**National Ethics Teleconference**

**Special 75^th^ Diamond Edition**

**National Ethics Teleconferences (NET Calls)**

**Yesterday, Today, and Tomorrow**

**October 29, 2008**

**INTRODUCTION**

Dr. Berkowitz:

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the National Center for Ethics in Health Care
and a physician at the VA NY Harbor Healthcare System. I am very pleased
to welcome you all to this, the 75^th^ National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of ethical concerns relevant
to VHA. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# ANNOUNCEMENTS

[CME credits]{.underline} are available for [listeners]{.underline} of
this call. To receive CME credit for this course, you must attend 100%
of the call, and complete the registration and evaluation process on the
LMS website: <https://www.lms.va.gov/plateau/user/login.jsp>,

To get a CME credit hour for participating in the conference call you
must complete the registration and evaluation process by December 1,
2008.

If you have any questions about this process or about the LMS website,
please contact the Project Manager, John Whatley, PhD, at (205) 731-1812
x312 or by e-mail at <John.Whatley@va.gov>.

# PRESENTATION

**Dr. Berkowitz:**

I am very pleased to welcome all of you today to the 75^th^ call in the
National Ethics Teleconference series. In today's call, we will look
back and forward:

-   to review the goals and scope of the NET Call series;

-   to learn how the series has influenced the structures and practices
    to improve ethics quality within VHA.

-   to illustrate by examples how participation in the series enables
    staff "in the field" to be "ahead of" and "part of", and sometimes
    to direct the ethics curve within VHA.

Joining me on today's call from the Ethics Center are Barbara Chanko and
Susan Owen. In addition, we are pleased to have Dr. Ellen Fox, Chief
Ethics in Health Care Officer for VHA, with us to introduce today's
call.

**Dr. Fox:**

Thank you Ken, I am extremely happy to be able to participate in this
Diamond Anniversary National Ethics Teleconference.

It is remarkable to look back over the past 8 years at the wide range of
ethical issues that have been addressed during this series of
teleconferences \-- everything from do not resuscitate orders back in
December of 2000 to this summer's call on the subject of ethical
considerations in the use of home oxygen by patients who smoke.

In some cases NET calls have anticipated issues that subsequently became
hot issues months or even years later. I am especially pleased that
participants in our NET calls have had a unique opportunity to get a
professional "heads up", and conversely to provide input into our
thinking on many of these ethical issues.

NET Calls have brought together the resources of the National Center for
Ethics in Health Care and the collective wisdom of literally thousands
and thousands of staff who are dealing with ethical concerns and issues
in health care daily in VHA.

I want to thank you and your team Ken for your pioneer work in
maintaining the NET Call forum and also to those of you in the audience.
Without you there would be no program.

This will be a fun hour as we take a look back in time, talk a little
about today's issues, and then take a look forward into the future of
ethics in health care.

Once again, thank all of you on the phone for joining us in today's
celebration, and to everyone who has participated in, and supported this
series over the years.

Ken...

**Dr. Berkowitz:**

I'd like to begin today's call by considering the history, goals and
other aspects of the NET Call series. Before I begin, I would like to
make sure that all of you in the audience know that ALL of the NET call
summaries are available on our Website -- last year there were over
14,000 file downloads of prior NET Call summaries!!

When I joined the Ethics Center in 2000 we decided to move from what
were then weekly regional calls, to monthly national teleconferences. We
felt this would create a regular national forum for ethics education and
discussion and at the same time we could begin to forge a nationwide VHA
ethics community -- something that I am very proud of. In 2008, the
average number of VANTS lines used per call has been around 200. Given
the fact that we have had the calls for eight years and many facilities
listen in groups, we have reached a nationwide VHA ethics community that
includes thousands and thousands of participants!!

The main intent of all of the NET Calls is to provide practical, useful,
and relevant information on ethical issues that arise within VHA, and a
forum to discuss them.

The process of developing each call is dynamic and interactive. We often
select topics for a particular call based on an ethics concern that has
been brought to our attention from the field, VACO program office staff,
or about a relevant interesting topic from the ethics literature. We try
to stay responsive and nimble by picking the topics close to the time of
the next call.

