~- u ETHICS NETWORK Board Members: Denis Barton Judy Cohen, PI10R~ Linda Cohen, ESQ Betsy Davis, RN ;-'IPI r Christine Graham Marilyn Hart, \CD James P. Leddy, \15\\ Robert Macauley, \ID Patrick "\IcCo~, REY J udy Peterson, R - ES, Cathy Suskin, ESQ Kevin Veller Honorary Board Members: James Bernat, \10 i\Iichelle Champoux Arnold Golodetz, \fl) Jean Mallary Marge Trautz Staff: Cindy Bruzzese, MP.\ Lindy Hatcher, \[5 \ Inside this issue: Director's i lessage 2 Health Care Ethics 2 Health Care Ethics 3 Meet the Board 4 Meet the Board 5 Order I akin!, ~teps 5 Register Your AD 5 Upcoming events 6 Health Decisions A publication of the Vermont Ethics Network Working to increase awareness and understanding of ethical issues in health care Volume 16, Issue 1 Fall 2009 Handbook for Rural Health Care Ethics: A Practical Guide for Professionals Health care delivered 10 a rural context-in closely-knit, tightly inter- dependent, small community settings-poses unique ethics consid- erations for clinical practitioners. A provider in a resource-poor rural set- ting may be faced with treating a family member, friend, business associate or neighbor, since the role separation between clinician and patient that predominates in the urban setting is less likely to occur in a small town. It is difficult for a provider to protect patients' privacy when their care occurs in clinics where neighbors, friends, and relatives may work. Similarly, it is difficult to establish a professional clinician-patient relationship when the patient is the doctor's former grade school teacher, or a member of the nurse's local parish. Ethical aspects of care are especially relevant and sensi- tive when the patient's health problem is stigmatizing, such as mental illnesses or infectious diseases. Because of the unique rural context, the solutions that health care providers develop to resolve complex ethics dilemmas may differ from solutions derived in urban areas. NEW Resource for Rural Ethics The Handbook For &tral Healt/) Care Ethics is designed to fulfill that purpose, and contains a case-based approach to analyzing, solving and anticipating health care ethics dilem- mas. The Handbook, edited by William A. elson, is authored by physicians, nurses, ethicists, and hospital adminis- trators who all have scholarship or experience in rural ethics, and was funded by a grant from the National Institutes of Health (NIH) ational Library of Medicine. To access the contents of the handbook, go to: http://dms.dartmouth.ed 1.1 /cfm/ resources / ethics!' HANDB~ R u ra I Health Care Ethics A PIIACTlCAI. GUIDE fOIl PRonSSIOHALS
Health DecisionsA publication of the Vermont Ethics Network
Working to increase awareness and understanding of ethical issues in health care
Volume 16, Issue 1 Fall 2009
Handbook for Rural HealthCare Ethics: A PracticalGuide for ProfessionalsHealth care delivered 10 a ruralcontext-in closely-knit, tightly inter-dependent, small communitysettings-poses unique ethics consid-erations for clinical practitioners. Aprovider in a resource-poor rural set-ting may be faced with treating a familymember, friend, business associate orneighbor, since the role separationbetween clinician and patient thatpredominates in the urban setting isless likely to occur in a small town. It isdifficult for a provider to protectpatients' privacy when their care occursin clinics where neighbors, friends,and relatives may work. Similarly, it isdifficult to establish a professionalclinician-patient relationship when thepatient is the doctor's former gradeschool teacher, or a member of thenurse's local parish. Ethical aspects ofcare are especially relevant and sensi-tive when the patient's health problemis stigmatizing, such as mental illnessesor infectious diseases. Because of theunique rural context, the solutions thathealth care providers develop toresolve complex ethics dilemmas maydiffer from solutions derived in urbanareas.
NEW Resource for Rural EthicsThe Handbook For &tral Healt/) CareEthics is designed to fulfill thatpurpose, and contains a case-basedapproach to analyzing, solving andanticipating health care ethics dilem-mas. The Handbook, edited by WilliamA. elson, is authored by physicians,nurses, ethicists, and hospital adminis-trators who all have scholarship orexperience in rural ethics, and wasfunded by a grant from the NationalInstitutes of Health (NIH) ationalLibrary of Medicine. To access thecontents of the handbook, go to:http://dms.dartmouth.ed 1.1 /cfm/resources / ethics!'
