doesn't want to be intubated?And so really helping to clarify the logic behind that and the reasoning for why it's, it would be unethical to do CPR without intubation.

21:33

And so we found that to be incredibly beneficial.And I will say what's interesting is this policy went live almost one year ago.So it was October 24th, 2023.So it's been a whole year.And the feedback that we have heard since then is how can we do that staff education like that for other things.

21:56

I just think you need that face to face opportunity to to bounce questions back and forth.You don't get that on electronic platforms or you know, little post, sign in post type, which is what we see a lot in healthcare, right print and post competencies and whatnot.

22:13

So I believe that that is what helped us to be as successful as we were in rolling out this new policy throughout our system.Do you think too, Stephanie, it helped that you are a nurse?I think sometimes the hardest communication is with the nursing staff, but the nurses are the ones that often have the confusion and are seeing kind of like things going down a path that could get to that point and are on alert and confused and raising this as an issue.

22:39

But the fact that you understand their concerns and their confusion, do you think that helped with the education?Yeah, I really think it it did.And I also think that having a physician, it was a physician and a nurse doing this education face to face, which was key in my opinion, because we were able to address the perspectives from both professions.

22:59

And so those physician nurse partnerships are so important.What type of questions or concerns did the folks at the bedside have when you were doing these educations?Well, there was a lot of argument about, well, if we don't allow patients options such as the limited code like we had forever, we are violating their autonomy.

23:21

And so really working through the logic behind that, just kind of the disconnect that that's not patient autonomy, that really CPR is an entire procedure and in order for it to be successful, you have to do everything that is part of that procedure.So really working on that.

23:38

Another thing that we heard a lot of at the bedside are those situations where a patient, and even if it's a patient who was receiving care downstate, now they're back home up here, they had the option to be a DNI only down there, it's not an option here.

23:55

And there was a lot of nurses that said, what do we say to patients who say I was ADNR at such and such hospital, Why can't I be 1 here?And there are those rare occasions I know even as I was an ICU nurse where you, you know, you can't feel a pulse.You jump on the chest and they push you off.

24:12

And you know, so sometimes again, in the heat of the moment, thinking that bag masking somebody only is just not, it's not logical to do that.You know, even if we get a pulse back to expect somebody to stand there and bag mask somebody to prolong their life, just, you know, trying to just really trying to help them think about it from a logical perspective versus an emotional 1.

24:42

And that's what I've seen a lot with the nursing staff, just that emotional connection to I need to do something and we're kind of telling them, well, but that is not something that is ethically permissible.Have you found that it's also helped just having the conversation?

24:57

I find that another issue that we have is nobody asked.And so the default is do everything and that might not be what the patient wants, but nobody had the conversation.And so we're just, you know, making everyone full code because we don't want to bother to have the the hard conversation.

25:14

Man, you know, if we could find out how often that actually happens, I think a lot of people make those assumptions, but it's difficult to know whether that's actually happening.You could certainly assume it is, especially if there's no supporting documentation of the discussion.

25:30

You just see that they're a full code or you see that they're ADNR or a DNRDNI.But you know, again, I think the discussions themselves, there's definitely an opportunity there around it.I know I've witnessed a lot of times where the even a nurse says ART, you know, when a patient says I want to be a full code, I want to be resuscitated and the nurse says, do you want us to jump on your chest and shove a tube down your throat?

25:53

Like that's that's not an informed decision, right?Like that's not how you have conversations about whether or not the patient is informed and able to make a decision based on what matters most to them.But that's how we see them.Right.And the way in which those discussions happen, I think show the the biases of what, what, what the provider wants the conclusion to be, right?

26:19

So I can describe chemotherapy in about 40 different ways, one of them being, you know, we're going to pump a bunch of poisons into your veins and hopefully kill only the the bad cells, right?And that's definitely persuasive in a certain direction, right?So if you, someone says, do you want us to jump on your chest and break your ribs and stick a tube down your throat, that's leading somebody to a certain conclusion where if you say, you know, do you want us to try to save your life?

26:43

You want us to, you know, a lot of other flowery ways of describing CPR in a in a way that also kind of shades the truth in a certain direction.Yeah, and I think even just the do you want us to save your life?I think is a little bit misleading as well because again, you know, so thinking, yeah, like I said, there's definitely some room for what what does it?

27:03

What should this conversation look like?Who should be having it?We, we received a lot of pushback from some of our providers who say, you know, I don't do code status conversations.And, and it just kind of, it kind of causes you to pause a little bit, you know, cuz in the hospital you have multiple subspecialties seeing a patient.

27:22

And so it was kind of being punted from one provider to the next and conducted in very different ways.And I don't think that that's unusual or only happening in my hospital.No, lots of providers don't like having the conversation.But to just sort of blanketly say, Oh no, I don't do that.

27:38

That's like, I don't have conversations about life and death with my patient who very well might die.Is a like absolutely outrageous thing to say.I had a provider once say that they are the ethics consultant on all of their patients and they don't need ethics to be involved because they are the ethical authority.

27:58

Oh, just.Be nice.One of my most favorite parts of being an ethics consultant is when you can get someone to like go have their aha moment.Like, oh, well, I hadn't thought of it that way.And I'm like, yes, let's think about it this way.Yeah.Do you have an example of that?

28:15

Honestly, a lot of it came through with the, the code status stuff, especially when I have, when I had staff who had, you know, strong convictions about why are we doing away with the limited code option And just literally the breaking it down too.

28:31

Let's think about what CPR is and what all goes into CPR in order for it to be successful.And it was just kind of, as we kind of, you know, peeled away the layers of the onion just kind of from a practical perspective, then I could see people come around.

28:48

Oh, I, you know, I haven't thought of it that way because I, because I've had some providers say, well, there, it's either life or death.And if I don't do CPR, they're going to be dead.And now I can't do anything.And it's like, well, but let's broaden that out a little bit more because I think you're right.

29:04

I think I think that's the message that's been out there as to why the community is really asked to learn to do CPR because it saves lives.And if I don't do this now, you know, somebody has died and and we have to acknowledge that cardiac arrest is a natural and expected part of the dying process.

29:21

Pretty much everyone's heart will stop at some point.Right, right.And there's this universal rule that you have to do CPR unless there's a DNR order.But yet the statistics don't support that.You know, it's always, the outcomes are always as good as we hope.

29:37

And so I just think there's a lot of room for us as a healthcare industry to really do something about this.After your policy change in the education, did you see any impact or hear any stories from patients about their, you know, improvement from their state of confusion or how it was helpful?

29:58

That's a great question.We really didn't do much inquiry into what from the patient's perspective or family perspective.We really just focused on staff, but I'd love to know whether it had a positive impact on patients, but we didn't really explore that.

30:17

So I've heard some people say sometimes we offer limited code because it is like a bridge to getting them to DNR, that maybe patients aren't just aren't quite or their families aren't quite willing to take that, that step.And so this is like one small way to get them, you know, toward.

30:35

And so eventually we want to get people toward DNR if they're on the path, but maybe they're not quite there yet.And so if the other option is full code, then if there's only these two star options that that doesn't get people moving.How do you what do you feel about those arguments?You know, and that's tough.I think in those situations, I worry that the healthcare professionals are taking on a decision making role that's not theirs to take, where they've made the decision.

30:59

This patient shouldn't be a full code for whatever reason.And again, we have to step back and remember what our role is in this equation.It's really to inform the patients, give them the information that they need to make an informed decision.And if it is such a thing that they're ponder, you know, we see patients go back and forth on a lot of things.

31:15

Whether or not they want to Trake and peg, whether or not they want to endure a particular surgery, we should be allowing them the time to think about those things and in the meantime, ensuring that they understand that if something were to happen, this is how we would respond.So we just want to make sure you're OK with that, but not necessarily trying to talk them into one way or the other.

31:38

And I see a tremendous amount of moral distress, a lot of times more so in nurses than providers who have those strong convictions about this patient should not be a full code.And I'll try to really like, well, tell me why, you know, tell me a little bit more about why you think they shouldn't be a full code.

31:56

I mean, based on the information about the wide range of misinterpretation that healthcare professionals have around what it means, I get why they all want to be full codes, right?So just helping them in ways to just inform the patients, empowering them to make decisions for themselves and try to let go of a feeling as though their bad decisions or decisions that we don't think they should be making are ours to somehow change.

32:26

So for our listeners who are, you know, in states all across the country and in different countries, how could they know what their local healthcare system or provider, how they approach code status, these types of questions?

32:42

That's a great question.You know, like I said, even in the state of Michigan, I see it, it's different at every health system.So to cross state lines, boy, I have no idea.I have no idea.That's that's why.

32:58

And I guess that's where I was getting at when I was talking about we as a healthcare industry, we owe more to our patients to get this right, to figure this out.The fact that we have such a range of misinterpretation and such a wide variation in code status options to me is problematic.

33:16

I mean, when you look at laws and, and you think of like out of hospital medical orders, like in Michigan, we have two, we have that, you know, do not Resuscitate Procedure Act and then we have our Michigan physicians in order for scope of treatment.It's pretty clear in the EMS protocols, you either do CPR or you don't, right?

33:32

And so why, why can't that also be applied in hospitals?You either do it or you don't, right?But we've really gotten, it's really gotten messy and I don't know how to fix it other than if anyone is going to try to fix it, it should be us, it should be the healthcare professionals, right?

33:51

This is such an interesting conundrum because usually what we're trying to do is add complexity and add nuance and trying to help people think deep differently and deeper.And whereas this issue is more like, no, it's either you do or you don't, right?It's either we're hitting the gas pedal or we're hitting the brakes, right?

34:08

It's kind of binary.So it's a little bit different type of motivation, but also different type of education and different type of problem solving that has to go into this type of issue.Well, and I, I can imagine there's several listeners out there who completely disagree with that thought process, right?

34:25

Who, who would to kind of your point, Devin earlier that it's, it's this gesture of I've done something, you know, for somebody or this, this feeling of it's a bridge to something else.But at the end of the day, are we doing a disservice to our patients by not being forthcoming with what CPR actually is, what it is intended to do, what it is, what all goes into CPR?

34:51

And I just wonder that if there's a better understanding both within the community, you know, they're not believing everything they see on television.But then even in the medical profession, is there a way to kind of close that gap a little bit?It might help too, if our providers knew more about or could explain better.

35:09

If you are DNR, that doesn't mean we're just going to leave you alone in your room and abandoned you.And, and part of it is that there are some providers who do feel that way, that oh, if, if their DNR, then they've given up.I've heard, I've heard actual physicians say that.And you're like, that's wild because there's so much comfort care that we can give to people.

35:27

There's still all sorts of care and treatment we give to people even when their DNR.And if we're not able to explain that, well, it might feel to the patient like, or their family like they're giving up.But we're not giving up on you.We just recognize that if you don't want us to jump on you and put a tube down your throat, or, you know, however more gentle you want to talk about it, we're not going to do things to hurt you, but we will continue to do things to help you.

35:51

Yeah, I love that.And I think that's I've also heard like loved ones say things similar to that, that gosh, if I, if I say yes, let's not resuscitate my loved one, I'm making the decision to kill them.When I hear that, it's very disheartening.

36:09

And again, it tells me we have really missed the boat here in the ways in which we're having conversations or the ways in which we're approaching CPR and DNR orders.I even remember during COVID I had so I even had a patient call me once and say, I want to talk to the, you know, ethics person because you didn't honor my wishes.

36:29

And I said, well, tell me, tell me about the situation.And she said, I had ADNR order and I had a heart attack and you took me to the Cath lab And I said, of course we're going to take you to the Cath lab.Your DNR order didn't even matter at that point.Like you had a heartbeat.We're going to treat you.You know, if you, you could have certainly said you didn't want to have or have your family members say you didn't want to go to the Cath lab.

36:50

But that's not ADNR order.Just so much misunderstanding around what that means.And I love your point, Devin, about just kind of softening that conversation a little bit more about there's so much we can do for people and it's not an all or nothing, right?

37:07

Which is sometimes how I've even heard CPR or code status conversations happen.Do you want us to do everything?And if they say no, it's well, now we're not going to do anything and just leave me in the room and let me die.And it's like, no, that is not what we're going to do or what it means.

37:24

Yeah, I know that a number of many, many institutions and people who work in clinical ethics have similar struggles with code status and the clarity of it and the process of it.And then once you have the process and the the policy kind of ironed out, doing the education is such a such a big lift, I think.

37:43

And so I think people are going to be really encouraged by your your success story.Thanks Ty.I really hope so and that, you know, that's that like I said, that's where we started with the policy and then we can continually refer people back to the policy when there's questions or concerns.

38:00

And so just having a well written policy I I think is key.I've read so many policies that I think, well, I don't even know what this thing is doing or saying.It's written by a lawyer, right?You're one of the good ones, right Ty?

38:18

Yeah, yeah.I'm one of the I, I think, so I don't know.Not a real lawyer, not a real doctor.Nothing's real.What a great place to end, Stephanie.This is so great and I think this will be really helpful to a lot of our listeners.

38:33

Thank you.I appreciate being here and I, you know, love sharing the story because it's something I'm incredibly passionate about and would love to see this get better on a larger scale.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darien Golden Stall for designing our logo and all of the artwork.

38:57

If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music, or wherever you listen.And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.

In this episode Steven Squires describes an intervention into ethics education that has taken off!

Transcript

0:00

Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy.I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.

0:27

All right.Good morning, Tyler.Good morning.We have a special guest with us today who's going to tell us another success story.Are you tired of success stories yet?Or are you really like into success?You know what, I I really like the stories where things go off the rails and everything is a disaster.

0:48

The pandemic was my favorite part of my life so far because everything was falling off the rails.No, none of that is true.So yes, the success story series is going well, amazing stories from people.And what I really like is that some of them are completely out of left field, right?

1:06

Like the way that we think about clinical ethics is kind of being expanded through some of these stories, so.Absolutely.All right.So today we had a volunteer who comes out of the best state, or at least one of the biggest states.

1:25

Wait, so I don't know what state he's coming from.OK.Are you going to say Texas?I'm going to say.Texas.I'm going to say Texas.But I but I was born and raised partly in Michigan, so you know.I have a colleague who said that he would never go to war for the United States, but he would go to war for Michigan Sounds.

1:46

Like something a Texan would say about.Texas.Yeah, Yeah, it's exactly what I thought.Have have you ever seen the bumper sticker that says I'm smitten with the mitten?Yeah, Yep.There's a lot of cleverness that goes on in bumper stickers in this the shape of Michigan.So there.Is.By Peninsula and Proud is another one that I'm a big fan of.

2:04

Oh.Very nice, very good.OK, what are we talking about today?OK, so you're from Texas, apparently?Yes.In Texas now, right?All right.So, Steven, please introduce yourself.Hi everyone, My name is Steven Squires.I I've worked in Catholic healthcare for about 18 years as an ethicist, mostly system.

2:27

I have done a lot of regional work.I've been a local mission leader, which is the position that is about the identity of the institution in Catholic healthcare.So I've done that.So in other words, I've worked in a hospital.So I do know somewhat of how it goes, but I've done a lot of system ethics as well.

2:48

I've worked for Bonds Core, Mercy Health and Trinity Health based out of Michigan.Both are large coast coast Catholic healthcare systems.And I intern a little bit with Ascension Health.

3:05

And now I'm here at CHRISTUS Health based out of the Dallas Fort Worth area.And specifically, as you can see in back of me, I'm in Irving, which if you could see back far enough, Dallas is back there in the skyline.So as far as my background goes, I started as a bio premed major in college.

3:27

And you know, a few organic chemistry scores can dash your hopes of becoming a physician really quickly if you don't do well.Was that organic chemistry?Yes, yes, it was.Oh, Chem Yeah.

3:44

And I've heard this story before.I, I, I did not do well.So, but it does, it does get you thinking because you had a lot of physicians say at the time, well, you don't need to be a physician to make a difference in healthcare.

4:00

And some of them even referred to ethics by name, which got me kind of thinking my life took somewhat of a different track because I was also passionate about education.So I got a master's in education and I worked for a little while in colleges, particularly in residents life and admissions and things like that.

4:23

And then I decided to make a pivot to try and go into healthcare ethics.Got a master's at Loyola, found I couldn't get a job with the masters 'cause people would say, well, are you a doctor now?Are you a lawyer?No.Well, I don't know what we can do.

4:39

So I went ahead and got the doctorate and that was I think in 2012.So that's the short narrative.Married three kids, oldest is going to college this next year.

4:56

She's a senior in high school.So we're looking at that whole thing and he's looking, he's looking at Rice, which I suppose is good.I just cough a little bit when I see the tuition.But.Well, you got to spend money on something and it might as well.That's right.

5:13

Education of your kids.OK, all right, so good.So tell so now you're working at CHRISTUS in Dallas and tell us a little bit about CHRISTUS large small.It's I, I assume it's a Catholic organization and then what your role is within this, that system?

5:29

Yes.So Christus is AI would say medium to large Catholic healthcare system.There's over 40 hospitals just in the US alone.Recently we we merged and are, are are working with are the parent company of a new hospital in New Mexico and we also have hospitals in three other countries.

5:57

So we're not just US based, we're also in other countries.And I believe when you incorporate the presence of the other countries, that's what makes us so large.It's just you may not see it because the main three states were in our Texas, Louisiana and New Mexico.

6:19

We're a little bit into Arkansas.I don't know if there's any hospital there, but it's mainly the southern US.Gotcha.And your role is as the the system director of ethics or what?How do you describe your role?Yes, I'm vice president of ethics.

6:34

I'd say ultimately, you know, ethics is my responsibility throughout the system.You know, as, as I'm sure you know, and as a lot of ethics roles are, the majority of my time is spent either as a backup to the backup, to the backup of cases or working with policy.

6:56

But I find a large part of what I do, which is even later today, I'm doing an ethics console training for folks who are in, we have a hospital in Santa Fe.And so we've got a group of folks who want to be ethics consultants.

7:11

And so that's that's part of what I do is by we'll do a training there in person.I zoom in or I teams in and we'll do trainings about certain things.So we've got lots of education within the system.

7:27

Like we have ethics webinars, which I hope to get you 2 involved with as continuing education.We have modules that are online for whenever somebody becomes a new ethics program member, so whether a committee member or consultant.

7:49

And then we have a specialty consultation training, which is like today, and they get practice in doing cases.So we'll actually go through the method, go through some good interpersonal skills, and then we'll try out some cases.

8:05

Great.Yeah.So today though, you have a is it a case for us or a policy for us?Sort of what is your latest success or what came top of mind when we said, hey, we would love some success stories?So the, the thing that came top of mind for me is this in, in my mind, a success story can be a, a process that's shown demonstrated success.

8:33

And I think for me, one of the things that I've always scratched my head at in bioethics is how we're so inclusive of people from every single different field because it's kind of AI don't know if I want to say add on, but it's like you come with kind of whatever your base knowledge is.

8:54

And then ethics is something you get kind of a super specialty in.And one of the things I haven't seen a lot of I, I don't think is people out of education proper now.I'm not talking about professors.

9:09

You know, we, my guess is if you look at the Constitution of our, or the, the composition of the American Society for Bioethics and Humanities, we've got a lot of academics.What my question would be is do we have a lot of those academics coming with a background in education, you know, like an EDD or a PhD in education?

9:34

So I think part of my part of my question and my intrigue being somebody who has a degree in education is if this is the majority of what we do.And I know of at least one survey of ethicists that said, you know, what do you do mostly with your time?

9:54

And the ethicist said, by and large, in practice, it's education.And so my question is, why isn't there more method into how we do that?Because education has methods.

10:10

And I think maybe an underlying assumption is, well, yeah, but that's for that's for higher education.Those methods are for schools.Well, not necessarily.I mean, education is whatever setting that that takes place in, if there's an information exchange.

10:31

So born out of that, that's kind of the backdrop to me saying I would like to be a lot more intentional on how education works within our system.Definitely in general, I'm working on some things with the Catholic Health Association right now with education.

10:54

But also why, why are we so?So this is the second part of the genesis of it.Why are we so stuck in Especially Lunch and learns?We love a lunch and learn.Yeah, I, I think there's room for them.

11:13

And I, I've backtracked a lot because I've said, you know, gone are the days of lunch and learns and somebody corrected me to say, no, they still have a place.It seems to me that lunch and learn is like the the hour of the day where you're most likely to get the most amount of clinicians, although I don't know that that's actually true or false.

11:34

But and then it seems like ethics education, like a lot of education is like any place that we can get any kind of FaceTime, we're willing to take it, even if it's not a great educational environment, right.So I've been asked to to give a lecture at like 6 O clock in the morning to transplant surgeons.

11:51

And I was like, I don't even want to talk about ethics at 6:00 in the morning to people who are coming off of shift, right.So that makes a lot of sense to me.So does it start with a weary eye?Do whatever you want, you know?Yeah.Yeah.

12:06

No, I, I think you're right.I, I think now here are the things I think you're right in the sense of, well, where else are you going to get people?Are you going to get people on their lunch break before their day really starts?

12:23

So like prior to the shift or right at the beginning of the shift or at shift end?But where I'm going with this is there I have seen just in when I was, you know, much, much more day-to-day in hospitals when we would do something like a moral distress rounds, short center rounds, the the people who could come in the beginning.

12:55

And now this is quite a few years pre pandemic.I saw that drop off just because in a certain amount of time, nurses really only have 30 minutes for lunch.So you if you've got an hour program, they have to make accommodations to stay most of the time.

13:14

And now a lot of them can't.And then when you're in a classroom, like in a classroom that's in the hospital, that takes people off the floors to go to that classroom, which is generally fairly removed from where they are.

13:30

And then they have to get back.And so if you look at a nurse going to get lunch, you know that that takes, you know, sometimes 5 minutes in the line or in the lunchroom, you know, just to give that 5 minutes to walk over, you've already done away with 10 or 15 minutes.

13:49

So that really started captivating my attention is, yeah, lunch and learns will often get physicians who have kind of an hour they can juggle with.It's less and less.We get nurses sometimes we can get chaplains, we can get social workers.

14:07

But it kind of depends.So my big thing is if you're not doing it at lunch, if it's tough to do it sometimes at the beginning and the end of the shift, what are we looking at that we could do that's embedded in other things?

14:24

And Ty, I think you made the comment like, well, we'll take whatever we can get.Yeah, that's, that's true.But can we, can we take that and make it really good, sometimes even independent of setting And, and my contention is yes.

14:43

And so that's why I developed what I was proposing to talk about today, which is called stat ethics.Stat Ethics.OK.That's that's the name 'cause you know we don't have enough acronyms in healthcare.

15:03

Stat ethics stands for short, timely, applicable, and team based is.That what stat stands for when doctors?Yale Stat.No, yeah, we're.Probably.Not all right.

15:19

So stat ethics, OK.And this is an educational kind of format framework that you came up with, you and your team.I don't know who's involved, but to address this need of being able to give high quality ethics education in a situation where we don't have a lot of time or the setting maybe not within our control.

15:39

Yes.Correct.Great, So.It's largely based on adult learning styles because it's very much of A misnomer that because we're all, we're all with very educated people.I mean, most, most social workers have at least a master's.

15:57

Most, you know, us, we have, we have doctorates and MD's are doctors.And you know, we, we're dealing with people who have high levels of education for the most part, right?We sometimes, sometimes people have their bachelor's and things like that.

16:14

All fine.But I think the, the go to thought is that people generally learn like you do in a, in a classroom.And that's not necessarily true.