For each NET Call we consider who else in VHA is relevant to include --
both in terms of content development, and target audience. Preparation
for many of the calls has allowed the Ethics Center to connect directly
with other national program offices, such as patient safety, infectious
disease, and public health, and we appreciate the collaborative nature
and helpfulness that we have uniformly encountered from our colleagues
in VHA. Altogether we have collaborated with over 50 content experts,
primarily from other national program offices, local facilities, or
academia. This collaboration with other initiatives or program offices
on NET Calls can start regular Ethics Center participation in national
work groups or other efforts, such as pandemic influenza, the MRSA
initiative, opioid agreements, the national dementia workgroup, national
patient record flags workgroup, to name a few.

The NET calls also provide an opportunity for the Center to educate
field staff about new revised policies or those in revision and answer
questions from the field about implementation.

Finally, precisely because we attempt to be responsive to ethical
concerns that arise and are addressed in real time, we have not shied
away from controversial topics such as coordinating VA and DoD health
records, privacy concerns around using social security numbers as
medical identifiers, the ethics of tissue banking, and terminal
sedation.

In the bulk of today's call, we will illustrate how participation in the
series enables VA staff "in the field" to be "ahead of" and "part of",
and to shape the ethics curve within VA. Ms. Chanko, before we turn to
specific examples, could you say a few words about the scope of the
series?

**Ms. Chanko:**

Several years ago, the Ethics Center decided to use the concept of
domains to capture the scope of ethics in health care. These domains,
and the topics and sub-topics that they encompass, allow us to frame our
work: to identify our priorities, articulate and implement common goals,
develop measures of ethics quality, and construct targeted educational
materials.

Many of you will recognize the domains that we use to describe the scope
of ethics in health care are: shared decision-making with patients;
ethical practices in end-of-life care; patient privacy and
confidentiality; professionalism in patient care; ethical practices in
resource allocation; ethical practices in business and management;
ethical practices in government service; ethical practices in everyday
workplace; and ethical practices in research. In selecting topics for
NET Calls, we try to make sure that over time all the domains are
represented. For example,

Within the domain of shared decision-making with patients, an April 2007
call focused on a National Ethics Committee Report: "Ethical Aspects of
the Relationship between Clinicians and Surrogate Decision-Makers."

Within the domain of ethical practices in end-of-life care, an April
2006 call focused on "Ethical Considerations of Cardiac Pacemakers and
Implantable Defibrillators for End-of-Life Care."

Within the domain of patient privacy and confidentiality, a March 2006
call focused on "The Ethical Challenges of Coordinating Mental Health
Care Between VHA and DoD."

Within the domain of ethical practices in resource allocation, a June
2006 call, which we will discuss later, focused on the "Influenza
Pandemic: Preparedness Planning and Ethics Concerns."

Within the domain of ethical practices in business and management, a
February 2004 call focused on "Copying, Pasting, and Duplicating in the
Electronic Medical Record: An Ethical Analysis."

These are only a very few of the calls that are found listed by date and
by domain on the Ethics Center website. Summaries of each call are
available. In addition, we have recently changed how we put follow-up
materials on the Web. In addition to the detailed summary there will
also be an executive summary with a few key take-home points, and a
short annotated bibliography.

**Dr. Berkowitz:**

Thank you, Barbara. Participation in the NET Call series allows each of
you to participate and contribute to real movement and ethical growth
within the system.

In order to illustrate this, we're going to consider NET calls that fall
within five of the domains: shared decision making; end of life care;
resource allocation; professionalism; and the everyday workplace.
Barbara, can you please start?

**Ms. Chanko:**

The first example to consider concerns the domain of shared decision
making, which considers how well the facility promotes collaborative
decision making between clinicians and patients.

We all know that VHA is committed to implementing shared decision making
and respecting patient autonomy. That being said, it is interesting to
note that limiting patient choice presents frequent ethical conundrums,
and is a frequent topic for ethics consultation, accounting for 7% of
the Center's ethics consultations, and almost 14% of ethics
consultations finished in ECWeb throughout VHA since the start of FY
2008!

The use of home oxygen for patients who smoke is a helpful example on
which to focus. This issue was first addressed by us in a NET Call in
October of 2001. At that time, the Ethics Center selected the topic for
a NET Call because the Consultation Service had received numerous
consultation requests during the preceding few months from facilities
who were struggling with this issue.

If we fast forward to July of 2008, we find that smoking and home oxygen
is still a hot topic and we again focused on this issue in a NET call.
Here again requests from local facilities, along with the availability
of updated empirical data, policy, and educational information, prompted
our decision to revisit this issue.

**Dr. Berkowitz:**

In order to illustrate how the NET Call tracks ethical and policy issues
across time, let's continue with the domain of shared decision making
and think about what developments have occurred during the seven years
between the first and the most recent NET Call about smoking and home
oxygen use? Barbara. . .

