Metaphorically speaking, Cathy Boutte has a way, as she puts it, of “catching on fire.”
One time it happened, she was about 30 years old, living in Los Angeles, working for an insurance company. The travel involved in the job wasn’t working out so she quit, moved back to her hometown of Shawnee, Kansas, went to work for Overland Park Regional Medical Center in the telemetry department, and graduated from the School of Nursing at Mid-America Nazarene University in 1992.
Cathy has an interest in bioethics dating back to her Benedictine College days majoring in philosophy. In 1997, she was working the ICU night shift when a colleague recommended that she apply for one of the open positions on the hospital’s Ethics Committee. She was accepted and has been “catching fire” on the committee for hospital improvements in quality and efficiency ever since.
In the early 2000s, Cathy and a few other committee members were concerned that the hospital didn’t have a palliative care team. “I got my hospice and palliative care certification, and we started a team.”
The next focus of Cathy’s passion was family presence during CPR. “I did research and presented a plan for family members to be in the room during Code Blues,” she said. “The case I’m most proud of was when I was able to get a son who was blind in the room with his guide dog.”
Named as co-chair of the Ethics Committee in 2009, she continues to serve in that position. In 2015, health issues led Cathy to her current role as a case manager. “We try to facilitate patients getting the right care on a timely basis, while making sure that all of their insurance requirements are met with no surprises.”
Education through Stories
“Nursing education is best done through stories,” said Cathy, “As a case manager I read patient stories every day and help figure out the best way to take care of them.”
Cathy presents a session on clinical ethics for newly hired nurses. Her key lesson is the concept of autonomy. “Nurses sometimes build up hostility about care for patients that they think isn’t going to help. ‘Don’t make me do compressions on this person!’ they say. ‘They’re frail! Their bones are going to break!’
“I teach that you can pass those issues up the line, but as nurses that can’t be our concern. The patient has the right to choose for themselves, and our job is to make it work the best we can for them.”
As for spare time, Cathy spends most of it working with her brother on what’s left of her grandfather’s original multi-acre vegetable farm. She calls it a “truck garden” because as a child, she remembers, “Every night we would pack up the produce on the truck. Grandpa would deliver orders down at the City Market between midnight and 1:00 a.m., and if there were leftovers, we would sell them out of the back of his truck.”
When you’re indecisive about whether to act, act!
You’re more likely to regret the things you don’t do than the things you do.
Having started her career as a paramedic in the Chicago Fire Department, by the time Lorraine Duncan finished medical school and completed her residency in Emergency Medicine in 2002, she had seen plenty of tragedy and encountered many moments of decision with no easily discernable right or wrong choice.
On staff since 2007 at Centerpoint Medical Center of Independence, a Level II Trauma Center, Lorraine is often the first physician to care for patients in critical condition who can no longer speak for themselves. Her experience of ten years on the hospital’s Ethics Committee and two years as its chair is evident in the skills she’s developed to communicate and connect with patients and families in the worst possible circumstances.
“What I’ve learned,” she said, “is that patients and families want to be heard and are starving for information. Often the family has been talking to the pulmonologist about lungs and the nephrologist about kidneys and the neurologist about the brain. I can sit with them and make a list of their loved one’s problems so they see what’s happening to them as a whole.
“What’s most important in these conversations is to go into them without expectations or preconceived ideas about what I want or what the doctors want. I’m there to listen and gather information.”
The one thing Lorraine never does is tell patients there’s nothing more she can do for them – and she cringes when patients tell her that’s what their doctor told them. “I explain that I have two buckets,” she said. “In the first bucket, I have many things that are going to be helpful, that will ease pain and impart dignity. In the other bucket are things that I’m not willing to offer because for sure they won’t help and may be harmful.”
HCA Midwest Health transfers all COVID-positive patients to Research Medical Center. However, patients who come first to Centerpoint with COVID symptoms are immediately placed in a negative pressure room, with staff who care for them fully suited in Personal Protective Equipment (PPE).