16:31

Adult learning theory and adult learning styles will tell us that adults can learn in very short bursts, like 10 minutes, 15 minutes.It has to be relevant, extremely relevant to what they do.

16:49

So don't my my theory is because we're in Catholic healthcare, Don't tell me what Aquinas said back in God knows when.Tell me how this is impacting my job now.And you would not believe the amount of times I hear.

17:08

Well, you know, Thomas Aquinas designed this.It was for when people were riding their horses and, you know, they, they trampled over other people.And whether it was double effect or whatever it went.And it's kind of like, yeah, you, you lost me already.I had a what?

17:24

So my mentor in clinical ethics, he always said that you have to, you have to be able to teach it to a trauma surgeon and not to be disrespectful to the trauma surgeons, but it doesn't matter what a client has said if you can't give practical advice to somebody who's in the trenches like a trauma surgeon.

17:41

And I think that's really the key skill of an excellent clinical ethicist is to be able to have that background knowledge of all the theory and, and the history of all of these different topics and concepts, but then translate it into something that a trauma surgeon, for example, can use.

17:58

So, so tell us more about this framework.Like what does it look like?A 10 to 15 minute model blitz of ethics education.So we have a little bit more as the background than just the meeting itself.So part of my theory too is we've also gotten lost generally that when we talk about ethics education, it never when you go to things like the Quinlan opinion or the President's Commission, when they talk about it, it never was the end goal of ethics was for our own education.

18:35

When I say our, I'm not talking ethicists, I'm talking Ethics Committee members or ethics consultants.They were never the end game.They were always the conduits.Then why is it then in it?

18:52

And, and by this point in my career, I've witnessed thousands.Because if, if you think about me going to 10 Ethics Committee meetings a month in, you know, virtually in different settings, I probably witnessed over 1000 Ethics Committee meetings.

19:10

Why is it most of the time when we talk about education, it's talking about educating ourselves.But then that never goes as were the conduits on to the final goal, which it always was.If you look at Quinlan and the the President's Commission, it always was that that's supposed to go out to the clinicians, to the associates, to the community.

19:37

And so how much are we not paying attention to that?It's kind of disturb us, but then it stops with us.It doesn't really get out anywhere else.And so that in fact is a huge bottleneck because there's people out there who are lay persons who probably don't have an ethics degree, that they've got an enormous amount of ethics knowledge that they could probably.

20:07

Teach fairly competently on a topic.And this is where the first point about stat ethics I want to get across is we're not asking people to be ethicists.What we're asking is to take a very finely tuned topic and to know the core issues about that topic.

20:31

I think anybody can do that.I mean, I wouldn't even ask somebody to wade into like NRP now or something like that.I what I do think we could do is, and this surfaced from, we had a particular case where it involved somebody who claimed to be the surrogate spokesperson for the children.

20:56

He was the oldest male, I think of three of three children.The other two were younger sisters.And then he was saying kind of interesting things to our staff members.And then the other thing that came up is he was trying to deny his mom from getting pain medicine, but he didn't have any good reason.

21:20

Like when we would ask, well, tell us about a conversation.Tell us about a time when you discussed that there was nothing.It was just, she shouldn't get this.And so I think going back to the topic that anybody should be able to say, for instance, you know, pain control is a basic right.

21:44

You know, unless there's an overriding conversation that, you know, for instance, believing in redemptive suffering, physical suffering or something like that, they're, they're in the absence of that, how can we go against somebody's fundamental right to pain control?

22:02

Now you can find out enough about say pain control and say the surrogacy priority order or whatever it might be to address that within a small time period.So that was kind of the first thing is we did when this launched and I'll, I'll, I'll describe it in just a second.

22:25

But when it launched, somebody wanted to do a hybrid between that and a lunch and learn.And so in essence, what they wanted was this is a 10 or 15 minute format that's within a meeting.So it's like a nursing huddle and we talked with the nurse supervisor to see if we can get 10 or 15 minutes in that time period.

22:46

Now this person wanted to do something that was like an abbreviated lunch and learn.So it was like a 30 minute lunch and learn or you know, 40 minute or something.And then that person who who is trying it out took a huge topic like surrogate decision making.

23:05

Not surprisingly, when that focus group got done, they wanted more.They didn't think it was enough time.But if you look at who it was, it was it was a small group of physicians and they had the time and they had a huge topic.

23:23

So they wanted to know more.They were curious.That's not what it was made for.So I'll I'll describe it very, very briefly.So the first thing is you need to identify a topic.And a lot of times that comes through a case where you feel like it just, it wasn't optimal in the way it happened.

23:47

Like we feel like there's some things we could learn from from that.The Catalyst case I mentioned for this first round of or the pilot, the second pilot of STAT was the case that I just mentioned.

24:05

And what we, what we want to do is identify that, then see where the questions were.Because in that case, the first questions were with the folks who dealt with the case.But then we heard others say, yeah, but that's interesting.

24:21

How was, you know, if somebody saying don't give pain meds, how should we respond?That's a good question.So then we thought, well, it's a broader group than just the folks who dealt with the case.We ask that somebody on the Ethics Committee, a point like a research and education person, have a point person for that particular topic.

24:47

That's the person who's going to begin the research for it.We have a form where our IT folks helped us design A form where the way it's done for quality control is the basic method of stat.

25:06

And this is very simple, three to five informational points, a very short case, three to five targeted questions about that case.And ideally that case should mimic, you know, the, the case that happened with, you know, altered details and everything, three to five questions about that case.

25:28

And then of course, that's going to generate discussion and then you leave with three to five resources.So it's kind of the rule of three to five, right?Yeah, the classic rule of three to five, which everyone has definitely heard of.That's right.That that might be on AT shirt soon.

25:47

A rule of three to five.OK, so a case based prompt or like Genesis and then some some questions, some resources for the people walk away with.And so what's been your experience utilizing this?Well, the, IT, it started, like I said, with that case and it was kind of perfect the way that one, the genesis of it, because if you were to take that and, and broaden it.

26:13

So one of the issues in that case was surrogate decision making.You've got the one guy claiming to speak for all the people that level, you know, it depends on what state you're in, whether it's the majority of adult children, whether it's an adult child, whatever it might be.

26:30

But that's, that's certainly something to look into.Whereas he claimed to be the person to speak.But is that really, is that really accurate?You know what, what do the other children think?And we found out later that they did want to be involved.

26:48

So even that claim of, you know, well, it's just me, you know, later on it seemed like it was the other family members want involvement.But if you were to take that and say, OK, we need to educate on surrogate decision making, you've now taken a topic that is a fairly focused topic and you've generalized it.

27:12

So if you're going to go with surrogate decision making, then you know, you get into, well, does this get into assessing capacity?Does it you know what, what are all the what about what's a reasonable amount of time?What's you know it, it can open up this huge thing.

27:30

Whereas we're really looking at what if one person on the level claims to speak for the whole level and you know, how do you how do you question that?Do you question that and how do you question it?That's what the issue is.

27:46

So don't don't generalize it, focus it.You know, so out of that case, I think there became like two or three stat ethics because one was on pain control and and pain control being a basic fundamental human right.

28:01

The other was about a decision, decision making level for surrogates and one person claiming to speak for everybody when you're not sure that's the case from the the hospital side.So the way we did it was we have a form that RIT set up where somebody on the local side types in the three to five points they think are the most important, gives a case, gives the three or five questions and the three or five resources.

28:34

Then what we do is we ask them to send the form to us because there's a, a part where they can put their their e-mail.What we ask is to put our e-mail us meaning ethics at the system level at Christa cells.

28:50

So in other words, having an ethicist kind of just give a second glance over what it is, right.And so then what we do is we take a look at that.Most of the time it's pretty good.They're just a little fine tuning things and we send it back to them and it arrives as this beautiful PDF because what it does is it has and I, I can send you a copy of the, the format is it has the topic and then it has the three to five points, the case, the questions, and then the resources.

29:28

So ideally what we'd like to do over time is to build up a library.Now it'll probably be a very large library because it's not just, you know, decision making capacity, it's in this instance and in this instance, But we're trying to build that up so that eventually somebody can just go to the library and say, oh, it's, it's already done.

29:53

I, I don't even have to do the little amount of of work involved to, you know, make one of these formats.So we send it back to them.They get, they get somebody like a supervisor who can give them time in the meeting format.

30:12

And for the most part, this is done at nursing huddles and they get that time and then they, they go and they discuss because other than the three to five points in the case, it quickly becomes very engaging because you ask these specific questions about the case.

30:34

And you know, that's, I mean, that's how it clinicians learn and adults learn is through cases that are really relevant.So it really is made as a discussion generator.And then, you know, when you close out at the end of all this takes is like 10 minutes.

30:54

When you close it out, that's when you leave people resources and they have to be either right there that you can give to them or publicly available because again, nurses and physicians and social workers and chaplains don't have access to the resources that the three of us might have as ethicists.

31:15

So it's got to be something that we've taken a look at and we said, yeah, this is, you know, that the, it's maybe something from core competencies or I, I don't know.But again, that's not, you know, you have to have the book to, to have it.

31:31

But maybe it's a a website that's a fairly respected source.A podcast, for example, an episode of a podcast.If only there were a good bioethics podcast that really was like educational and entertaining and like anybody could listen to.

31:48

Somebody should really make a podcast like that.I, I think there's a, there's a, there's a market for that.So there's.Good job with the upsell.I love that.That's great.A podcast on it, you know, something that people can listen to on their way home from work.

32:06

It's really accessible.So we did that and the initial results were phenomenal.And by that I mean we asked three questions about method.So it wasn't necessarily on the topic.

32:23

Now that we've ensured the method is good, now we're asking questions about the topic, but the method I asked three questions, is this method more convenient compared to traditional methods like a lunch and learn I?

32:41

We asked, is this more user friendly?Now that's an open term, but is this more user friendly to you than a traditional method like a lunch and learn in a classroom?And then is this more helpful to you?And what we got back was shocking because it was a 5 point Likert scale from status, much less in all of those factors to status much more on the far side.

33:13

Yeah, so tell me the the things you measured again.So usefulness.Convenience.It was convenience, user friendliness and helpfulness.We didn't we didn't define anything which it's open for interpretation, but when we got the results back on the Likert scale, it shocked even me 48 nurses.

33:37

So this we had in essence 3, three kind of little pilots, but when you conglomerate the scores, 48 nurses said, I think the convenience was 74% better than traditional methods.

33:54

The user friendliness I believe was 75% better and the helpfulness was 76% better.So basically, if somebody told you there's a method you can use for education that is nearly nearly 100% better than anything they've encountered, or a traditional method, my question is why wouldn't you use that?

34:20

I consider it at least.Yeah, 100% better.Well, OK, maybe I'll change the thing that I'm used to doing.Yeah, exactly.You know, I, I got that back.I'm like, wow, this, this is really cool because in essence, we were still reeling because that that first time where somebody wanted to do a hybrid approach.

34:42

I had to say, but that's not what it's made for.It's not made to be a hybrid of something else.It's made to be this.And we kind of went back and forth and then I thought, well, let's give it a try and see how it goes.Like I said, it was mostly to physicians and it was a very general topic and the timing was longer.

35:03

Will people left wanting more because they're in a classroom, They're thinking this wasn't an hour long.I have an hour long, I have questions.This whole topic wasn't explored.And so in my mind it made sense why they're like, no, I I don't want to go down less time.

35:23

I want more time.Well, if we had refined the topic more, if we had done it for nurses, if we had done it in the setting and you know, then I think you'd see a different result.And I would argue that's what we saw.

35:40

Yeah, it it seems so.A question strikes me that sometimes like the customer isn't always right.And what I mean by that is I don't know that the quality of education is directly tied to the satisfaction of the educated, you know, the person in the classroom.

35:58

So yeah, no good, really good point.Or that they would know best how to like improve that education if they were felt wanting, right?Like they can assess whether they enjoy the education, whether they felt like they learned something, whether it was relevant.And I think we should take their word for it, right?

36:14

Like, no, you just you really were educated and you didn't even realize it.It's probably not the best way to respond to that.But if you said, OK, you there was something lacking, how would you feel it?That's shouldn't be on the on the learner.That should be on the educator to think through.Like the learner might have some thoughts that you should listen to, but really it's the educator's job to figure out how to fill that.

36:34

And the intuition that you just needed more time might not actually be true.It might be that you needed more concentrated education.So it sounds like, yeah, that that that impulse that you initially had bore fruit that you either need to do a whole long lunch and learn or you need to do like these micro stat teachings.

36:52

And, and that's why I'm curious so on, on that front, three other Catholic healthcare systems have now picked this up and are trying different versions, trying their own version of it.And I'm really eager, I'd like to get maybe a call together so we can all talk and see how it's going and what the feedback is, because one system is trying it with their administrators.

37:17

And I'm wondering, well, how's that going to go?Because this really, I've even resisted saying, you know, is this something we should do for physicians?And maybe part of it is because of that when I scratch my head because of that first pilot with physicians saying I want more, this wasn't enough.

37:37

I, I guess where I'm going is this is shown the success with groups of nurses and nursing huddles.And so I, I think whether or not that works with physicians in the different setting, I, I don't know.

37:53

We certainly can try, but what seems to work is for nurses on this.I can even imagine this working for sometimes when I teach just in a undergraduate classroom, I like to open with like, hey, this thing happened or this thing could have, you know, usually I make it up like, what if you were the ethicist?

38:13

What would you do?And we can't spend 30 minutes on it because I need to get to the rest of the Lesson plan that day.I just want a little micro like, what's your impulse here?And how do you how would you justify that?And I need it to be quick because I need to get to the rest of it, the rest of the teaching for the day.But I'd love some like but but they always want to talk about that one thing for like an hour, so this would be a great way to do that too.

38:35

Yeah, I can see it in the medical education setting too, because one of the ways that I like to teach is split up people, you know, students into small groups and give them each an individual case.And then it's only like a, you know, maybe 15 minute and process of analysis.And then they come back and report out what it was.

38:52

And each one's a unique case.And so all of them get the whole students, all group get to the whole class gets to see or hear about 6 different cases for example.So seems like it could be very useful in that regard as well.Yeah.I think one of the things I've always been puzzled by is I, I don't know how familiar with it you are.

39:10

There was a model of ethics now probably 20 years ago called Next Generation Ethics, which was that, you know, it's supposed to be strategically proactive, integrated metrics driven, focused on mission and values.

39:26

Those were the four pillars of it.I think that, you know, this is something where, first of all, my view of how ethics committees go is that particular model started out of Ethics Committee meetings, becoming a philosopher's club.

39:51

And kind of like you were saying, everybody loves to talk about cases.I mean, there's in a sense, is there anything wrong with it?I don't know.But in my book, there are certainly a lot of other things we could be covering in a meeting other than rehashing a case that, when you think about it, if the case has already happened, past tense.

40:15

Why are we going over everything over and over?I mean, for people who are familiar with what clinical meetings are, they're very short into the point.It's like a, it's like a military briefing.And I kind of get to, but if we've talked about this for an hour a case, it's already done.

40:39

And we didn't talk policy and we didn't talk education and we didn't talk about the patterns that are merging within the system.We didn't talk about community relations.But what's the outcome to that case?It's already done.

40:56

So I I don't other than for our own awareness and kind of, you know, talking about and maybe making things a little better for the next time.But I think that's where the next generation method started with frustration of but aren't we missing a whole bunch of things?

41:13

If if we become kind of a philosopher's club and let's face it, most of us, us being not Ephesus being more like doctors and nurses and social workers, if most folks that isn't really what they do.

41:31

Again, the question comes back to how much are we serving others versus ourselves in in that case.And I'm not trying to be mean, I'm just trying to be realistic in in that.So what I think is interesting too is on the case side, when you go to the meeting, the cases should be really minimal.

41:54

You know what went well, like a delta, You know what went well, what didn't, what can we change that type of deal.The reason I'm mentioning that is because I also resist taking meeting time necessarily to do a lot of education for ourselves because that can be done in other settings, like a podcast in a car.

42:19

Like a podcast in a car.Podcast in a car and I know people who do that, so they'll they'll, I mean, they'll listen to a pod, they'll listen to an ethics podcast in the car.So have that for your continuing education, offer your education for ethics program members at a different time, either a podcast they can upload or we do half an hour kind of quick ethics lunch and learns for all ethics program member continuing education.

42:51

But the reason I say that is then at the meeting, it became it can become more operational to OK, we had this case, here's what's happening culturally.And so here's where we might need to do a stat ethics education.

43:09

How are we, you know, does anybody want to be point even now, you know, as a group, let's think of what are the biggest three to five things we want to get across?And then how can we alter the case so that it's more anonymous?You can actually use it in an operational sense during Ethics Committee meeting time if you carve out the space for it.

43:33

So that's that's kind of why I got into all that other stuff is it's like we, we should be, we really should look to clinicians as a model on how to run a very operationally efficient mission.And we need to kind of speed up the pace or we're going to lose people.

43:52

Because whether we realize it or not, I would say our clinicians operate with like military, like efficiency in what they do.So that that's a lot of it, yeah.Yeah, it sounds like almost you're flipping the classroom.

44:09

Use a flipped classroom model for your Ethics Committee education, giving them the the meat of it in the background.And then when they get to the meeting, they can actually apply it, which is, you know, aligned with a lot of adult education theory as well.So good on you, as they say down under.Yeah, I love this, Steven.

44:25

I think that's a great intervention.It sounds like the results were really positive and you were and are a success.Good.Very good.Well, the most powerful motivator I've ever heard is no, you can't do this.

44:42

And when I first mentioned the idea, there was at least one colleague.I think there might have been two.Or like, you can't do education that amount of time and a subject.And I'm like now, because you said that I'm going to make this hard.Yeah, I see your personality type there.

45:00

Yeah, Yeah.Well, it's a personality type, but it's also reality, right?Like I'm thinking then when this person said that, I'm thinking you know nothing about adult learning or at least you don't seem to demonstrate anything you know about adult learning.

45:17

So I think for me it's what's the kind of new generation or next way that we can work with our clinicians on education.Great.Well, I think we have to leave it there, Steven, but we appreciate your your insights.

45:35

This this new model you've described sounds like it's going really well.So yeah, keep up the good work and we'll look to follow what you guys are doing down there in Texas.Sounds great.Thanks, Steven.OK.Thank you.Bye.

45:51

Bye.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone.So a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork.If you're into what we're doing, give us a rating on Apple Podcast, Spotify, Amazon Music, or.

46:13

Wherever you listen.And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.

In this episode we discuss another success story with Dr. Jennifer Bell who helped her medical center think about how to ration scarce CAR-T Cell cancer treatments.

Transcript

0:00 

Welcome to this episode of Bioethics for the People, the most popular bioethics podcast on the planet according to Grandma Nancy.I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every single day. 

0:17 

And I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here right now, would probably be golfing.All right, Tyler, so we have another success story to share today from a fellow Canadian.Yes, I love Canadians, of all the nationalities, they're my favorite. 

0:37 

Have you ever, I don't think you even talked about this in the podcast we did about you, Tyler, is that you're Canadian?Well, kind of Canadian.I was born there.I can have dual citizenship if I ever fill out the paperwork.Oh, you've never filled out the paperwork?No, it's like $125.00 fee and I've never never actually filled it out, but. 

0:55 

That says something about your like extreme optimism about our political situation that you've never like in the back of your mind, Go said maybe Canada might not be such a bad choice for me.Yeah, maybe this year will be the difference maker though.We'll see.OK, so we've got a Canadian with us. 

1:10 

Well, I'm actually dual citizen.Yes, dual citizens are the best.I grew up in Georgia and now I live in Toronto, so.All right, so we've got Jennifer Bell with us, who's a senior bioethicist up north of the border, and we'll let her introduce herself. 

1:27 

Yeah, well, I I already told you more about me than I think I tell the average person.So I am.I won't start from birth.I'm currently a senior bioethicist in Toronto, ON and Director of Bioethics Research.I'm at the University Health Network and I'm affiliated with the University of Toronto. 

1:47 

Very cool.So, Jen, what does your day-to-day look like?Well, I mean, actually it's changed a little bit because I just was awarded a fellowship actually in AI and compassionate healthcare, but previous to that, which I just started a couple of weeks ago.So I've been seconded to that and it's a research fellowship, but, but prior to that my, my day was very clinically oriented. 

2:10 

I mean, I provide clinical, organizational research and policy and education ethics across our organization.I primarily support Princess Margaret, which is our cancer hospital.But organizationally, I do a lot of work for the entire organization as it goes. 

2:28 

So, you know, day-to-day it's, I mean, as those of you who work in healthcare settings and our ethicists there and you're sort of beholden to what kinds of consults and questions come up and you can never really anticipate what those might be.So that's sort of exciting, but also a bit daunting because you know, you're called on to be sort of have knowledge about all these various areas. 

2:51 

But it's sort of a generalist in a sense, at this hospital at least, because I, again, serve a larger population than just the cancer system.So it could look very different depending on the day.But generally, I will be responding to a clinical consult, a bedside consult. 

3:09 

Maybe there's a policy coming through that needs an ethics perspective.Right now, we're in the midst of creating sort of AI protocols and procedures.And so there's a lot of opportunity there for ethics input on that.So, I mean, it really varies, yeah.And I know that Tyler has experience with this too, but I've been part of hospital systems that get like 1 consult a year, and then I've been part of ones that get more like 1 consult a day. 

3:36 

My guess is you're getting even more than that.So what is your typical load like?How often are you being called to consult?Yeah.Well, I should preface this.I'm not a sole bioethicist working in this network.Actually one of five others.So there's six of us.We're not all full time. 

3:52 

So me in particular, I have 3 days that I devote to practicing ethics in the healthcare in our, in our healthcare network, but I'm also paid to do research.I have a nice dual role, which is it's hard to come by, at least in Canada. 

4:08 

I don't know how frequent you have these opportunities in the States, but so my day, my week is actually split into normally it's changed a bit now because I've started this fellowship, but before this it was three days clinical organizational research ethics practice and then two days I had devoted to actually conducting research and bioethics. 

4:28 

I would say that's incredibly unusual.That is a lot of time for research.That is really cool.Yeah, yeah.And it's not grant funded either.So it's it is a permanent sort of part time research position, a full position in its entirety, but the research side is actually well as guaranteed as you can be. 

4:47 

That's cool.One of the topics that we're covering on this kind of series group of episodes is success stories.What we want to do is highlight some of the good work that clinical ethicists are doing.Number one, because they, I think clinical ethics and being an employed clinical ethicist is a fairly unusual type of position. 

5:06 

Most people don't know that this position exists, but it's easy to envision, you know, the worst case scenario or really terrible cases where an ethicist is useful.But sometimes those get sad and those get heavy.Those talking about those cases all the time. 

5:22 

So we wanted to talk about success stories.And so you have a success story that you are going to share with us.Yeah, Yeah, I do.And thanks.And it just, it just dawned on me that I didn't actually answer Devin's question about how many consoles we get.I I was leading into it and then and then digressed. 

5:40 

But as a snapshot, because we have, you know, almost 6 at the system varying kind of responsibilities to ethics within our service, we have around 350 consults a year.I don't know how to make sense of that necessarily.I mean, that's one of the questions of our, of our profession, of our discipline is how do you benchmark this? 

6:00 

But but yeah, we are a busy service, a very busy service.And actually the success story stems from an organizational ethics consults.So actually most of my work has tended to be at the Cancer Center and it's tended to be organizational in nature. 