**Ms. Chanko:**

The ethical analysis of the issue has remained fundamentally the same.
The principle of respect for autonomy means that patients have the right
to self-determination, in this case about choosing how to behave within
their own home. The principle of non-maleficence requires that health
care practitioners avoid harm. Practitioners have a duty to encourage
smoking cessation and support patients as they try to stop smoking and
also to ensure that patients understand the safety risks of continuing
to smoke while using home oxygen. In addition, when considering the duty
to prevent harm, we need to acknowledge our duty to prevent harm to
third parties, such as health care workers or other residents or
community members, and to attempt to assess the magnitude of potential
harm objectively.

Over the last decade, there has been growing interest in smoking and
home oxygen in the medical and ethics literature. Studies have shown
that the risk to the patient and others, although quite serious, has not
been shown to be very large.

A fundamental change that has occurred during this time is that VA has
released a new Directive 2006-021, "Reducing the Fire Hazard of Smoking
When Oxygen Treatment is Expected," to provide guidance to facilities as
they craft policies to address this issue. The NET Calls about smoking
and home oxygen have been widely read and cited and have informed our
thinking and VA policy development in this area. The Ethics Center was
represented on the workgroup that developed the new VA directive.
Throughout, we have emphasized that from an ethics standpoint, we should
treat cases individually and not make generalizations about those who
continue to smoke; we should first educate and support patients in
smoking cessation efforts; we should do everything we can to educate our
patients about safety and safe practices; we should not treat smoking
and home oxygen differently than other situations where a patient may
put themselves or others in danger by not fully complying with a
treatment plan; and we should ensure that procedures are be in place to
help facilities deal with difficult cases in a systematic, consistent
way.

In addition to conducting a NET Call to discuss this Directive with
facilities, the Ethics Center is also in the process of preparing
materials through iMedConsent that can assist these local efforts.
Drafts of these materials consist of two \"agreements\" (one for home O2
use and one for inpatients and their visitors) and one \"checklist\" for
home oxygen safety. These materials are not quite ready yet, but when
they are they will be publicized.

**Dr. Berkowitz:**

Thank you, Barbara, for illustrating in concrete terms how the NET Calls
track with, and inform, ethical thinking and policy development across
time. Lets move on to another domain; end of life care.

The first NET Call back in December of 2000 was on the topic of DNR
orders, a topic that is complex and multi-faceted and that has received
repeated attention through NET Call discussions. Dr. Owen, could you
elaborate?

**Dr. Owen:**

Ethical concerns related to DNR fall under the broad domain of ethical
practices in end-of-life care and the topic of Cardiopulmonary
Resuscitation (CPR).

As Ken mentioned, DNR orders were initially addressed in the first NET
Call in December of 2000, "DNR Orders and the Electronic Medical
Record." The most recent NET call on DNR Orders, "State-Authorized
Portable Orders: Out-of-Hospital DNR Orders and Orders for
Life-Sustaining Treatment -- Important News for VHA," was held on in
July of last year.

In the seven years between these two calls, NET Calls have considered
the answers to several questions that are at once related and distinct:

-   Who should enter a DNR order and why?

-   What role, if any, should judgments of medical futility play in
    decisions to write a DNR order?

-   Should family members be able to be present during resuscitations?

-   What procedures should DNR orders include?

-   How should DNR orders be managed in the context of adverse events?

-   What are the provisions of VHA handbook 1004.04, "State Authorized
    Portable Orders" which was released in June of 2007?

**Dr. Berkowitz:**

Thank you, Susan -- again, summaries of all of the calls can be found on
the Center's Web site. Years of discussions around DNR related themes
have informed ethical thinking and policy development in this area! The
interest in learning about the nuances of DNR orders remains quite
strong and thinking in this area continues to evolve; in the last six
months alone, the Ethics Consultation Service has received several
requests about the writing of DNR orders for persons with suicidal
behavior or risk, a topic we are beginning to consider as a possibility
for a future NET Call. I would like us to spend the next few minutes
delving a little deeper into how discussion and thinking about DNR
orders have evolved within VA, and how the NET Call series has tracked
and informed this evolution. Dr. Owen, could you take us back to the
year 2000 and discuss the first call on this topic?

