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Educational Resources: Appendices

Appendix A9

Steps on the road to a new clinical ethics committee

Graham Behr and Jon Ruddock, Central and North West London Mental Health NHS Trust

1. A core group of three clinicians (two consultant psychiatrists and one senior nurse) drove the process (and each other) from the outset.

2. Experience of established CECs was obtained by joining a local Acute trust CEC and visiting other CECs.

3. Core group attended training events through ETHOX and Imperial College, London.

4. Liaison with other new CECs was established (via ETHOX) and details of their functioning obtained (for example their remit, composition, process of selection, administration, and issues of liability and accountability).

5. The core group decided on local priorities to shape the remit of our CEC.

6. Discussions were then opened with the Medical Director

7. This was followed by a presentation of the proposal to the Trust-wide consultant meeting to sound out the reception such a committee might have, elicit concerns and involve consultants from the outset to avoid their being alienated.

8. Further discussions took place with the Chief Executive preparing the way for a formal proposal to the Trust Board.

9. Then followed a formal proposal submitted to the Trust Board with opportunity for the Board to put questions directly to the core group.

10. Following Board approval further meeting were held with the Chief executive to discuss particularly the composition of the CEC and begin seeking an independent chair (whom the Chief Executive subsequently appointed in consultation with the core group).

11. The core group then selected both the special members (lay person, religious representative, philosopher, lawyer etc.) as well as clinicians from within the Trust.

12. The ‘special’ members were selected by informal process; whomever the core group felt would do the job best was approached. However, for reasons of equity, a more formal process was adopted for clinicians. Explicit criteria were developed to judge suitability (Document 1), a Trust-wide advert was sent out on e-mail (Document 2) and applicants were short listed and interviewed by telephone. This process resulted in 24 applications and 10 interviewees for the four clinician places on the committee.

13. The Trust Secretary prepared contracts assuring confidentiality and indemnity which were completed by members before clinical discussions were embarked upon.

14. The CEC then invited referrals via Trust wide e-mail (Document 3). A pilot site was given priority for fear the CEC would be unable to meet the demand from the whole Trust initially. However, this turned out to be unnecessary (referrals have come in at a steady rate of about 1/month.)

15. The core group continued to meet between the monthly CEC meetings. This was both to iron out administrative issues (see pitfalls) and to develop a way of synthesising the discussions from the meeting into a format that was concise and helpful for the referrer, as well as forming the basis for a potential educational database.

Pitfalls

1. Having both a budget and an identified person for administration is essential from the outset. Vast amounts of clinician time were spent on administrative tasks and having this agreed from the outset would have smoothed the development of a functioning committee greatly.

2. The process, from conception to fruition, took two years in this instance. Clearly it need not take that long but the sorely tested patience of the core group was repaid by having a CEC which was acceptable to all stakeholders and whose composition allowed it to function effectively.

Document 1: Criteria for Clinical Members of the CEC

Criteria to enable short listing and interviewing

  • Interest in the subject of medical ethics
  • An ability to work in a group
  • A commitment to the group

Other considerations

  • To broaden range of clinical background
  • To broaden geographical representation
  • Prioritise bringing special knowledge/ability/experience

Process

  • Circulate ‘Expression of interest’ (EOI) form with core group contact details
  • Consider possibility of being on co-optee list
  • ‘EOI’ form has core members details for queries

Shortlist on basis of EOI then interview

Interview questions

  • Blurb about high interest and basis on which we are choosing
  • Clarify whether applicant is close to clinical decision making?
  • Would you be able to commit to a monthly meeting (e.g. every first Wednesday of the month 5.00- 6.30pm)?
  • What roles might this committee fulfil?
  • What case that you have encountered might such a committee usefully deal with in your view?

Document 2: Advertisement for Applicants for Members of the Clinical Ethics Committee

  • Should I divulge those details to his family?
  • Did she really consent to treatment as an informal patient?
  • At what point is my patient’s suicidality his responsibility rather than mine?
  • Why should I treat this patient; she wants treatment but has been unable to make use of anything offered?
  • How much of a threat must this patient pose before I feel we should withdraw treatment?
  • She says she chooses to live in squalor but is that a real choice she’s made?

These are the kinds of questions clinicians face every day in mental health. We often make them by consensus or by invoking a ‘senior’ opinion. Increasingly, however, clinicians across all disciplines and specialities are making use of clinical ethics committees to assist with decision making in complex challenging cases. There are currently over fifty such committees in the UK. This month CNWL has become the first mental health trust to establish such a committee.

The committee will comprise a chair (external), lay person, service user, lawyer, ethicist, faith representative and a number of clinicians.

If you are a clinician and:

  • have an interest in ethics
  • have expertise in ethics or some related field that would enrich the discussions
  • are willing to commit to a monthly meeting from 5.00 until 6.30pm for at least one year

...Consider applying to be a member of this committee!

In addition to the above criteria we will endeavour to represent clinicians from different disciplines and geographical parts of the trust.

Please note that this offer applies equally to employees of local authorities who are working within CNWL Trust structures.

If you are interested please send the following details to Dr Graham Behr

  • Name
  • Job
  • Site
  • Description of knowledge, skills or interest which would enhance the work of the committee

If there are more applicants than places available (four places available), a transparent selection process will be undertaken using the above criteria.

CLOSING DATE FOR APPLICATIONS IS FRIDAY 5 SEPTEMBER 2003

Document 3: Advertisement of Clinical Ethics Committee

CNWL now has a Clinical Ethics Committee (CEC), the purpose of which is to assist clinicians in making vexing clinical ethical decisions by reviewing them from an ethical perspective. Some examples might be:

  • At what point is my patient’s suicidality his responsibility rather than mine?
  • How much of a threat must this patient pose before I feel we should withdraw treatment?
  • She says she chooses to live in squalor but is that a real choice she’s made?

These are the kinds of questions clinicians face every day in mental health. We often make them by consensus or by invoking a ‘senior’ opinion. Increasingly, however, clinicians across all disciplines and specialties are making use of clinical ethics committees to assist with decision-making in complex challenging cases. There are currently over fifty such committees in the UK. This month CNWL has become the first mental health trust to establish such a committee.

The committee comprises of a chair (external), layperson, service user, lawyer, ethicist, faith representative and a number of clinicians who represent different disciplines and geographical parts of the trust.

The committee has begun to take on both casework and policy-related work. In an attempt to broaden the base of referral sources and increase access to the CEC, we are formally inviting referrals from all clinical professionals. However, to help us gauge the prospective volume of referrals, for the first month referrals are to be invited from one directorate. We would strongly advise that the service user’s care team is informed that the case is being discussed by the CEC, and that their contributions are encouraged.

Copyright of Appendix A9 is held by Central and North West London Mental Health NHS Trust

Graham Behr and Jon Ruddock

Central and North West London Mental Health NHS Trust