6:16 

I think that might be because I'm there three days out of five and I'm just not, I'm not as present on, on the units walking around or participating in rounds as much as maybe I would be if I were there five days.I mean, I think that might be some reason. 

6:32 

But I have also just had a lot of uptake in terms of organizational ethics issues and leadership has brought me on to some of these issues and it's just kind of propelled from there.So the success story that I wanted to share with you all is an organizational, I'd say organizational ethics success story in the sense of success of being involved as an emphasis being included embedded I think in the process and the questions. 

6:59 

It was an important and still is actually an important issue that we're working through at the Cancer Center that, but that's the setup.It might be helpful to some of our listeners who might not be as familiar with the work of clinical ethicists to just describe briefly the difference between sort of a clinical ethics consult and an organizational consult. 

7:19 

I generally understand those as a clinical would more come from a physician or someone on the healthcare team, maybe even a patient, other family members saying like what's happening here doesn't seem quite right or there's an ethical dilemma I'm seeing at bedside versus an organizational question might be more like the process itself that we have some sort of policy that we have doesn't seem to be working for us. 

7:40 

So we need a higher level console that says we need to think about how our systems are running.Is that how you make that distinction?Yeah.I think that's a really, that's a really helpful distinction.I would have made something similar, but maybe not as eloquent. 

7:56 

Yeah, clinical ethics is more about direct patient care.We got consulted by all those parties that you just mentioned.Many people don't know, especially patients or public members that they, at least in our service, they are free to contact us for a consult.They don't need to pay for it. 

8:12 

So that's something we're always trying to strive for in our services to let people know that they can contact us, doesn't have to be the healthcare team contacting us.And then organizational, yes, just as you just described, I'm often involved in policy guidelines, anything that would sort of touch a systems level of how a practice might operate or a program might function that has ethical components to it. 

8:39 

I mean, lots of ethicists I know have been involved, for example, in informed consent policies in their institution.So that's a, a pretty typical 1.And I know, you know, we talk sometimes about these hybrid cases.My colleague Sally Bean has a great article describing hybrid cases where you might have a clinical ethics consult, a patient, a consult involving direct patient care. 

9:02 

I'll take an example from my own practice.We had a patient that was uninsured in Canada.We have public insurance, but it's only available to those people who have status in Canada, that being immigration status.And that's how we define uninsured or insured government provided insurance. 

9:21 

And so there's going to be some folks without that eligibility and don't have the access.So we've had many consults that arise during direct patient care about whether we should or should not, the healthcare team should or should not provide care to certain patients who are uninsured.And as a result, a long time ago, I developed with senior leadership a policy around how the hospital ought to approach this issue. 

9:43 

So that's a good example, sort of a hybrid case where an organizational ethics issue is informed by a clinical ethics case.Yeah, in my experience, that's almost always how they go is that somebody identified something on the bedside that then needed a policy to make sense of, like how we would think about future cases. 

10:01 

So how did this case or this success story, how did it land on your desk?So for the success story, I have to actually go back several years.This was pre COVID when it landed on my desk, so to speak.So it was 2019 and I have been quite involved in the self therapy working groups at Princess Margaret's. 

10:25 

So like prior to this, the stem cell transplant program and we had actually written a paper and developed a process around prioritizing patients to stem cell therapies.And so I knew this group very well.And the director of the cell therapy, the cell effector therapy program approached me basically and said, look, we have this cellular therapy, it's called Karti cell therapy. 

10:53 

This is a kind of immunotherapy for cancer where you take your own immune cells, you engineer them and make them better able to attack cancer.This is a, you know, highly specialized therapy.It's very resource incentive. 

11:10 

It's very expensive and it's only performed at specialized centers.Princess Margaret being one of those very few centers in Canada, and I know in the United States there's also select centers that apply.Not every center has a cell therapy or CAR T cell therapy program.So she approached me actually and said, look, I'm really concerned about the way that we're currently allocating very scarce spots of this CAR T cell therapy to patients. 

11:38 

We come together currently, we discuss the patients that are eligible, but you know, I'm worried that it's not.It could be better.Like the process for deciding which patients should get the next slot.This process could be better.She was worried about the squeaky wheel effect where a patient's physician might just be more vocal about a patient and it might just that patient may rise above the others then in the decision making. 

12:03 

And she just wanted some guidance and transparency and really an ethical framework around this process to support it.That is like when we teach about the first dialysis committee that had to decide.So they were like hundreds of patients, thousands probably around the country who and but like 3 dialysis machines and the physician says Yikes, I can't just make all these decisions on my own. 

12:26 

I need an Ethics Committee.And in that case, they, I think we've talked about this on the podcast before, found like representatives from the community to do this who ultimately made some pretty biased decisions.But now we have these professional ethicists like yourself presumably have some expertise in this and now you're being tapped to do it. 

12:43 

So it's like a different model then.It'd be great to sort of compare this at some level.You should I'm, I'm always good at telling people what they should be writing.Do a comparison of like those kind of original committees that were formed.And and this like has a similar sort of problem.But now we have a new profession that's that is there to address it. 

13:02 

And so can we do better than the original dialysis committee that what they used to call the God committee?Yes.So this, as you say, this is not a new ethical problem.The clinical context had changed.We're not talking about dialysis anymore, but we're, we're and we're not talking about transplant because we know we still have this in, in solid organ transplants where the organs are extremely scarce. 

13:25 

This is a bit different.This is our T cell therapy is it's not, it's not an organ, it's it's a product.It's a product that's made from a patient's own cells.It's engineered.It's a little bit different.It's not an absolute scarcity.I suppose that's the difference. 

13:41 

There are other things that make this product scarce or limited.So there's capacity challenges, for example, manufacturing challenges.It takes a lot of people to be able to make this therapy available.So I, I can get into the various challenges if you wanted, but suffice to say that this is a therapy that is very, very, very intensive, complex and and only performed at very limited centers. 

14:12 

And presumably very expensive.Yes, very expensive.So I think, I mean the last number I heard was it's $500,000 a product and I'm not sure if that actually includes all of the bedtime.Sometimes these patients need to go to the ICU. 

14:29 

So I think that's an average, but it could, I think it could be more than that given all the needs that sometimes go along with it.So incredibly resource intensive type of therapy.Remind me, what type of cancer is this treating or or what types of cancer is this useful for? 

14:48 

So it's, it's been approved for blood cancers mostly, so leukemia, lymphoma cancers and it's been used mostly third line.So these are, these are patients who have tried several lines of therapy already and they're now on maybe their third line and nothing else has worked. 

15:09 

And CAR T, they are eligible for CAR T at that stage.It's going to be available for multiple myeloma.In fact, the product may have already come out two months ago here in Canada and may be more available in the States earlier, but it's the blood cancers.However, I will say that in clinical trials, CAR T's being explored for solid tumors as well. 

15:30 

It's sort of lots of people are very optimistic about CAR T cell therapy, but it just hasn't shown yet to my understanding, as great of benefit or usefulness in solid tumors as it has in blood cancers.Janet, sounds like you know a lot about cancer. 

15:46 

I mean, it makes sense that you're in the you're in the cancer hospital mostly.But for your kind of work and for what you are tasked to do with thinking about resource allocation, how important was it that you understand cancer, like the pathophysiology of cancer, The, you know, sort of the mechanisms of cancer, the science of cancer? 

16:05 

How much of that is really important for you to be able to know in order for you to think about resource allocation of this chemotherapy or this immunotherapy?Oh my gosh.I think this is almost an existential question.Yeah, Because I, I struggle with this.I want to know as much as I can. 

16:22 

I try to learn as much as I can.It's, I mean, obviously it's beyond me.Like this field is just so fast-paced, so complex.I went to a conference last year in immunotherapy, the bio can RX conference in Canada.It's, it's really pushing the boundaries of our T cell science and just sitting there to look at all, all the various permutations of vectors they're exploring like ways to get the cell into the engineered cell back into the cell and, and what should carry it in there. 

16:50 

Like it's just beyond me.So I, I try and just have a basic level of understanding at least to be able to converse with people and ask good questions.But you really, I really rely on my colleagues to, to fill that medical gap. 

17:10 

Obviously I'm not trained in medicine so doesn't come easy.So you were approached to help develop this allocation process for this particular expensive, high resource intensive cancer therapy.So how, how do you even approach the question? 

17:26 

Like how do you even get started on something like this?As as you may or may not know, you know, I come from the background and philosophy.And so I, you know, I've studied John Rawls, I've studied different models of justice in theories. 

17:42 

And but when it comes to actual sort of clinical application of some of these series there, it's difficult.So when it comes to problems of distributive justice.So this is problems of justice where demand outstrips supply and decisions need to be made about how to allocate. 

18:01 

There are some raining sort of philosophical approaches.So you could take a utilitarian approach, which would just mean trying to maximize benefits to the majority of people.When you look at the literature, because you as an ethicist, part of I, I see part of my job is going to the literature to see what's been tried, to familiarize myself with the theories and a possible approaches and to do some evaluation on my own about what might be most applicable to the situation that I've been consulted about. 

18:34 

But generally, I mean, utilitarian approaches have been criticized in problems of distributive justice because you still land up with or you still end up with discussions around, well, what counts as maximizing benefit?What is benefit?And then we get into discussions or disagreements potentially about what benefit might mean. 

18:54 

Is it elongation of life?Is it quality of life?You know, there will be disagreements.And then obviously utilitarianism as a theory fails to consider properly or appropriately the needs of the less well off or the minority because it's very much concerned with what the majority is owed. 

19:12 

The other approach in the literature for distributive justice problems is an egalitarian approach where everyone deserves equal based on personhood, deserves equal amount of resources distributed to them.But obviously the first problem there in this situation is that there isn't enough resources to go around to everyone. 

19:32 

And so we can't give everyone equally the amount that they deserve.We can't give everyone a slot for car T because we are very limited in car T slots.And that's why we have this problem where we need to justify why one person should get it or be prioritized over somebody else. 

19:50 

Or could somebody wait and this person get it now or, or are they not fit to wait?So egalitarian approaches also sort of fail the test.And so in the literature, of course, there's recognition, I guess, of these limitations of these two approaches to distributive justice. 

20:07 

And somebody very smart developed an accountability for reasonableness model.That's right, we don't remember anybody's names.So that you can edit this.No, there are some people who are like so good about saying this person thought this and wrote this or like lawyers, sometimes they're really good about saying like this versus this case and this court said, but we are not like that. 

20:30 

And yeah, so somebody smart said something smart, right?You are my people then.Yeah.So they developed accountability for reasonableness, which is really just a process for making decisions.So it it outlines various principles that ought to be met in a decision making process where reasonable people disagree. 

20:55 

And so we already know reasonable people are going to disagree.In this situation, we're going to have debates about should this person go or should that person go.And so this process, accountability for reasonableness sets out some criteria that a decision making process ought to meet in order to be considered fair. 

21:13 

There are several stages in application.So as an ethicist, I came in then and suggested we use this approach, accountability for reasonableness to tackle the ethical issue of prioritization of patients to CAR T cell therapy given the disagreement and given the scarcity of CAR T cell therapy. 

21:33 

So this reasonableness account is published in the literature and and why did you think that this would be the best approach?I mean, why not just lean into utilitarianism like that?Seems like the most cut and dry to me.Yeah, I mean, we did have discussions and so in our process, you know, we invited different parties. 

21:50 

So part of accountability for reasonableness to go back to your diet to tell us this example, one question might be, well, who was at the table or at the where?Was it the right people at the table?And if, you know, a certain group was left out, could that have been a factor in arriving at what we would now consider a skewed outputs or decisions made, You know, that we would now reflect on and say, well, maybe this wasn't quite right. 

22:15 

And so part of the process for accountability, for reasonableness, I'll just say A for R is to and invite relevant stakeholders.Of course, then you're then you're tasked with the question, well, who, who is relevant here?And very helpfully or somewhat not at all helpfully, I think the guidance is will anyone that will be impacted by the decision. 

22:41 

OK, not helpful in our sense.I mean, CAR T cell therapy involves a lot of people.I mentioned it's very complex.You know, you have to take cells from a person's body.You have to, it's called apheresis, where you you actually have a bed space as a patient. 

22:58 

You would go to that bed space and have your white blood cells in this case withdrawn from your arm probably at the catheter.So this is a process that needs to happen.Those cells will be extracted.So you need a local cell processing facility to extract and keep and freeze those cells. 

23:17 

All of this is required.It's overseen by accreditation bodies.So you need to have the trained staff to be able to do this and handle the cells appropriately.Quality is very, very important in managing in this process.So you need to have quality and auditing process and like it takes a lot actually to do this. 

23:38 

And then once you have the cells you can, you need to distribute it to the manufacturer.So they need to be transported to the manufacturer in Canada.That means transporting it to a site in the United States.So we don't have a manufacturing site, apparently one that's for standard of care up and running in Canada. 

23:55 

So we send it to the state and then you wait four to six weeks for them to engineer the cell and then and they transport it back to us and then we keep it in our cell processing facility and then the patient comes in and we infuse the cell back into the patient.So this is just to illustrate that it's a very, it's a very complex process. 

24:14 

There's a lot of people involved.There's cell coordinators, there's nurses, there's obviously the oncologist, there's patients, there's their family members, there's, you know, bioethicists, there was myself, there's leadership that overseas a lot of this part T cell therapy, I should also mention can touch other areas of the hospital. 

24:34 

So again, some of the side effects of part T cell therapy can be severe.So some of these patients might experience cytokine release syndrome, which is like an influx of your immune cells sort of sort of exploding in your body, going haywire as a result. 

24:51 

And it needs to be managed and it's very severe.You can develop neurotoxicities based on this.It can be very harmful and it's best managed in an ICU by very trained staff that know how to manage this.So, so now you can see right there, there's other people that are impacted by CAR T cells. 

25:11 

So bringing in potentially the viewpoints and considerations of the ICU of our chemotherapy units, of our apheresis unit.So there was a lot of people to consider in this case to bring together and we did have quite a large working group when we began this project of about 35 people. 

25:30 

That's too many cooks in the kitchen.Not all of them came all at once, but to get the point about utilitarianism, I didn't forget it right there.There's I mean, there's so many people and but there's a lot of difference of opinion then about how exactly this, how do you define and understand benefit in this patient population? 

25:52 

And we have lots of discussions around who would be most likely to benefit from CAR T cell therapy.And this was where I found it very interesting as a non medical person because the discussion came out around, well, you know, someone is someone who has greater disease progression may have a greater chance of benefit of CAR T cell therapy because their disease is progressing. 

26:18 

It's their last line.They really need this.It's their only option.And the disease is, it is advanced, so they have a greater opportunity to benefit because there's no other options for them and they can't wait very long because their disease is progressing.But then others would say, well, if their disease is progressing, then they may actually not do so well with this therapy. 

26:39 

It may be too far gone or they may be too sick, or they may have other comorbidities.So we should be allocating this to someone who is sort of less sick in that sense they they could derive more benefit from this.What strikes me about the case, the problem that you're working is that the same analysis and the same issues come up whenever we're talking about scarce resources. 

27:03 

And so we could be talking about ventilators during Kovid, we could be talking about solid organ transplantation, we could be talking about something as simple as diabetes medication, right?So whenever there's a scarcity of resources, which there always is some sort of scarcity, some sort of limitation, then we have to make really hard decisions about who gets what. 

27:23 

And there's a letter of different ways of approaching it.And I think people who aren't familiar with these types of cases mistakenly assume that it's fairly simple that we just, you know, list people and they've got criteria and then we, whoever deserves it, whatever that means, gets that organ or that medication or that resource or whatever. 

27:44 

But it's so it's so much more complicated and nuanced.And when I'm teaching students about allocation of scarce resources, if there's almost always a point when they start going through the problem set or the the case and then they have to stop and be like, wait a second, this is way more complicated than I Then then we started thinking this was. 

28:02 

So I think that's part of the benefit of having an ethicist in the room is like, we anticipate complexity probably better than most people.But yeah, it sounds like you're struggling with the same thing.And if it's not immediately complex, we can show how it is.Yeah, We're good at making it seem really complex. 

28:19 

It immediately kind of like struck me as like very similar to organ donation.But I think Tyler's right that a lot of scarce resources like this.But I think what I am struggling with is not that it's easy with organ donation, but we do have some sense of we've been doing organ donation long enough where we can sense like if somebody is too far gone to receive the benefit of the organ. 

28:40 

But with COVID, it was really unclear.Like we were using tools to help us understand, like how people, how close people were to death such that maybe treatment wouldn't help them.But we were really unclear about it because COVID was so new.It was such a novel disease that we were really unsure if our tools and our measurements were correct. 

29:02 

So is is this therapy somewhere in between there, like we have some evidence of its effectiveness for certain populations depending on disease progression?Or is it more like COVID where it's just so brand new that we're not certain of our own measurements?So I would say that it's more leaning towards the COVID scenario and obviously not entirely. 

29:21 

A lot of the studies that the approvals have been based upon the FDA, Health Canada, European nations have based approvals on our early phase trials.So phase one, phase two trials.The long term effects of this therapy in this in these populations is, is not well known. 

29:42 

We're starting to know a little bit more, but it's there's a lot of uncertainty.There's also a lot of uncertainty around predicting which patients will do well exactly.So there's a lot of medical uncertainty.They have scales.Frailty is seen as maybe a significant factor in considering whether someone will do well comorbidities. 

30:00 

But I've witnessed my medical colleagues struggle with this around making predictions or knowing or having knowledge about which patients will do better.And a lot of their research in this space, or not a lot, but a stream of research in this space is about trying to figure out which patients will do better on this therapy than others. 

30:21 

That makes the ethics really complex too, because if you don't have good facts about who's going to benefit, then you really need some other.I see now why you're saying utilitarianism can't work here because we just don't have enough facts about outcomes, so we need some other kind of model.And I might touch on one criteria that came up because it was interesting discussion in our group and it's come up in other allocation decisions before and that is age. 

30:46 

So did you allocate a scarce resource based on age?And this came up in our discussion as well.And you know, to the to the point about not having all the facts, there isn't much research to show that age is predictive or correlated with outcomes in car T cell therapy. 

31:08 

There isn't good rationale for leaning on age as a determining factor or criterion to consider in allocating patients.So in our working group, we had a lot of discussion and patients were included in our working group and they were very adamant that age should not be a criterion if we cannot justify it based on sound evidence, medical evidence. 

31:35 

And we had disagreement about whether we actually had that sound medical evidence.And in the end, we as a group decided we did not.So age was excluded from our list of factors to consider when prioritizing patients.And I know that age is a very contentious factor in discussions of other resource allocation discussions. 

31:55 

Yeah, because age can either age as a criterion doesn't tell us whether being older is an advantage or being younger is an advantage.And also it's interesting.I think it's important that you tried to link your decision about whether or not age is a criteria to evidence, because a lot of evidence is based upon all evidence is based upon research and the research is based upon protocols. 

32:19 

And there are exclusion criteria, probably based upon age, in the underlying research as well, which also complicates it.Yeah, but can't we say like a 99 year old?OK, maybe it will or won't work for them, but gosh, how many years did they have left if they get therapy or not? 

32:35 

I mean, they're, I wouldn't say that, of course I love old people.But I have heard people say that like, you know, even if we don't have evidence that it'll help or hurt based on age, just by nature of like human lifespan, if we're giving therapy scarce resources to people who are very, very old, they just won't derive the same benefit as somebody who's very young. 

32:53 

The general population feels that way.But I agree with you that it shouldn't be good criteria.Yeah.And especially in the context of Car T, when people are this sick, if you take a 45 year old person who's that end of line cancer treatment, this is their last sort of shot, but they have a whole host of comorbidities associated with their illness. 

33:16 

Very they have a not good medical gestalt here is they could be harmed by CAR T and actually not derive any benefit versus obviously a 99 year old who's very, very fit and otherwise healthy. 

33:33 

I mean, this is a very a little bit far fetched scenario, but I mean, you will see quite a significant age difference in some of the candidates.And I think the rationale is that it needs to be based on the underlying condition.I mean, we're all going to die, but there's certain things about, you know, frailty or having other conditions that make us more vulnerable to, to not doing so well other than relying on age. 

33:58 

Because if you rely on age to differentiate the 99 year old, then you're going to have to rely on that threshold to make differences of other age groups as well.And I'm not sure that that would stand up.Yeah.So making a choice between a 99 year old and a 19 year old may be easy, but making a choice between a 55 year old and a 65 year old, I mean, that's where it really gets into something more problematic if you don't have clear justification for it. 

34:22 

And I'd say the other interesting very contentious area that we engaged our working group in discussion about and had very heated discussion about was psychosocial factors.And this comes up in organ transplant as well.CAR T cell therapy, it's infused in hospital, but it requires a lot of a caregiver. 

34:42 

So patients it's, I believe it's actually mandatory to have a caregiver to be eligible for CAR T.So we might worry about those patients obviously who lack, who are more isolated, who don't have a caregiver, maybe don't have the financial means to hire somebody to care for them while they're going through Car T and then the time spent at home monitoring their symptoms for many days afterwards. 

35:07 

A caregiver is very essential for good outcomes for CAR T, good medical outcomes for CAR T So we had a discussion around, well, what would happen if a patient didn't have a caregiver?Should they then be excluded from parting a slot?And our overwhelming consensus from our group was this should not be an exclusionary criterion. 

35:28 

Lacking a caregiver shouldn't mean that you don't have access to CAR T Rather what it should mean is signal that we need a lot of social support around this person and to find ways to enable them to have the the caregiving support or some social resources to enable them to get there. 

35:47 

You know, you have to have a very well resourced center with social work with in our case, we also have some philanthropic funding to be able to house patients in a hotel or some supports.Or we had an agreement with another care center that enabled some of our very unstably housed patients to go to receive aftercare of Car T so they could have that follow up care. 

36:13 

So it was a signal in our process to identify patients who lacked a caregiver, not to exclude them, but to then wrap around support for them.But this is similar for for transplant as well.As I understand it's that there needs to be some demonstration of a caregiver and obviously that's tied to socioeconomic status and other. 

36:32 

I'm really glad you made that decision.I'm like really heartened by the, the justice framework that you're using here.But it also required a lot of, like you said, supports from the health system that you work in.All right, So you've gotten together the stakeholders, you've thought about criteria.What's the next step then? 

36:48 

I mean, the bulk of this process is engagement and discussion really.So you're bringing together all these differing viewpoints, these differing values considerations.You're finding areas of overlap and trying to signal to people as an emphasis, as a facilitator of this process, finding ways that people are actually speaking the same language, even though they may seem at first to be in disagreement. 

37:17 

They're you're asking questions to elaborate on certain reasons why certain people think that aid should or should not be a factor.Or can you tell me why?So the process of actually getting people together to identify what are relevant criteria for the decision was the bulk of the engagement and it took place. 

37:38 

We were, we were interrupted by COVID.So there was.Like we all were.And COVID put other other pressures as it did for everything, other pressures on the car T cell process.You know, we had a lot of exodus of healthcare workers.We had bed space that was reallocated. 

37:56 

You know, there are drugs that we use in car T cell therapy that were then used actually for COVID, the viral vectors.So the thing the the thing that helps the engineered cell go back into the cell when it's when the white blood cells are taken from the patient and engineered at the manufacturing facility, they engineer the T cell and reinfuse them. 