HANDB~ R u ra IHealth Care
Ethics
A PIIACTlCAI. GUIDE fOIl PRonSSIOHALS
Message from the Executive DirectorIt has been a busy start to the fiscal year forVermont Ethics etwork. In July, we moved theoffice to its new location on 61 Elm Street inMontpelier. August was met with the arrival ofLindy Hatcher - our new Manager of Operations,and in September we welcomed four newmembers to our Board of Directors. Thesechanges are all part of the organizations' longrange plan to increase effectiveness and visibility asethical issues surrounding quality care, societalvalues, individual goals and preferences, and stew-ardship of health care resources become focalpoints of ongoing health care discussions.
From a programmatic standpoint, VE willbecome more engaged in supporting the work ofhospital ethics committees. To better understandthe issues as they play out in rural settings, werecently met to conduct a needs assessment ofrural facilities in an effort to enhance the role ofethics committees across the state. A summary ofthat meeting and recommendations for movingforward will be the basis for ongoing and futurework of the organization.
The new palliative care and pain managementlegislation (Act 25) precipitated another new areaof focus for Vermont Ethics etwork this year.Network planning and development as it relates topalliative care and pain management servicesacross the state were seen as ongoing needs to beaddressed. To initiate this work, VE distributeda short questionnaire to providers asking for infor-mation related to current structure, gaps, and
recommendations for improvement. ursJOghomes, residential care facilities, assisted livingfacilities and insurance companies were alsoqueried. Responses are being compiled and theinformation will be used as part of our report tothe legislature in January. This information willserve as background data for a statewide meetingin larch. VE will sponsor a gathering ofprofessionals and other stakeholders who have aninterest in shaping systemic improvements topalliative care and pain management servicesacross the state. The goals of this meeting will beto briefly review the current understanding ofhow these services are being accessed anddelivered; to prioritize common themes thatemerge relative to gaps and recommendations;and finally to map out a statewide plan forimproving palliative care and pain managementfor alJVermonters.
Our work plan is lofty but we are grounded inour core rrussion. As you know, the VermontEthics etwork has been involved in health careethics for nearly 25 years. Our work dates back tothe time when medical ethics first moved out ofits traditional home among academics and physi-cians and into public discourse, and we have been"doing ethics" ever since. But what exactly does itmean to "do" health care ethics? Every so oftenit's good to pause and reflect upon what we doand why and how we do it. The following articlerepresents for some a "review," and for others, anintroduction into why this work is essential to thefuture of health care. Cindy Bruzzese, Director
Understanding Health Care Ethics: A ReviewMany providers work in settings where ethicalissues arise daily. Others are exposed to ethicsquite unexpectedly, as when abruptly faced with adifficult choice about their own or a loved one'scare. But what exactly is health care ethics? At itssimplest, health care ethics (a/kl a "medical" ethicsor "bioethics") is a set of moral principles, beliefsand values that guide us in making choices aboutmedical care. At the core of health care ethics isour sense of right and wrong and our beliefs about
rights we possess and duties we owe others.Thinking carefully about the ethical aspects ofhealth care decisions helps us make choices thatare right, good, fair and just.
Our ethical responsibilities in a given situationdepend in part on the nature of the decision andin part on the roles we play. For example, apatient and his or her family play different rolesand owe different ethical obligations to eachother than a patient and his or her physician.
The 4 PrinciplesIn the US, four main principles define the ethicalduties that health care professionals owe topatients. They are:
1) Respect the patient's decisions andvalues. Every adult patient of soundmind has the right to decide what is tobe done to his or her own body. Thisincludes the right to have the information needed to make an informed decision and an absolute right to refuse unwanted treatment. (Autonomy)
2) Do good. Help the patient advance hisor her own good. (Benificence)
3) Do no harm to a patient, eitherintentionally or indirectly. (Nonmalificence)
4) Be fair. Treat like cases alike and workfor fair distribution of medical benefitsand burdens among all people. Uustice)
All 4 duties are considered to be in effect at alltimes. In theory, each duty is of equal weight orimportance. In practice, however, at least in theUS, respect for patient autonomy (principle 1)often takes priority over the others.
Isn't This Just Common Sense?At first glance, the four principles may seem likethey are just "common sense." After all, it seemsobvious that a physician has an obligation tohelp his or her patients and to not harm them,ete. The problem is that sometimes the variousethical principles come into conflict with oneanother, creating an ethical dilemma. Forexample, a patient with terminal pancreaticcancer may be offered a round of chemotherapy,which the physician believes could add 3-6months to the patient's life. The patient, how-ever, wants to spend his final months goingfishing in Montana and saying goodbye to hisfriends and family. The physician's obligation torespect the patient's preference (autonomy) is inconflict with the obligation to try and help himmedically (beneficence). Therefore, a choiceneeds to be made, and choosing one means thatthe other may not be honored.