**Dr. Owen:**

The first call focused in part on who may write DNR orders, with the
policy being that the physician who is responsible for determining the
propriety of a DNR in a particular case is the senior attending or staff
physician is responsible. The question about who can actually enter a
DNR order -- and why -- has evolved over time and persists to this day.
The Center has interpreted policy to allow house staff to write DNR
orders transiently under certain limited circumstances with the
Attending retaining responsibility for the decision making; the issue of
whether additional mid-level practitioners, such as Physicians
Assistants or Nurse Practitioners, can also write such orders, remains
under review.

**Dr. Berkowitz:**

Ms. Chanko, could you describe the issues that relate to ongoing
discussions of DNR orders that were raised in the next call entitled,
"Recent Reports from the VHA National Ethics Committee: DNR Orders and
Medical Futility and Advance Proxy Planning for Residents of Long-Term
Care Facilities Who Lack Decision Making Capacity," which was held in
June of 2001?

**Ms. Chanko:**

Certainly. This call discussed the issue of whether or not a physician
may unilaterally enter a DNR order based on grounds of futility.
According to policy, futility is not permitted as a basis for writing a
DNR order. This has not changed over time. Futility judgments are value
judgments that reflect beliefs about quality of life that no one other
that the patient or authorized surrogate can make.

The NET Call endorsed a procedural approach to disputed judgments about
futility that is outlined in DNR policy, VHA Handbook 1004.3. This
approach involves a process that emphasizes procedural justice in
working through these dilemmas.

Again, it is important to emphasize that now, as then, futility cannot
be used as a reason that a physician would unilaterally impose a DNR
order on a given patient or surrogate without their permission.

**Dr. Berkowitz:**

Another call,**"**DNR, Family Presence During Resuscitation" that was
held in August, 2001, is comparatively straightforward. The call
discussed reasons for and against family presence during the process of
resuscitation, reflecting a consensus that family presence is ethically
justified if the family wants to be there, and there are adequate
safeguards and supports in place.

Another DNR-related NET Call entitled, "Do Not Resuscitate Policy
Revision: Controversial Topics", was conducted in March 2002, several
months before the current VHA Handbook 1004.3 was released. This was a
particularly pithy call. Dr. Owen, could you provide an overview of the
topics discussed during this call?

**Dr. Owen:**

Certainly. This call reviewed the process of policy revision. We also
discussed two other topics, whether or not a person should have to be
terminally ill in order to have a DNR order, and the restriction on the
authority of house officers to write DNR orders.

This change was consistent with sentiment expressed on the NET call in
2002! The requirement that a patient be terminally ill to be eligible
for DNR status was eliminated when VHA Handbook 1004.3, was released in
October of 2002. Since then any patient who feels that application of
cardiopulmonary resuscitation would be contrary to their wishes and
interests can be made DNR.

This call also anticipated the future role of out of hospital DNR orders
stating "...the issue of out of hospital DNR is definitely one of the
issues we are going to take up and we will work with our working group
and with Counsel to see how we can come up with a policy that makes
sense." Out of hospital DNR orders was a topic that was discussed again
in 2007, and addressed at least in part through the creation and release
of a new policy on state authorized portable orders that we will
consider in a few minutes.

**Dr. Berkowitz:**

The fifth DNR call in the National Ethics Teleconference Series,
**"**What Does DNR Really Mean?" was held in June, 2005. The purpose of
this call, which was followed by a FAQ entitled DNR (Do-Not Resuscitate)
Orders, was that of a refresher to make sure that participants could
answer question such as the following:

-   What interventions are included in CPR?

-   When may a DNR order Be Written?

-   Who may write a DNR order?

-   Should other life-sustaining treatments be provided when a patient
    has a DNR order?

-   How do DNR Orders relate to advance directives?

-   What should practitioners do when family members disagree with a DNR
    order?

The answers to these questions remain the same as a FAQ sheet was
released as pat of the NET Call follow-up in July, 2005; a link to it is
on the Ethics Center's website and will be provided in the follow up to
this call.

Moving on, Ms. Chanko, could you talk about another NET Call topic, DNR
orders in the setting of adverse medical events?

**Ms. Chanko:**

This call was occasioned by several situations brought to the attention
of the Ethics Consultation Service when a person with a DNR order
experienced a cardiopulmonary arrest for an unanticipated reason; i.e.,
an unexpected intervening event unrelated to the patient's underlying
disease. For example when a DNR patient in a nursing home drowned while
bathing, or a DNR patient arrested from massive bleeding after a central
line insertion, the team was unsure whether or not to attempt
resuscitation despite the DNR order.