38:18 

They use a viral vector to get that, to get the car T reinfused into the cell.Those viral vectors were being used in the COVID vaccine.They were also being used in other gene therapies.And there was actually a shortage during COVID for that.So there there was pressure. 

38:36 

You know, I'm in Canada, it's a publicly funded health system.We have scarcity based on just finite resources.But there was also this manufacturing limitation that hit the globe for car T US included.Everyone was hit by this viral vector shortage because of COVID.So there were many ways that COVID interrupted our process. 

38:53 

So when when you were developing your process, you didn't put in a contingency plan for a global pandemic that creates resource scarcity across the entire globe?You will in the future, I'm sure.Seems short sighted.We are all learning to incorporate the unexpected. 

39:09 

But I think that also highlights the like the contingent nature of a lot of ethics clip clinical ethics work, right?And so it's very uncommon, I think for a really competent, excellent clinical ethicists to say, this is the right thing, right?This is our process, this is how we're going to do things. 

39:26 

It's morally the case of here, here's a couple of options.And if this, then this is what we should do, right?And if this happens, then this is what we should do.And even in our policies and processes, we we get that if then type of approach.I think that that's common for really good clinical ethics is to be able to identify what are the ifs and what are the thens of what we're dealing with. 

39:49 

Although the global pandemic may be threw a sulfur a loop.And I think also another thing I said before that I studied philosophy when when I was doing my degrees, the other thing that I've struggled with in actually teaching other ethicists to do this strange job that we do. 

40:07 

Is that you can never apply theory in the way that theory intended.You know, it's this is messy real world.And that may seem obvious to many people, but when you're an idealist and you've studied some of these theories, you know, it's a little bit hard to accept. 

40:25 

I think when you come in, you know, out the other end and you're actually practicing ethics in, in the clinical space.So I, I would be the last one to say that, you know, we followed this process.They for our accountability for reasonableness to a perfect TI think that there there is always a, a good, you know, pause for reflection about what we could do better. 

40:47 

So for example, I think the discussion that we had and the, the people we involved in the discussion was very strong.We involved patients, We did a separate focus groups with patients.I think that they were engaged actually very well and their thoughts were heard on many points, not just the age criterion, but there were, there were other points that they made. 

41:07 

Adherence was once a criterion for patient prioritization.If a patient was seen as unlikely to adhere to the to the protocol of CAR T, which again is is very comprehensive, they have to commit to a lot of appointments and following, you know, drug regimes and so on and so forth. 

41:26 

Early on that was thought to be a factor.Patients vetoed that almost immediately.Adherence should not be a reason to exclude anyone from CAR T.They emphasize that we need to look at the reason for non adherence.You know, is it the case because a mother of three children can't actually attend her appointments because she's got competing childcare demands and can't make it to the center because she lacks a car? 

41:51 

Yes, we ought to attend to those complexities of this particular patient's experience.So adherence was actually one of those things that was thrown out very early on and that was because primarily of the patient voice.So Jen, I love hearing about all the particularities of what the group came to, and I just wonder how you think about your role and the success of what you're doing from the ethics perspective. 

42:17 

I hope that this story is is a successful example of an embedded ethicist facilitating a process that was engaging for everyone and that helped to develop a transparent and hopefully fair framework for allocating a scarce resource. 

42:41 

I think the benefit of having a bioethicist involved here is that, you know, I, I don't think of myself as a neutral third party.I have my own perspectives and values and beliefs as an ethicist.I come from a philosophical paradigm. 

42:58 

I come from a feminist philosophical paradigm.I mean, I have, I have to do work of reflexivity as well in my practice, in my ethics practice.But you know, I do think that there is a stance that I can take by offering a tool, which is accountability for reasonableness in this case, to a clinical team that was struggling with a decision, where they were not only struggling with a decision, they wanted to do the right thing, but they're also mired in their own power hierarchies of medical power hierarchies. 

43:33 

They needed somebody to be able to come in and level the playing field in a sense, to say, well, that coordinator's voice, that patient's voice is just as important as the medical director's voice.And kudos to the medical director for bringing me in and being open to the process because, you know, the practice of ethics is really reliant for good or I'll, I think on relationships that can place us in difficult situations sometimes. 

44:05 

But a for R is a, again, a process where you're not asserting a certain position upfront.You're really trying to come to compromises, and again, that may be coming to decisions that the group has thought is justified, where you as an individual may still have reservations. 

44:26 

But hopefully through dialogue and an empowered engagement, you can reach a solution that people can say it's OK, we understand, even though we may not fully agree, we understand.And I think an ethicist is just very crucial and important in that process. 

44:44 

Jen, I think that your your institution is very lucky to have you there and also it is wise in using your skills to help benefit this process.It So what what you're talking about reminds me of something that my my mentor at UCLA, Doctor Hines, said, that a good clinical ethicist is able to help people find their moral voice, but then also be able to hear the moral voice of other people. 

45:08 

Yeah, that's lovely.I, I, I love that.I might use that.Yeah, feel, he loves it when I steal his stuff, so feel free to use it.So, Jen, thank you so much for sharing that story.I think resource allocation is one of those topics where we sort of talked about it before COVID, but man, it has become just an obviously really important discussion and it sounds like you came up with a really great framework for working through it at your center. 

45:34 

Yeah.Thanks so much for the opportunity.It was quite painless to do this so.That's what we like.That's going to be a new tagline.Quite painless.Thanks for listening to this episode of Bioethics for the People.We can't do it alone.Thanks to Christopher Wright for writing and producing our theme song. 

45:52 

Darian Golden Stall for designing our logo and all the artwork you don't see because this is a podcast.If you like us, please rate us on Apple Podcasts, Spotify, Amazon, or wherever you listen to podcasts.And if you love us, visit our website bioethicsforthepeople.com to snag some of our merch. 

In this episode we do a deep dive into the work and life of our co-host Dr. Tyler Gibb.

Transcript

0:00

Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy.I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.

0:27

All right Tyler, the long-awaited Dr. Gibb episode.Here we go.Here we go.I'm a little uncomfortable.I got to be honest, a little nervous about this.I I will be gentle.OK, I'll try to be as candid and non meandering as I can.

0:48

But all right, well, don't change your personality.We want the we want the listeners to know you.So first, just tell me about your current role.Where are you this morning?How do you introduce yourself?Go.Yeah, so I am currently an associate professor in the Department of Medical Ethics, Humanities and Law at Western Michigan University, Homer Stryker, MD School of Medicine, which is in Kalamazoo, MI, so kind of the southwest corner of Michigan.

1:23

And I'm also the Co chair of our department, but it's a really small department.So that sounds better on paper than it really, really is, except I get to go to a lot of meetings about random stuff.But yeah, so that's what I do here in Kalamazoo.And how did you find yourself?

1:39

You're not from Michigan, right?So how did you get from, how did you get there wherever, wherever you were?Like, tell us the trajectory.Like how did you find yourself there?Yeah.So I grew up in Indiana, kind of Northwest Indiana, just outside of West Lafayette, IN, which is where Purdue University is.

1:57

And my dad was on the faculty for his whole career at Purdue University.So that's where I grew up, but we moved here in 2015 from Los Angeles and we were in Los Angeles because I was finishing A2 year postdoctoral fellowship in clinical ethics at UCLA.

2:19

Impressive.So did you always know you wanted to be a bioethicist?No, I had, that's such a funny question because there was no such thing as a bioethicist.So I I had kind of a meandering educational journey.This may come as a surprise, but in my friend group in high school, I was the dumb jock that people made fun of for being dumb.

2:42

That is surprising.Yeah.Mostly because you were a jock.I just don't see that for you.Yeah.Yeah, there's a lot of reasons why that's strange, but yeah, my friends used to make fun of me for being the dumb one.But then at some point I fell in love with learning and knowing things.

2:58

And so in college I took a seminar class like a 7:00 AM really brutal class that all pre Med students had to take and it was just called bioethics.Wait wait wait, you were pre Med?I was, yeah, yeah, yeah.How did you go from being a dumb high school student to being a pre Med college student?

3:16

Well, life, the vicissitudes of life.Yeah, like I said, it's kind of a meandering journey, but I went to a small college after high school called Wabash College, go little Giants and tried to pursue a career in mediocre football, which didn't work.

3:34

Then I left for left college for a couple years.I was raised in the Mormon church, which also surprises some people.And I went and was a missionary in Japan for the Mormon Church for two years.And then, yeah, had a great time.

3:50

Learn how to speak Japanese, learn how to eat sushi with with the best of them.So it was a good time.Can you say something in Japanese You.Want me to to to prove that I can speak Japanese?No, I'm not going to do that.I'm going to.I'm going to.Yeah, it's.

4:05

Been so long.So I used to speak fairly well, like fairly fairly like fluidly, but I it's been what, 20 years now?And so in my head I'm still just as as fluent, but I'm sure it would be terrible coming out and recorded for all eternity so.Fair enough.

4:21

Yeah.So I went to came back from Japan, moved in, started going to college part time out in Utah and then kind of got re enrolled in a Community College there and then just kind of kept going and kept going and kept going until there was no more school left to go to.

4:38

So.So.So at what point were you in?Were you were pre Med at Wabash?Is that right?Yeah.So I ended up graduating from Brigham Young University out in Utah.And it was there that I obviously was trying to figure out who and what I was going to do with my life.

4:57

And I definitely spent many semesters as pre Med doing all of the pre Med classes, physics O chem, chemistry labs, like all that stuff.Yeah.And part of the requirement was this bioethics seminar class.

5:14

OK, so say more.Yeah.So 7:00 AM once a week go to this seminar and we just had readings and we were supposed to go and discuss.But the professor who was in charge of it, he didn't want to be there.None of the other students wanted to be there.Like everybody hated it except for me.

5:29

I was in the front row every week.And I was like looking around at the class.I was like, this stuff is so interesting.Like, why are you guys all not listening or why is this professor phoning it in?Yeah.So that that was my very first introduction to it.That's incredible that you were more enthusiastic about the class than even your professor.

5:46

Well, I mean, it's not that surprising, is it, that I was like, wait a second, let's talk about this.But yeah, it was a terrible class.And I thought that I thought that that is like the type of question, the quite the type of thing that I'm really interested in.OK, yeah.

6:02

So you weren't like a failed pre Med, which sometimes happens.You were doing pre Med, you were passing classes, but then you got introduced to bioethics and even though your professor wasn't great at teaching it, which is actually pretty heartening to all the bioethics professors out there, is like people can get into your topic even if you're not great at teaching it.

6:23

Obviously we're great teachers so we don't need to worry about that.But that just tells you how compelling the topic is, and it's it switched your whole career.Yeah, so at that time I was still trying to figure out, yeah, I was doing well in all my pre Med classes and you know, even O chem and there's a couple that are kind of wieder classes like that, like organic chemistry lab and stuff like that.

6:42

But no, I was doing fine.I had a couple more semesters before I finished up because that, like I said, I was doing kind of a Community College for a while and then enrolling full time and also working and stuff.So I was taking my time getting through undergrad.So I had a couple more semesters and I took a class in, I can't remember the name of the class, something in the anthropology department.

7:05

And that's what really like blew my mind.I was like, there are people who get to sit around and think about like what different cultures think about health and illness.And, and so I took a medical anthropology class and that's what I really fell in love with was this idea of different communities, different groups of people like approaching this concept about health and Wellness and disease in very, very different ways.

7:35

So from there though, you decide not to be AMD, but you decide to be a JD.So how did you, so you know from Jock in high school to oh, should I be a physician or should I be a lawyer?Like how did you then get into the law?

7:52

Yeah, yeah.So part of my struggle in life is that I am trying to make up for things that I did in a previous life.So lots of, lots of trying to make up for kind of adventurous adventures earlier in life.

8:08

So when I was in this, this spot when I was taking these anthropology classes and falling, falling in love with like this idea, like this big, big picture, big concepts of like health illness, like healthcare systems.I went to West Africa for two summers in a row with a medical anthropology professor just to do research about.

8:30

So it's called medical pluralism or basically the idea that there's different healthcare systems existing within the same community.And so we went to West Africa and did research looking at the difference between like traditional healers, like traditional herbalists and different healers called like bone setters or priests.

8:50

And that was existing at the same time in the same community with like Western biomedical, like British trained hospital system.And so looking at the, the interaction between those 2 is what we really spent a couple of summers doing research on which I loved.

9:06

And I think if I were not married and did not have children, I would have pursued a medical anthropology PhD program and just been like, you know, doing field studies and living and, and doing that.But as happens to all of us, not all of us, to the lucky of us, I fell in love, got married, and then the idea of dragging my family along to West Africa to do field studies became less and less, not, not less appealing, but like less practical.

9:37

But then having fallen in love with the idea of these big ideas and teaching, I kind of came to the realization that I didn't want to be a doctor for a person, right?I didn't want to be somebody's doctor.But I wanted to look at these issues of health and illness and the ways that systems and our communities and our politics and our laws influence people's health in either good ways or bad ways.

10:03

And so one Ave. into that is looking looking at it through the legal lens.And I think like a lot of kids who grow up who are maybe a little bit smart mouthed and and can talk back to to to adults and hold interesting conversations with grown-ups.

10:19

I was always told that I should go to law school and that would be something that would be good for me.Does it translate?Is it the case that if you're a smart mouth kid, you're good?You're good in law school.No, not unless you turn into a smart mouth lawyer.But I didn't really turn into a smart mouth lawyer.

10:35

Yeah.So then that was kind of a big realization.And then I was looking at graduate programs rather than medical programs because I wanted to, I really wanted to be a professor.Like I, I like the, I like the life, I like the interaction with students.I like wrestling with big complicated topics and reading and writing and doing that stuff more than I I thought that I would enjoy being a a person's doctor so.

11:01

So you're living the dream.Well, kind of.It's also probably a lot of revisionist history going on into this story as well, right?Yeah.So then started looking at graduate programs.And a really wise professor of mine said that for, he said for you, Tyler, he said, I think law school would put you in a competitive advantage when you're trying to find a job.

11:26

And also it's a good fall back plan.You can do a lot of things with a law degree.It's not cheap, it's not easy.It's not it's not quick.But for me, that was kind of my practical side winning out a little bit where I thought, you know, what if this professor thing doesn't go well, which is kind of a, it's a kind of a crapshoot.

11:44

I mean, getting a job as a professor, especially if professor of like ethics or philosophy or religion, I mean, it's hard.And so I thought, boy, I'm going to have to provide for my family at some point.And so having a backup plan doing law, I think was kind of the practical choice.

12:04

Yeah, that makes total sense.And I was not on my radar when I was like, yeah, I'll do an M division and APHD.It was like not as marketable.You were.It makes more sense to like if you're going to have a fall back, the law is a fall back.Although when you graduated from law school, wasn't that right at the point when even getting a job as a lawyer was becoming much, much more difficult?

12:26

It was the worst, Yeah.So I was, I was looking almost exclusively at dual programs.So PhD and or a JD MA program is because I wanted to have that opportunity to teach where just a straight JD program wouldn't allow that as easily.

12:44

And so I found this program at Saint Louis University, which apparently nobody had ever done before, and it existed on the books.And so I applied to the law school and got accepted.And then I deferred for a year and then applied to the PhD program.

12:59

So I so I matriculated.I entered Saint Louis University, having already been accepted to both programs.I didn't realize you were the first.Wow.So you were the trailblazer JDPHD at Slew?Yeah, there were a couple other folks in my cohort.There were three of us who all started at the same time in the pH, in the JDPHD dual program.

13:20

But they after law school, they continued a little bit, but they ended up just kind of relying upon their law degree.And I think they're doing very well.I don't have a lot of contact with them, but I'd like to.Kelly, Shane, reach out.So, so, yeah.

13:36

So you were the first to graduate with both of those degrees.And OK, for those who are unfamiliar, how long does it then take?Is it any quicker to do them at the same time?Yeah, so I, I started law school in 2007 and then the way the program works is you finish the law degree with the with the dual credits and then you go on for the PhD program.

13:57

But SO started in 2007 and I left Saint Louis in 2013, so 6 years.Yeah, that's faster than so a law degree takes three years, and a PhD can take anywhere from four to seven years. 7 is still the average.

14:12

Yeah, yeah.And then when I left, I went to UCLA to do the postdoctoral fellowship, and that's where I finished writing my dissertation.And so I graduated in 2015 with the PhD, but I was mostly done by that point, so.That makes sense.I didn't realize you were still writing the dissertation.

14:27

So but this talk about the fellowship because that's a full time job.So how were you writing your dissertation with this full time job with a family and children to take care of?Yeah, I have a Good Wife.That's that's how I answer that question.It was hard.

14:43

I do not recommend it.I was just in Saint Louis at ASPHA couple of weeks ago and meeting with a couple of current JDPHD students and was talking about my experience.It I I would get up early in the morning and write on my dissertation.Then the kids would get up, we'd do the morning stuff to school, go to the fellowship, do that all day, come home late, have dinner, bath time, put the kids to bed, and then I would go right until in the morning.

15:12

So it was, it was rough, but we finished it.You know, our advisor said it can't be good until it is.And mine got to the is point and never got past that.So, yeah.So graduated from UCLA, their fellowship program, which is excellent.

15:30

If anybody is looking for clinical ethics training programs specifically, you can't ask for much better than UCLA's program.And then went on the job market, interviewed a bunch, and then landed here.

15:46

We've kind of talked about it that in other episodes, but you and I were looking for jobs at the same time and both ended up here in Michigan for a while.Yes.And my guess is the JD did help you because we were up for all of the same jobs and you got your job 1st.And I think they were like these, these are both stellar candidates, but this one has a law degree and that one has a divinity degree.

16:07

And on the whole, JD is just going to be a little bit more impressive to most job positions.JD wins there.Yeah, I, I tell people that I did the, I did the PhD.So doctors, when I'm in the room, they have to call me doctor.They call me doctor, but I did the law degree, so they actually listen to what I'm saying.

16:27

So yeah, yeah, it's, it's helpful.Every once in a while I'll say, okay, putting on my lawyer hat.Actually did that in a meeting just recently.But I don't usually, I don't lean into it very much.I never took the bar, so I'm not barred.I can't practice law but I can play one on TV and podcasts apparently.

16:46

Yeah, Yeah, you can.Just, you can say things like, you know, putting on my lawyer hat, right, which gives a certain kind of cachet to what you're about to say.Yeah.But you can say that like putting on my what pastor hat.Yeah.Putting on my chaplains hat.I could say that depends on who your dog you do, I suppose.

17:03

Yeah, yeah, yeah.So you did this.So the fellowship, you're like doing intensive clinical ethics.And so you have then tons of experience.But actually, as I remember, at Saint Louis University, you led Ethics Committee meetings.I remember going to meetings that you had at the hospital where you would sort of help run ethics too, right, Which put you in a good position to get this fellowship, which are also really competitive.

17:26

Super competitive, yeah.There's not enough good high quality fellowship training programs, I don't think postdoctoral training in clinical ethics.So towards the end of my time at Saint Louis University, again, thinking about jobs, thinking about children, supporting my family, it became very clear to me that I would best be able to support my family by working somewhere in clinical ethics because clinical ethics pays better than a, you know, entry level humanities professor at some university, right?

18:00

And so just looking at the job salaries, I was like, I need to get more training, more experience in clinical ethics.And at the time, Saint Louis University's program wasn't didn't have much of A clinical ethics emphasis.And so Erica Salter, who's now the chair of the department there and directing the PhD program, she had some contacts and she and I worked together to help kind of weasel our way into some brown bag lunches in the hospital, meeting with ICU residents and having conversations about cases.

18:29

And I think that's kind of where it it came from.And what what was interesting for me is the law is interesting to know.And it's interesting to be able to like, you know, refer back to and read and understand.But I think the most benefit that came from law school was being able to quickly think on your feet in a public space about really detailed things, right?

18:51

And so being able to sit in a meeting and and read a policy quickly and interact with people who are in crisis and be able to have those kind of conversations, that's a skill set that I think law and lawyers have that's different than a lot of other people in clinical ethics.So.

19:07

Yeah, totally worth the half $1,000,000 you paid for that skill set.Well, it wasn't that.Yeah, Well, maybe, yeah.And so I, I really kind of fell in love with clinical ethics, particularly because it reminded me of when I was working in the, the legal aid office and working for the law clinic in, in law school where where, you know, clients would come into us with some sort of crisis.

19:33

And we had to quickly understand where what they were talking about, what the law was, and then give them some sort of meaningful advice that would help them in their lives.And oftentimes it really made a big difference.And so it's a lot of the same skills that I think really good lawyers have, just in a different setting and be able to do that with people who are in crisis about medical decision making or, you know, end of life decisions or something like that.

20:00

Mm hmm, right.So you do the two year fellowship, you're set up well to be a clinical ethicist.I also didn't realize you like forged the path of the practicum at slew.So I have you to thank for lots of things besides just being my.Friend, it was Erica Salter.I'm sorry, Erica Salter.So then you get this job in SO and your job is kind of hybrid, right?

20:21

So you do clinical ethics for the hospitals and you teach the medical students.So talk about that.Yeah, It's really a great situation because so our medical school is fairly new.I mean it's been around since just before I got here.So we are kind of developing all of the curriculum and the clerkships and like everything as we were going.

20:40

But at the same time, we had two really strong hospital system partners here in Southwest Michigan.And they both had identified a need for kind of expert level clinical ethics support for their committees and their consultation services.And so I was hired in to not only help with the curricular needs of the medical school, but also to meet these two hospital needs, which has turned out really great.

21:03

I spent about 1/3 of my time doing clinical ethics and then maybe 1/3 doing research and writing and admin, then a third doing teaching.So it's, it's perfect.I I love my job so much.So what kinds of things do you do with the Med students?So you got to build the curriculum, which is really cool.

21:21

So as somebody who was there in the Med school from the ground up and you have the most beautiful Med school building and lots of fireplaces and water features.That's how you know it's nice.It's just a stunning medical school, but you got to like be there from the ground up building curriculum.So what kinds of things were important to you as you thought about what?

21:38

What should Med students need to know about clinical ethics?Yeah, and so one, one of the one of the best parts of my job is my my colleague, the other Co chairs Mike Redinger said.He's a psychiatrist and obviously a physician, but comes from his undergraduate Notre Dame.

21:57

So kind of has that Catholic ethics, Catholic healthcare approach, as well as just being a great person to work with.And so the two of us together were able to kind of dip our feet and, and dip our toes into a lot of different areas because there was just kind of a vacuum of infrastructure.

22:17

So for example, we said, you know, we would love to teach as much as we possibly can.And as a result, we've been able to have our ethics and humanities and law type of curriculum material interspersed throughout all four, four years of the curriculum.

22:33

So one of the first lectures that we give to our medical students is about professionalism and what it means to be a doctor and how that has kind of changed historically, but also what it means today and how social media impacts that.So that's like day one, not day one, but week one.

22:49

It's like professional identity formation.And then all the way through like one of the last sessions that we do with the students is again, kind of like here we are like four years later, like what have we, what have we done?What have we accomplished?And so a lot of like like virtue development type of professional development type of ideas, we talk a lot about being about trust and trustworthiness.

23:11

But then we also have have a lot of fun.There's a session that I get to do with the 4th year students where we, we do a mock malpractice trial.I was.Just going to say I got to witness this and it was so fun.Yeah, it's, it's great.I don't know of a lot of other places, I don't know maybe any other places that do a mock trial with fourth year medical students.