Growing ImportanceIssues related to choices in health care are ofgrowing importance in our lives. For centuries,when a patient sought a doctor's care, there waslittle for anyone to "decide." Medically, littlecould be done if you suffered a stroke orcontracted tetanus from stepping on a rusty nail.Now, however, advanced medical science andtechnology make it possible to extend life beyondnatural limits, sometimes far beyond. Increasinglyit is possible to extend life past the point thatmost people say they would want to live it. This isa profound change. Survival is no longer theissue; quality of life is. And this change cangreatly complicate medical decision-making. Thebasic question often is no longer "What can bedone?" but rather "What should be done?"Should invasive surgery be performed on aterminally ill patient who is near death whendoing so will only prolong the dying process?Does a patient have a right to care regardless ofexpense? When patients' needs exceed availablemedical resources, how should those resources bedistributed?
Everyone's ResponsibilityDiscussion of these questions is not just forhealth professionals. Moral choices in medicineare the responsibility of patients, families and thewider society as well. Some ethical decisions canbe made only by the patient. For example, onlythe patient, in consultation with a physician, candecide what quality of life is acceptable to him orher. Other decisions - like health care reform -can be made only by society as a whole, at thelevel of public policy. Part of our job as citizensis to inform ourselves about ethical issues inhealth care and to understand the ethical impli-cations of the care choices we make both asindividuals and as a society. Cathy Suskin, ESQ
We Want To Hear From You!Please share your thoughts and ideas for topicsto be included in future VEN newsletters.E-mail your ideas to: [email protected].
Meet the Newest YEN Board MembersDenis Barton is the Vermont Director of Public Policy for Bi-State Primary Care Association (Bi-State).Bi-State is a not-for-profit association that represents Community Health Centers and other safety-netproviders and is dedicated to expanding access to health care for all. Combined Bi-State membersprovide preventive and primary care services to over 146,000 patients at over 60 sites throughoutVermont.
Prior to joining Bi-State, Denis served as the Director of the Vermont Office of Rural Health and PrimaryCare within the Vermont Department of Health. He has served the State of Vermont in other manage-ment activities since joining state service in 1996. Immediately before moving to Vermont, Denis servedas Executive Director at the Rhode Island Psychological Association and the Rhode Island Pharmacist'sAssociation. He has served as an elected School Board member and as a Board Director for many non-profit organizations. He has a Master of Business Administration in Health Care Management from theBoston University Graduate School of Management.
Linda Cohen is a health care attorney at Dinse Knapp & McAndrew, advising clients on a variety ofregulatory, transactional and litigation matters. Ms. Cohen's practice concentrates on client counselingand litigation involving a wide range of provider reimbursement issues relating to commercial as well asgovernment payers. She has substantial experience in commercial contract negotiation and payment re-lated litigation for large health systems. Ms. Cohen has arbitrated, mediated and litigated several providerreimbursement disputes through conclusion and has appeared before the Provider Reimbursement Re-view Board.
Additionally, Ms. Cohen handles issues relating to Medicare fraud and abuse laws, Medicare reimburse-ment, compliance issues, federal Anti-Kickback law, physician contracting and state regulatory compli-ance. Immediately before joining the firm, Ms. Cohen served as the Director of External Appeals and as aregulatory compliance attorney for the Health Care Administration, a Division of Vermont's Departmentof Banking, Insurance, Securities and Health Care Administration. At BISHCA, Ms. Cohen was primarilyresponsible for enforcement of health insurance laws and regulations relating to insurers and managedcare organizations. She also ran the external appeals program which affords consumers an independentappeal of claims denied by commercial insurers.
Before relocating to Vermont, Ms. Cohen practiced in the health care and commercial litigation depart-ments of Cozen O'Connor in Philadelphia. While at Cozen O'Connor, Ms. Cohen participated in therepresentation of national health care systems in reimbursement disputes and a class action related tobilling practices. She also represented large and small providers in contract negotiations, fraud and abusematters and provided regulatory compliance advice. Ms. Cohen represented a variety of commercialclients in contract related disputes for a wide range of issues including title insurance, real estate leasing,non-competition agreements and anti-trust. Several of those actions included trials and arbitrations toconclusion. Ms. Cohen also participated in product liability defense of manufacturers of fire preventionand detection products.