This call provided a good opportunity for faculty to double-back and
reiterate the differences between DNR orders and Advance Directive
documents. For example:

-   A DNR order is a medical order written by a physician. An advance
    directive is a document authored by a patient.

-   A DNR order applies immediately. An advance directive applies only
    after the criteria specified in the advance directive.

-   A DNR order is a clear, unequivocal instruction to practitioners not
    to initiate CPR. An advance directive requires interpretation before
    implementation; and

-   DNR orders refer only to withholding resuscitative efforts during a
    cardiopulmonary arrest. Advance directives should be used to express
    goals of care and preferences regarding a much broader array of
    treatments.

This call also provided the opportunity to reiterate and emphasize
several procedural safeguards included in our DNR policy that help
assure clear communication between providers and patients about DNR
orders: e.g.,

1.  discussion is required prior to writing a DNR order;

2.  the attending physician must honor the patient's wish and cannot
    write a DNR order without the patient or surrogate's approval;

3.  VHA does not allow automatic suspension of DNR orders for the
    operating room and procedures, but rather planned intervention
    requires prior review and reconsideration of existing DNR orders.

The ethical conclusion -- then and now -- is that, in order to respect
patient autonomy, DNR orders may be disregarded only in the rarest of
circumstances: i.e., if the DNR order was written in error or it is
clear that it doesn't represent patient's wishes. Along with that, it is
imperative that communication and education about the exceptionless
aspect of DNR orders be made absolutely clear to patients and/or their
authorized surrogates when they consider authorizing DNR status.

**Dr. Owen:**

In the most recent NET Call relating to DNR orders held in July of 2007,
"State Authorized Portable Orders and Out-of-Hospital DNR Orders and
Orders for Life-Sustaining Treatment" were discussed and we shared
Important News for VHA about a new policy.

The release of VHA Handbook 1004.04, "State-Authorized Portable Orders"
was important news in more ways than one. Beyond the obvious fact that
for the first time it allows VA to honor its commitment to patient
autonomy across the continuum of care, the release of this handbook
reflects an arc of progress that began with the first NET Call
discussion of DNR orders in 2000, and included the discussion of out of
hospital DNR orders in 2002.

Before we turn to the final example we will discuss today of how the NET
Call series track ethical and policy evolution within VHA, it is
important to emphasize one fact about the process of planning the NET
Calls. We work to connect the calls by periodically revisiting important
ethical topics and keeping participants informed about policy
developments and thinking about controversial ethical issues. We believe
that the group of seven NET calls related to DNR orders provides an
excellent example of how the Calls both educate participants and bring
the voice of the ethics community to the table to inform VA thinking.

**Dr. Berkowitz:**

On that point, it is striking again to me to look back and see how the
NET Calls related to DNR orders have tracked and informed VA thinking in
this evolving area. Without participation from you -- our listeners and
members of the VHA ethics community -- the value of these calls and
subsequent related activities would be diminished greatly. In short, we
rely on our ethics community, and NET Calls is one way that we tap into
you; I thank all of you for your contributions! Thus far we have focused
on two domains and topics -- limits to patient choice within the domain
of shared decision-making and DNR orders within the domain of ethical
practices in end-of-life care \-- to illustrate how participation in the
National Ethics Teleconference series enables staff "in the field" to be
"ahead of" and "part of" the ethics curve within VA. A side benefit of
this retrospective is a review of several key issues in health care
ethics. We turn now to calls that focused on the topics of disaster
medicine, SARS, and Pandemic Flu, and cut across the domains of resource
allocation, professionalism, and everyday workplace.

Returning to you, Ms. Chanko, could you provide a context for this
discussion?

**Ms. Chanko:**

Certainly. Recently, the Ethics Center participated in a satellite
broadcast on the ethical considerations in the planning for Pandemic
Flu. The Ethics Center has been centrally involved in this planning in
VHA. Ethics Center materials covering "Ethical Issues in Pandemic
Influenza Preparedness" can be accessed on the National Influenza
Exercise website; a link will be provided with the follow up to this
call. The White House has tasked the Department of Health and Human
Services (HHS) to take the lead in developing guidance for allocating
scarce health and medical resources during a flu pandemic. In concert
with HHS, the Ethics Center is developing guidance to assist VA
facilities, including a detailed discussion of ethical values that
inform the plan.

Ethics Center leadership and participation in this planning process
reflect discussions of disaster medicine spanning back to soon after
9/11 that is documented in three NET Calls: "Disaster Medicine: Unique
Ethics Challenges" (April 2002) ;"Health Care Ethics Issues Raised by
SARS" (June 2003); "Influenza Pandemic Preparedness Planning: Ethics
Concerns" (June 2006).