23:29

But it's based upon the Terasov case, which is we did an episode a couple of weeks months ago about the Terasov case.I don't want to spoil it in case there's any medical students listening, but it's a good time.Everyone dresses up.There were a lot of fun outfits, There were a lot of fun accents.

23:46

Yeah.People decided accents were a good idea for the smoke trial.I loved it.Yeah, yeah, yeah.Lots of costuming pre pandemic, we got to go to the local courthouse and actually the probate court judge that actually does a lot of the like the competency hearings and stuff locally.

24:05

He allowed us to use his courtroom and but as our student body grew, we outgrew the space that was available.So we just do it in here in the building.We set it up and, you know, students are the bailiffs and the jurors and the witnesses and the judge and, you know, to wear robes and gavels and all kinds of stuff.

24:24

It's a lot of fun.So that's the, so the third of it is the the clinical ethics, which you talked about 1/3 of it's the teaching.And so talk about the other third, which is your research, like what is really exciting to you to research and write on?Yeah.So there's, I guess there's a wide variety of things that I've written on and done research on, but most of them coming from my clinical ethics work.

24:48

So a case will come up or we'll I'll be having a conversation with somebody about some sort of kind of obscure technology or something.And that will spark an idea that will spark a conversation that will spark a a paper research question.And I try to use include students as much as I can.

25:07

I don't think my goal, this is kind of a, I'm not promoting this as a goal for everybody, but I, my goal is to always be a co-author.So I I've never published something where I'm a sole author, a primary single author, but also I love being like the second or third or fourth author.

25:28

Well, that's, but that's normal in bioethics publishing.It's it, it's it's not as if nobody ever single authors anything, but quite a bit of research in bioethics is co-authored.Yeah.Yeah, you have to be really good at collaborating.I think so, yeah.My, I, I want my epitaph to be the best third off there in the game.

25:49

So I'm, I'm a, I'm a good editor.Yeah, What's a what's a publication that you're particularly proud of?Besides our publication.Obviously, besides our stellar publication.Publication, there's been a a couple that I'm so there.I'll tell you about one that I is my favorite publication and then like the big publication and then one that I'm working on.

26:11

So one of my favorite publications is when I wrote with a buddy of mine here at W Med, who's moved on since since then.But his name was John Mincer and he's a poet.And we wrote a paper, We did a research project where we were gathering and analyzing urban legends about medicine.

26:30

And so we collected probably close to 500 different urban legends and analyzed them about like kind of what are they?What's the moral of them?Why are they being told like, what are some of the kind of literary constructs or aspects of it?

26:48

And so can.You give an example.Yeah.So an example, see, I mean, some of them are have to do with kind of the medicalization of people in unflattering ways.So like, you think about the urban legend of like the hook, right?A couple is like making out in the car and they hear over the radio that's, you know, a deranged killer from the local prison has escaped and he's got a hook on his hand.

27:14

And, you know, they, they hear scratching on the window or something like that.And so there's like this medicalization of individuals in the, in the stories.And so that's, that's one category.But there's also ones that have that are really common that lots of people have heard about.And what's interesting about urban legends is they don't have to be true or not true.

27:33

The fact that they are told is like sufficient enough.And so you think about somebody meeting the story of somebody meeting a, you know, a beautiful woman in the hotel lobby.They have some drinks.She seduces him back to her hotel.

27:49

He wakes up in the bathtub, missing a kidney hooked up to tubes, like with a note saying sorry or something like that, Right.So that's that's an example of a a medical urban legend.OK.And so you, what kind of things did you come out with gathering all of these?

28:06

Oh, it's so interesting.I, I would love to go back and and kind of delve into them deeper, but we so the, the article that we wrote was basically a taxonomy of all of these different kinds of urban legends, but it's entitled.I know a guy who once heard oh.It's great, yeah.

28:22

Which is a great article.OK, so and what's your most fancy famous article?Well, I've got a couple that were in big journals.So I, I was part of, there were three of us who wrote a paper that got published in the New England Journal of Medicine, which is a big one.And then I was involved in another group that we wrote a couple of papers about during COVID that gets cited quite a bit.

28:45

Annals of Internal Medicine was where one of those words at so.Those are two very prominent medical journals, and it's unusual to get ethics stuff in those kinds of journals, so kudos to you and your team.Yeah, thanks.Yeah, it was, it's it's cool.I mean it, it's fun to publish things.

29:02

It's fun to have ideas that actually get out into the world.And then people cite and people think about and hear about.But but you add up all of the citations and and references of all of my papers over my career and the podcast outdoes that in one episode.

29:19

Oh, absolutely.Yeah.It's like, not even close.Yeah.Not even close.Yeah, So what?So what are you working on now?I'm, I'm involved in a big project right now that is looking at professional misconduct, OK.And so think about like the board of nursing or the board of social work or the board of medicine.

29:39

Each state has one of these boards, and part of their responsibility is to discipline and punish people who misbehave.And so I'm involved in a project here in Michigan that is looking at all of the ways in which providers have misbehaved over a period of time and looking at trends and patterns.

30:00

And, you know, hopefully with an eye towards, like, how do we avoid this?And if people are really bad actors and shouldn't be practicing healthcare, maybe we need to do a better job of getting them out of healthcare.Yeah.And from what you've told me, it's doesn't seem like these boards are punishing physicians too severely for the kinds of misconduct that they might be doing.

30:22

Yeah.That's true.None of the boards.So the Board of medicine, the board of nursing, there's about 25 different boards in in Michigan that where our research is focused and it's eye opening, I think a lot of problems with the system.

30:39

And I think what's what's surprising to me the most is how much, quote UN quote, losing your license is brought up in clinical practice.Like, oh, we can't, we can't do that.I'm afraid that they're going to sue us and we're going to lose our license.And you know, stuff like that you hear about all the time.

30:55

And so I have a unique perspective of being like, OK, from a legal perspective, putting on my lawyer hat, the risk is very, very little or the amount of consternation put into like the act of getting sued is disproportionate to like the rates of actually being sued or actually losing a lawsuit.

31:15

And so that's kind of an overblown fear, in my opinion, for healthcare providers.Very real people experience it and it's it's horrible.But then also the other motivation of being like, well, you can lose your license for this thing.And truth is like it takes a lot to lose your license and usually a lot of bad things over a long period of time.

31:35

OK.Yeah.So it's not like one thing you did that may have been iffy and you lose your license.No, not, not even close.I not even like one time you did something really bad and then you still don't lose your license.Like I mean, you can get fined and suspended and all that stuff and it's not a pleasant, you know, process by any means.

31:53

But it's yeah, losing your license once you get it is actually you have to earn losing your license and sometimes multiple times over before you actually lose it.Yeah, so super interesting project.And tell me about your who is your aspirational bioethicist?

32:08

Like who do you love to read?Who do you sort of follow?Yeah, there's a couple people who I really like.So one of my colleagues, Parker Crutchfield, has he been?I don't think we've had him on the podcast yet.We'll have to.He's one of my favorite writers of all writers, fiction, non fiction.

32:26

He is just like a clear, crisp writer.And I don't agree with everything he writes.Obviously I don't agree with everything anybody writes, but he's one of my favorite writers.I would say as far as like bioethicists that I like to read.I think there's a couple of people who, regardless of what they're talking about, like, I will go and listen to him speak, right?

32:46

I think so.Our mentor Jeff Bishop is on that list.Like, his way of looking at the world is just really interesting, I think, and very different than the way that I look at the world.And I always learn something from him.So yeah, you, of course, Devin, a big fan.

33:02

Big fan of your work.Goes without saying.Yeah, yeah, there's a number of people especially so there's some young bioethicists who I think young, like our age, who I think are doing such interesting work.Joel Joel Reynolds at at Georgetown, for example.Are there like a lawyer bioethicist that you enjoy reading?

33:21

Yeah, so I mean some of the big names, so Thad Pope, Thaddeus Pope up in Minnesota, he's a JDPHD, does a lot of like end of life work, physician assisted suicide aid and dying, stuff like that.Yeah, yeah, there's, there's a handful.

33:37

Yeah, that's, that's a press you.Yeah.And what are your, what's kind of like a dream in bioethics that you have?Have you checked off all the things that you hope to do in bioethics, or what's still on your bioethics bucket list?Yeah, I I still have the dream of finishing a book.

33:58

I think that that's not something that everyone has to do in in academics, but for me that that's something that I still aspire to do.Yeah, I think a lot of what I want to do has is like bioethics adjacent.And so I'm really interested in developing, helping folks around here develop kind of an international experience for our students that has to do with, you know, ethics of working in under resourced communities and the ethics of kind of concierge medicine and travel medicine and global health that and that kind of Harkins back to my medical anthropology core love.

34:37

At some point I want I want to construct the projects such that somebody could walk in and be like, is this an anthropologist or is this a an ethicist?So.Yeah, cool.Those are good.Those are good aspirations, seems to me.So a book, a book which is totally doable, you can do it.

34:53

You did write a dissertation.I did write a dissertation.That's like prime for a book.I could turn it into a book, maybe, yeah.You could maybe maybe.Then I got to go back and read it again, and that might be the most painful.Part might be worth just writing a whole new book.

35:09

It's on my shelf sitting right there though, so.Yeah, I remember you had it bound.I did.I had it bound and I gave it.I gave a couple of copies to people who are important to me.Nice.Well, that's it.That's literally all the interesting things I can think about talking.We we totally exhausted your your world.

35:26

OK.Yeah.Good.Thanks, Tyler.All right.Thanks, Evan.You're my bioethics CRO, and it was nice to learn.I feel like I actually did learn a little bit about you.There are some things you slipped in there I didn't know before.Good.Thanks for tuning into this episode of Bioethics for the People.

35:45

We can't do it alone.So a huge shout out to Christopher Wright for creating our theme music and to Darien Golden Stall for designing our logo and all of the artwork.If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music, or wherever you listen.

36:03

And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.Really.I didn't like you in grad school.I liked everybody.OK?I liked everybody.OK.

36:19

Well, not.Everybody.Definitely not everybody, OK

You asked for it, so here it is… the “Who is Dr. Stahl” episode. We do a deep dive into the path that brought Devan to where she is today.

How did she first get interested in Bioethics? Who were some of her most influential mentors? What is she currently working on?

In this episode Dr. Tim Lahey describes how he helped his institution curb violence against health care professionals.

Here’s an open access copy of Tim’s article describing his work on combating workplace violence:  

https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13355

Transcript

0:00

Before we begin, Please note that the names and specific details of the clinical cases we discuss in this episode and in all of our episodes have been altered to protect patient confidentiality.Now on with the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy.

0:21

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.All right, Tyler, we have another exciting success story to share today.

0:49

Great.These success stories are so much fun because they're such different kind of perspectives of what benefit clinical ethicists can have on a lot of different people in the healthcare settings, so.Absolutely.And I don't have to sit in silence for an hour after the podcast like I had maybe last season where I was just in existential.

1:12

Like that was the hardest thing I've ever heard.This is more like great.We are such great people doing great work.Yeah, so so far I've been taking a lot of notes about like ideas or projects or like tweaks that I want to incorporate into my practice.

1:29

So I think it's been really helpful.So today we've got a a repeat customer, a repeat guest on the podcast.So, Tim, do you want to introduce yourself again?Well, thanks for having me on the podcast again.It's, it was a pleasure the first time and, and also since I think I was a contributor to doom and gloom my last time through.

1:49

I'm happy to finally show the other side.So I'm Tim Leahy.I am the director of ethics and an infectious diseases physician at the University of Vermont Medical Center in Burlington, Vt.Great, Tim.So what's the entry into your success story?

2:05

Is it a case?Is it a policy?Is it some education before you launch into the of course the success?How did it start?This success starts with a failure, which exemplified a pattern of failures that our institution was experiencing having to do with violence.

2:22

We had a young nurse who was a couple years out of training who was taking care of vulnerable patient who suffered from a major mental illness and was hospitalized for for a life threatening medical condition.

2:38

And then what felt like a fairly routine moment of care, she was leaning over the bed to adjust something on the the patient and IV the patient took a swing at her and fractured her jaw.Her her perception was that this sort of came out of the blue.

2:59

But as we, the institution dug into what had happened, there have been some signs that this patient had a pattern of violent behavior previously.And the more we heard about this case, the more we heard from the nurses on that floor and then in other units and then other forms of clinicians that man, they were facing a lot of violence in their clinical practice more than before.

3:26

And to distressing disagrees.And and so that sort of caused us to embark on an institution wide response to the problem of violence directed at healthcare workers.How long ago did this happen that.

3:42

Particular catalyzing event was four years ago.OK.You know, and I think many institutions have experienced rising rates of violence for several years, actually rates that were rising before the pandemic and then took a steeper increase during the pandemic.

4:01

And and and so there is that kind of sense of this was a catalyst because it was so bad, but certainly part of a pattern.For some people, this will be old news, still alarming, but.But they have heard of this.But some people might be shocked that healthcare providers are routinely hit or hurt by patients.

4:20

Do you know what the rates of that are?You know, it, it, it, it is a little bit hard to capture with perfect accuracy because we know that violence in healthcare settings is underreported.And so, you know, I think we know, for instance, overall rates of employee injuries in healthcare settings are on the order of 20 times higher than in other industries on average.

4:49

Then the, the, the rates are really quite differently distributed in different locations.You know, so for instance, psychiatric hospitals and inpatient hospitals see a lot more violence directed at healthcare workers than say outpatient primary care clinics.

5:06

Or different healthcare workers will face different rates of violence.Nurses overwhelmingly experience the bulk of violence, whereas physicians and other healthcare workers just sort of drop into the room more episodically during the day, experience far less.

5:25

So the, the numbers are sort of tough and, and I suspect all of our numbers are underestimates because a reasonable number of times people will have one of these tough experiences of, of being verbally abused or being physically threatened or being actually hurt that are not reported because they they may view it as part of their routine clinical practice.

5:48

Yeah, and, and do you think the rates of nurses is just because they have more interactions with patients?Or do you think there's something about nursing itself it's more intimate or it can't be that people don't like their nurses as much 'cause all the data I've seen is that people really like nurses.

6:04

So what is it about nursing that sort of opens people up to that kind of violence?It is an interesting contrast to the fact that nurses are among the most respected groups in our society.So why would we, why would our members of our society also be hitting them?You know, I, I think it has to do with two things that that you pointed to. 1 is just the frequency of contact.

6:24

Nurses have many more hours in the day with the patients, particularly inpatient nurses.And so naturally just their, their degree of exposure can be greater.I do think, however, that there are some other social dynamics that play a role.Power dynamics is, is a piece of it.

6:41

I think, you know, those of us in healthcare certainly will recognize that people will treat nurses differently than they treat physicians in many different ways.Perhaps physicians are treated with a different level of respect, whether or not they deserve it.And so I, I wonder if that maybe stays the hand of somebody who might be otherwise a little disinhibited.

7:02

And then I also wonder about gender dynamics.You know, while increasingly equal numbers of men and women are in position roles, nursing is still predominantly a female role.And women experience more violence directed at them than men do.

7:20

So I I wonder if it's some mixture of all of those.Yeah.Well, so the incident you raised, even if we might be somewhat familiar with it, it sounds like this nurse was really hurt by this patient.And so it sort of was the catalyst to a bigger conversation.

7:37

You can imagine that there's a, a, a tough mixture of challenges in there.You know, of course, anybody confronting violence has has to deal with whatever physical injury happens and and then of course, the other versions of trauma that might happen.

7:55

I do think it's worth thinking about how it's a special kind of of experience of, of violence to do it when trying to minister to somebody in one's workplace.And, and the way that that can have, can bring in that, you know, this is very different, for instance, from, say, the experience of trauma in a war where one expects for conflict to be there and maybe sort of showed up ready for that.

8:26

Whereas this nurse, like many healthcare workers, described being completely shocked that suddenly this person who she thought she was in a therapeutic relationship with would, would strike out at her.I, I think also there is this conflict between our expectations of ourselves.

8:43

How much are we supposed to sort of subordinate our own needs in order to take care of others with processing this trauma?You know, naturally, if somebody's going to threaten me at my first response might be to protect myself in some way to get away or do it.But if I'm trying to, you know, sort of put that patient's needs above my fatigue or other needs, might I be a little bit less likely to protect myself?

9:07

And might that compound some of the sense of trauma of that experience?Yeah, 'cause it does seem like it's different if I'm walking down the street minding my own business and get assaulted.And part of that is just like wrong place, wrong time, like I'm minding my own business.Like it's just kind of the the randomness of that type of action.

9:24

But if I'm engaged in the thing where I'm doing something selfless and trying to help somebody, and then because of that interaction I'm the victim of violence, it feels like another layer of assault or harm.Feels to me like it's kind of in a similar space to intermittent partner violence, where violence is is bad to experience no matter what.

9:46

But if it's the person that's supposed to care for you, I think that that gets particularly complicated and it and it naturally leads to questions about is this relationship good for me?What does it mean if this, if I don't have this relationship in my life?And I think there are some interesting parallels to the experience of healthcare workers who have had to go through violence and the questioning they do about, well, can I still come back to work?

10:10

Do I feel safe to do that?Am I has this hurt my passion to, to help with people?Is it OK for me to say that I need help at work?Are other people's going to say, oh, you're just supposed to buck up and deal with it?It's a very complicated way of thinking, and I think it certainly has the risk of compounding healthcare worker burnout, the problem of nursing attrition, which is huge at many medical centers, a really complicated problem.

10:39

Yeah, and one that I wouldn't necessarily think is like the job of the ethicist to fix.How did you get contacted?Like how did you get involved in the case?Yeah, great question.You know, it turns out that we our door into this conversation had to do with the question of professional obligations.

10:57

You know, if a patient who has exhibited a pattern of threatening or fully assaultive behavior still needs a given form of clinical care, are we obligated to still provide that clinical care?Or is it OK to step back and consider withdrawing certain forms of clinical care in response to that behavior?

11:18

So that was the the door that I had.You know, ordinarily when when violence happens in a healthcare space, you call security.You don't, you don't say where's the Ephesus don't fix this.I am uniquely unhelpful in those types of situations.Yeah.

11:34

Yeah.So I, I think it was an absolutely a post hoc response to that experience of, of violence that as the team was taking care of the affected nurse, they were seeing pattern of repeated behavior and starting to feel out with their institutional and personal obligations to that patient.

11:56

And, and honestly, we, we were getting asked that question repeatedly with many cases.And I think it was that pattern of repeated consults and, and just how impactful these cases were on our healthcare workers that led us to implement a, a, a bigger response.

12:14

And that's, that seems like a tough ethics question to me because on the surface of it, any, most any other profession, if your client hit you, there would be no question that you would not be obligated to serve them anymore.But we have a different sense in health care because the reasons which people might become violent might have to do with the very thing that brings them into the hospital, right?

12:38

Or regardless they are sick and in desperate need, like they wouldn't be in the hospital unless they had to be.So there's a different kind of sense of like what we owe them.But even from like a, a legal perspective, if I'm a public defender assigned to a client that has a constitutional right to an attorney and dude cold cocks me, like I, I can say I'm no longer this guy's attorney, right?

13:03

So there are really different duties based upon the roles.But the healthcare worker role is, I think, unique in that way, in a way that I, I can't, I can't even imagine and I can't, I can't envision a different profession that would have that same sort of hesitancy of is it OK if I don't engage any further with this individual?

13:23

I, I, I think those are great, great reasons why this is so complicated.And, and I think just a layer in another dynamic that, that, that still further complicates it is patient centered care that I think we've had this rolling conversation over the last, you know, 1020 years about redressing some of the paternalism or, or I'm on this campaign to, to invert those letters and call it parentalism.

13:53

So it's not sexist that, that we, that we're trying to fix the parentalism of yesteryear and the kind of doctor knows best approach, but instead to sort of partner with our patients and to deliver the sort of healthcare that they most want.

14:09

And I think that good trend toward better responsiveness to individualized patient needs is, is I think another thing that puts people back on their heels.And so the, the reflex to say, no, you can't do that.The rules are, are a little bit atrophied.

14:26

I think actually in, in what is overall a good way, you know, that we may have been a little too willing historically or arguably presently just say my house, my rules and this is how you're going to get your care.And I think we're still working through how to how to do better as a system to meet each person's needs where they best need them met.

14:49

But but yeah, it's it's tough to transition from that conversation to, wow, I just got hit, what am I going to do?So what are we going to do?So I'll try to tell you a story of an accumulation of interventions that started with that sequence of ethics consultations and A and a team we brought together to address them and ended up becoming an institution wide response that ultimately was out of ethics control.

15:21

You know that we we pass it on to people who are better positioned to do it, but I think helped help that come to pass.So in response to that pattern of what we sort of generically called unsafe patient behavior, we formed a task group task force to deal with the question of one, what sort of policy language might we put to these balancing acts of of about professional obligations toward patients who are threatening or violent and, and really just sort of use that as a platform to do a needs assessment for what else beyond a policy needs to be done.

16:00

And I say it that way because I think a lot of us put time into creating policy documents with full knowledge that they can grow dust on a shelf that that, you know, sometimes a little, you know, word file is not the answer to the world's problems.

16:18

But we did feel like the bringing together the task force of of the right stakeholders to work on that first was sort of a, a low risk team forming process that would help us move in the direction of additional interventions that might be a little bit more tangible.

16:35

And so the the first piece was trying to get a stakeholder group just like we would with any policy creation, making sure, for instance, that we had outstanding representation from nurse leaders and nurses who spent a lot of time at the bedside, but all of the, you know, clinician groups that you can imagine from nurses, physicians, social works, chaplaincy and beyond.

17:00

We also wanted to make sure that the partnership with security was intact right up front.And we also built in some representation from facilities because we knew that security is intimately related to facilities concerns like locks and magnetometers and other interventions that the institutions do.

17:23

And we ended up using that group over the course of several months, drafting a document that was partly attempting to frame some of the ethics and tension around the space.Because honestly, I think our discussion on this podcast mimics the conversation we had in that multi stakeholder group where we were essentially focusing on the ethical values that would lead you not to inhibit care and response to violence.

17:52

All the reasons why we expect our patients to be nice to us and then tolerate it if they're not.And so we wanted to make sure we first developed an ethical vocabulary around some of the reasons that might move us to create boundaries.And that was, I think, useful for the policy document, but but also has been informative for subsequent institution wide and and even local conversations about our response to violence.

18:21

Because we knew that if we were going to make some boundaries or sometimes say, say, that that form of care was going to be withdrawn in response to a given behavior, that that we wanted to be able to justify it and make sure it was clear to our neighbors that that wasn't some draconian response, but actually something anybody would do.

18:40

This all sounds like good process, right?And and I'm glad to know that Tyler and I had some good instincts on the kinds of considerations you I feel reassured.Yeah.I mean, this, this issue is it, it happens across the country, right?It's not unique to your institution or our institution.

18:57

I think part of it is an overall maybe erosion in the trust or the respect of the healthcare professions.I think the pandemic had a lot to do with that, but I don't think that it was only because of the pandemic.I think that that level of discourtesy and disrespect and distrust was well on its way developing or progressing, and the pandemic kind of tipped it over.

19:19

We struggle a lot with this idea of professional violence that is tolerable versus intolerable, and particularly because, like you said, the people who are often committing the ones the violence are the ones who need our care the most.So it is this catch 22 that has this emotional slash professional slash like personal identity overlay to it.

19:42

That that feels like a really important point to emphasize that it's much more likely that somebody who behaves violently toward a healthcare worker is experiencing a mental health illness.It's more likely that they have substance use disorder, for example.And I do think we need to grapple with our contribution.

