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On March 11, the World Health Organization (WHO) declared COVID-19 a pandemic, pointing to the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. To discuss some of the ethical issues regarding COVID-19 we are joined by Dr. Ken Iserson and Becket Gremmels. This episode was recorded on Friday March 20, 2020. Our guests in this episode include: Dr. Ken Iserson, Professor Emeritus of Emergency Medicine at The University of Arizona, Medical Director (Emeritus) of the Southern Arizona Rescue Association (search & rescue), a Supervisory Physician with Arizona’s Disaster Medical Assistance Team (AZ-1), and a member of the American Red Cross disaster response team. Becket Gremmels, System Director of Ethics for CHRISTUS Health based in Irving, Texas. CHRISTUS Health can be found in 60 US cities and is comprised of 60 hospitals and long-term care facilities, as well as 175 clinics and outpatient centers. Additional resources relating to or referenced in this episode: Improvised Medicine: Providing Care in Extreme Environments, Ken Iserson Joint Statement on Multiple Patients Per Ventilator Must I Respond If My Health Is at Risk, Ken Iserson Triage in Medicine, Part II-Underlying Values and Principles, John Moskop and Ken Iserson Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Dignity Health COVID-19 Library Portal features current CME opportunities related to COVID-19

We hear many stories these days about immigration. Certainly, healthcare workers see undocumented individuals in Emergency Rooms or clinics. What is that experience like of being undocumented and needing healthcare? What would be helpful for clinicians to know? Does healthcare ethics have something to say on this topic? Today we hear from two healthcare leaders on these issues. One, who was an undocumented person and who later became a physician in the United States, and the other is the healthcare leader who supported her journey. Our guests in this episode include: Mark G. Kuczewski, PhD, is the Fr. Michael I. English, S.J., Professor of Medical Ethics and also Director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University, Chicago Dr Johana Mejias-Beck, internal medicine pediatrics specialist, currently at the University of Missouri, Kansas…and one of the first undocumented students to attend the first medical school in the country to accept applicants with DACA status. Additional resources relating to or referenced in this episode: Limbo Really Exists: Undocumented Youth at Risk, Mark Kuczewski, Johana Mejias-Beck, Amy Blair, and Matthew Fitz Treating Fear: Sanctuary Doctoring, Loyola University Chicago - Neiswanger Institute  Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Kuczewski, M. G., Mejias-Beck, J., & Blair, A. (2019). Good sanctuary doctoring for undocumented patients. AMA journal of ethics, 21(1), 78-85. Kuczewski, M., Blair, A., Fitz, M., & Mejias-Beck, J. Limbo Really Exists: Undocumented Youth at Risk July-August 2019. Kuczewski, M. (2019). Clinical ethicists awakened: Addressing two generations of clinical ethics issues involving undocumented patients. The American Journal of Bioethics, 19(4), 51-57. Samra, S., Taira, B. R., Pinheiro, E., Trotzky-Sirr, R., & Schneberk, T. (2019). Undocumented Patients in the Emergency Department: Challenges and Opportunities. Western Journal of Emergency Medicine, 20(5), 791. Ellis, P., & Dugdale, L. S. (2019). How should clinicians respond when different standards of care are applied to undocumented patients?. AMA journal of ethics, 21(1), 26-31

Health disparities and health outcomes for African Americans, is egregious… Regarding pain medication, a 2019 published article offered that the pain of African Americans is systematically under-diagnosed and under-treated Our guests today will offer stories and discuss insights on end of life care in the African American community. Our guests in this episode include: Patrick Smith, professor at the Duke Divinity School and associate faculty with the Trent Center for Bioethics, Humanities, and History of Medicine at Duke University School of Medicine. Dr Farr Curlin, Josiah C. Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities and History of Medicine, and Co-Director of the Theology Medicine, and Culture Initiative at Duke Divinity School. Claretta Dupree, Chair of the Academy of Fellows at the Center for Bioethics and Human Dignity at Trinity International University, Deerfield, Illinois. Additional resources relating to or referenced in this episode: Center for Practical Bioethics, Richard Payne, MD Palliative Care in the African American Community Perceptual Contributions to Racial Bias in Pain Recognition Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Boucher, N. A., Raghavan, M., Smith, A., Arnold, R., & Johnson, K. S. (2016). Palliative care in the African American community# 204. Journal of palliative medicine, 19(2), 228-230. Elk, R., Johnson, K., Reaves, A., White-Hammond, G., Williams, S., & Vaughan, L. (2019). “God Is Able”: Miracles and Hope in Our African-American Patients: Challenges, Historical Perspective and the Way Forward (FR459). Journal of Pain and Symptom Management, 57(2), 427-428. Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301. Johnson, J., Hayden, T., True, J., Simkin, D., Colbert, L., Thompson, B., ... & Martin, L. (2016). The impact of faith beliefs on perceptions of end-of-life care and decision making among African American church members. Journal of palliative medicine, 19(2), 143-148. Rhodes, R. L., Ukoha, N. C., Williams, K. A., Elwood, B., Knox-Rice, T., Lee, S. C., ... & Halm, E. A. (2019). Understanding underuse of advance care planning among a cohort of African American patients with advanced cancer: formative research that examines gaps in intent to discuss options for care. American Journal of Hospice and Palliative Medicine®, 36(12), 1057-1062.