Judy Peterson, RN BSN is President and CEO of Central Vermont Home Health and Hospice(CVHHH) in Barre, Vermont where she has worked for 26 years. The agency is a not-for-profit, full-service, Visiting Nurse Association offering a wide variety of community health services to the Residentsof Washington and Orange Counties.
Judy graduated from the University of Vermont with a Bachelor's degree in Nursing in 1973 and promptly
joined the Peace Corps where she served in Latin America for almost 3 years. Upon return to the U.S.,Judy began working at CYMC in Barre, VT but quickly returned to home and community based healthservices in a variety of Vermont locations and also Philadelphia, PA.
Over the years, Judy has aided in development of a wide range of new programming at CVHHH,including Hospice, Long Term Care, Traumatic Brain Injury, Private Duty services, and telehealth. Shehas participated on many community and state level boards and task groups including COVE, TBIAdvisory Council, Nursing Facilities for the 21st Century, DAIL's Long Term Care Sustainability Study,Woodridge Nursing Home, Project Independence, Association for Cerebral Palsy, and many others.Judy is currently a Trustee for the Central Vermont Medical Center and has recently become a boardmember for the Vermont Ethics Network.
Judy has appeared as a guest presenter at the American Society on Aging national conference inChicago, IL and Anaheim, CA, addressing issues related to providing high quality care to the frail elderlyand people with permanent disabilities. She has also served as a trainer for the Department of Agingand Independent Living's Case Management Program and Successful Aging Conferences.
Cathy Suskin is an attorney with longstanding personal and professional interest in hospice, end of lifecare and medical ethics. She has worked in both the public and private sectors, serving early on in hercareer as a civil rights investigator in the Vermont Attorney General's Office, a judicial clerk in VermontDistrict Court and an instructor in legal writing at Vermont Law School, and more recently as AssociateGeneral Counsel to the Vermont Environmental Board and in private practice. She also does freelancewriting and editing. Cathy has a graduate certificate in Bioethics from the Medical College of Wisconsinand sits on the Ethics Committee at Central Vermont Medical Center.
We are updating our website in order tofacilitate ordering our Taking Steps booklets.Soon, you will be able to order this helpfulresource to advance care planning and otherimportant information related to medicaldecision-making online at the VEN website:www.vtethicsnetwork.org.
• TALK to others about your values andfuture health care wishes.
• GO to www.vtethicsnetwork.org for theVermont Advance Directive Forms andfor comprehensive information aboutAdvance Care Planning and AdvanceDirectives.
• COMPLETE your Advance Directive.• REGISTER your Advance Directive
with the Vermont Advance DirectiveRegistry-an easy and secure way to giveyour health care providers immediateaccess to your wishes about health caredecisions.
Coming Soon - Order Taking Steps Online Health Care Planning is for Everyone!
For more information about the VermontEthics Network or to order our Taking StepsBooklet, contact us at 802.828.2909 or viae-rnail at [email protected].
,<.fuAin?Crkl)~
-. ,i~~Toincrease awareness and understanding of ethical issues, values, and choices in health and health care" ' .•• ~ •... ~":. ~--r. ~.•. ~"''i' •..-,." _' ~
Vermont Ethics Network61 Elm StreetMontpelier, VT 05602
March 22, 2010: Statewide Palliative Careand Pain Meeting at Gifford Hospital
VEN will sponsor a gathering of professionals and otherstakeholders who have an interest in shaping systemicimprovements to palliative care and pain managementservices across the state. Contact us for more informa-tion at [email protected].
April 16, 2010: National Health CareDecisions Day
The National Healthcare Decisions Day initiative is acollaborative effort of national, state, and communityorganizations committed to ensuring that all adultswith decision-making capacity in the United Stateshave the information and opportunity to communi-cate and document their health care decisions.
Monday, April 19, 2010: VTand NH Ethics Meeting atDHMC, Auditorium E
The 31st Meeting of the Vermontand New Hampshire Hospital EthicsCommittee Network. For moreinformation, please VISithttp/ /:ccehsl.dartmouth-hitchcock.org/ ftles/index.html.
Monday, October 4, 2010:VT and NH Ethics Meetingat DHMC, Auditorium E
The 32nd Meeting of the Vermontand New Hampshire Hospital EthicsCommittee Network. For moreinformation, please Visithttp/ /:ccehsl.dartmouth-hitchcock.org/ files/index.h tml,
Monday, November 1, 2010:Bioethics Training Day atDHMC, Auditoria E & F
For more information on theBioethics Training Day, visit theCenter for Continuing Education inthe Health Sciences website:http/ /:ccehsl.dartmouth-hitchcock.org/ flies/ index. html.