Those of you who are familiar with the Ethics Center role in pandemic
flu preparedness, including the preparation of educational materials to
assist local facilities, will find it very interesting to look back at
the earlier calls, which identify and anticipate key ethical issues
about disaster management that we are currently discussing in relation
to pandemic flu: e.g., the necessity for a shift from individual, to
public health ethics, which focuses on how best to achieve the greatest
good for the greatest number; the importance of planning in advance how
situations of scarcity will be handled; the necessity for clear, fair
and consistent triage processes when resources are limited;
consideration of the clinician's duty to treat, despite sacrifices to
him or herself; the role of the institution in helping to ensure that
staff both have the safest work environment possible and know how
important they are to the success of the plan; and in providing ways to
assist staff in meeting other obligations, for example, to their
families..

**Dr. Berkowitz:**

A final objective of this particular call is to learn how the National
Ethics Teleconference series has influenced structures and practices to
improve ethics quality within VHA. We have already devoted a
considerable time in today's discussion to showing how the series has
influenced quality through continuous education about critical domains
and topics of ethics in health care. The series has played an analogous
role during the period of time that IntegratedEthics was first discussed
until its recent implementation at all facilities.

In this case as well as those previously discussed, participation in the
NET Calls will help you be ahead of the curve regarding quality
improvement, through implementation of IntegratedEthics, and in
particular the use of the CASES approach to Ethics Consultation and
ECWeb.

Throughout the series, the NET Calls have focused regularly on ways to
improve quality within VA. This trajectory includes a discussion of
"Core Competencies for Ethics Consultation" in 2002; a description of
"CASES: A New Approach to Ethics Consultation" and "The IntegratedEthics
Initiative: What it Means for Your Facility" in 2005; a review of
"Informed Consent Practices: Lessons Learned from Implementing
iMedConsent" in 2006 and a celebration of the launch of the
IntegratedEthics Initiative in 2007.

The Ethics Center is committed to improving ethics quality throughout
VA. Precisely because the NET Call series is flexible and prepared in
real time, the calls can play a significant role in responding to ethics
concerns of those in the field and serve as a vehicle to both educate
and disseminate information regarding the release of policies and
initiatives. Discussions on our NET Calls inform our thinking on ethics
topics.

Before we turn to today's discussion portion of today's call, I would
like to reiterate that thinking about key topics ethics in health care
has evolved during the course of the NET Call series and that the series
has tracked, informed, and sometimes driven this evolution. I hope we
have shown how central the participants are to the interactive forum
that the NET Calls are designed to be, and again can't thank all of you,
as well as staff and leadership at the Ethics Center, EES, VANTS, and
other VA staff enough for your participation, help and support over the
years.

We try to identify ethics topics that will allow us to weave the subtle
balance of education, open discussion, and evolution of thinking into
this series. If you have ideas for such topics please let us know, this
is your series as much as it is ours!

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

We saved plenty of time for you -- our listeners -- to continue the
discussion.

-   What do you like about the NET calls?

-   What can we do better?

-   Are there topics we're missing?

-   Or things we can do to make the NET calls easier to listen to, more
    fun, or more approachable?

-   Would you like accompanying slides? Or would that be overkill?

**Ms. Mason, Sacramento, CA:**

I'm Preventive Ethics Coordinator for the Northern California Health
Care System. I think that it would be helpful to have slides because of
the different learning styles that people have. I know that I'm more
visual and I try to jot down notes; auditory is difficult for me, so I
would find it helpful. Thank you.

**Dr. Berkowitz:**

Great, thank you.

**Dr. Lowery, Durham, NC:**

I'm the IntegratedEthics Program Officer in Durham. I'd first like to
say thank you to all of you for these NET Calls and all the things that
you've done for those of us in the field. It's just been tremendously
helpful. As for the issue with the slides, I think that would be helpful
in part because we take this information and go and educate people
within our own facilities. If we have some materials to start with, it
really helps to cut down on preparation and prevents us from having to
reinvent the wheel each time. So any of those kinds of materials would
be greatly appreciated.

**Dr. Berkowitz:**

Thank you, Jill, and thank you for being a part of our ethics community
for the many years that we've known you. Do people like the topics that
we're picking? Do people think that we're on point, that we're on a
level that people want to hear these discussions?