New research findings regarding HIV status will impact how we understand and practice disclosure of HIV status of patients... specifically whether or not to disclose a sick patients’ HIV serostatus to their family or partner. The new research demonstrates that when an HIV-positive person sticks to their treatment, their HIV is undetectable and untransmittable (U=U). Our three guests are working together on bioethical projects to spread the awareness of U=U. Our guests in this episode include: Jamie Crist, JD, MA a Clinical Ethics Fellow at the Baylor College of Medicine, Houston Texas and doing clinical ethics consultation at Houston Methodist Hospital. Jamie has a JD and Masters in Bioethics at Case Western University. Nicole Meredyth, MD, is a clinical ethics fellow at Weil Cornell Medicine in New York Presbyterian Hospital. She is also completing her surgical residency at Weil Cornell University. Nekee Pandya, MD; is a clinical ethics fellow at Weil Cornell Hospital and also a hospitalist at that hospital. Additional resources relating to or referenced in this episode: HIV Law and Policy CDC HIV Treatment as Prevention HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Eisinger, R. W., Dieffenbach, C. W., & Fauci, A. S. (2019). HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. Jama, 321(5), 451-452 Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505. Ngure, K., Ongolly, F., Dolla, A., Awour, M., Mugwanya, K. K., Irungu, E., ... & Wamoni, E. (2020). “I just believe there is a risk” understanding of undetectable equals untransmissible (U= U) among health providers and HIV‐negative partners in serodiscordant relationships in Kenya. Journal of the International AIDS Society, 23(3), e25466. Calabrese, S. K., & Mayer, K. H. (2019). Providers should discuss U= U with all patients living with HIV. The Lancet HIV, 6(4), e211-e213. Tobin, S. C. (2019). U= U gains strength with release of PARTNER2 data. Aids, 33(3), N1.

Consider someone leaving a hospital, after their care is completed at that location, to return to their home and local community. As discharge plans are made to continue their care, their healing, their rehabilitation, are there ethical challenges that arise? Can there be biases that shape that plan because of their ability, disability, lack of family support systems or resources available in the community? What are the frameworks, tools, approaches that an assist all involved? Our guests will offer their experience in these discharge plan dilemmas and offer the practical approaches they have utilized every day. Joining us in conversation in this episode are: Debjani Mukherjee, trained as clinical psychologist and clinical ethicist, is Director of the Donnelley Ethics Program at the Shirley Ryan Ability Lab, Associate Professor of Physical Medicine and Rehabilitation and Medical Education at Northwestern University, Feinberg School of Medicine. Preya Tarsney, trained as a lawyer Bioethicist - Donnelley Ethics Program at the Shirley Ryan Ability Lab and a Lecturer of Physical Medicine & Rehabilitation at Northwestern University Feinberg School of Medicine and faculty lecturer at the University of Chicago, MacLean Center for Clinical Medical Ethics. Kristi L. Kirschner MD is a physician in physical medicine and rehabilitation and has practiced in this area for 30 years. She also has a background in clinical ethics and physical disability ethics and a faculty member of the university of Illinois College of Medicine where she directs the sub-theme of Humanities in Ethics for the College of Medicine. Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Beware of Discharge: A Case Exploring the Ethics of Societal Expectations Placed on Families at Hospital Discharge Castro, A. R., & Tsimicalis, A. (2020). Beware of Discharge: A Case Exploring the Ethics of Societal Expectations Placed on Families at Hospital Discharge. Home Healthcare Now, 38(2), 98-104. Evaluation of an integrated model of discharge planning: achieving quality discharges in an efficient and ethical way Wells, D. L., LeClerc, C. M., Craig, D., Martin, D. K., & Marshall, V. W. (2016). Evaluation of an integrated model of discharge planning: achieving quality discharges in an efficient and ethical way. Canadian Journal of Nursing Research Archive, 34(3). Rehabilitation as “destination triage”: a critical examination of discharge planning Durocher, E., Gibson, B. E., & Rappolt, S. (2017). Rehabilitation as “destination triage”: a critical examination of discharge planning. Disability and rehabilitation, 39(13), 1271-1278. Thinking about the patient's wishes: practical wisdom of discharge planning nurses in assisting surrogate decision‐making Kageyama, Y., & Asano, M. (2017). Thinking about the patient's wishes: practical wisdom of discharge planning nurses in assisting surrogate decision‐making. Scandinavian journal of caring sciences, 31(4), 796-804. Schlairet, Maura C. "Complex hospital discharges: Justice considered." HEC forum. Vol. 26. No. 1., 2014.