20:03

To the emergence of violence in the healthcare space that that there is kind of a natural presumption that anybody who strikes a healthcare worker fully created the violence themselves.And, and I think we can recognize that it is always wrong to hit or threaten a healthcare worker while examining some of the contextual features that may have made that violence more likely.

20:28

So one of the things that we tried to sensitize our or, or sort of to develop within our stakeholder group and then sensitize our institution to were some of the ethical justifications for making boundaries.For instance, we not only have an obligation to deliver the standard of care to everybody no matter what, but there are also institutional obligations to protect workforce safety.

20:53

And so how do we satisfy those obligations at the same time?Or if we know that the experience of violence is not equitably distributed and leads to, for instance, greater experience of harm on the part of nurses, then how would we make sure that there's not an unjust response at the institutional level to the experience of violence?

21:23

You can imagine that if you had maybe just to be a little bit stereotypical about it, if you had wealthy, well respected physician leadership of an institution who decides to Pooh, Pooh the nursing experience of violence, you could imagine how that exactly perpetuate some of the maladaptive power dynamics that we've seen in healthcare.

21:47

And whereas if we say, well, wait a second, we're noticing that not only is it our nurses who are experiencing more violence, but it's our nurses of color who are experiencing violence.Then the the, the healthiness of our response to that violence is partly about protecting our our institution from nursing attrition and from nursing burnout and supporting the well-being of our staff and also rather intimately connected to our DEI efforts to make sure that everybody who works here feels like they belong.

22:17

So that I think was helpful to us.And then of course many of our clinicians were really helpful in characterizing clinical situations in which they would or would not be comfortable making some boundaries.So for instance, if a clinician is trying to perform life saving therapy on a patient, the example would be in an intoxicated patient who's just been brought to the emergency room after a motor vehicle accident, was sort of lashing out and disinhibited because of their intoxication, but also has, say, a pneumothorax from a rib fracture.

22:55

You know, that that person is their life is in danger and we really want to save their life.And we'd hate to say, hey, buddy, why don't you get a better attitude and come back to us at risk?You know what I mean?I mean, that's the last story nobody wants to be part of.

23:11

And so, so we started talking about, well, in that case, we might be more aggressive in our use of say, sedation to address that person's pain and perhaps to help them calm down.Or maybe to if there were an antidote of the substance that intoxicated them, help them reduce their disinhibition while also making sure we never flinch from providing life saving care.

23:36

On the other hand, if the same level of violence were directed at a phlebotomist who's drawing a routine yearly cholesterol for somebody, well, come on, the stakes are much higher.We could certainly say, hey, come on back when you're in a better mood.

23:52

We'd love to care for your cardiovascular disease by drawing this blood, but it can wait.Yeah.We, we've run into a similar type of conundrum where we have patients who are exhibiting problematic behaviors and there's no question that the behaviors are problematic.

24:10

They're either verbally or physically confrontational or aggressive.But the patient is a dialysis patient and the outpatient dialysis clinic has a very low threshold of what kind of shenanigans they're willing to tolerate.And they're very quick to say, Nope, you're done, you're cut off and leaving these patients who sometime, you know, there's mental health concerns there, there are other things going on in their life that may help to give some context to the behavior.

24:36

But then they are reduced to dialysis through the emergency room, hopefully, if that's an option or sometimes not.But yeah, it's contextualizing the severity of the behavior with some sort of plausible explanation for the behavior makes us a lot, I think, more complicated.

24:53

I do think the receipt of chronically indicated, potentially life saving care like dialysis or cancer chemotherapy is another example, can make these situations even more complicated.We will feel sort of an obligation to deliver the right frequency of dialysis despite outbursts of violence that happened or the right dose of chemotherapy.

25:17

We want to deliver the standard of care.And so I think a lot of our conversations started focusing on what degree or amount of responsibility can the patient hold for a health outcome that's maybe not suboptimal in response to their behavior.

25:37

I think we can think of it in the space of patients who miss appointments or do not adhere to medications that we expect, of course, that they own some responsibility, assuming they have the, you know, cognitive and logistical capacity to to hold their up their end of the bargain.

25:53

We expect people to shoulder the responsibility of health outcomes that happen from non adherence to care.We give them the dignity of risk in other hands.And, and so part of this was identifying what piece of, of the perhaps temporary withdrawal of medical care might be understood as the patient's responsibility that they have capacity to shoulder.

26:17

Is that ever tricky?I mean, I imagine I can imagine patients who, you know, the capacity is waning.They, you know, it's, it's hard to pinpoint exactly like how how culpable they are for their actions in any given moment.Absolutely agree.And I think maybe that gets to a piece of our work that went beyond policy.

26:37

You know, that, that our policy essentially gave people a language such as we've been discussing to, to weigh the pros and cons of either continued provision of, of life saving care despite violence.

26:52

With some, you know, protective measures put in place like security presence versus temporary withdrawal until the patient can and improve their behavior, along with other preventive things that we'll get back to.But that we realized that there were so many contextual features of each story that it was impossible to kind of, you know, prefigure in advance what, what to do in a given case.

27:18

And that that partly our clinicians were doing this on a day-to-day basis and appreciated sort of the, the wording to be able to deliberate more effectively, but also needed to be able to call more effectively on leadership responses.And that the experience of our clinicians was huge variability in what happened.

27:38

You know, that some nurses, for instance, were told by their nurse supervisors, this is part of the job, just suck it up and deal with it.This is part of being a nurse.Whereas other nurses got really quite different, I would say more adaptive responses of, wow, that's really difficult.

27:53

Let me make sure you have connection to the support at work.You let us know if you're willing to care for this person.Again, if you prefer not, we're going to put these measures into place.You know, why variation?And so norming what best institutional practices are, I think was important.And then we found that for the hardest cases where each team with or without unit support really still felt they were not sure how to strike the right balance in a given patient's care, we wanted to have an institutional resource to call upon.

28:23

And so we were able to catalyze with a collaboration between ethics and medical psychology and one of our associate chief medical officers who ended up being sort of the motive forces in that initial policy and needs assessment work.

28:39

We were able to successfully advocated our institution for funding for a behavior response team that essentially would drop into these cases led by a medical psychologist, but bringing together whatever stakeholders were appropriate to that case to essentially adjudicate what the particulars of that situation would dictate as a plan ahead.

29:03

And as you can imagine, kind of analogous to an ethics consultation, this was partly just about getting the different viewpoints in the room and syncing up the different professions despite different experiences.But also the medical psychologists had expertise in not only management of some of the mental health issues that might be contributing to the situation, but also in directly intervening with the patient so that some of those drivers might help, and connecting any affected clinicians to needed psychological care.

29:43

So I've seen in some hospitals like a.It's almost like a call overhead call, like a Code Blue for a violent patient, like a Code Gray, I think is the one that I'm most familiar with.Is that the type of like activation that would, you know, trigger the response from this team?

30:02

You know, this was a wholly separate pathway.We had an emergent, you know, get security of the room right away.Code 8, we call it, that was already running, but the hope was that this behavior response team would not only sort of deal with the the clean up that happens after that blow up happens and sort of decision making about, well, what now do we do to deescalate that conflict or, or make decisions about boundaries.

30:37

But that might even be enlisted when there's a concern about the future likelihood of a code aid happening and how could we kind of prevent it from happening.So this was less emergent, but both preventive and responsive.Interesting.It seems almost like I've heard of some like local police departments have social workers or mentor mental health professionals respond to certain type of mental health calls as the, you know, mental health first responder.

31:03

But it sounds kind of similar to that, having somebody with particular training maybe in trauma informed care or some of the psychological issues, but also like somebody who's cool in a in an emergency and can talk through hot activated people.

31:20

Absolutely.And you know, we we're very fortunate that our security personnel are quite skilled and de escalation and really good at using force as a absolute last result resort.But but yeah, having a multidisciplinary sort of slower acting, including preventive approach has been critical.

31:42

So that was really helpful in it and it did sort of, you know, to your point, Devin, it sort of changed the role of the ethicist a little bit because we went from sort of naming the pros and cons of different ethical responses to advocating for systems responses, you know, assisting in the drafting of the the ultimately successful proposal that added FTE to medical psychology and got somebody to catalyze this behavior response team.

32:10

Oh, and I this is, this is so crucial.So you can bring people together to talk about the issue.You can write a new policy and that's kind of part of most people's work.And they think of it as like the kind of the volunteer work to improve the hospital.But you can't have a responsive team that reviews cases, acts in current cases, and that's just their volunteer time.

32:28

You can do that, but that's asking a lot of people who have, you know, a lot of work to do.So you got them paid to do it.You got them time within their their work day to actually do that thing.That's huge.It was I was really proud of that success that, you know, I was part of, but I don't want to claim sole credit.

32:48

That was, it was a team that made this happen.And, and, and I think I do want to call out that that required a really sensitive tuned in senior leadership team.And so we were very fortunate to have a chief medical officer and a chief nursing officer who fully understood the impact of violence on their healthcare workforce and we're troubled by it and wanted to visibly make responses.

33:11

And and you can imagine that partly that was because they are outstanding leaders and also those were sensibilities that we had worked to cultivate so that they were regularly receiving the data on the number of employees going for help after injuries and etcetera.

33:29

What do you think that your role and background as a clinical ethicist added to the team or to the project?Like what was the value add of you being there?I think there were.There were three things.One was that values laden language was really important in part because different people, different stakeholders have really diametrically opposed instinctive responses to these situations.

33:55

Some said you do whatever the patient needs, Others said that's not safe, I'm not going to do that.And they're both really reasonable but knee jerk reactions.So I think it was helpful to help everybody have more balance responses and and maybe just sort of move from the the domain of emotion into that thinking about what is a good boundary.

34:19

I think the other piece is that it was important to think about not just ethical speech, but ethical action.We really wanted to make sure that since this was a recurring plan, this was clearly a systems issue that we, you know, the ethics maybe was not perfectly poised to say what the nature of the intervention was.

34:40

We're not, you know, experts in managing mental illness, but saying there is a contribution to this of mental illness or, or this needs to be multidisciplinary cause security needs to be partnering with these specialties.I think was a piece of, of our perspective, I think partly from a clinical ethics perspective, seeing the recurrent pattern, but I think also from an organizational perspective and seeing the wide impact of it.

35:07

I think the third piece of our contribution to the the success, such as it was, was trying to tell the stories of, of the impact that we were not only hearing from a wide array of stakeholders about the many ways this was impacting people.

35:26

Not just the person who got hit, but the concerns people had about sort of withdrawal from the therapeutic alliance and subsequent provision of kind of half assed healthcare or whether certain patients whose behavior were seen as threatening were actually just being confronted with violence.

35:48

You know, as we dug into this, we kept on hearing lots of different versions of this story that complicated the balancing act.And I think our ability to be in the room both with the frontline stakeholders and with the senior leaders and to say, hey, this is a good response.

36:06

But for example, there are some equity issues that are that this case is calling up that we need to make sure we have a good response to.I think was really helpful because it, I think it helped generate institutional momentum for a multi modality response that there was no single fix.

36:25

You know, that we needed this team, but there needed to be other responses.And I think that was helpful too to tell those stories.I did want to emphasize the role of bias and, and diversity in some of our deliberations because it led to some unexpected successes from the behavior response team.

36:44

So, you know, by design, we were planning this team to be an aid to our healthcare workers who were dealing with difficult cases.And, and I and I think what we definitely heard from some of our clinicians, what they call difficult patients, you know, it's a problematic phrase, but I understand why people use it.

37:01

I've heard much worse.I've heard much worse phrases used.That's right, difficulties is a.Is a much more.Powerful word.So what we found as the behavioral response team launched Burst as a a three unit pilot and then ultimately across the entire inpatient institution was that there were times when the healthcare team had clearly increased the risk that there was an outburst.

37:30

We didn't want to say that they were to blame for violence because of course our at least our patients with capacity own responsibility for this.But but there were times when we could see that healthcare speech or institutional policies were perhaps flaming the fans of a potential conflict and and that there were some real preventive opportunities that not uncommonly intersected with our diversity, equity and inclusion efforts or with our efforts to combat healthcare worker bias.

38:03

So to give you an example there, we had a a patient who was from the sub-saharan African country who was a large man who was understood by the healthcare worker to be behaving in a threatening fashion.

38:20

When we, our behavioral response team, sort of engaged in that case, it turned out that that patient spoke a language for which a local interpreter was not available 3D and investments in video interpretation had been a little slipshod so that the patient was not being fully understood when he was talking about unaddressed pain.

38:45

And he began to quite frustratedly talk about his UN addressed pain with a raised voice in a fashion that once those facts became clear, you'd say, well, gosh, I can imagine myself doing that.But since what he was saying was not well understood, the nurses at that time who came from different races started perceiving him as more threatening than I think he actually was.

39:13

And it was an understandable reaction.This was a a big man speaking in a raised voice to a smaller woman.But also this was a healthcare worker facing a patient whose names were not needed, who is quite appropriately advocating for needed care.

39:29

It was incredibly helpful for us to realize that there was a little bit of a pattern of events like that of either racial or language or other differences.A similar perception of threat came from a a patient who could not hear a worker who was speaking perfectly fluent English with a bit of an accent.

39:50

And the worker thought that they were being discriminated against in a somewhat threatening way because of their accent.But it was the worker saying, they were repeatedly saying, I cannot read your lips, but if you'd wear one of those masks, I can.I can understand you and I want to understand you.

40:06

And so coming into these situations that were coming to a head might have gone to violence.And helping healthcare workers see their contribution to it and to modulate it was helpful.And, and I think we were lucky in that, you know, I think if we had pitched the team to be, hey, we're the people that you call so that you can identify your contribution to a violent situation and fix it, nobody would call, right?

40:32

But we were called to help.And largely we were helping make boundaries with people who are just being violent.But we did identify as a bonus these cases where we could help our people have better de escalation training.That's a that seems like, yeah, the the other side maybe that I wouldn't have immediately thought about.So super helpful to talk to people and see patterns.

40:50

So have you been able to see a decrease in incidents of violence or at least people are more happy with the response to violence, sort of what has been the success on the backside?Yeah.So Fast forward, this effort has a nucleated process that other institutional leaders have properly taken over from the small ragtag team that started it.

41:12

And so the there had been other responses to violence across the institutions, for instance in our ER and they were sort of happening in little pockets without much mutual awareness.So we a great thing that our security and facilities leaders did was brought together a task force to improve mutual awareness of all of those responses from the behavior response team that we help create to some of those the DEI output of that to what they were security was doing in the ER and beyond.

41:45

And fortunately, that multi modality response has been followed by a 3540% depending on the month reduction in the average number of code 8 calls, the average number of employee outreach for responses to physical violence experiences in healthcare.

42:06

So we've seen a lot of a lot of improvement.And, and I think the improvement goes beyond the numbers.You know, I, as you pointed out, Tyler, I suspect that some of this was due to forces outside the institution, you know, election season stress I'm sure was contributing or some of the pandemic stress.

42:25

And, you know, our institution can't fix that.But I do think that not only can we do a better job with our responses to violence when it washes up on our shores, I think also we've been able to show people that the institution is taking meaningful responses and that we do care.

42:41

You know, that there is somebody who has your back from somebody to care for you if you're dealing with PTSD from the experience to somebody you can call if you're just worried about such a thing happening.And I think that has been helpful for people who are not directly involved in the response to feel cared for by their Co workers.

43:00

And then also, I think for those of us dismayed by healthcare workers, facing violence gave us a sense of agency 'cause there really were things that we could do to make a difference.Yeah, that seems so helpful because in cases that I've tangentially been aware of or been involved in, that's my biggest, I don't know, the struggle I guess is like I'm like, I can empathize and I can listen, but I don't have any solutions.

43:25

But having not only just resources but a team seems like such a great thing to be able to offer to people in in teams in these situations.Yeah, I bet people who are listening are going to really be taking notes on this podcast.

43:40

I mean, this is something every hospital deals with.And a 30 to 40% reduction in violent acts is is huge.That's really big.Yeah, I think it's it's really a huge success both for the people like medical psychology helping defuse some of these situations before they come to a head to the great de escalation work that our security and now an increasing percentage of our nursing leadership force are engaging in.

44:06

We, we also got some senior leadership support for enhanced de escalation education.It's, it's, it's taken a lot of work for people to deal with this different manifestation of illness, but I think it's been gratifying for them to, to see the results of their intervention.

44:23

And, and importantly, you know, you don't call ethics when somebody's being violent.I don't have training in that.You also don't necessarily call ethics to de escalate the violent event.But I think it was helpful for us to help name the nature of the problem and to bring together the group to have the solution 'cause they're out there and and we work with really skilled people who can implement them.

44:45

Great.Well, thank you so much, Tim, for sharing that story and that success.Thanks for hosting, I'm really glad you guys are helping change the dialogue.I think we all could use a little sunshine on our day, so thank you.Awesome.Great.Thank you, Tim.Thanks for tuning into this episode of Bioethics for the People.

45:03

We can't do it alone.So a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork.If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music, or wherever you listen.

45:22

And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.

In this episode, Dr. Becket Gremmels discusses a success story involving a pregnant teenager and her parents.

To learn more about Dr. Gremmels, check out his podcast Ethics Lab here: https://www.missiononline.net/ethics/ethics-lab/

Transcript

0:00 

Before we begin, Please note that the names and specific details of the clinical cases we discuss in this episode and in all of our episodes have been altered to protect patient confidentiality.Now on with the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy. 

0:22 

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.So Tyler, we have a very special guest today, somebody who I probably text at least every other week because I have a question about clinical ethics. 

0:52 

This is my absolute go to person and the first person who trained me in clinical ethics.Did you know that?No, it actually like taught little baby Devin how to do clinical ethics.That's right, I was in the final year of my PhD program.I moved back to be with my husband in Tennessee and this person was working already as a clinical ethicist at the hospital and I begged him to let me shadow him. 

1:19 

Really.I had no idea.All right, so who is it?It's our good friend Beckett.Welcome, Beckett.Beckett, thank you.Glad to be here.Yeah, introduce yourself with all of your positions because you're a very important person.Oh.I don't know about that, but so I'm the assistant vice president for theology and ethics at Common Spirit Health, which is a large Catholic health system. 

1:42 

And I've also been at CHRISTUS Health.I was the system director of ethics there and then also at Saint Thomas in Nashville, which is where I met Devin all those years ago.I think you actually first met me when I was a chaplain, right?Yeah.You were in the CP program. 

1:58 

Yep.And then you came back.Yep.I would definitely remember.That so Common Spirit is a large healthcare system.What makes it unique?Tell us more about Common Spirit.The size I think is part of it.I mean we've got I think 143 hospitals in 24 States and 180,000 employees. 

2:14 

If you include contractors and stuff like it's, it's it.It boggles my mind still.I've been here 4 plus years and it still shocks me how large the organization is.So that that in of itself makes it unique.We're the largest nonprofit health system excluding the VA. 

2:31 

Wow.And I think the third largest even when you include for profit.So it's it's huge.I think another unique factor is, I mean, we are a Catholic health system.So that certainly has its own unique elements to it.Definitely.But even within that we have non Catholic hospitals within our Catholic health system. 

2:48 

So that that's a unique feature too that that follow most of of Catholic teaching, but there's going to be some pieces that they don't follow so.Which could be, I imagine, a whole episode on its own.That that could be as well.It's very different.Yeah.So even within Catholic healthcare, we're pretty unique. 

3:04 

Yeah, but we asked you here today because I imagine you, in all the years of practice, have many, many success stories.I've heard great stories from you, but we asked you today to just pick one.And actually, Tyler and I have no idea what you're going to talk about as is our, you know, way. 

3:23 

So you have a case that you feel particularly like shows a success that you had in your work.So this was a case I had quite a while ago.So not not anytime recently.And it's one of those things where somebody says something and you're like, really like that's happening. 

3:41 

I didn't ever think that could happen sort of a thing.So this was a young woman who came in to deliver a, a baby, I think I believe she was 15 years old and didn't have any clinical complications with the pregnancy itself. 

3:58 

The she had prenatal care, everything went went fine as far as that's concerned.And she had a whole birth plan written up, which is many people do nowadays.It's rather common to have this is kind of what I'd like to have.I definitely want this.I definitely don't want that.And I mean, you can Google and get a whole checklist about that kind of stuff right now. 

4:17 

Part of her birth plan was that she wanted a natural birth, and that means something very different to everybody who says that they want that.And for this particular patient, what she wanted was no pain medication as part of her natural birth.That's what Tylers wife said too, right Tyler? 

4:34 

She never took any pain medication.Yeah, my I, I'll brag about my wife for a second.Three kids, all natural births and like she walked herself from the delivery room to the recovery room, usually with like a nurse standing behind her, but and they were like nurses like slow clapping like as she was walking down the hallway. 

4:54 

She's awesome.I want to brag on myself that I had, I asked for the most unnatural birth plan possible.I was like, give me all the drugs.Give me.I don't want to experience any of this.That's impossible.You experienced quite a lot of it, but I have a very low pain tolerance and took all the drugs I could. 

5:15 

That that's my wife give me the drugs she's we have 4 kids and and for one of them it didn't take so she ended up doing it naturally.Unbeknownst to her, at least one side didn't take so.All right, so 15 year old wants all wants to experience the the pain. 

5:32 

No pain medication whatsoever and comes in kind of spontaneous delivery, no induction, right.And around term, I want to say it was like 30 and a half, 39 weeks and uncomplicated pregnancy.Everything's going fine and labor's going fine. 

5:48 

She's progressing just as you would normally expect.Baby's doing great, everything's going well.And then she stalls and she gets to 9 centimeters and she just kind of stuck.The contractions are still there.They kind of are not as frequent as they would be that increasing in frequency and intensity that you would typically expect. 

6:06 

She stops dilating at she's kind of stuck at 9.And I mean, that happens.That's not that unusual.It occurs.Not what you want to happen necessarily, but it certainly can happen.And content labor continues.And the doctor just kind of says, let's assess it, let's talk about it. 

6:22 

Let's just kind of see where we are.Let's give you some more time.Well, more time turns into more time turns into more time.And now she's been there for almost 24 hours, stuck at 9 centimeters.Oh my gosh.And, and just so we're, we're all on the same page, 9 centimeters is 90% there, right, 10 centimeters, yeah, 10 centimeters is considered fully dilated and. 

6:45 

The baby's not in transition yet.Partially not, not completely, not enough to really obviously push through.Because usually what happens is my non physician understanding is the head pushes on the cervix, which is really what kind of forces the dilation in effacement to really go all the way complete to where she can actually start pushing and and deliver. 

7:06 

Poor thing, this is a lot of pain for a long time.Yeah, well, and I I mean, I don't mean just not an epidural.She didn't have Tylenol, she didn't have non opioid pain meds, no opioid, nothing.Wow, just and 15 years old, mind you.Right.So but what I would do, but more power to you. 

7:23 

Like great, go for it.That's what you want all the way.Let's do it.Do you have any any insight into why she was doing that?Was it like a natural?Was it religious?Was it any idea like what her motivation was for?Not taking the drugs, no, I I think it was just personal. 

7:38 

I I don't know what her exact reasoning is.That's a good question.I would imagine it's not religious to simply based on how the rest of the story unfolds.OK, but that's what I would imagine.And the physician gets to the point to where they say that, look, if, if you don't deliver soon, we're going to have to do AC section because you're, you're not, you're not progressing or it it and, and the baby's kind of getting stuck. 