“It’s been very difficult with COVID because you can only have one family member with the patient,” said Lorraine. “The reason I keep doing what I’m doing is the human connection. I wish I didn’t have to wear a mask. I really miss being able to see a smile or frown, having to rely on body language. It’s limiting and stressful.
“COVID has opened the public’s eyes to healthcare workers and what we go through, but what they don’t know about is the physical abuse that happens every day to nurses, physicians, techs and others in the ER and ICU.” Lorraine sees physician suicide is an under-recognized tragedy.
“You don’t get paid for serving on the Ethics Committee,” she said, “but in return you learn about resources like the Center for Practical Bioethics and you benefit from the multi-disciplinary voices in one room discussing cases. Ethics fills up my emotional tank.”
There’s something bigger than us in the universe, and when it taps me on the shoulder I know to listen.
Palliative care doctors get asked this question a lot: What led you to specialize in care for the seriously ill and dying, and what keeps you going in such emotionally draining work?
Brandy Ficek’s answer probably isn’t very different from others in her field. “I’ve always felt that the purpose of medicine at its core is to help people,” she said, “and that this work offers the greatest opportunity to make a difference in people’s lives.”
She continues, “I love the relationships that I build with patients and families so that even in their toughest times they feel they have a voice and an ally.”
Building on Excellence
After her family practice residency, Brandy’s hospice and palliative medicine fellowship at the Mayo Clinic in Phoenix, AZ, offered the opportunity to participate on the hospital’s as well as the clinic’s community-based hospice program’s ethics committees.
That experience led to her recruitment to serve as chair of the Ethics Committee at Cancer Treatment Centers of America in Goodyear, AZ, where she was the Medical Director of Quality of Life and Palliative Medicine before joining Stormont-Vail Healthcare in Topeka, KS, in 2017.
Brandy felt honored to take over Stormont’s well-established Ethics Committee and build on its openness to improvement. An improvement she’s most proud of is the committee’s response upon recognizing that many of the cases coming to its attention were originating at the bedside.
“We took a look at ourselves,” she said, “and realized that, while we had strong representation by physicians and top administration, we were missing perspective from the bedside. Now we have representatives from the clinic, hospital, nursing, social work, spiritual care, education – every swath of the organization. Which not only results in more robust conversations, but enables us to see how decisions impact those taking care of patients day in and day out.”
“The most important thing I’ve learned from serving on ethics committees,” said Brandy, “is to listen and not make assumptions. I can review a case and think it’s clear cut. Then, hearing others’ perspectives, you realize that there are many things to consider and not always one right answer.”
Brandy’s interest in all perspectives also propelled her to an MBA from Louisiana State University in 2017.
“As a medical director straight out of fellowship talking to administration,” she said, “I felt we were coming at issues from two different angles. I wanted to better understand where they were coming from and to better support my departments and programs.”
Brandy expects communication skills will be increasingly important in addressing the ongoing challenges of COVID-19. “I think the pandemic will change medicine and, in doing so, change bioethics,” she said.
To emulate my parents, who taught that we are all connected,
and meant to use the gifts we’ve been given to make our community a better place.
Amidst the coronavirus pandemic and as a member of Hospital Incident Command, it’s not the “what ifs” that keep AdventHealth Director of Clinical Operations Kara Hess awake at night. It’s not that she has nearly 50 direct reports or daily challenges of managing multiple departments, each often needing attention simultaneously. It’s not even the weight of decisions she faces each day. What keeps her awake is the flood of ideas in her mind to address each new challenge.
“I spin on solutions,” she said, “I have a passion for process improvement and love being a part of difficult decision making, especially in healthcare.”
Sooner is Better
These are among the traits, along with experience, that make Kara so valuable to creating an ethics-rich environment at AdventHealth. Kara’s initial enthusiasm five years ago for joining the hospital ethics committee is rooted in her background in critical care nursing.
“As a nurse,” she said, “it is extremely important to be a strong patient advocate. I’ve always had a strong will to help others, to argue a good point, and to not be afraid to go against the norm.”
Kara’s outlook on ethics – and life in general – is that “sooner is better.”
“Developing a plan can help guide decisions when faced with unexpected situations,” said Kara.
