Abstract
OUTCOMES: 1. Describe the components of CASE, a US Department of Veterans Affairs clinical ethics consultation tool and opportunities to resolve ethical dilemmas near end of life. 2. Identify resources and collaborative opportunities for inpatient palliative care and ethics consultation teams caring for dying patients and distressed families and healthcare providers. BACKGROUND: Ethical dilemmas commonly complicate care and comfort near end of life. Family members and providers may especially experience ethical dilemmas when surrogates are required for patients without capacity or known wishes. The US Department of Veterans Affairs (VA) aims to improving ethical quality through its implementation of a standardized approach to ethics consultation based on consistent and systematic use of widely accepted ethical standards and norms and by recruiting consultants from the interdisciplinary team. CASE DESCRIPTION: An 87-year-old hospitalized veteran with low blood pressure and hypoactive delirium was identified as seriously ill and at high risk for imminent death. The cosurrogate daughters reported their mother shared no prior preferences for care near her end of life. Despite early palliative care team involvement, the daughters could not reach treatment decisions and reported their own moral distress. After 10 days, concerned nurses called for an ethics team consultation to “help with patient suffering and family disagreement.” The palliative care team and the ethics team together applied the novel VA ethics consultation model and collaboratively addressed the ethical dilemma, aligned care to maximize comfort, and alleviated staff moral injury. DISCUSSION: We will describe the structure and application of the VA Ethics Consultation Program's CASE approach (clarify, assemble, synthetize, explain, support) as a tool with which palliative care teams may effectively resolve surrogate conflict near a loved one's end of life when no prior preferences are known. Through CASE methodology, including review of substituted judgment/best interest standards and specific negotiating techniques, the ethics and palliative care teams supported successful quality outcomes for the patient, family, staff, and the healthcare system. CONCLUSION: A systematic approach of ethical reasoning, such as CASE, can support interdisciplinary palliative care teams to resolve ethical dilemmas while improving quality outcomes when death is expected and imminent.
