Ethics Committees & Ethics Process
The DADS Quality Assurance and Improvement vision for the role of ethics committees in Long Term Care is that
Every nursing facility will have access to an ethics committee.
Definitions and Scope
An ethics committee is a multidisciplinary group that can assist physicians and families to make difficult treatment decisions. Ethics committees may also develop policies and guidelines concerning ethical issues in the delivery of health care. The functions of an ethics committee include advising, consulting, educating, and deliberating with physicians, nursing staff, residents, and families about ethical issues within medicine, including such issues as advance directives, decisional capacity, end-of-life treatment, and the initiation or termination of treatments.[1,2] Ethics committees are best viewed as a part of an ethics process that addresses building and maintaining an awareness of and expression of the values of the resident, family, care team, and society in order to bring these values to bear on clinical decisions.
A LTC facility can utilize an external ethics committee (i.e., one that is in a hospital, is community-wide, or part of another LTC facility) or have an established in-house ethics committee.[1,3,4,5] A large proportion of nursing home residents have limited decision-making capacity, and many have little or no contact with their relatives or friends.[6,7] Thus, facilities without access to an ethics committee typically rely on the primary care physicians or primary care team members to address ethical dilemmas on a case-by-case basis through meetings with families and/or residents.[1,4] In such instances, relying on institutional policies and legal advice rather than a formal ethics process, the process may overlook the complexity of decision making in individual cases and may insufficiently involve residents and families in the process.[3,8]
Federal and State Requirements
The enactment of the Federal Nursing Home Reform Act of 1987 and the Patient Self-Determination Act (PSDA) of 1991 have prompted LTC institutions to implement mechanisms for addressing ethical issues and dilemmas.[9,10,11] The former act sets standards of quality, specifically with respect to resident rights, and defines relevant aspects of the survey processes. The PSDA requires hospitals and other health care facilities, including LTC facilities, to develop policies for advance directives and to promote awareness of treatment options and alternatives.[10,11] Several state legislatures have delegated specific roles to ethics committees.[12,13]
Eliminate the Barriers
Identify and address common assumptions that are barriers to using an ethics
ASSUMPTION: There is no need for an ethics committee.
Having an ethics committee helps facilities to put in place policies that can better account for the complex and unpredictable range of ethical dilemmas that may arise in long term care. Using a multidisciplinary ethics group helps to guard against the tendency to create policies that are based solely a single perspective such as that of administrators, physicians, or attorneys alone. A multidisciplinary committee is better able to reflect the richness and diversity of the moral life in a pluralistic society.
ASSUMPTION: Ethics committees are a poor means for responding to ethical dilemmas (i.e., ethics committees create undesirable bureaucracy and diffuse responsibility).
Ethics (standing) committees that act as entities for educating the nursing staff, residents, and their families about ethical principles and ethical issues in patient care do not typically function as decision-making entities. Ethics committees cannot practice medicine. They do not deliver care at the bedside nor write orders. Ethics committees should serve to enhance decision making without becoming the ultimate authority of the patient, his or her surrogate decision maker, or both, and the physician to reach the final decision in difficult ethical cases.
ASSUMPTION: An ethics committee can interfere with physician autonomy.
The ethics committee is not the ultimate decision maker in ethical dilemmas. The committee complements the roles of the primary care physician, care team, resident and family by providing a forum in which all perspectives regarding an ethical question can be heard.
Select an Ethics Process Model
There are other factors to address.[3,4,14,15,16,17] Is there a a need for an in-house ethics committee? Do your residents, physicians and families face care decisions concerning artificial nutrition and hydration, palliative care, life support, and choices such as whether to undergo forms of treatment that rarely offer lasting benefit? Do your staff and the attending physician ever disagree on treatment matters? Do family members ever disagree among themselves concerning treatment decisions? Are the ethical dimensions of these choices, decisions and conflicts being recognized and managed in a manner that promotes shared decision-making?
Is an in-house ethics committee feasible?
- Can your facility make the necessary commitment of time and money to use outside consultants?
Does your facility have access to all of the resources needed to develop
and maintain its own ethics committee (i.e., staff, community support, and
Joint ethics committees involve the sharing of ethics committee duties among
nursing homes or acute care facilities. The main models of this type of
committees are the
Committees in the same geographic location
- Example: Representatives of LTC facilities in Sonoma County, California formed a committee that convenes bimonthly at a meeting called "Cooperative LTC Bioethics Forum." Its members later formed the "Sonoma County Bioethics Network."
- With help from hospice, health maintenance organization, and paramedic service representatives, this committee drafted policies and procedures for emergency treatment decisions, which were sent to all LTC facilities in this county. The recipients were asked to consider adopting the policies.
Committees sharing the same values and cultures
- Example: The Health Facilities Association of Maryland (HFAM) worked with nursing homes to establish ethics committees with other homes located in the same geographical area.
- The HFAM sponsored workshops for facilities interested in establishing joint committees. Eight joint committees, each composed of four to six facilities, were established. These facilities reported that the network helped them gain confidence in making ethical decisions and improving working relationships with their peers. Additionally, the diversity of the committees allowed the discussion of a wider range of ethical issues and concerns.
Committees that are part of the same corporate chain or under the same ownership
- Example: Mt. St. Vincent Nursing Home in Holyoke, Massachusetts established an ethics committee that served three LTC facilities (i.e., Mt. St. Vincent, the Beaven Kelly Home, and St. Luke's Home, all of which are under the ownership of Sisters of Providence Health System).