End-of-life care, patient suffering, legal guardianship, and capacity to grant consent are a few examples that her team has been involved in.
“It is beneficial to review cases and learn together,” said Kara. “We try proactively to talk about relevant cases and potential conflicts with all disciplines and perspectives represented on the ethics committee.”
Kara understands that issues in health ethics can be hard to grasp. Given the current coronavirus pandemic, she asked her son, “What happens if the hospital runs out of equipment? Who makes the decision to choose one patient over another? For instance, if there’s a 95-year old placed on our last ventilator and Granny comes to the hospital and needs one, who should get it?”
“That’s a terrible decision to make, Mom,” he said.
“It is,” said Kara, “but someone has to make those decisions and they shouldn’t just be based on my opinion. They should be fair, based on facts, and teams of people grounded in ethics.”
My Christian philosophy emphasizes fairness. That no person is better than the other. That all of us were born with divine rights and the need to be respected.
How does a tennis pro director of a park facility in Nashville working on his master’s degree in religious studies end up as Director of HCA Healthcare’s Center for Clinical Ethics?
In Ronn Huff’s case, you start by going to a dinner party where you meet a clinical ethicist who tells you about his work at two HCA hospitals. You find it fascinating and he hires you as his administrative assistant. After grad school in 2001, you join HCA as a clinical ethics consultant and part-time educator for Nashville area HCA hospitals.
Then in 2016, recognizing the need for expanded system-wide education and quality assurance, HCA establishes a clinical ethics department with you as director. Now you’re responsible for ongoing clinical ethics committee education across the healthcare system’s more than 180 hospitals.
Supporting Clinical Ethics
“Clinical ethics has a crucial role in hospitals,” said Ronn. “But it’s is almost entirely composed of volunteers who may not have much ethics training and are being asked to consult on a timely basis on complex cases. We felt they needed more support.”
Ronn welcomes support from the Center for Practical Bioethics.
“Learning that Ryan Pferdehirt [Director of Membership and Ethics Education] is available to assist with ethics committee training and policy development is a blessing to me,” he said. “Good clinical ethics committees are more than the sum of their parts. They don’t happen by accident or by just assembling smart people in a room. Planning and practice are incredibly important.
“I especially applaud the Center’s work,” he continued, “in developing an industry standard for advance directives. Thoughtfully designed directives are crucial because they touch so many people, and I haven’t seen any resources that are better.”
Raising the Bar
The coronavirus pandemic has intensified Ronn’s focus on improving advance directives.
“We haven’t moved the needle on completing advance directives in decades,” he said. “The Patient Self-Determination Act, which says we simply have to ask if the patient has one and offer information, is a low bar. The coronavirus underscores the importance of identifying surrogates and having conversations earlier.”
Ronn is particularly excited about working with the Center to improve advance directives by adding more nuanced language that clarifies when and how advance directives apply.
A Buddhist married for 33 years with two grown children, Ronn likes to bike and play golf. And he’s still a pretty good tennis player.
Everything changes; everything is connected; pay attention.
-- Jane Hirshfield
A couple of years after jumping at the opportunity to serve on Children’s Mercy Hospital’s Ethics Committee and as physician liaison for the hospital’s organ donation team, Laura Miller-Smith was going through some old papers from high school and came across the thesis she wrote to graduate with honors.
“My paper was on the ethics of organ donation and, I thought, my gosh, this always appealed to me,” she said, “and today I’ve circled back to topics that I feel passionate about and have become a part of my soul.”
As Associate Medical Director for Cardiac Critical Care and chair of the hospital Ethics Committee since 2017, Laura has seen the committee’s impact firsthand.
“Our committee has done multiple consults on Fetal Health Center patients carrying fetuses with very poor prognoses and unlikely survival after birth,” she said. “These cases cause a lot of moral distress and ethical questions from multiple departments and disciplines, each of which balance risk and benefit differently.
“The committee began providing education to all the departments involved in these cases, empowering them to address concerns by engaging all stakeholders earlier and maximizing informed consent for the mother.