Brain death is a fundamental ethical topic that is complex and often fraught with emotion. As ethics committees are faced with considerations involving brain death, these cases are often those that stick with professionals the most. Our lead contributor in this episode Becket Gremmels, System Director of Ethics at CHRISTUS Health in Irving TX is in conversation with two nationally recognized ethicists who explore the complexities and challenges surrounding this foundational ethical concept. Our guests in this episode include: Dr. Alexander M. Capron, University Professor, Vice Dean for Faculty and Academic Affairs, Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Professor of Law and Medicine, Keck School of Medicine, Co-Director, Pacific Center for Health Policy and Ethics at the University of Southern California Dr. Michael Rubin, neurointensivist and clinical ethicist in the department of neurology and neurotherapeutics in the Peter O'Donnell Jr. Brain Institute at the UT Southwestern Medical Center Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Capron, Alexander M. "Beecher Dépassé: Fifty Years of Determining Death, Legally." Hastings Center Report 48 (2018): S14-S18 Russell, J. A., Epstein, L. G., Greer, D. M., Kirschen, M., Rubin, M. A., & Lewis, A. (2019). Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement. Neurology, 92(5), 228-232 Greer, D. M., Wang, H. H., Robinson, J. D., Varelas, P. N., Henderson, G. V., & Wijdicks, E. F. (2016). Variability of brain death policies in the United States. JAMA neurology, 73(2), 213-218 Kumar, L. (2016). Brain death and care of the organ donor. Journal of anaesthesiology, clinical pharmacology, 32(2), 146 Lewis, A., Bernat, J. L., Blosser, S., Bonnie, R. J., Epstein, L. G., Hutchins, J., ... & Wijdicks, E. F. (2018). An interdisciplinary response to contemporary concerns about brain death determination. Neurology, 90(9), 423-426

Why would the question of whether to provide food and water to a patient come up at all? One might assume it is always helpful and never harmful to offer nutrition and hydration to patients. Is that accurate? When might it be appropriate or not appropriate? Our lead contributor in this episode is Alan Sanders, Vice President of Ethics Integration and Strategy at Trinity Health is in conversation with guests in this episode to explore a number of ethical issues related to providing nutrition and hydration to patients who cannot feed themselves. Our guests in this episode include: Dr. George J. Giokas M.D., Director of Palliative Care, Palliative Care Partners, Inpatient Palliative Care Consult Service, Ellis Hospital Fr. John J. Raphael, SSJ, Catholic Chaplain and Staff Chaplain at Saint Thomas West Hospital in Nashville, TN