This committee meets monthly and has developed policies on issues such as
DNR orders and withdrawal of artificial nutrition and hydration. It also
holds discussions on ethical issues and offers recommendations to the
- Committees in the same geographic location
Joint LTC and hospital ethics committees
- Example: Brady Memorial Nursing Home in Mitchell, South Dakota is affiliated with two ethics committees - one at the local hospital and the other serving the Presentation Health System.
The joint committee meets bimonthly to discuss ethical issues related to
the elderly and educate physicians and staff members about various ethical
issues. Some sessions are open to public to increase ethical awareness in
In addition, ethics rounds and consultation teams may be a more appropriate
option for your
facility.[15,18,19,20] (See Event-Driven Ethics Process
Staff the Ethics Committee
Be selective in recruiting members, if possible. The following characteristics
- Patience. Establishing an ethics committee may take two to three years so patience is required.
- Compassion. Committee members need to be able to deliberate ethical issues from the residents' perspective.
- Optimism. Given that many ethical dilemmas are difficult to resolve, the members must be optimistic in such efforts.
Openness. The nature of ethical dilemmas is that they defy simple answers.
The members should be open to learning so that they can consider carefully
all of the expressed opinions about an ethical issue.
Members of the ethics committee must represent a wide range of disciplines.
In a 1988 national survey of LTC ethics committees, the majority of the LTC
committees consisted of the following members:
- Medical Directors
- Nursing directors
- Social workers
- Clergy members
- Other nursing staff
- Attending physicians
- Family members
- Patient advocacy group members
- Establish a formal educational plan for the committee members. Participating in study groups, discussions, and attending continuing education in medical ethics are all useable components for the educational plan.
- Involve your Medical Director. Establish the purpose and function of the ethics committee.
- Review and perform the steps in Establishing an Ethics Committee.
Identify existing ethics committee resources in your community.
- Is there a hospital-based ethics committee in your community?
- Do other LTC facilities have their own ethics committee?
- Can your facility enter a partnership with an existing ethics committee?
- Review local, state, and national regulations and guidelines for handling ethical dilemmas.
- Establish an ongoing educational process for ethics committee members.
- Determine the most suitable ethics committee model for your facility.
- Advertise the ethics service to your medical staff.
- Provide a clinical staff in-service that describes the ethics service.
- Use your existing quality assurance process to compare your outcomes when the ethics process is used and outcomes when it is not used in order to evaluate the effectiveness and benefit of your ethics process.
- Use the clinical literature (QMWeb Resources), educational materials, journal articles, videos, and guest speakers to educate nursing staff, residents, and families about the ethics process and how they can use it in making difficult decisions.
- Provide continuing education on ethical dimensions of clinical decision-making in LTC for staff, residents, and families.
Part II. Routine Ethics Process
- Outline the purpose and functions of the ethics committee.
- Establish a schedule of regular ethics committee meetings.
- Use the routine scheduled meetings to review facility policies and procedures.
- Allow time during each meeting to address individual resident care situations.
Establish an ethics consultation system - ethics rounds and/or an ethics
- Ethics rounds can be used to bring ethical issues to the medical director.[15,19] The attending physician, members of the care team and family can present an issue and their personal perspectives during ethics rounds.
- Ethics consultation can be provided by an individual or a consultation team. The consulting team works with the primary care team to address ethical issues.[18,20]
- Establish a mechanism for convening ad hoc meetings of the ethics committee members.
There are no licensure or certification requirement for LTC facilities to have an ethics committee. However, there are requirements for appropriate surrogate decision-making (e.g., ICF/MR State Standard for Participation 25 TAC §406.310) as well as provisions for developing valid advance directives (e.g ., NF State Licensure TAC §19.403(g)) that can be met through the use of a appropriate ethics process.
Decision-Making at the End of Life - 2003 DADS Geriatrics Symposium
- End of Life Care
The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.
Winn P, Cook J. Ethics committees in long-term care: A user's guide to getting started. Annals of Long-term Care 2000;8(1):35-42.
Texas Association of Homes and Services for the Aging. Quality of life and ethical issues in long-term care (pdf file)
Cassel CK. Ethical problems in geriatric medicine. In: Cassel CK, Riesenberg DE, Sorenson LD, Walsh JR, eds. Geriatric Medicine. 2nd Edition. New York, NY: Springer Publishing Co., Inc; 1990:38-40.
Ethics Committees: Allies in Long-Term Care. A Guidebook to Forming an Ethics Committee. Washington, DC: American Association of Homes and Services for the Aging; 1990.
Feinsod FM, Levenson SA. Procedures for managing ethical issues and medical decision making. Annals of Long-Term Care 1998;6(2):63-65
Hoffman DE, Boyle P, Levenson SA. Handbook for Nursing Home Ethics Committees. 1995. Washington, DC: American Association of Homes and Services for the Aging.
Levenson SA, Feinsod FM. Determining decision-making capacity and selecting a primary decision maker. Annals of Long-Term Care 1998;6(11):370-374.
Levenson SA, Feinsod FM. Considering specific treatment options. Annals of Long-Term Care 1999;7(2):74-83.
Levenson SA, Feinsod FM. Implementing effective ethics in decision-making programs. Annals of Long-Term Care 1999;7(6):232-237.
 Winn P, Cook J. Ethics committees in long-term care: A user's guide to getting started. Annals of Long-term Care 2000;8(1):35-42.
Robert L. Fine, MD, FACP
Review Date: 4/12/2004
Dr. Fine is a Geriatrician and Director of the Office of Clinical Ethics in the Baylor Health Care System.
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Last updated: April 13, 2004
Links updated: January 27, 2006