“The Ethics Committee doesn’t want to be the keeper of ethical decision making but rather to teach people throughout the hospital how to inform their work in an ethical way.”
One of the key benefits Laura has gained from her ethics training and committee experience is an appreciation of the value of alternative perspectives.
“I’m always amazed,” she said, “by the number of times I hear one or two perspectives on a case, but then I hear a third and fourth perspective and my viewpoint shifts. You need to have everyone’s perspective to truly understand the case.”
Laura grew up in Colorado Springs and completed her undergraduate and medical training at the University of Missouri-Columbia. At home, she enjoys the multiple perspectives of her husband and three children, ages 12, 9 and 7.
To make each day better for my patients and colleagues.
Sarah Oland’s roots in ethics date back more than 20 years, back to the late 1990s when she was a social worker at Overland Park Regional Medical Center.
Sarah joined the hospital’s ethics committee and was asked by its chair, a nephrologist, to serve with him as co-chair. “He probably noticed that I was always the one to jump into family meetings and conversations about end of life,” she said.
“These were the developmental years where I grew in my ethics passion,” she said. “The Center for Practical Bioethics helped form and train our ethics committee. We worked closely with Robert Potter and Rosemary Flanigan at the Center. I also took part in training by the Center to facilitate advance care planning with patients and families in the hospital.”
Sarah joined the Midwest Transplant Network in 2002, where she’s the Senior Director for Hospital and Family Services, and has continued to participate in the Kansas City Regional Ethics Committee Consortium ever since.
“Ethics conversations take my brain to a different place, a different way of thinking that serves me well in so many aspects of my life,” she said.
Midwest Transplant presents interesting opportunities to exercise such thinking.
“Sometimes,” she said, “the legally correct thing to do in an organ donation situation doesn’t feel like the ethically correct thing to do. Such as when a parent is the suspected perpetrator in the death of their child, and they are then the legal decision maker in the resulting opportunity for organ donation. Or when next-of-kin for an eligible donor can’t be located.”
Lately, Sarah is leaning on her ethics training to help address a whole new set of ethical issues raised by Covid-19.
“We’re going to have to wrap our heads and scientific minds around how this disease is transmitted. We are concerned about the risks and benefits to recipients being immunocompromised in these times. Scarce resources and restricted hospital visiting have changed the traditional ways we have cared for donor families, yet our focus on compassionate care cannot change.”
Born in Boulder, CO, and raised in Wichita, KS, Sarah earned her Master’s Degree in Clinical Social Work at the University of Kansas in Lawrence. She and her husband, a soon-to-retire public school teacher, have lived for the last 30 years in Kansas City, Kansas, with their two rescue dogs.
I try to live my life with abundance of gratitude and grace. I’ve always been drawn to problem solving and coming up with win-win solutions based on the values of those involved.
For Bethany Ruhl, discernment about the direction of her life grew in large part from her relationship with her grandfather. When she was a teen, something moved in his heart and he decided to teach her how to drive, even when his own wife had never been allowed to drive. Bethany saw how his attitudes towards women became more open-minded and she wanted to offer that opportunity to grow and thrive to other people.
Bethany offers that opportunity every day now as Chaplain and Manager of Spiritual Wellness at Saint Luke’s Crittenton Children’s Center, where she provides spiritual and emotional counseling for children who are hospitalized for mental health issues and teens in the residential foster care system. Many of the children Bethany serves have experienced trauma or abuse.
Guidance with a Safety Net
Her first exposure to ethics committee work occurred during her Clinical Pastoral Education residency at Saint Luke’s Hospital. When hired by Crittenton, she took over the chairmanship of its ethics committee, which meets quarterly, and a seat on the Saint Luke’s Health System committee, which meets monthly.
“I love the interdisciplinary nature of ethics committees,” said Bethany. “At Crittenton, our committee includes therapists, doctors, nurses, behavioral health technicians and administrators. The diversity of thought helps us come up with better solutions to ethical problems.”
Bethany makes a point to talk about the Ethics Committee in new employee orientations. “I want to let them know that the ethics committee is available to provide guidance and a safety net if thorny issues arise.”