Goals of care is a term so common to health care professionals and yet, our guests describe significant clinical experiences in which the lack of discussion around goals of care led to problematic cases. A goals of care conversation is an important element at the foundation of high quality discussions around code status. In this episode lead contributor Mark Repenshek, Executive Director of Ethics and Mission at Hospital Sisters Health System in Wisconsin, is in conversation with national experts and clinicians who discuss this important topic. Our guests in this episode are: Dr. Kenneth A. Berkowitz, MD FCCP Chief, Ethics Consultation at VHA National Center for Ethics in Health Care, Associate Professor of Medicine and Population Health at NYU School of Medicine Dr. Tim Jessick, DO, Chair/Co-Founder Palliative Care Network of Wisconsin Palliative Medicine Physician, AdvocateAuroraHealth Dr. Jill S. Lowery, Psy.D., Chief, Ethics Policy, National Center for Ethics in Health Care at Veterans Health Administration Dr. James A. Tulsky, MD, Chair, Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute, Chief, Division of Palliative Medicine at Brigham and Women’s Hospital, Professor of Medicine at Harvard Medical School Helpful Goals of Care Resources: VHA National Center for Ethics in Health Care - The Life-Sustaining Treatment Decisions Initiative

Informed consent is one of the foundational ethical principles in health care that supports patient autonomy, or stated differently, the patients right to self-determination. More and more the standard for what clinicians should inform patients about the risks benefits and alternatives of treatment are no longer determined by what a responsible body of physicians deems important, but rather by what a reasonable patient deems important. What is needed to meet that goal is a collaborative communication process between clinicians and patients that integrates the best evidence available with the patients values and preferences to promote high quality health care decisions. In the United States at least half of the states have adopted the reasonable patient standard regarding informed consent. This episode of EthicsLab Essentials is led by lead contributor Rachelle Barina, VP - Mission Integration at SSM Health based in Wisconsin and is in conversation with two nationally known guests: Dr. Jenny Heyl, Director of Ethics at Mercy Hospital in St. Louis Dr. Kayhan Parsi, Professor of Bioethics at the Neiswanger Institute for Bioethics: Loyola University Chicago

The big picture is that 115,000 men, women and children await organ transplants in the United States. Even the largest football stadium in the US could not fit the number of patients on the national transplant waiting list. In 2016, 33,600 transplants brought new life to patients and their families. Since 1988, 683,000 transplants have taken place in this country. In this episode, our lead contributor Becket Gremmels, speaks to a transplant surgeon, an ICU doctor and a health care ethicist about some of the foundational ethical approaches that honor organ donors, the patients who receive those organs, and the health care professionals who care for both. Our guests in this episode include: Dr. Carol Bayley, past Vice President for Ethics and Justice Education at Dignity Health, San Francisco Dr. Anji Wall, Abdominal Transplant Surgeon at Baylor Medical Center, Dallas Dr. Wes Ely, Intensivist at Vanderbilt University Medical Center and Nashville VA Hospital, Nashville

As patients, surrogate decision makers, and clinicians discuss goals of care, questions arise regarding what interventions will physiologically work and what interventions will honor the patient’s values. Do Not Resuscitate Orders are one of the interventions frequently discussed. Our lead contributor on this episode, Mark Repenshek, Executive Director for Ethics & Mission at Hospital Sisters Health System, in Wisconsin is in conversation with guests to explore a number of ethical issues related to Do Not Resuscitate orders that include, but are not limited to: a) Patient/Surrogate desires for full resuscitation despite the intervention’s lack of efficacy in specific clinical circumstances, b) Consideration of partial codes as a “compromise” co-status, c) A physicians’ professional right to limit the use of resuscitation efforts in certain circumstances. The episode also introduces a new series within the EthicsLab Podcast called EthicsLab Essentials. This new series is designed to be an introductory series of modules to enrich ethics committee members. Our guests in this episode are: Dr. Jacqueline K. Yuen, MD, geriatrician, palliative care physician and medical educator. Dr. Yuen is now Assistant Clinical Professor, Department of Medicine at the University of Hong Kong Dr. Michael Ruben, M.D., M.A., neurointensivist and clinical ethicist Dr. Gregory Holt, M.D., Ph.D., pulmonary critical care physician at the University of Miami and VA Medical Center in Miami

