I. Suggested Steps

1. Secure leadership buy-in

Institution leadership approval and support is essential for an effective ethics committee. Considerations should be clarity about available resources prior to setting up the committee.

2. Educate staff

Involve staff in a needs assessment to identify areas that require education and policy analysis, and to give staff an opportunity to share ethical concerns at the facility.

3. Choose committee members and a chair

The chairperson should be a good moderator and one who is committed to open discussion when cases are presented. 

4. Train committee members

Provide the necessary education/tools to committee members. Consider having an established ethics expert provide initial ethics training in the principles and methodologies of ethical deliberation. 

5. Identify guiding principles

The committee should identify guiding principles and an ethics analysis framework for deliberations.

6. Write Policies and Procedures

Before developing formal policies and procedures, it may be helpful to start by developing a committee charter that describes the composition, mission, structure, and functions of the committee. This can become the basis for more formal policies and procedures. 

The policies should begin by stating the purpose and mission of the ethics committee. They should then address the following general issues:

  • The goals of ethics consultation and the ethics committee.
  • Who may request ethics consultations.
  • Who may perform ethics consultations.
  • What requests are appropriate for the ethics committee.
  • How participants’ confidentiality and, when appropriate, anonymity, will be protected.

Among the functions and purposes of the ethics committee, the following may be included:

  • Increasing awareness of ethical issues and dilemmas in LTC.
  • Developing policies and procedures relevant to ethical issues.
  • Contributing to proper management of ethical issues and dilemmas.
  • Developing mechanisms to enhance the autonomy of LTC residents.
  • Respecting individual residents and staff (the stakeholders).
  • Facilitating teamwork.
  • Educating staff, residents, families, administration, and the committee itself in ethics principles and methodologies.
  • Dealing with ethical issues transparently.
  • How the committee will identify and initiate an ethics consult.

The issues that should be covered may include:

  • Who may contact the ethics committee.
  • How the ethics committee is to be contacted, both during working hours and at night or on weekends and holidays.
  • How the ethics committee will perform initial fact-finding to determine the appropriate way the conflict is to be handled.
  • What is the method for case analysis.

  • How the ethics committee will report its findings and recommendations, including documentation guidelines.

    Who may contact the ethics committee

    Generally speaking, it is advisable that any person can contact the ethics committee. Obviously, the patient or resident is the primary focus, but family members, staff, and other relevant personnel should also have access.  It will be up to the ethics committee to  determine the appropriate course of action. The committee may serve as a resource for attending physicians facing troubling choices or conflicting care demands.

    How the ethics committee is to be contacted, both during working hours and at night or on weekends and holidays

    It may be most convenient to set up a dedicated phone line with voicemail to allow easy contact with the ethics committee. In addition, it would be advisable to distribute a flyer or pamphlet describing the purpose and function of the ethics committee, including not only the ethics “hotline,” but the names of key members who can be contacted. A mechanism would need to be instituted to ensure that the “hotline” is checked regularly.

    How the ethics committee will perform initial fact-finding to determine the appropriate way the conflict is to be handled

    It is impractical to immediately involve the entire committee once a request for ethics consultation has been received. The committee will need to decide how the initial assessment of the case will be made. One option is to have an individual evaluate the case and determine whether a full committee meeting is necessary. Another option is to designate rotating teams of two or three members to evaluate and triage the case. Some requests may have relatively straightforward solutions and will not require the full committee to be convened. 

    What is the method and timeline for case analysis

    Whereas it is not necessary to indicate the specific methodological analysis that will be used for deliberating ethics cases, it is best that one or more structured formats be adopted by the committee.  

    There may also be cases in which the full committee may need to meet with the resident, family, or healthcare team. The policies and procedures need not specify when this is appropriate but should allow for the attendance of key involved individuals when appropriate.

    How the ethics committee will report its findings and recommendations

    One of the most controversial and contentious issues facing ethics committees is whether its findings and recommendations should be recorded in the medical record. A variety of viewpoints exist; however, it is probably a good idea to document the deliberation and recommendations of the ethics committee in the medical record. 

    It is also a good idea to maintain clear minutes. The committee should confer with facility counsel to determine how these are best maintained and the impact on discoverability.

7. Establish committee processes:

  • Select an appropriate meeting frequency.
  • Establish an agenda for a meeting.
  • Determine what criteria must be met for the committee to review a case.
  • Decide how the results of committee deliberations and decisions will be documented. It is probably a good idea to document the deliberations and recommendations of the ethics committee in the medical record.
  • How will the meeting minutes be maintained? The committee should confer with facility counsel to determine this.

8. Pilot the process

Test the process and deliberate, and then modify it as required.

II. Education

The education of committee members is crucial to establishing and maintaining a successful ethics committee. There are several dimensions to this phase of committee development (modified from an article by Winn and Cook, Annals of Long-Term Care 2000;8:35-42). It is essential to foster open discussion, cultivate respectful interpersonal relationships, and promote trust. Components of the education process are as follows:

  • Explain and discuss the goals and objectives of the committee
  • Set a realistic agenda
  • Review and discuss ethical principles in healthcare
  • Review and discuss models of ethical decision-making
  • Determine the format of education, such as:
    • Article review
    • Case illustrations
    • Retrospective case review
    • Invited speakers
  • Identify resources, personnel, literature, costs, and budget.