Critical Thinkers of the World
In the setting where she works, a typical issue might arise from a difference of opinion between the treatment team and a parent. “Serving on an ethics committee is a way to make a deep difference in the lives of patients and families,” she said. “And beyond that, you’ll learn so much.”
“Your horizons will be greatly expanded because ethics committee people are the critical thinkers of the world. We think proactively about problems so we will have an ethical framework to address them when dilemmas arise.”
Bethany is currently pursuing a Master of Arts in Counseling. She earned her Master of Divinity degree from Central Baptist Theological Seminary, and she is ordained by United Church of Christ. She also holds a BA and MA in French Literature.
I believe that God has a preferential option for the poor and marginalized, including the vulnerable children & teens we serve at Crittenton. I feel like it is the call on my life to help everyone understand that they’re worthy of unconditional love and care.
For Nancy Schroeder, like many who get involved in healthcare ethics, there was a precipitating event. For Nancy, it was an end-stage HIV/AIDS patient at Baptist Medical Center in the 1980s.
“He was in and out of the hospital, on and off a ventilator,” said Nancy. “This particular admission, he was telling me he was tired and didn’t want to go on a vent anymore. But his mother, a widow, wanted everything done, and the physician taking care of him wasn’t listening to the patient. He was more concerned about her feelings.”
Hearing Both Sides
Nancy shared her frustration about the case with a colleague, who suggested she take it to the hospital’s newly formed Ethics Committee chaired by Dr. Larry Rues.
“The attending physician and I presented our cases,” said Nancy. “The committee encouraged the physician to talk with the mother and the patient together instead of individual conversations. In the end, the patient didn’t go back on the vent. He was allowed to die with his mother at the beside.”
Shortly thereafter, Dr. Rues invited Nancy to join the committee and ever since, through multiple job changes, she’s stayed involved with ethics committees and the Greater Kansas City Regional Ethics Committee Consortium.
She stays involved, she says, for two main reasons.
First, when you have access to an ethics committee, you are never alone in dealing with conflicts between patients, families and providers.
Second, the Ethics Committee Consortium helps her be a better advocate and facilitator of communication among all parties.
“When I joined the Visiting Nurse Association five years ago,” she said, “they were super excited that I had ethics experience and would keep the VNA involved.”
A third generation nurse and ever a caregiver, Nancy cares for her mother, who had a stroke about a year ago, at home. She and her husband Larry have four grown children, one of whom lives in the same house in East Brookside where Nancy grew up.
Always treat people the way you would want to be treated.
A normal day for Sally Schwab, Director of Spiritual Health for Mosaic Life Care at Saint Joseph Medical Center in St. Joseph, Missouri, begins with spiritual reflection and the morning report from one of the 10 staff chaplains under her supervision.
After that, the day could involve any of several other responsibilities. Sally directs Mosaic Life Care’s accredited Clinical Pastoral Education program overseeing students learning how to be chaplains. She provides clinical oversight of pastoral services for acute care, mental healthcare, long-term acute care and an outpatient cancer center. She provides leadership to St. Joseph’s Organ and Tissue Donation program. She leads a system-wide initiative on advance directives.
Ethics Committee Leadership
And, since the day in 1989 when she was hired at Heartland Health (now Mosaic), she’s played a leadership role in the hospital Ethics Committee and its four subgroups: Policy, Education, IRB and Ethics Business (i.e., consultations).
“I was a resident at Baptist Medical Center in Kansas City when I did my training to become a chaplain,” she said. “Rosemary Flanigan from the Center for Practical Bioethics taught part of the curriculum. So career-wise I grew up with the Center as a teacher and as a community to be engaged with. I think part of the reason I was hired at Heartland was because I had that association and could step into Ethics Committee leadership.”
Sally further credits the Center for stimulating her interest in palliative care. She brought the idea of starting a hospice to the hospital, formed a business plan and directed the Hands of Hope Hospice, now Mosaic Life Care Hospice, from 1998 to 2004.