**Ms. Underhill, Canandaigua, NY:**

This is Sue Underhill from Canandaigua and I do find these topics very
valuable. In the future, I would like maybe to see a call explore the
Medical Orders for Licensing and Treatment (MOLST) that have been
approved for New York State. I would like to see how that could be
addressed and utilized within the VA system for continuity of care
across settings.

**Dr. Berkowitz:**

Thank you, Sue, that is a great topic. I'll refer you to the July 2007
call, "State-Authorized Portable Orders: Out of Hospital DNR Orders and
Orders for Life-Sustaining Treatments, and to VHA Handbook 1004.04 on
state-authorized portable orders. Handbook 1004.04 covers a lot about
MOLST forms, what they are and how to use them. Those two resources
should get you going. But we'll also put this on the list for further
thinking about a NET call to cover things that aren't covered here. So
thank you. I also want to point out to people as we always say, if you
have a topic or there's something on your mind, send it into to us at
vhaethics on the Outlook system, indicate that it's a suggestion for a
NET call topic, and we will definitely add it to the list for
consideration. And again many of the topics that we get do come from
suggestions.

**Ms. Chanko:**

This is Barbara. I'd just like to add to that. At times, we'll put out a
NET call on a topic, so let's just talk about state-authorized portable
orders as an example, and generally those come out when a Handbook has
just been released. The purpose is really to help guide staff in the
field as they begin to implement those new handbooks and those new
policies. But it's often important if folks feel like they need a call,
to sometimes revisit those topics. Especially after people have begun to
implement the policies, they may find new challenges that they hadn't
anticipated. Sometimes a venue like the NET call is a good opportunity
for people to talk about how the implementation is going and to help
each other as they begin to implement these policies, which often are
very complex when it gets down to the actual nuts and bolts of
implementation.

**Dr. Berkowitz:**

When we do these NET calls about new policies and implementation, we
really try to be very practical, and to address things that people will
be thinking about. Have people found this to be the experience, as
people think back on them?

**Ms. Underhill:**

I think the timing has been really good with the NET calls to support
what is actually going on at the time in within the VA system.

**Dr. Berkowitz:**

Great. That's good to hear, because we really do try to do that.

**Ms. Wright, Little Rock, AK:**

Hi, this is Candy Wright from Little Rock. I'm the Consultation
Coordinator and I just want to second that suggestion about the
state-authorized portable orders. How are others handling those that are
received across state lines? We've pretty much got things solidified for
the Arkansas portable orders, but my interest concerns questions about
what to do when we receive a patient from another state if they have a
portable order.

**Dr. Berkowitz:**

Candace, you know if you have specific questions, you can always send
that to us at vhaethics and you know we try to get back to you as soon
as we can.

**Ms. Wright:**

Yes, and I so much just want to indicate my appreciation also. In
researching an ethics question, such as smoking and home oxygen and
those different things, you can pull all the books together off the
shelf and look up laws and so forth, but to have the Ethics Center data
and position, the VA Ethics Center, is very supportive, emboldening us
as we put forth our recommendations.

**Dr. Berkowitz:**

Thank you for those nice words. Usually when we have these discussions,
we tend to be much more directed, we can predict what things people are
going to want to talk about and how much time to leave. Today, we've
tried to talk a little bit longer because we actually thought that
people might not have that much to say about the NET calls and I think
that I'm sort of hearing that. We don't have to go the full hour if
people want to stop before the hour, that's fine. We can, in addition to
the NET call series, give you a gift of 10 minutes. But I do want to say
that we can take as much time as you want up to the top of the hour. Are
there any further thoughts about any of the topics that we talked about
concerning the NET calls as a series, or in the spirit of our "From the
Field" section, do you have any other ethics related topics on your
mind?

**Dr. Conti, Indianapolis, IN:**

This is Andy Conti from Indianapolis and I'm the IE Board Chairperson.
The one thing that I'm wondering about for consideration in the NET
calls is once you go through the planned discussion on a topic, would
people find it helpful or would you all be in tune to the possibility of
giving a case example where you work through that particular topic in
the CASES approach to give us some practical help on the CASES approach
to some of those topics?

**Dr. Berkowitz:**

I think that's a really interesting suggestion that I hadn't really
thought of. Has anybody got any comments?

Second the motion?\
\
**Ms. Wishner, Long Beach, CA:**

It's Denise in Long Beach. I agree also, I think that would be a good
idea.