First and foremost, the facilitators should discuss the rationale that has brought about the decision to establish an ethics committee in the LTC facility. The steps leading up to the convening of the first committee meeting should be carefully reviewed, while encouraging interactive discussion when needed to clarify questions, issues, or concerns.

Second, a copy of the proposed guidelines for the ethics committee should be distributed and discussed. The committee members should be given the opportunity and the authority to decide minor changes in the guidelines that reflect the culture and perspective of the committee members, as long as the proposed changes do not contribute to liability. Legal counsel input may be needed but often can be given quickly if the counsel is a member of the committee. Both establishing a process of discussion and encouraging self-direction of the committee are very important to promoting trust between the committee and the facility management, which is key to the continued functioning of an effective committee.

Third, the time commitment of members must be discussed. During the initial education phase of the committee, meetings generally should be held monthly or every other month, with each meeting lasting 1 to 2 hours. Any member who is not able to fulfill such a time commitment should be allowed to resign so that another member can be appointed.

Fourth, the confidentiality of committee discussions should be reviewed. The committee must decide whether to keep minutes. If minutes are to be kept, then a secretary should be designated and appropriate precautions taken to ensure confidentiality of the minutes.

After the completion of these steps, the committee should be ready to proceed with its self-education. The committee facilitators (and consultant, if one is available) will need to set a realistic schedule and determine when the basic education of the membership should be completed. Once completed, the committee may decide to meet less regularly; quarterly meetings are usually sufficient.

Several educational formats may be used to encourage member interest, interaction, and continued participation. These formats include article review, case illustrations from texts or practice, and invited speakers. For committees that have been functioning for more than 6 months to 1 year, case consultation and retrospective case review are other educational opportunities.

As new members join the committee, their introduction to the new role and to the committee should be as comprehensive as when the committee was first formed.

III. Core Competencies

Ethics committees in LTC nursing facilities will face issues that generate requests for consultation from a variety of domains. These may include, but may not be limited to, the following:

  • Ethical dilemmas arising from caring for older adults in the face of declining functional capacity
  • Ethical dilemmas arising from transitions of care and placement of older adults
  • Ethical dilemmas arising from care near the end of life
  • Decision-making processes and assessment of capacity for informed consent in residents with various levels of impaired cognition
  • Shared decision-making processes with the patient, family, or legally authorized representative when the resident’s decisional capacity is declining
  • Maintaining resident privacy and confidentiality in the facility
  • Professionalism of medical practice in the nursing facility
  • Ethical issues of resource allocation in the facility
  • Ethical issues in business and management in the facility
  • Ethical issues for staff in the workplace, including moral distress
  • Ethical issues involving research in the facility (however, the ethics committee is not an institutional review board [IRB])
  • Ethical issues regarding the validity or interpretation of advance directives executed before admission to the facility

To provide a setting in which consultations involving issues from these various domains may be effectively performed, a nursing facility ethics committee should manifest each of several core competencies, either collectively or through at least one member of the committee.  

A nursing facility ethics committee must have, through its members, certain assessment and analysis skills, including the ability to:

  • Identify how much uncertainty or conflict underlies the need for consultation
  • Access relevant ethics literature, policies, guidelines, and standards

A nursing facility ethics committee must have, through its members, certain process skills, including the ability to:

  • Establish expectations for consultation and determine whom to involve
  • Utilize institutional structures and resources to facilitate the implementation of a chosen option
  • Communicate and collaborate with other responsible individuals, departments, or divisions within the institution
  • Facilitate formal meetings
  • Document and communicate consultative activities
  • Identify systems issues and delegate follow-up
  • Evaluate the consultation process and provide quality improvement
  • Effectively run a consultation service in the facility

A nursing facility ethics committee must have, through its members, certain interpersonal skills, including the ability to:

  • Listen well and communicate interest, respect, support, and empathy to residents, family members, staff, and other involved parties
  • Educate residents, family members, staff, and other involved parties regarding the ethical dimensions of the issue generating the consultation
  • Elicit the moral views of the resident, family members, staff, and other involved parties
  • Represent the moral views of residents, family members, staff, and other involved parties
  • Enable all involved parties to communicate effectively and be heard by other parties
  • Recognize and attend to various relational barriers to communication

A nursing facility ethics committee must have, through its members, certain knowledge competencies, including knowledge of:

  •  Moral reasoning and ethical theory as it relates to healthcare ethics consultation
  • Bioethical issues and concepts that typically emerge in healthcare ethics consultation in the nursing facility
  • Healthcare systems as they relate to ethics consultation in the nursing facility
  • Clinical context as it relates to ethics consultation in the nursing facility, particularly geriatric issues and syndromes, as well as patterns of the trajectory of functional decline in older adults
  • The particular healthcare institution in which the committee is working, as it relates to ethics consultation
  • Local healthcare institutional policies relevant to ethics consultation
  • Religious, cultural, and moral beliefs and perspectives of the resident and staff
  • Relevant codes of ethics, professional conduct, and guidelines of accrediting organizations as they relate to ethics consultation
  • Health law relevant to ethics consultation

This section was adapted and modified from: Core Competencies for Healthcare Ethics Consultation, 2nd ed.  2011. Glenview, IL: American Society for Bioethics and Humanities. Modifications were made by members of the PALTmed Ethics Committee to tailor the competencies to the specific task of a Long-Term Care Ethics Committee.