Spirituality and Covid-19
Sally seeks out opportunities, especially in terms of leadership and administration, to bring spiritual presence to persons who are suffering, their loved ones and caregivers. Facing the unprecedented challenges of Covid-19, she’s focused on finding creative ways to achieve spiritual presence while following social distancing guidelines.
“We’re providing nurses with resources to support patients whose rooms they can’t enter for their safety and to conserve PPE (personal protective equipment). Offering a prayer through the overhead system, through a caregiver blessing and on a bookmark on patient dietary trays, she believes, has communicated a sense of caring throughout the hospital.
“What I’ve experienced and learned,” said Sally, “is that God stands with the poor, the hurting and the suffering, and that ethics is a way in today’s world that we live out the mandate to be with and stand with persons in need.”
To act justly, love mercy and walk humbly with your God.
“It’s not a hard job,” says social worker Karlie Speicher. “It’s hard situations. I problem solve. I get my high from helping people.”
From Cardiology and Oncology to the NICU and Women’s Health, Karlie has been helping patients and families at Saint Luke’s Hospital for nearly 30 years. She’s currently assigned to the Internal Medicine Clinic, where typical problems range from mental health to transportation.
Advance Directive Advocate
Karlie was a great candidate for ethics committee membership before she even knew it.
“I always wanted to promote advance directives,” she said. “I sometimes think we wouldn’t have ethics committees if we had more advance directives so we knew what patients’ wishes were.”
Karlie was recruited to the Saint Luke’s Hospital Ethics Committee about five years ago, quickly landing on the subcommittee tasked with developing policies to unify all of the ethics committees throughout the Saint Luke’s Health system. The process left Karlie with deeper understanding of ethics consultation services and the kinds of policy issues that ethics committees are called upon to address.
So much of ethics committee work, she says, is about communication. Take the moral distress that occurs when a clinician feels pressured to act in conflict with their own values. “The committee can look at that, work with those involved, apply principles of ethics, and offer advice that leads to a better outcome.”
Originally from Fremont, Nebraska, Karlie earned her Master’s in Social Work from the University of Missouri and Master’s in Public Administration from the University of Missouri-Kansas City. She has two children and many outside interests, including triathlete competition, travel, reading and the arts.
I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.
Some of us are lucky to have mentors. For Noreen Thompson, a psychiatric mental health clinical nurse specialist at the University of Kansas Health System for the past 30 years, the mentor that stands out among several is pediatrician ethicist Bill Bartholome. Bill served on the board of the Center for Practical Bioethics since its founding in 1984 until his death from esophageal cancer in 1999 at age 55.
Noreen and Bill first crossed paths in the late 1980s. Noreen had been consulted on an oncology patient suffering with paralysis and tremendous pain who did not want her life prolonged. The case was causing great moral distress for the physicians and nurses caring for her. Around the same time, Bill was working to establish a clinical ethics service at the hospital, but running into some resistance from physicians.
“I called Bill to present the case on the clinical unit,” recalled Noreen. “There was standing room only.” Soon afterward Bill asked Noreen to join the hospital Ethics Committee, where she’s served as a lead consultant ever since. Noreen also chaired the hospital’s Patient Rights Committee in rolling out the Patient Self-Determination Act. For more than a decade on National Healthcare Decisions Day, she coordinated a table to educate KU employees about the importance of completing Medical Durable Power of Attorney and Advance Directive forms.
Every Case Unique
Every case is unique, says Noreen. “The goal is to offer choices and guidance based on ethical principles. To illustrate, Noreen describes the case of a homeless man who came to the Emergency Department with severe frostbite, screaming that no one was going to take any part of his body.
“The orthopedic doctors were beside themselves. Psychiatry helped with guidance about appropriate medication. Ethics was asked to help them decide the right thing to do. A surrogate decision maker could not be located. We advised that if the surgeons believed there would be irreparable harm unless they amputated and saw no other way to treat the patient medically, then it would be in the patient’s best interest to perform the surgery without the patient’s consent. We also guided them to use the advice of Psychiatry and to inform Anesthesia prior to surgery of the unsigned consent as well as the ethics consultation note.
“And yet, in a similar case, our surgeons were able to use long-term IV antibiotics instead of surgery. It’s not one size fits all.”