8:09 

It's not really coming through and you're going to get an infection.If we don't, 24 hours is about the time where they start saying, OK, we need to start having a conversation about how do we precipitate delivery?How do we make delivery happen one way or another?Because you're going to start getting infected. 

8:24 

And that historically is one of the most common causes of maternal and infant mortality around delivery.Is that child bed fever, purple fever, right?Because you labor stalls, they can't make it go faster.And bacteria does what bacteria does right? 

8:41 

And the patient?Sorry, go ahead.No, just so we're at a crucial point right now and you'll probably say this, but at some point they call you because I don't know why they would call you, but I'm eager to find out.Right now there's no reason to, right?Just normal clinical care, everything sounds good. 

8:57 

Well, the patient says so the physician says, I have one idea before C-section, right?Because the C-section, I know you didn't want that.That's definitely not natural, right?That's not the natural birth and and the my idea is an epidural and the physician's idea, reasoning behind that is look, pain causes you to your muscles to contract. 

9:14 

That's just what pain does, no matter where it is.One, sometimes A cause of being unable to dilate is your pain.It's hurts so much that your body just tenses up and your muscles can't relax fully to allow that dilation to occur.That was his his reasoning.So my recommendation he said as a physician is epidural. 

9:32 

That's what I recommend for you to have because that can relieve your pain, which could allow you to fully dilate and deliver the baby.The patient says, well, you know, I really didn't want an epidural, but you know, an epidural is less intervention than C-section.So yeah, cool, let's go for it.How she could form any coherent sentence at that point in her labor is beyond me. 

9:51 

But the patient's parents say no.We refuse to consent to the epidural.Oh, and interesting.Oh oh.Uh oh.Because it depends on where, what state you live in whether they have the authority over their child in that way or not. 

10:07 

Yeah.Exactly.Oh, goodness.OK, so she has kind of changed her mind after experiencing the the labor and her parents, who was, are they at the bedside?Are they calling in like at the bedside, at the bedside? 

10:23 

And are they like cheering her on and saying no no, no you, you can do this with no pain medication.Kind of in a certain sense, but I mean, just to be clear, to your point, Devin, that state laws vary drastically on this.You have some states which have no limitation on minors making decisions. 

10:41 

Like in Louisiana, the statute says a minor can make a decision just as if they were adult and there's no age limitation.Now, in practice, obviously that unhappy you don't have your 3 year old consenting to stuff, but that's what the statute says, right?And then you have places like minor standing in Connecticut.There's no ability for somebody who's 17 years and 352 days to make a decision and then there's everything in between, right? 

11:02 

So the state really makes a difference there.But I think that up until this point, the parents have been completely fine and supporting the patient and, and being very appropriate and caring and compassionate as you would expect parents to do when their 15 year old daughter is delivering a baby. 

11:22 

It was their reasoning for refusing.I think this is what prompted the Ethics Council.And the reasoning for refusing was not to your point.I wasn't religious, right?It wasn't like we have a philosophical, religious, moral objection to this.It wasn't no, you can do it. 

11:37 

You just need a little bit more, you know, backbone and you can push through and you could do it.It was she needs to feel the pain so she doesn't get pregnant again.No, she has felt the pain also.That not a verifiable way to ensure that. 

11:57 

Wow, that is like gut wrenching reason.Interesting, that's A twist I was not expecting.So they want her to feel all of the pain in order for her not to get pregnant?Don't love that, I'm going to be honest.Don't love and it's putting her life in danger.Like I guess if she dies she won't get pregnant again but well. 

12:16 

I mean, it kind of is putting her life in danger if the only option is non intervention.But if the other option is C-section, right, that's that's enough.That's not going to necessarily put your life in danger, right?So there is another option besides an epidural.But are they OK with C-section? 

12:32 

Unclear.OK, never quite got to that point, so.Yeah.And so you and so you get this call at what point during this process?Right about that time when the reasoning was there.So, well, what what happened?If the so the physician says, I'm going to order it anyway, I don't care, we're going to do it. 

12:51 

Patient says go, I'm go.Good, Good for that physician.And the anesthesiologist walks into the room for a consent conversation and discussion, and the parents chase him out and you can hear them screaming up and down the hallway.We're going to sue you.If you come anywhere near her and touch her at all, you're going to be sued. 

13:08 

So anesthesiology to understand Lisa's, I'm not going in there again.Yeah.And that's the point where the ethics consult occurred.OK.So was it by the anesthesiologist or by the physician?I I think it was collective.OK.It was a collective call for help. 

13:25 

Basically.Well, and are you like an emergency?So typically most clinical ethics consultants don't work fast enough to like.Like unless you're a full time clinical ethicist who has a pager 24/7, you're not expected to answer consults like immediately. 

13:42 

But this one has to be answered immediately.Yeah.And that structure at that time, it was 24/7.Wow.So.I think it's really unusual to get truly emergent ethical issues.I've had a handful in my career, but this sounds like sounds like one of them. 

14:03 

Yeah, I've had some too, but they're they're pretty rare.But yeah, this was one where a quick answer is is probably needed.How do you approach this so before you we get to like your answers and your analysis, like what are you thinking as an ethicist going into being called into this case? 

14:20 

Yeah.I think there's lots of literature about the discrepancy I think between how we think about decision capacity and minors ability to make decisions and statutes.And obviously there's no perfect answer for this, right?And it varies so widely. 

14:35 

I mean, Nebraska and Alabama are 19 years old, not 18 years old.What because why?I don't know, because Puerto Rico also, but most states it's 18 is the age of majority.But those three, it's 19.I don't know why, it's just this.I'm sure there's some historical reason that somebody can tell us, but I don't know. 

14:53 

I thought looked it up.That just shows you, I think, how arbitrary it is to say that I think we can all agree a 2 year old shouldn't be making decisions and somebody who's, you know, 1817 years and 350 days, what does 6 days matter, right?At that point?It's always going to be arbitrary to some extent, but we got to pick some time. 

15:11 

But but that that was going through my head is does this person really have the ability to make the understanding that does she understand what she's consenting to and agreeing to?Can she make that decision?And you know, when you get to 1415 or so, you start asking those questions to where sometimes they, they probably could understand, right? 

15:27 

I've seen some 14 year olds who are way more mature and able to understand than some 25 year olds and and vice versa.And there's a whole bunch of different factors that go into that.But that that was kind of what's going through my head is, is that typical?Does this patient have capacity? 

15:43 

Have they been given appropriate information?Can they actually give informed consent or not?And then other questions about what, what is policy say, what does state law say, all that kind of stuff?And how does how does that conflux work in this particular case?I I think what an interesting wrinkle to this case is not just the consent or refusal of treatment, it's specifically pain medication. 

16:08 

And I think pain medication often is in a category by itself for different, you know, for for reasons that surrogates.I don't know, I'm really uncomfortable when people start saying that person should feel more pain, right? 

16:23 

Avoidable pain, particularly in a situation like this.So tell us more.Yeah.So my initial response was because I was somewhat familiar with the state, I was relatively new to working in that state or with that state. 

16:39 

And because I work with states that I very often don't live in, I've actually worked with states that I've never visited.So that's an interesting factor of being at a system level of a role, but I didn't know the local policy because I was new to working with this, with this place. 

16:56 

So I knew state law had a number of different exceptions, as many states do to when minors can make decisions without or against their parents consent her wishes.And they're very often emergency situations and and often many states make exceptions for pregnancy related treatment. 

17:15 

And this particular state had that exception.Any treatment related to pregnancy the minor can consent to on her own.I mentioned that had a conversation with the physician and the physician says, well, that's not what policy says.Policy says minors never make decisions in any circumstances whatsoever. 

17:32 

So we have a kind of a conflict between what potentially you you think could be the general approach of this patient seems to have capacity seems to be getting consent and has has agreed to and hospital policy and state law.There's the all three of them don't really necessarily with each other, which is always an interesting position to be in as an ethicist, especially when and when you're recommending something or when the right thing to do seems to be not permitted by the law, that that's one dilemma. 

18:00 

And another one is when the policy says something different than the law says, which is also different from what you're recommending.So you kind of have kind of a trifecta almost of a conflict between what seems to be appropriate and what what constraints there are on behavior. 

18:17 

I feel like if, if between the two, like if I would feel more comfortable saying the state law says this, but our hospital policy says this, overriding the hospital policy in favor of the law.Because clearly somebody wrote a bad policy and we've all helped to craft policy and we could do so after the fact identifying that the policy didn't seem to match the law. 

18:38 

The policy needs to change probably because as, as especially Beckett knows who goes before the legislature all the time to advocate for stuff.It's really hard to change laws, but it's pretty easy to change hospital policy.Yeah, well, sometimes it depends on the hospital.Fair enough.But yes, it does. 

18:54 

And I think we can all say, I think everybody could probably point to at least one law.We think that that was a badly written law.Sure, especially the more you start to read them.I think that I would agree that it's a lot easier to kind of change hospital policy and override that that that is the opposite.So yeah, but that's what this case led to. 

19:11 

We had conversations brought in risk and legal and and looked at the policy, looked at this that the law and said clearly this doesn't line up.Here's good reasons to permit what the law permits, especially in a case like this.And so we ended up changing the policy based on that one case, conform more to the exceptions and stay law. 

19:34 

But how fast did you?I mean, you didn't do all, you didn't have to rewrite hospital policy before you let this poor girl get her epidural, right?No, the, the wheels of hospital administration don't usually turn that quickly.So no, they, they don't.But we with, with risk and legal, we did allow this particular case to go through knowing that we were going to then change policy as soon as possible. 

19:55 

It it did only take I think about four or five weeks.So it was relatively quick as far as a policy changes.I'm currently involved in a policy.That's been going on for like November will be two years.So just to give you some perspective.Yeah.And yeah. 

20:10 

So in this particular case, once that was made clear to the end, I mean, I when I went to the unit, when I heard this and I printed out the statute and I printed out the policy and had conversations with anesthesia and the physicians and the nurses and everyone.I mean, I don't think anybody felt that they shouldn't place the epidural once the patient agreed to it. 

20:30 

I think there were just kind of concerns about the implications of it.But once those conversations occurred and we had the blessing of legal and risk, then then the clinical care for that patient was able to proceed and she received an epidural and was able to avoid AC section.So how did the the parents react to being informed about did? 

20:48 

Did you?Were you the one that informed them that?I think that's an interesting question about how much an ethicist gets involved in face to face conversations with patients and family members.And normally I err on the side of getting involved.I, I'm meeting them, I, that's usually my default position. 

21:03 

I always though ask the care team, is that a good idea or is given the dynamics, is that going to make it more difficult?And in this particular case to a person, they said it'd make it more difficult.And so I did not actually meet the patient and, and the family in this particular case. 

21:23 

But if they had had a very negative reaction to the news, then I, I may have very well done that.But when they heard the news, they weren't exactly happy about it, I would say, because they had their vision of what should happen and that was not it.And but that they kind of continued on and didn't really object that much and she received the epidural. 

21:45 

And did they sue?You they did not sue as far as.They, I think people shout that in the heat of the moment and it's not actually all that common to follow through.Well, especially a case like that and I've had a number of conversations with plaintiffs attorneys and that's not the kind of case that they want to take, right. 

22:03 

I mean, on the on the cynical side of things, you could say they only get paid if they win and they know they're not going to win a case like that really, because what jury is probably going to side with the parents in that case?They're going to be hard pressed to find a duty to death.But on the other side of things, what I've heard them say, the non cynical side.And, and I, I mean, I know many plaintiffs attorneys. 

22:20 

So I, I have a soft spot in my heart for those individuals and my family who are, but they, they say, look, that I got into, into medical plaintiffs law, medical law to find the bad actors and hold them accountable.I'm not going to take a case where I think this is a bad actor, but I've had a few of them even say I spend more time talking patients and family members out of suing when I felt the physician acted appropriately in the hospital, elected properly. 

22:43 

Then I do actually those the, the big names that people are worried that that's kind of what they that's what they've said.And most importantly, they were wrong.Like they were ethically wrong to want their daughter to suffer in this way for those reasons, right? 

23:00 

At least, you know, my ethical judgement would be like, this was a bad thing for them to do.They might have had reasons for that that they thought were justified.But I don't want to make patients suffer for to like a swage this kind of perception by surrogates that this might teach her some sort of a lesson. 

23:18 

I think that the reasoning had been different.It, it, it may have resulted in the same outcome, but a different conversation that they had said, look, as as part of our, to your point earlier, to religious tradition or our values, our beliefs is that this is that we're, we're a naturopathic approach, that kind of thing, which is definitely out there that a lot of, a lot of I've even had delivery cases where that's a, that's an element of it that, that would have been maybe a disagreement about values, perhaps that, you know, we might, I might disagree, but that's a reasonable cogent approach to take. 

23:45 

There's some logic there behind it.This was quite different in the reasoning I think, and that made a big difference in the recommendation in the process to to help resolve it.Do you think, Beckett, if you had been in a state in which minors have no say over care, even in pregnancy, that you would have advised something different? 

24:06 

I don't know about advise different.I think it would have the conversation would have been different about just so you know, doctor, this is a potential risk that you're taking if that's the route you want to go as a.So that may be more of a here's the options.Here's the pros and cons of each options sort of an advice as opposed to here are the options and here's the one that I think is best and and recommend. 

24:27 

I mean, I would certainly say as a Catholic health system, one of the benefits is having our mission and our values to be able to come into the conversation when it's appropriate.And certainly getting patients pain treatment.It's a part of our our commitment to respecting the dignity of the human person. 

24:43 

And so even in a case where perhaps that was, it was not the statute did not permit for minors to make decisions, that would have certainly been the position I would have advocated for.To an extent, yes.It may change how I approach it, but maybe probably not the ultimate recommendation I would say. 

25:01 

Yeah, I think a really good clinical ethicist has to be very aware of the laws relative to what they're doing.And if there is ethical advice that conflicts or at least isn't exactly in line with state statute or even federal law, they have to be able to articulate that and and be able to give good advice that this is what the law says and this is a reasonable interpretation of the law. 

25:23 

However, ethically, this is a different approach.And then leave it up to the physician to to actually make the decision about what they want to do.Yeah.And you always catch that with talk to legal, talk to risk.You got to have those because they're the ones who are going to help you actually interpret that.But in this particular case, I'd talked to those folks enough about this situation about minors that that I knew what they were going to say, which is exactly what I was going to say. 

25:49 

It's nice when that it's a little bit easier when the law agrees with you.But I mean, I don't think even if the law hadn't been quite so clear, it seems to me you don't.The law doesn't say you have to do whatever parents say in terms of medical care for their children, right?There's all sorts of other ways you might talk about the restrictions on parents. 

26:08 

We're not forced to do what they say.And if they make a really bad judgement that endangers the life of their child for no good reason, then we can override them.So there might have been other ways to argue about this had the law not been so clear.Yeah, usually you would look at something and even those those states where you don't, minors don't have the ability to make decisions. 

26:29 

There's court cases where doctors or hospitals have, have supported the minor against parents when they're making decision like that.I mean, the classic case is obviously Jehovah's Witnesses and and blood transfusions.Like there's strong court precedent for that.But that takes time, right?Usually in that situation, you've got 48 hours or so to get a court order in in in court hospital time is very different from judicial system time, right? 

26:53 

And judicial system is like what, a month, six weeks, That's quick.Hospitals you, you know, six hours and your decision type window is gone.Blood transfusions usually got more ability to play with that.And this one, we didn't even have six hours to get a court order really, right.Yeah, We had a case recently where it was a woman who had a mental health issue, but she had articulated that she only wanted natural birth, but it was very heavily influenced by her mental illness. 

27:20 

And the ethicist and the the legal team actually proactively went to court and got permission to do AC section of over her objection because of her mental illness.This is the first time I've ever seen that.Wow.Do you think that there's anything the parents could have said that would have persuaded you? 

27:36 

Like is there any rash reasonable justification for the intentional infliction of avoidable pain on a minor?There's so many values wrapped up even in the way you just framed that, that it's intentional infliction of avoidable pain, right.I mean, to me, I, I think, I think that reasoning about, look, we're part of a community that that values natural healing processes and we, we frown upon technical medical intervention, right? 

28:05 

Which again, there's many people out there who espouse those values.And if the patient says, yes, I'm a part of that community, yes, I espouse those values.To me that would prompt a conversation if OK, patient, give me a reasoning.What is it?Is it that you're just having a a moment of weakness and and yeah, you really do believe in those values that really, really is what you want. 

28:24 

Or is it that you've change those values are found an exception based on this particular circumstance or what is it?But I think that would prompt a conversation with the patient more so than just flat out overriding with the patient says to me, it's hard to find if the patient clearly didn't have capacity to make decisions, right. 

28:42 

I've had many women who've given birth say, boy, when you're at 910 centimeters, it's hard to find any capacity to make rational decisions at that point.Never having been in that position myself, I can't say one or the other, but this seemed to be a cogent person who was talking and and making sense.So the reasoning made sense and it was in line with the clinical recommendation. 

29:01 

So that that's whether you're a minor or not.That's a hard 1 to override I feel like in any situation.Yeah, I think I agree.Refusal of pain medication is something that is particularly maybe not troublesome, but it's interesting in in different ways than other types of treatment refusals I think. 

29:20 

Yeah, I I think about other scenarios where you're talking about someone else refusing pain meds for the patient and that's usually end of life.The patient can't make their own decisions and the family refuses.And there's a whole bunch of reasons to go into that from I don't want them to get addicted to, you know, some sort of redemptive suffering understanding. 

29:37 

And, and those situations, I've seen a handful of cases where the patient made it very clear maybe that they didn't want pain medicine or that they do value redemptive suffering, especially at the end of life.And that was a big importance to the patient.And those are situations where we've thought through and said, OK, maybe that would be appropriate, maybe that would be what, but that's because it's what the patient wants. 

29:58 

The patients clearly stated before they lost capacity that was in line with their values, not something that the surrogate that the surrogates values that they're making using to make decisions with.So, but the most cases that were of pain medicine refusal, I, I, my recommendation has usually been no, because you can't show me that's what the patient would want. 

30:20 

Yeah, these seem like the exceptions to the rule that the rule is you, you provide pain medication when necessary and there might be some instances in which you wouldn't, but those, those require quite a bit of rationale.Yeah, it's definitely a premier fasciet rule, but it's a it's a hard, hard face to overturn there. 

30:38 

Well, Beckett, what I really like about this story is that in the face of parents screaming I'm going to sue you if you do this, it's hard to know exactly what that physician and anesthesiologist would have done, right?So because you were there, it made a positive difference for that patient. 

30:56 

And because you were there, you got to recognize that the hospital policy on this said something that contradicted the law and needed to be changed.Who knows what would have happened had you not been there?I don't know, you know, it's one of the the rare instances where I do feel like I can say I, I did clearly make a difference in that my presence was beneficial not just to the patient, but then future patients as well. 

31:19 

Can't always say that, especially in hospitals, because many hospitals don't have an ethicist for that kind of on the ground support.And I mean, they don't burn down, right?There's still functioning.So it's hard to point out that that clear benefit, but I think in this case you can, you can really look to it and say I made a difference hopefully. 

31:38 

Yeah, you're a hero.Yeah.Do what I can.This is a yeah, this is a great case.Thanks for sharing, Sharing it, Beckett.And I agree.I think that one of the unique things that we get to do in our job as a clinical ethicist is to be at the bedside and see where policy and state law are actually impacting people's lives in a real way. 

32:03 

And gives us an insider, gives us an opportunity to change that either policy or work on state level legislative changes.But that that's an aspect of being a clinical ethicist that I didn't anticipate even when I was going through my training until I actually got on the ground and was doing clinical ethics as professionally. 

32:23 

So yeah, it's super interesting.Yeah, there's a an odd dovetail I think between those those pieces of state law and and even federal law to some extent and policy that it's an odd conflict that I certainly never expected for sure. 

32:39 

Well, thanks, Becca.We really appreciate you sharing this story.I'm sure we'll get you to share more stories in the future.All right.Thank you.Have a good one.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork. 

33:01 

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In this episode, Stefano Mugnaini shares a success story about how he was able to work with wardens on behalf of incarcerated patients.

Transcript

0:00 

Before we start this episode, just want to remind you to protect patient privacy, the details and names in the cases we will be discussing have been changed.Now on to the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy. 

0:20 

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.Good morning, Tyler. 

0:41 

Good morning.All right, so we're kicking off a special series of cases of interviews with clinical ethicists who had some success at their institution, pushing through a policy or a procedure or really crushed a case.Sometimes we just need hopeful, uplifting stories. 

0:59 

Yeah, the last couple seasons have been a little dark.We're going to be honest.A lot of our work can be tough like that.I'm really excited to highlight some some victories, some successes.All right, so who do we have for today?All right, we've got Stefano from Alabama. 

1:16 

I I avoided saying your last step because I'm still, I can't, can't say it in my head yet, Munyanini.Munyanini.Munyanini.OK, Stefano, no, I'm not going to try again.I'm going to let, I'm going to let him introduce himself.All right, Stefano, you introduce yourself.OK. 

1:32 

So I'm Stefano Munyeni.I'm originally from Florida, but I live in Alabama and I'm one of the two primary clinical ethicists at the University of Alabama, Birmingham.My colleague Sybil is next door.And the two of us are pretty much, we work pretty closely with the Ethics Committee and everybody else, but we're, we're the two folks that spend most of our time dealing with specific ethics issues and consults. 

1:55 

In my experience, it's actually pretty awesome that you have two full time people.So how big is your hospital?I don't know what the most recent numbers are, but we're somewhere in the neighborhood of 1200 beds.Whoa, so you're big?Yeah.And we have a separate hospital that's AI don't know 2 miles down the road. 

2:13 

It's a was originally a rehab orthopaedics and rehab facility that's been converted to a acute care hospital.And and then we have a big clinic complex that we mostly we step in to help guide decisions about tooth extractions and things like that over there, but but other procedures as well. 

2:35 

So.Dental clinical ethics, that's an underexplored area for us, I think.Well, so my neighbor's working on a doctorate and she, that is an area that sort of out of the blue she has become deeply interested in.So we're really not sure why, but she's not even sure why. 

2:52 

But it is something we get a lot of calls because of the, the way this sort of surrogate hierarchy works in Alabama.If someone is truly unrepresented, we can step in and, and consent and make most of their decisions.And there are a lot of folks who come to us from group homes and things like that who need dental work done and don't have anybody who's able to consent. 

3:15 

So that is a a strangely growing part of our area of responsibility.So.Cool.But today you will have another kind of patient that you want to talk about.So did this start with a case with a particular sort of incident at the hospital that kind of kicked off what you now see as a success story at your hospital? 

3:37 

Yeah, it it actually, for me, it started as a paper that I wrote for school and it concerned a case that happened at UAB before I was here.And in in defense of my mentor and predecessor, Wendy, Wendy Walters, who is a wonderful person who really brought me on board. 

3:57 

She wasn't really involved in this case either.This was one of those things where everything sort of went down without ethics involvement, and years later, sort of it became clear what had transpired was not what should have transpired.So I wrote a paper about this case and then found myself reviewing policies related to it and realized that our policy didn't really accord with state law as interpreted by the judges involved. 

4:29 

That seems like a pretty big oversight.Yeah, I mean, that's so often the case, right, That we we run into a case and we had one a couple of years ago where it was novel case that we'd never seen before and went to the literature.And like the the society statement said, before this happens at your hospital, we recommend that you develop a policy to address this. 