**Dr. Berkowitz:**

Great. What we could do would be to think about and tie the discussion
to the steps in the CASES approach and the steps that we would tell
people to go through, thinking about either how to approach a particular
ethics consultation or how to apply the ISSUES approach and the
preventive ethics materials. So we could tie some of the discussions and
presentations about topics to what we've been saying about the
implementation of IntegratedEthics. People might find it useful to think
about some of those different areas. Great suggestion. We'll definitely
consider that. Any other reactions to that or anything else?

**Ms. Wright:**

This is Candy again. Along that line, I presume that the National Center
reviews the ECWeb consultations, at least perhaps a percentage of
responses. And I've often wondered when I enter a consult response into
EC Web -- is this way off base or have I forgotten something key to this
that should have been included, and perhaps this might inform the
scenarios to be developed for the conference calls.

**Dr. Berkowitz:**

Thank you, Candace. I want to clear up one misconception right off the
bat. We do not go in and review your local facilities ethics
consultation records unless we tell you that we are going to do that. It
is certainly not our intent at this point, or our desire really, to get
in the habit of looking into other people's consultation records. We do
generate reports of aggregated data and we certainly can think about
statistics. That gives us a good idea as a whole in an aggregated way
what people are doing, the processes they are following, and what parts
of the CASES approach they are using or not. These reports also provide
information on whose requesting ethics consults in our system, about
which patients, and which domains and topics those consults fall in. But
we really do not review your records. So if you want help with a
particular record or if you want us to talk to you, if you're unclear
about what's going on in a particular consult, we're definitely
available for all that kind of consultation or technical assistance at
the Ethics Center. I really want to emphasize again that we don't go in
and look at all your records.

**Ms. Wright:**

Thank you. I appreciate that information.

**Caller, Muscogee, OK:**

I agree on the value and appreciate the effort expended in preparing
ethics conferences of the past. We've never really assessed or thought
about the ethical concerns of staff: the case managers, even the initial
interviewers. I wonder if there is a possibility of addressing some of
those issues.

**Dr. Berkowitz:**

I think that that's a really good point. Those of us who were last week
at the American Society of Bioethics and Humanities meeting attended
several presentations on moral distress. I think that may be at least
part of what you're getting at: moral distress that staff feels in
delivering health care, and then as a separate topic maybe moral
distress that people feel or experience by being ethics consultants. You
know it's not without some price that comes with that. We rarely add
ourselves to that list. Is that the type of thing that you were thinking
about?

**Caller:**

I was thinking about sometimes the conflict that the case manager may
have, both with the family, with the physician too. It gets into whose
on first or who has the last say, but that leaves the case manager
perhaps in a difficult position.

**Dr. Berkowitz:**

Right. And again we're very sensitive and I think need to be more
sensitive to that type of moral distress that people feel. I know from
the literature that if its not addressed properly, it can lead to what
is sometimes referred to as moral residue, and that can lead to burnout,
dissatisfaction, staff turnover, etc.

I think that there's also some sort of an overlap here with issues that
some are facing in the domain of professionalism, and some of this has
to do with people's responsibilities and duties and thinking about their
professional roles. So great suggestion and we'll add this to the family
of thinking on our topics list.

**Caller:**

Thank you.

**Dr. Berkowitz:**

Anyone else? OK. I think then that we'll take today's prerogative to
wrap it up five minutes early and as always, I say thank you all. Have a
good day. I again want to thank everyone whose worked hard on the
development, planning and implementation of this call. It's not a
trivial task. I really appreciate everyone's effort, including those of
the Ethics Center staff and EES staff and VANTS staff that support these
calls. Again, I'll direct you to our website at
<http://vaww.ethics.va.gov/>

for all the summaries of prior national ethics teleconferences. If you
are on our email list, you'll receive details about the posting of the
summary of this call and the follow-up and the announcements for the
next NET Call, which is scheduled for Tuesday, November 25^th^, 2008, at
noon ET. Stay tuned to your Outlook e-mail for further details of that
call when the time gets closer.

**Ms. Chanko:**

And maybe we'll have slides for you.

**Dr. Berkowitz:**

Maybe we'll have slides for you, but no promises yet. And again, any
suggestions for topics or anything you have to say, you can reach us at

<vhaethics@va.gov>

Thank you all, and have a great day.

**REFERENCES**

VHA Handbook 1004.2. "Advance Care Planning and the Management of
Advance Directives."

VHA Handbook 1004.04. "State-Authorized Portable Orders."

VHA Directive 2006-021, "Reducing the Fire Hazard of Smoking When Oxygen
Treatment is Expected."