Time for a New Hobby
“Born and raised in Philadelphia, PA, Noreen and her husband moved to Overland Park in 1983, where they raised a son and daughter. Now that her children are grown, Noreen is making time for a new hobby.”
“I love to sing,” she said. “I joined my church choir at St. Francis Xavier Catholic Church.”
Not to judge. To eliminate suffering if you’re able, to listen and to be a caring presence.
As a family practice physician, Jennifer Tieman enjoys patients at all stages of life but is particularly fond of maternity and end-of-life care.
“They sound like opposites,” said Jennifer, “but are really very similar in that both are times of momentous transition in family life and both present opportunities to help people form their medical goals and plans.”
Her position as director of the Family Medicine Residency program at Research Medical Center and as co-chair of the hospital’s Ethics Committee also presents opportunities for Jennifer to help the next generation of family physicians and other clinicians to improve communication with patients and families and to encourage them to provide care that is driven by the goals and values of their patients.
Jennifer grew up in the rural Illinois town of Sandwich. A teenage single parent, she entered the University of Chicago Pritzker School of Medicine the same year her son started kindergarten and graduated in 1998 having also completed a clinical medical ethics fellowship.
“I always had a strong interest in the doctor-patient relationship, how patients understand what we talk about in medicine, and how patients and families make decisions,” she said. “We may not like to think about it, but medicine is a culture as well as a profession. We have our own language and beliefs based on science. We have excellent medical reasons for the things we recommend, but patients often have more important reasons why those recommendations don’t work for them.
“Ethics is pretty easy,” she said. “You can usually boil a decision down to beneficence, autonomy, non-malfeasance or justice. The hard thing is helping people meet each other where they’re at. It’s totally about communication.”
Disparities and Trust
Unfortunately, communication has become much more challenging since COVID-19.
“We take care of a largely urban underserved population with a lot of racial disparities,” said Jennifer. “Many of our consultations involve cases where the family wants to do this, the medical team wants to do that, and what it comes down to is that the families and patients have difficulty trusting us.
“It’s even harder with the pandemic because families can’t be at the hospital. We don’t have much opportunity to develop a relationship with them. We carry iPads around but with PPE they can’t even tell if we’re smiling.”
Jennifer’s son, now 32, is the oldest of her four children. She’s completed 25 marathons in 17 states, with the goal eventually to run in all 50. At home in the meantime, she stays crafty. That is, she likes to decorate cakes, cook, sew and knit.
The patient is the most important member of the medical team.
Nothing we do matters if it doesn’t align with their goals and beliefs.
Kimberly Williams was born at the small rural hospital, Phelps Health in Rolla, Missouri, where for the past 25 years she’s practiced nursing, starting with medical oncology.
“I’ve sat with many patients at various stages of disease,” she said. “I’ve always felt that we didn’t do enough to inform or better prepare people for the end. I always felt it was my duty to be honest. So working with the ethics team here has been a natural for me.”
Rebuilding the Ethics Committee
Kim got involved with the hospital’s Ethics Committee in 2015 when she became the Manager of Case Management and responsible for the team in 2017 when she became director of the department.
“At that time, the team pretty much met when there was a perceived ethical issue,” she said. “We made a report but there wasn’t any training for team members.”
About three years ago, she started working with Dr. Alexander Gamble, who specializes in supportive care, to rebuild the hospital’s Ethics Committee into a high functioning, multi-disciplinary team. “We want to develop and educate the team to be able to contribute back to the organization and not just deal with one tough case at a time,” she said, crediting Center for Practical Bioethics resources for helping to guide the process.
“It’s a process that’s ongoing, with the current focus on providing training tools for the team and on identifying a community member to join us,” said Kim. “The community member would not participate in case review, but share information and a lay person perspective with the community.”
Beliefs and Systems
Kim sees two lessons learned so far from her ethics committee work.
First, she said, “It’s really important to check your personal and cultural beliefs at the door and focus on the right thing to do for the patient. And, second to evaluate not only the case but the system and how it contributed to the issue.”
