Ethical Deliberation at Alegent Health

[1] Alegent Health is a large multi-site, faith-based, non-profit healthcare system in the Omaha, Nebraska, greater metropolitan area. Alegent Health is co-sponsored by two church-affiliated systems: one Catholic and one ELCA. Faithful to the healing ministry of Jesus Christ, and guided by the social teachings of our sponsors, we are called to servant leadership that demonstrates a commitment to holistic, collaborative health care within our communities. At Alegent Health, we understand that commitment to fall within a framework of Theological Foundations and Values that are reflected in our Mission Statement. These markers of our identity and purpose shape us as we strive to address the numerous challenges that face health care today.

[2] To assure that our Mission is fulfilled as we address these challenges, we have developed systems to support ethical deliberation and decision-making. One such system is our ethics team structure, which includes our system-wide Ethics Council with oversight of our various single-hospital based Ethics Committees and our continuum of care-focused Ethics Committees (such as our Home Care, Behavioral Health and Improving End-of-Life Care Committee). This structure is organized through our Ethics Center in partnership with the office of Mission Integration Leadership. Through this team structure topics of emerging concern within the health care arena are discussed as they relate to Alegent Health and those we serve, and opportunities for ethical deliberation, education, and policy and practice improvement are identified.

[3] At its foundation, this system of ethical deliberation and decision-making is rooted within the principle of health as a shared endeavor between providers, individuals, social networks and society. As it says in the ELCA’s Social Statement on health care, “Just as each person’s health relies on others, health care depends on our caring for others and ourselves.” As a shared endeavor, the system of teams engaging in ethical deliberation within our organization and within the communities we serve, allows us to collaborate both internally and externally as we address such challenges as access to limited healthcare resources, care for the poor and disadvantaged, and emergency response and preparedness.

[4] As a starting point, we approach ethical deliberation with a spirit of discernment. This spirit of discernment calls us to enter into dialogue with a readiness to engage with others, an openness to hear ideas that may be new or different than our own, and a willingness to learn, understand and be surprised by what we find through the process of ethical deliberation. Dialogue within this approach of ethical deliberation is facilitated using a framework that includes an exploration of the situation as it relates to the social teachings of our sponsors, the Alegent Health Mission and such principles as self-determination (or respect for autonomy), justice, stewardship, and health & finitude. We use a tool called the “Arenas of Inquiry” as part of our deliberation and decision-making journey to help us structure our analysis of options through a discernment process that centers on faithfulness to our mission, engagement with our stakeholders and commitment to our identity and vision. See Arenas of inquiry for Mission-Based Decision Making. By using this framework for our dialogue, Alegent Health leaders, providers, ethics team members and key stakeholders are better able to identify, explore and understand the tensions inherent within the situation, and are better prepared to address emerging concerns related to the health and well-being of our community.

[5] One example of this model for ethical deliberation, discernment and decision-making in action has been in response to the recent outbreak of the H1N1 flu virus in our communities. In preparation for this particular emerging issue, the Alegent Health Ethics Council began a process of ethical deliberation nearly two years ago in collaboration with key organizational and community stakeholders. Using the learnings from other communities who had faced similar outbreaks, and building on the frameworks developed by colleagues from throughout the country, Alegent Health ethics team members and others began a dialogue about the competing tensions inherent within a pandemic situation. Teams at various levels within the Alegent Health ethics structure discussed such things as:

the competing obligations of providers and caregivers as they balance their professional duty to provide care and their personal duty to meet family needs and other responsibilities;
For example, when the home care Ethics Committee reflected on past experiences with the delivery of home care services under severe weather conditions, they recognized both unexpected capacities for team collaboration and previously unidentified challenges such as limited communication capabilities during power outages. They saw that their nurses and other professional staff had a wide variety of personal obligations (for example, some had small children who may be at home without supervision in the event of school closings, while others had aging parents in need of support and care at some point following the emergency but may not have had immediate needs like young mothers); and they understood that for each nurse to do their very best to care for the needs of patients, they needed to feel confident that their personal obligations were met first. As a result, they developed a strategy for encouraging personal preparedness through the development of disaster plans and emergency preparedness campaigns for both patients and staff; and they worked out collaboration plans among staff for identifying case and shift triage opportunities that allowed teams to find a balance between case coverage and meeting personal obligations throughout the emergency response event.

the struggle to find a balance between respecting individual liberties and assuring the common good of the community as it relates to decisions regarding mandatory or voluntary vaccination and vaccination guidelines;
For example, when discussions arose about whether or not providers could opt out of receiving seasonal flu vaccines, group dialogue and discernment processes that involved key stakeholders and experts from across the organization and the community led to a recommendation to consider allowing for health care professionals to decline receiving the vaccine but require that they take additional infection control precautions (such as wearing surgical masks in all patient care areas throughout the flu season) to assure the safety of those for whom they were providing care. While this approach honored the individual’s personal decision related to vaccination, it offered an extra level of protection for staff and patients alike in cases where the care providers were not vaccinated.
the effort to assure that care is provided in patient- and family-centered care environments while limiting visitor access within healthcare facilities in order to minimize exposure;
For example, as the number of H1N1 flu cases increased in our communities, the response team determined that visitor guidelines would become much stricter than they usually are. This meant that patient care areas that were usually open to any visitors (adults and children) at any time, would now have limited access in order to protect the patients, the visitors and the community as a whole. Communication related to this was offered by signs in the lobbies of our hospitals that provided the new guidelines as well as information about why the guidelines were in place and who to contact for additional questions.
The responsibility to understand surge capacities in order to be both good stewards of limited resources and effective providers of health care services.
For example, as determinations were made about locations for H1N1 vaccines, the response team worked with population and community tracking mechanisms to identify pockets of outbreaks and locate vaccine clinics in those areas in order to maximize the availability of professional staff to meet the volume needs for vaccinations, and in order offer community members access to limited flu vaccines as effectively as possible. Continual communication via our intranet site and email alert system provided our staff with information about vaccine availability at various sites and for various levels of risk for exposure. Once immediate needs at higher risks were met, availability levels were adjusted to assure that vaccines were delivered in a way that maximized the use of limited resources.

[6] As the recent H1N1 outbreaks were developing in the communities served by Alegent Health, representatives from ethics teams were involved in numerous components of the response. Because the ethics team structures and the systems to support ethical discernment and decision-making processes were already in place, many members of the response teams had already been trained to engage in ethical deliberation. In some cases, such as the allocation of scarce resources and upholding the duty to care, teams had already participated in preliminary deliberation around a number of complex questions. In other cases, team members were able to engage with openness to consider additional ethical dimensions of the situation. Now – as the H1N1 outbreaks wind down we are preparing to use the framework of ethical deliberation and the guidance of our sponsors to better understand our recent response and better prepare our future response to outbreaks and pandemics as they emerge.

[7] As the above experiences illustrate, at Alegent Health we turn to our ethical deliberation structure when we are especially challenged as a health care provider to understand how we are called to love our neighbor while managing competing tensions. There are always opportunities to continue to grow in our abilities to serve on this ever-evolving journey, and we learn from each other as we continue on this shared endeavor to care for the health care needs of ourselves and of others.