Success Story of Complex Cases Committees

Bioethics for the People

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

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32:12

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