For example, say you have an 85-year old nursing home resident with no guardian who needs surgery and is suddenly unable to make decisions. How did they get to that point? Who failed to recognize this patient had no one in charge before it became an emergency?
“We would want to take a step back and put processes in place in our organization to ask the right questions,” said Kim.
Kim has three children and two stepchildren. She earned her Bachelor’s and Master’s nursing degrees from Central Methodist University.
No matter how bad something is today, it can’t be your defining moment. Always look toward tomorrow.
For many, the desire to pursue a career in medicine shows up early in life. For Jerry Wilmes, the decision to apply to medical school evolved from an undergraduate degree in wildlife biology followed by several years as an industrial health and safety engineer.
“I was in my late 20s when I got to thinking about what to do with my life,” he said. “I had a longstanding interest in medical ethics, humanities and philosophy.” Jerry graduated from the University of Missouri School of Medicine at Columbia in 1987 and spent a few years in private practice, but felt called upon to do other things.
When he returned to his hometown of Maryville in the early 1990s, where he now serves as Medical Director for Mosaic Life Care Hospice and Palliative Medicine as well as Medical Director of Wellness Services at Northwest Missouri State University, he believes it was fate to be asked by SSM Health to serve as the inaugural Medical Director for the newly-formed Maryville, MO Hospice branch. In that same timeframe, he met and developed a rich personal and professional relationship with the Rev. Sally Schwab, who at that time was serving as Director of Spiritual Care for Heartland Regional Medical Center, later to become Mosaic Life Care.
“In hospice and palliative care, working with patients and families, you are truly in a privileged and sacred space,” he said.
And, he believes, it was fate to be asked to serve on the ethics committee for Heartland Health (now Mosaic Life Care) in St. Joseph, Missouri, as well as the ethics committee for St. Francis Hospital (now Mosaic Maryville).
A Better Clinician
Some three decades later, what all those years of ethics committee experience have underscored for Jerry is the value of communicating with others in the healthcare system and thinking about issues from an ethics framework.
“Serving on ethics committees, in my opinion, makes you a better clinician because it helps you think about situations from a more comprehensive and compassionate perspective.”
Beyond that, he said, “Ethics committees have been instrumental in the development and growth of our palliative care program and in helping the healthcare system navigate difficult situations.”
Jerry has four adult children, eight grandchildren and spends as much time as possible outdoors.
It’s not about me. It’s about living a life of meaning, purpose and, hopefully, making a difference.
The focus of the Saint Luke’s South Hospital Ethics Committee on which Vice President and Chief Nursing Officer Julia Woods has served for the past five years is education and prevention.
“A great deal of committee time is spent discussing what’s going on locally so that we can take lessons learned back to the nursing staff and prevent future conflicts,” said Julia. “For example, we walked through a scenario where the patient was near the end of life and the son’s wishes were different from the patient’s. It was eye-opening to listen respectfully to all parties so that all feel that their concerns are resolved.
“Our committee is run by Father Ron Verhaeghe, who brings forth topics and leads the discussion,” she said. “We talk about basic principles of ethical decision making, and the Center for Practical Bioethics has great tools for that.”
Risks and Benefits
Inspired by an uncle who was a nurse anesthetist, Julia felt called to service for others at a young age. Born in Wichita with her dad in the military, she moved frequently during her early years. She earned her Bachelors in Nursing from Washburn University in Topeka and her Master’s from the University of Kansas.
“I love to pull apart risks and benefits, so I jumped on the opportunity to be part of the Ethics Committee and learn how different perspectives weigh into patient decision making.”
As Vice President and Chief Nursing Officer, Julia helps plan and organize patient care services. She anticipates new and challenging questions will arise from the coronavirus pandemic, with a lot of interest in equitable decision making.
Direction in Conflicts
“The thing I’ve learned from serving on our Ethics Committee,” she said, is that you need to listen to all parties involved in a conflict so that you understand their perspectives and, ultimately, can advocate for the patient.
“Ethics helps you see what direction to take when conflicts arise.”
Honoring what the patient wants for themselves and doing my best to provide it.