Have you ever experienced an event, a situation or a decision where you felt that your professional integrity had been compromised? It may have occurred because of something you did, something someone else did or simply a number of events that lined up in a way that made you feel that you were between a rock and hard place. In that moment you probably experienced moral distress. In this episode, we look at moral distress in the health care environment. What are the clinical situations that cause moral distress to arise, what can be done to respond, can it be cured or is it a part of our moral life? Our guests in this episode are: Dr. Cynda Rushton, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University Dr. M. Sara Rosenthal, Ph.D., Professor and Founding Director, Program for Bioethics, Departments of Internal Medicine, Pediatrics and Behavioral Science Chair, Hospital Ethics Committee, University of Kentucky and co-creator of the Moral Distress Education Project Dr. Beth Lown, Chief Medical Officer of the Schwartz Center for Compassionate Healthcare Resources referenced in this episode: The Schwartz Center The Moral Distress Education Project The Boston Globe Magazine - Article by Ken Schwartz Facilitated Ethics Conversations: A Novel Program for Managing Moral Distress in Bedside Nursing Staff A Health System-wide Moral Distress Consultation Service: Development and Evaluation Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals

One of the challenging areas in clinical practice today is wanting to honor patient wishes but not being clear on the competency or capacity level a patient with dementia or behavioral health issues. In this episode we explore different challenging situations that ask: a) What is the best assessment of capacity? b) What level of risk should be supported? c) How might health care professionals approach these situations at a deeper human level? Our guests, who are national experts in this area and will offer insight and practical consideration and approaches to the questions list above and others. Our guests in this episode include: Sherri Boggs, Quality, Patient Safety & Education Manager, Our Lady of Peace Hospital Dr. Stephen Post, international speaker, best selling author and the Director for the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University Dr. Paul S. Appelbaum, New York State Psychiatric Institute and Columbia University Department of Psychiatry Dr. Ali Abbas Asghar-Ali, Michael E. DeBakey VA Medical Center Sessions are monitored on a monthly basis by CME office and content confirmed to be evidence based and without bias. Secondly, the CME Program Director and CME Coordinator reviewed and approved all material prior to the educational activity being approved to confirm that the educational activity was evidenced based. Peer reviewed journals and other literature are used, as applicable during discussions. References for Further Study: Kontos, N., Freudenreich, O., & Querques, J. (2013). Beyond capacity: identifying ethical dilemmas underlying capacity evaluation requests. Psychosomatics, 54(2), 103-110 Calcedo-Barba, A., Fructuoso, A., Raga, J. M., Paz, S., MSd, C., & Pons, E. V. (2020). Evidence on the capacity of severe mental disorder patients to make well-founded decisions about their healthcare: a meta-review (Doctoral dissertation, Universidad Anáhuac, México) Kelly, B. D. (2017). The Assisted Decision-Making (Capacity) Act 2015: what it is and why it matters. Irish Journal of Medical Science (1971-), 186(2), 351-356 Ganzini, Linda, Ladislav Volicer, William A. Nelson, Ellen Fox, and Arthur R. Derse. "Ten myths about decision-making capacity." Journal of the American Medical Directors Association 6, no. 3 (2005): S100-S104 Finch, J. (2019). Assessing mental capacity and making decisions. British Journal of Neuroscience Nursing, 15(4), 187-189

Health care professionals, patients and family members could all agree that patient wishes about their care are important and need to be respected. Why then, nationally, do only 30 percent of adults have an advance directive that documents those wishes? Given that statistic, how could the town of La Crosse, Wisconsin, achieve the surprising goal that 96% of people who die there have an advance directive or similar documentation…such a difference from the national average? Some wonder how to begin such a conversation while others ask what the best systems to put in place are? Yes, there are better tools, practices and systems that can help us. Our guests in this episode include: Bernard “Bud” Hammes, PhD, Executive Director, Respecting Choices, A Division of C-TAC Innovations David Bailey, Physician ENT and Chief Medical Officer for Memorial Health in Lufkin, TX. Kate (O’Rourke) DeBartolo, National Field Director, Institute for Healthcare Improvement at The Conversation Project Suzanne Engelder, MSW, ASW, The Center for Advance Care Planning and Advocacy

Are there better ways to build and support a culture of clinical ethics in healthcare? What might that look like? What has worked and how could the ideas and tools offered be implemented? In the late 1990’s the idea was proposed, why not marry the work being done in health care ethics with quality improvement methodology. Would this type of “Thinking Differently” help us get traction and improve the systems and initiatives that clinical ethics tries to accomplish? These are some of the questions and issues that our guests will wrestle with as well as offering concrete examples and even practical solutions being tested today. Our guests in this episode include: Mark Repenshek, Sr. Director of Ethics, Ascension Health Bob Strickland, Sr. Vice President Performance Management, Catholic Health Initiatives Bob Scheri, Vice President Mission Integration, CHI Memorial