4:50 

They're like, OK, great, that's not helpful.So, so you had a, so there's a case, historic case, probably one that sticks in the memory of some of the clinicians who were involved in ethics, particularly around incarcerated patients is what you, you had mentioned.And so you did an analysis for school and then came back and and we're able to work on actually changing the policy in order to to help it help that situation. 

5:15 

Yeah, the first, the first policy here that has my name on it is, you know, related to this case.So that's for me a little bit of a point of pride.I felt like I kind of hit the ground and got something done, so yeah.That's great.Aspirational student work, Yeah.Yeah. 

5:31 

So walk us through it.What?So tell us about the case and and kind of how you got involved with it.OK, so in 2014, there was a patient who was brought to us from Saint Clair County Corrections Facility, which is in Springville, AL, which is probably an hour, not quite an hour outside of Birmingham. 

5:56 

And this was a guy who was doing life in prison for a 2007 murder.And somebody in the prison, he and this other individual had had kind of a series of conflicts that eventually ended in Marquette Cummings, who was the the individual in question being stabbed in the eye with a Shank and which, you know, pretty rough situation. 

6:26 

Obviously it, it sounded like in hindsight, there might have been opportunities to keep these guys separated and it didn't really happen.So he was stabbed in a prison fight or in a fight in prison and was brought to us and very quickly transferred to the neuro ICU. 

6:45 

He came with a piece of paper that included instructions from the warden that no heroic measures would be taken to save his life, which is a quote.I'm not sure how they defined heroic measures, but, but this was essentially sent with the paperwork from the from the warden and he was made DNR by one of the physicians that evening. 

7:10 

Somewhere along the way, the patient's the the patient's mother showed up.And here's where the story gets pretty murky.The reporting that I was able to uncover, she either was allowed to visit but not be involved in goals of care conversations, or she possibly wasn't even allowed to visit the bedside. 

7:31 

The reporting on that varies, but in in either case, decisions were made.The expectation and the understanding of the team was that Mister Cummings was probably had already probably progressed to brain death, but before any of the the neurological testing had begun, on the warden's instructions, they withdrew support and allowed him to expire. 

7:58 

This, not unexpectedly, perhaps led to a lawsuit.So this paperwork I've did you ever see that piece of paper?Was it in any of the reporting?What did that even look like?That unfortunately I have no idea because this happened in 2014 and I came on board in 2022. 

8:18 

So my understanding was it was literally just that, you know, we get a, we get a, a packet from the prison Infirmary and the prison medical staff.And my understanding it was just basically a sheet of paper, like like a face sheet or something that had someone had printed on their take no heroic measures. 

8:40 

And then they were in contact with the warden via phone and it was a phone conversation where they said go ahead and withdraw.OK, so they were consulting it.They didn't just go off this one piece of paper.No, no, OK.There's immediately two big ethics questions that come up.The most glaring is, does the warden have authority to make decisions on behalf of the incarcerated patient? 

9:01 

And the second is how they allow or how should we allow or inform families about the incarcerated patient being in our hospital.And I, I think I know the answers to those questions that apply for most states.But I mostly get the second question because I think the first has well been settled in our policy. 

9:22 

But I want to get to how Stefano was able to change his policy to get to it.But there is some gatekeeping that can happen and then there's some gatekeeping that cannot happen.But I typically get the kind of are are we allowed to call the family and tell them, which is a second kind of question.Yeah. 

9:38 

And part of where this gets complicated in Alabama is there is really broad statutory authority given to wardens to gatekeep communication and visitation.I mean, basically universally they're allowed to say who's allowed to visit, who's not allowed to visit, who we can call, who we can't call. 

9:56 

Practically, there's a certain amount of, hey, we called the warden to ask if we could call the family, and they haven't gotten back to us.So what can we do?And my tendency is to say, well, until, until they say no, unless there's a really obvious reason why we should be concerned, my inclination is to go ahead and make that contact. 

10:23 

But most of the time we do try to at least talk to the warden first.One of the things that came out of not our policy change, but this case in particular has been it's made prison wardens much less inclined to want to get into the weeds of these cases. 

10:43 

And also has, I've found that they have sometimes even in conversations I can just mention, are you familiar with Cummings or Davenport?And they'll say, yeah, So what do you need from us?Oh.That's good.And they're much more willing to work because they recognize that their authority does have a a terminus at some point. 

11:05 

So tell us about that case.What is?Is that the case that came out of like that legal case?Yeah.So, and I think that that I'll actually say, I think part of the reason that our policy, our, so our policy stated in our informed consent policy for convicted inmates, the warden of the prison is their surrogate decision maker. 

11:26 

I'm not completely sure how that was part of our policy, but I think it has to do with there were a couple of other cases that sort of unrelated that sort of affirmed that to some extent a warden has some medical decision might they actually said might possibly have some sort of medical decision making authority. 

11:48 

I think most of the time that's when they're inside the, you know, the prison complex.But, but so because our policy stated that everyone just kind of followed the policy and let the warden call the shots.What I've what I've found now having this in the in the background, they, they are, they are quick to say, we recognize that we're not really in charge here. 

12:11 

But with this particular case, what ultimately happened was the estate of the family sued and said that they cited a couple of different things.They, they sued on the basis of the prisoner not having been separated from this antagonist, because I think there were two or three separate cases where Mr. Cummings was either in an altercation or was attacked or was harassed by this other individual. 

12:40 

So they sued on that basis.They said it was essentially cruel and unusual punishment, that there was no isolation and separation.I think that was kind of thrown out.They also sued on the basis of the warden claiming authority for, you know, making end of life medical decisions for the patient without having any express right to claim that authority. 

13:04 

And so then it all hinged on a question of which this is a timely question, I guess, whether a person acting in that capacity can actually just use their position to claim immunity, qualified immunity in the course of their official duties. 

13:23 

And that was where the whole case kind of hinged.Yeah.So he was saying, not only did I have the right to do this, I'm protected by the law for having made that decision.You can't come back and sue me.The law protects me in these scenarios.To which the judge said what?It's one of my favorite quotes that came out of actually. 

13:42 

So there were two decisions in this case because it was heard by the local court and it was heard by the 11th Circuit Court.And there are great quotes in both of the decisions.Not that legal briefs briefs are usually really great reading, but these were.Tyler loves them.Tyler, I know I some of them are really a rollic in good time. 

14:02 

So so judge by the name of William Pryor, who was the 11th Circuit Court judge.He's actually cited Ashcroft versus Al Kid, which was a Guantanamo Bay case that came out of, you know, in the early days of the ostensible War on Terror. 

14:19 

They were just rounding random people up and throwing them into Gitmo and then figuring out the charges later.So in this case, Pryor says based on his reading of that breathing room afforded by qualified immunity is generous. 

14:35 

Although qualified immunity provides government officials with a formidable shield, their entitlement to raise that shield is not automatic.So.All right, so trans translate that for us.Yeah.Well, so basically he said, yeah, you can do almost anything behind the guise of qualified immunity, but you yourself can't determine when qualified immunity is a relevant defense. 

15:00 

And in this case, the the broader issue was, and I think this had been mentioned by Judge OTT in the lower court ruling, he said, he said the the problem here is when there is a statute that lays out a surrogate hierarchy or anything else. 

15:22 

And I, I always screw up the Latin here, but there's this legal principle of expressio unius alterius, exclusio or something like that, Exclusio alterius, which means if one thing is included, all other things are excluded. 

15:38 

I took Latin for four years in high school and I can barely remember 2 phrases.I know I'm killing it.My, my professor, my teacher somewhere is so proud.But basically it's this idea that if, if you include something in a statute, then anything that is excluded, anything that's not included in that statute is necessarily excluded. 

16:02 

So in this particular case, the state provides a surrogate hierarchy for end of life decision making and it it names a bunch of different people as potential surrogate decision makers specifically at end of life.And anybody not named in that statute then is implicitly excluded from the statute, right and. 

16:23 

Let me guess, the Warden is not on that list.Turns out they are not.As I mentioned, they do have.There is a another state law that lists very broadly all of the stuff a warden is in charge of.And it does include things like visitation and communication. 

16:41 

But it does not provide any room whatsoever for a warden calling a hospital and saying, in the popular parlance, hey, go ahead and pull the plug.There's just nothing there for that.Yeah.So, so is that a new state law or do you think your policy? 

16:57 

So I guess my question about your policy is it sounds like your policy was not in accordance with the state law, right?That your policy was allowing the warden to make decisions even though state law didn't allow the warden to make decisions.Is that right?Yes, but I think it's more that the law had never been really explored in this particular context. 

17:21 

And so there was an interpretive process and and I mentioned there, there are a couple of other, the most notable one, another case was about a guy who was the acting something or other supervisor at Tutwiler, which is a women's maximum security prison. 

17:41 

And he's, he was in this acting role for like 18 months and he wanted to get the job permanently.And they, they didn't offer it to him.And they cited the fact that he was a male and they felt like he couldn't do the, the duties of this, this job as a male. 

17:57 

And one of the things that it hinted at was a warden had some responsibility for the medical needs of inmates.And if it's a warden, he couldn't understand the needs of a female inmate.And that was one of the reasons why he was not chosen for the law. 

18:16 

And so there's there's this sort of legal nod to the idea that perhaps wardens do have some involvement, appropriate involvement in medical decisions.And I think that was probably what was used to sort of justify this idea.But no one had ever really tested it related to an end of life situation. 

18:34 

And that's what happened in this case.Stefano that is such a leap though.I mean for this like kind of obscure case, a male female discordance to presume then that the warden can make any and all end of life decision.Seems to me like a hospital lawyer was either like totally in the dark about this policy being written or made quite the like inference from that case, which seems like, come on, I can't be like a popular case in Alabama that everybody knows about. 

19:02 

So like, dredge it up is like, well, I guess I'm going to make a leap here and say wardens get to make decisions for patients while they're in our hospital, which again, is like a different context because making medical decisions in the Infirmary and making medical decisions in the hospital is also not the same thing. 

19:19 

Yeah, Yeah.That case is Edwards versus Alabama Department of Corrections from 2000, by the way.And I'm just speculating.I really don't know if that's how it was interpreted, but my guess is that's one of the only cases that was ever involving this idea of wardens and decision making. 

19:37 

And I suspect that is the the leap that was made.But I agree, I don't think that it was necessarily an appropriate one, but I think you could probably interpret that as to say, well, as long as the decisions in question are not technically end of life, there's at least the defensible aspect to that policy, even if it's not maybe the best idea. 

20:00 

Seems like a bad idea.OK, Yeah.I agree.I totally agree.Let's give them the benefit of the doubt and say they were trying.There wasn't a lot of directions, so they did the best that they could.But then this case happens and it's very clear that the warden is not supposed to make end of life decisions. 

20:16 

And then you're this great student who recognizes this.You get hired at the hospital.You look over the policy and go, uh oh, there's a big problem here.So how did you move from like I see a problem newly hired clinical ethicist who wrote a student paper once to actually changing your hospital policy? 

20:34 

Yeah, and this is where my zeal outstripped my wisdom or my my, my phronesis, as Pellegrino would say, I guess.Yeah.Out kicked your coverage is how we yeah.I just, I just basically started pounding my desk and screaming in ethics meetings, in Ethics Committee meetings. 

20:54 

I mean, I probably wasn't quite as dramatic as I think I was, but I just said I, you know, we run into these cases constantly and I don't think this is a workable system.We're clearly contrary to the law.So then I also just started, I probably shouldn't say this for something that's going to be out in the world. 

21:13 

I just started coming up with my own practice trying to figure out how I could navigate these situations.And it, it so happened that the summer when we were working on the policy revision, we had a couple of situations where there were pretty significant aspects to the situation that made it where like the warden's ability to limit visitation was probably a good idea because of some safety concerns, because of the, the violent nature of some of the, the crimes for which these people were incarcerated and concerned that there may be people out there with a, a real desire to get back at them. 

21:53 

And that actually gave me a really good opportunity to have some long conversations with the warden at, at one of the prisons and kind of work out a process that, although clunky, was at least workable, which is essentially, we contact the warden anytime we get a patient in this kind of situation, you know, possible end of life imprisoned. 

22:15 

We have them automatically get ethics involved.We make contact with the warden and we basically say, you know, we've got to talk to family to get the right person acting as surrogate.How do you propose we do that?Do you want to be the first contact or do you want us to be the first contact? 

22:32 

And most of the time we've gotten very little pushback.And they've said, yeah, let us make contact with them first and then we'll get back in touch with you.And, and so once they've made first contact and we've had some conversations with them about things like visitation, generally speaking, they will allow some limited visitation and most restrictions on communication are, are off the table. 

22:55 

So somewhere in that process, I was able to come back to the Ethics Committee and say, listen, I've just sort of come up with a, a sort of workable way of, of, of doing this.And I really think we should enshrine that into policy. 

23:11 

And then they called my bluff and said, great, write the policy and send it to us of.Course they did, of course.Who else wants to write that policy?That's great.So it started with the relationship.I mean, that makes a lot of sense to me is you started talking with the warden because it's easy to kind of pigeon hole somebody as being like a bad actor or like unreasonable if you've never actually tried to have the conversation. 

23:32 

So you establish this relationship, you sort of set the terms.This is genius by saying, but by giving over some authority, saying you know the context, would you like to be the first to reach out or not?So that and you didn't frame it as a question.You said so that we can find the appropriate decision maker. 

23:51 

And so by setting the terms that way, there was no ambiguity about who was supposed to be making these decisions.Yeah, that's great.Yeah.And you also, you also set it up.So like the thing that we cared about most, the ethics consultation service or you cared about most is making sure that, that that question was answered right. 

24:11 

And it didn't become like a, a power struggle about like who's in charge of this patient?And, and you know, are you transferring authority and, and all these other things?I find that that's often the the most important thing that ethics consultants can do is help distill the question into, OK, in this situation, regardless of all the other weird contacts that is going on that we can or can't control, we want to make sure the right person is making the right decision for this person as they die. 

24:38 

Right.And I think a lot of a lot of people are gonna agree with that as the, the, the problem that we're trying to solve.And here's an example of, you know, a way in which I figured out how to do it.And I think that's really great.Yeah.Tell me about cold calling the, the warden.How'd you get in contact with them 'cause I've cold called a lot of people. 

24:56 

I cold called presidents at hospitals.I've cold called probate court judges, legislators.I've never cold called a warden.You know, Once Upon a time I worked in sales and I hated cold calling and I wasn't very good at it.But I will say prison wardens are easier to get a hold of than just about anybody else. 

25:15 

It's remarkable, at least in Alabama.And and I think some of that is there is a certain weight when I get a hold of the person that answers the phone for them and say, hey, I'm one of the ethics consultants at UAB Hospital.We've got a patient here, need to talk to the warden. 

25:31 

There's not usually a lot of gatekeeping.They're pretty quick to put me through because they recognize that, you know, there's some pretty critical things happening.The other thing I mentioned earlier, a lot of times, I'll invoke this case and most of the, there's a, there's a fascinating website called Prison Legal News that again, surprisingly interesting. 

25:54 

But most of the wardens that I've encountered have have become aware of this case such that they're very quick to say, yeah, we understand that this is not something we can make decisions about, but we need to, you know, figure out what we're going to do.So I've actually found that they've been much less, I mean, much more accommodating and much less resistant than I probably would have expected. 

26:15 

I've had a different experience with jails than with prisons, but that is probably a sub.I don't know if that's the subject for now or for another day.What do y'all think?Well, maybe try it out and see.We'll see if it makes it fun, OK?OK, no, tell us. 

26:31 

So the biggest, the biggest issue with jails is because it's much more of a transient situation, most of their medical staff are outsourced from out of state.So my impression and encounters with them has been that they care very little about what the laws in Alabama actually are. 

26:51 

And their biggest concern is, I mean, they're, they're not, they don't feel responsible for the patient in the same way that prison medical staff and other staff, all other things being equal, I think they do have a sense of responsibility for the people under their charge. 

27:08 

And I don't see that same level of a kind of a sense of responsibility from the jail.So we've gotten a lot more pushback from jails saying, no, we we're making all these decisions, we're telling you what to do.And also jails are really quick at end of life to just release somebody. 

27:24 

And I mean, they they sort of couch it in compassion terms, but I think it's more about not getting saddled with a lot of medical bills.But I don't know if that is maybe too judge mental on my part or not.That's interesting.So I heard a guard once say who was standing like positioned outside of a hospital room, say something to the effect of you can't let him die. 

27:47 

He has to serve out his term.My goodness.As as if like it like justice demanded to keep this patient alive or to prolong his death because he hadn't quite fulfilled his sentence.Which was just like a mind boggling thing to say, but wouldn't happen with a jailer who is less concerned with that because they presumably aren't in for long sentences. 

28:10 

Yeah.I mean, that's generally speaking, you're on your way somewhere else if you're in jail.That idea, though, of, you know, we can't let this guy die because he has more, you know, suffering to do before his sentence is up, That bothers me on a theological level more than anything else, I think. 

28:29 

I love that theological level.Absolutely.Like there's so much wrong with a statement like that.Yeah.Maybe for another episode.Yeah.So I do have a question, Stefano, something I was thinking about when we talk about what a warden can and cannot do, so can in Alabama and I think in a lot of states filter communication. 

28:48 

And that's actually I've this bit has been explained to me, like you were saying as a safety issue, that if some people in this person's life were to know they were in the hospital that you could get access to them, that might place them at a safety risk or their family at a safety risk. 

29:05 

And that actually does make sense to me.And so you have to have a relationship with a warden who's not trying to like punish, right in the, in the incarcerated person, right?There could be bad actors in this, but we'll presume that that's not what's going on.But my, my posture toward that has always been that there has to be such an explanation in order for us not to reach out that, that there really has to be a reason. 

29:28 

They can't just say, oh, I'm not going to call the family for arbitrary reasons.They have to say, they have to very affirmatively say this is a safety risk.They have to be able to explain that, right.And so sometimes we do press a little bit.If they say, no, we can't contact the family or, oh, no, I'm not going to do it.Say, well, we're happy to do it unless you think there's a, you know, unless you can give us a compelling reason not to. 

29:49 

What do you?Think about is that just to jump in?Do you think that's any different than the criteria we use in order to limit anybody's visitation to any of the patients, though there's something unique about being incarcerated that changes that? 

30:05 

Yeah.Stefano, what do you think?Well, so yeah, I, I think that the same basic premises there that there are situations where it isn't necessarily safe to have someone coming into the hospital.I think the only difference or distinction is in one case you do have a legal statement that a warden has this particular authority. 

30:28 

Whereas if it's, you know, the hospital having to make that decision, it's it's our own sort of policy that suggests that we have that authority.An additional wrinkle to this, they just passed a law in Alabama fairly recently that allows someone to designate a an essential caregiver who basically, without really strong reasons, is not allowed to be asked to leave the room at any time. 

30:59 

And this was some response to baggage from COVID when there were times when people really probably should have been allowed to have somebody in the room with them, especially if that person was willing to bear the risk of being in that room and they were excluded.So they wrote this law that basically says, you know, you can designate an essential caregiver, you can designate up to four and they can alternate. 

31:19 

And one of them has a right to be with you at all times with the exception of a sterile procedure or, you know, something where you're, you can't have somebody in the room or if there are behavioral dangers that arise.So there's like that additional layer kind of legal pressure to, to allow access. 

31:39 

But I think that really the distinction is just that a warden is named.But I tend to view that as a sort of a negative right, in that until they tell us no, the assumption is like any other patient, we can reach out to family for, for good or for I'll. 

31:56 

That's the way that I tend to interpret that authority.Yeah, that I think that makes a lot of sense.Yeah.So what one other question as we kind of wrap up this, this case, what is the rate or your experience with incarcerated patients having completed advanced directive paperwork? 

32:15 

Very, very limited.I don't have a specific number on that.Anecdotally, I've been here two years and we average about 5 to 600 consults a year.A lot of those are very quick.Hey, who's the surrogate phone calls? 

32:32 

They're not super involved, but so I don't know.I've probably been involved in close to 1000 situations and I can only think of one case where an inmate had an advance directive when he arrived.Now there have been some who have filled them out here, but I don't think it's very high. 

32:50 

Yeah.I, I don't, I, I guess when, as I think about that question, like I don't think I've ever read anything about those rates or statistics or outreach into that population for that point.But maybe I'm just ignorant on the literature.It'd be a great like in processing thing to do though, right? 

33:05 

If anything were to happen, what would you want?We do, we do have a, an intervention here where part of the nursing intake is asking some of those questions and it, it gives an opportunity to flag a chaplain to come and fill out an advance directive with a patient, which is AI think a really good thing. 

33:24 

Unfortunately, what we wind up with in a lot of cases is someone, even if they initially express interest, a lot of times when someone comes to actually fill the AD out, they're like, Nope, no interest in doing that, not going to talk about it or they have lost capacity.And then either case it becomes a a a moot point. 

33:40 

Well, Stephanie, would you say that this policy that you wrote, I mean, you were kind of already doing it, but you wrote it into policy it, it sounds like then it's been a huge success, right?So are other people now following your strategy?You think it's been mostly successful? 

33:55 

You said this, the jailers maybe not quite so much, but what do you think the success rate now is of this policy that you wrote?Well, I think the biggest challenge that we're running into now is education and dissemination of the policy.It's been, it's worked really well. 

34:11 

When we have done it, we've had multiple situations where we were allowed to get someone's daughter to see them, you know, at end of life and participate in their, in their at least the decision making around, you know, what that death looked like.I can think of multiple cases where we were able to accomplish that. 

34:31 

And I, I, I feel really good about that.I think it's been very successful.The challenge is an institution our size, it's been very difficult to to get that information out to the people.So we do a monthly didactic for the ICU resident group. 

34:50 

We do something with the ICU fellows each year as they come on board.We teach a didactic for the nursing residency, which, you know, all new hire nurses that are new grad nurses that are they come on board couple other little situations. 

35:07 

And we make sure to talk about this in every single, every single group of people that we speak to.And yet still in a lot of cases, we'll eventually get looped in and they're like, well, the warden's just been consenting to everything up until now.But somebody said maybe they're not supposed to. 

35:24 

So we thought we would call you.And we love those because we're like, sweet.It's an opportunity to educate everybody who happens to be standing in this corner.But I think that's the thing, it's been really successful.But we've, we've not, we've not come up with a comprehensive way to let everybody in the institution know, hey, the policy has changed. 

35:44 

And you know, we've thought about sending mass emails and things like that.But I don't read any of those.So I find it so.I mean, I mean I read them all and digest them deeply.But you understand the impulse not too.Yeah, Yeah, yeah, right.Exactly.Good. 

35:59 

Well, good luck on continuing to educate.That's such a big hurdle.You can have the perfect policy, but if no one knows it exists, it's not the perfect policy quite yet.Right, right.Yeah, that's a good point.Good.Well, thanks, Stefano.We appreciate you being here and thanks for telling us about your success story.Yeah. 

36:14 

Thanks for having me, this is really fun.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darian Golden Stall for designing our logo and all of the artwork. 

36:32 

If you're into what we're doing, give us a rating on Apple Podcasts, Spotify, Amazon Music, or wherever you listen.And if you're really into what we're doing, head over to bioethicsforthepeople.com to snag some merch.It's it's statutorily can't talk. 

36:55 

You might edit that out.It is.Statutorily granted to the Warden.