There are several models for systematically evaluating and analyzing dilemmas in medical ethics. LTC may utilize any of those models. One of the most commonly used models is the Four Topics Model devised by Jonsen et al. This is a case based approach that allows an organized review of the facts and issues in a given case, according to four topics: medical indication, patient preferences, quality of life, and contextual features. Each topic or box represents a systematic means of organizing the questions related to corresponding ethical principles. 

  • Under the topic "medical indications“ are questions that determine how the facts of the case determine what constitutes beneficence and nonmaleficence. 
  • The topic “patient preferences” contains questions that establish the patient’s autonomy and how that autonomy fits into the ethical issue at hand. 
  • “Quality of life” contains questions that further clarify what is considered beneficence and what is considered nonmaleficence, according to patient’s own values. 
  • “Contextual features” contains grouped questions that tease out other influences on the case and incorporate principles, such as loyalty and fairness.

Once the facts of the case are organized, it is important to identify the ethical dilemma(s), if any.

open the four topics model

Reproduced with permission from Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 9th Edition. New York, NY: McGraw Hill. 2022

Establishing and Conducting Ethics Deliberations in Long-Term Care

Creating the Forum for Ethics Deliberation

Ethical issue deliberation may be undertaken in several ways depending on available resources for LTC.

Ways to Conduct Ethics Deliberations.

In person: in person interaction between committee members. It may be difficult for everyone to make it in person.
Telehealth (telephone, video) : a viable option.  More people may be able to join in discussion.   Disadvantage: lack of in -person interaction, technical challenges if phone line is down or slow internet connection (for video)

Addressing Ethical Consideration at Facility

Facilities should have a clear set of policies and procedures (ethics committee or otherwise) in place to address ethical issues that may arise.  Policies and procedures should be sufficiently specific to address the most common ethical issues, but not so detailed or extensive that compliance becomes challenging.

These policies and procedures should also be in compliant with state and federal laws and regulations governing commonly occurring ethical issues.

Federal regulation 42 CFR 483.85(c)(1) requires nursing home to have a compliance and ethics program that develops standards, procedures, and policies vis-à-vis ethical issues.
Staff at the facility should receive education as to whom/where/how to contact when they come across ethical challenges at the facility.