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Hospitals that offer behavioral health services (substance abuse counseling, residential mental health, and outpatient counseling) may want to consider forming a separate subcommittee of their regular bioethics committee to examine specific organizational and clinical treatment issues.
Community Hospitals of Indianapolis Inc., a central Indiana integrated health network of four tertiary care hospitals, six immediate care centers, three nursing homes, and other specialty care centers, did just that after providers decided they needed a better framework for addressing ethical challenges unique to behavioral health care.
"Behavioral care is a far different kind of care than medical-surgical types of care," says Mel Schroeder, director of pastoral care for Community Hospitals, and a member of both the network’s organizational ethics committee and the new behavioral health ethics committee. "Behavioral care involves complicated relationships with payers, deciding who defines coverage, how the level of payment is determined, for example, what regulatory bodies are involved, and how government agencies get involved. It is a lot more complex, and there tends to be a lot more issues than simple ethical biomedical issues."
In behavioral health, you have issues of competence, of consent for treatment, and even treatment benefit, that are much more complex than what occurrence in medical-surgical sites of care, says Paul Stewart, MD, PhD, medical director of the network’s behavioral care services. "A patient’s competence for making treatment decisions often is in question," he notes. "Some-times you have family wishes that are opposed to patient wishes and maybe aren’t serving the patient well, whether they are conscious of it or not, are really based on family inconvenience or family pressures."
After attending a conference on managed care and ethics, she decided to find out how ethical conflicts in behavior health were resolved in her service area, says Sue Main, quality resources coordinator for behavioral care services at Community Hospitals. "I began to look at what we did when managing ethical questions that arose," she recalls. "I found some gaps. Typically, a staff person would just talk to another staff person about ethical questions; sometimes they’d go to their manager."
The providers of behavioral health at the hospitals wanted to establish a procedure that ensured that the treatment decisions made reflected the appropriate clinical and ethical values and that their decision-making process was examined and scrutinized, says Jon Hendrix, EdD, a private bioethics consultant who advises the hospital system and helped establish the committee.
The committee spent about a year in preparation before "opening its doors" for ethical consultation. During that period, they chose members of the committee, and went through a process of education and development of ethical guidelines and priorities that would govern their services. "We looked at things such as what is coercive or what is voluntary in treatment," Hendrix adds. "Sometimes, we have to institutionalize people because they are mentally ill; that is often very coercive and not very voluntary."
The committee also reflected on a set of basic principles that should guide the delivery of their services, he says. "They decided, for example, that methods that support self-respect should be encouraged; methods that are not destructive of individuals’ ability to reflect rationally should be used whenever possible; and methods which rely upon deception or which affect the personal identity of individuals should not be used," he says. "Methods of influence which are physically nonintrusive are to be preferred over methods that are intrusive."
The process is not as simple as it may sound, given the number of different therapies and treatment modalities that have been open to providers of mental health services and disagreements between some experts over what treatments are appropriate or inappropriate, Hendrix emphasizes. "The history of behavioral treatments has really been wrought with some wild things," he continues. "[including] shock therapy, chemical therapy, and behavior modification treatments."
Community Hospitals has three separate bioethics committees, one at each of the three tertiary care facilities and an overall organizational ethics committee at the network level. The behavioral care ethics committee exists as a subcommittee of the organizational ethics committee, says Stewart.
"It’s important to note that the bioethics committees at the hospitals are subcommittees of the medial staff at each of the hospitals," he says. "We are not just comprised of members of the medical staff, but have members who are from administration, quality resources, human resources, legal, the chaplain, as well as the clinical staff, psychiatrists, psychologists, and therapists who are on the front line."
The network provides a variety of behavioral health services, says Stewart. "We offer chemical dependency treatment as well as treatment for the emotionally ill. We have partial hospitalization programs, day and evening programs, and partial residential for both children and adults. We also own a traditional community mental health center. And, we have a special inpatient unit for the chronically mentally ill who need short-term stabilization."
It is important that the committee have representation from all of those levels of care as well as the representation from managers and administrative staff, he says, because the committee considers not only matters of clinical treatment, but other issues as well. "One of the first issues that we took to the organizational ethics committee was the issue of confidentiality of mental health services for employees," adds Schroeder. The committee uses a consequentialist model of bioethical decision making that takes into account not only how actions will reflect the organization’s values and priorities, but also the potential consequences of each course of action.
Although the behavioral ethics committee members originally would have preferred that hospital employees seek mental health services elsewhere, after considering the financial difficulties this posed to the system, which is self-funded, they developed other recommendations. "We ended up with some fairly substantial recommendations for the hospital to protect employees’ confidentiality, but in a way that was also fiscally sound and didn’t sink the hospital from the financial sense."
A current "hot-button" issue for the committee is the concept of futile care in behavioral care, says Schroeder. "This is a common bioethical issue in the medical-surgical arena. But, for mental health, that issue of futile care has not been addressed."
Their mental health providers are frequently asked to treat patients for whom they believe nothing more can be done to treat their illness, he adds. "We have admitting physicians saying to our crisis folks, Please, please, please do not readmit so-and-so; treatment is of no value in this case,’" says Stewart. Federal legislation, however, requires hospitals to admit and stabilize patients who pose a credible threat to themselves or others.
How to deal ethically with that situation and with patients who have a history of violence to other patients or staff, also is a problem they face. "How ethically do you deal with a patient who has a history of violence toward staff when he or she presents again for services?" asks Stewart. In a recent situation, a severely mentally ill man with a history of violence, who had been a frequent patient in the mental health inpatient stabilization unit, was readmitted to the unit and threw a computer monitor at a staff person, barely missing her. After he was stabilized, the man was discharged and then taken to jail by police to finish serving a sentence for a crime that occurred prior to admission.
Several discussions by the behavioral ethics committee resulted primarily in recommendations to increase education of staff members and security personnel in how to deal with these potential problems. "Surprisingly, our No. 1 choice was education: education of families, of patients, and staff; having enough well-trained staff, people who were sensitive to changes in patients who were prone to violence; and having security staff who were cross-trained to function as providers on the unit," says Stewart.
"We surprise ourselves. I think if you asked any committee member, going into the discussion, what they thought their No. 1 recommendation would be, they probably would have said something like having more security personnel — not that we needed to improve education."
For other hospitals considering a behavioral care ethics committee, Stewart and the other committee members recommend taking time to establish guiding principles and learning about processes of ethical decision making. "Don’t do any quick-fix setup; make sure you take the time to train, read, and do some education," he says. "And, get the right people on the committee."
It would also be helpful for other committees specializing in behavioral health ethics to network and share information, says Main. Most such committees are located at facilities that are primarily mental health providers. There are few tertiary care facilities that have taken this step, she believes. "It would be nice for us to have some contact with them and share ideas so we would not feel so isolated."
• Mel Schroeder, Paul Stewart, and Sue Main, Community Hospitals of Indianapolis, Community Hospital North, 7250 Clearvista Parkway, Indianapolis, IN 46256.
• Jon Hendrix, 107 Glasgow Drive, Edinburgh, IN 46124.