Penrose-St. Francis Health Services

All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

PENROSE-ST. FRANCIS HEALTH SERVICES INTERDISCIPLINARY PRACTICES

SUBJECT: Ethical Practice

PREVIOUS DATES: Code of Ethical Behavior, 5/95, 1/98, 7/98, 7/01 EFFECTIVE DATE: 6/10 Resolving Ethical Issues, 1/91, 1/93, 10/95-Ethical Decisions about Medical Care, 1/91, 3/93, 5/94,3/95, 7/96, 6/01, 6/04, 1/08

RECOMMENDED BY: Interdisciplinary Practice Committee, Bio-ethics Committee

ADMINISTRATION APPROVAL: Jeff Oram-Smith, MD, CMO Katherine D McCord, RN, CNO

PURPOSE: To identify the code of ethical behavior for Penrose St. Francis Health Services (PSFHS) and to promote ethical behavior in all business practices, as well as patient care practices, especially in the areas of marketing, admission, transfer, discharge, billing, purchasing, and contractual relationships between Penrose St. Francis Hospital and its associates and physicians, other healthcare providers, vendors, educational institutions, payers and the community we serve. All patient care practices will be consistent with the Ethical and Religious Directives for Catholic Health Care Services, National Council of Bishops, 4th Ed, 2001.

1. Marketing: It is the policy of Penrose St. Francis Health Service to restrict all marketing efforts to those services and procedures which are within the technical and licensure limits to the hospital. Marketing programs will promote the dignity of the individual and present an accurate, straightforward and honest depiction of the expected benefits of diagnostic and therapeutic procedures.

2. Contracting, Disclosure: Penrose St. Francis Health Services and its agent will deal honestly and fairly with clients, customers, vendors, competitors, payors, and financial partners. All communication and disclosure information shall be clear, accurate, and sufficiently complete to assure that the may not be misleading. Financial and operational reports shall be truthful, fair and accurate. Patients need to be informed of why the hospital is utilizing contracted services and how that particular service provider was selected.

3. Billing: Penrose St. Francis Health Services will deal honestly with all payors, (e.g., self-pay, insurance companies, HMOs, PPOs, Medicare, and Medicaid). Accurate and prompt billing practices shall be maintained and all billing issues resolved according to organizational policies and payors contracts. Questions and conflicts regarding organizational policies, payors contracts, and conflicts regarding patient billing will be resolved expeditiously.

4. Conflict of Interest: Any persons having an investment, financial interest, or compensation relationship, direct or indirect, with any supplier, client or competitor, shall make prompt disclosure to the hospital and seek evaluation for participation in the transition.

5. Individual Responsibility: Our ethical position respects the individual, while acknowledging the interdependence of every person within the larger community. It is our responsibility to administer and use wisely the physical, technological, financial and human resources for meeting healthcare needs. It is also our responsibility to educate, to conduct research and to advance science so that the quality of care and the efficacy and efficiency with which resources are used can be improved over time. It is our responsibility to educate the public as to its healthcare responsibilities and to work toward the effecting of policies, which will enable quality healthcare. We believe deeply in the sacredness of human life as a unique creation of God, the dignity of the individual, and the right of all persons to be treated with respect and compassion. Therefore, a patient has the right to expect:  Reasonable access to care  Care that is considerate and respectful of one's personal beliefs and values  To be informed about and participate in decisions regarding one's care  To participate in ethical questions that arise in the course on one's care, including issues of conflict resolution, withholding resuscitative services, forgoing or withdrawal of life-sustaining treatment, and participation in investigational studies or clinical trials  Security and personal privacy and confidentiality of information  To designate a decision maker in case one is incapable of understanding a proposed treatment or procedure or is unable to communicate one's wishes regarding care  To access protective services if needed Page 1 of 4 IDP E-02-a All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

In exchange healthcare professionals have the right to expect that the patient will:  Follow the care plan prescribed by the physician, nurses or other members of the healthcare team, and agreed upon with the patient as a participant in that decision  Provide accurate and complete information about all matters pertaining to the health care of the patient and be an active participant in the health care plan developed especially for the patient  Be reasonable in demands and expectations of the health care team  Respect the privacy of roommates and maintain confidentiality of any medical information about roommates or other patients.  Be considerate of other patients and encourage visitors to be considerate, particularly with regard to noise and number of visitors  Notify the physician or nurse the diagnosis, treatment or prognosis if not understood.  Accept the consequences associated with refusal of the prescribed medical care plan  Recognize that health care providers are deserving of respect and consideration and be responsible in requests of them  Abide by the rules and safety regulations as they apply to each patient  Be prompt in the provision of information necessary for insurance processing of bills and accept the financial obligations associated with care  Advise the physician, nurse or patient representative/patient interview volunteer of any dissatisfaction the patient may have in regard to the care given or hospital services

6. Confidentiality: Health care professionals should not divulge details of a patient's name, diagnosis, treatment, or condition without permission, except as required by law. Patients entering Penrose St. Francis Health Services should be informed about what information is recorded, how it is used, who will have access to the information and what these practices may mean to the patient. 7. Admission, Transfer, Discharge: The decision to admit, transfer and discharge patients will be based solely on the best interest of the patient to insure treatment which is appropriate to the patient's needs and therapeutic goals, and meeting EMTALA policy E-01-1 for referral.

Resolving Ethical Issues

1. All personnel are committed to supporting and living out the mission and values of PSFHS in their daily work, acting in ways which merit the trust and confidence of the community we serve.

The MISSION: We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities.

Our CORE VALUES:  Integrity: Honesty, directness and respect for commitments made.  Stewardship: Respectful use of all natural, human and financial resources.  Spirituality: Acknowledgement of its central role in facilitating mental, physical and emotional health.  Imagination: Creativity and innovation in all we do.  Respect: Respect for all persons and for our Christian identity, heritage and missions of our sponsoring organizations.  Excellence: Striving to exceed the clinical quality, customer service and cost performance expectations of our customers.  Compassion: Sensitivity and responsiveness to persons in need.

2. All personnel are committed to resolving ethical issues related to patient care. Practices that support this are: - attempting to resolve ethical issues by conferencing among family, physician and staff caring for the patient. - accessing the Medical Ethics Committee when conflicting opinions arise. The Medical Ethics Consultant who is on call can be accessed through the hospital operator. The Medical Ethics Committee will convene as needed for discernment of the issues. - accessing the on-call Medical Ethics Consultant through the hospital operator when a staff member wishes. - individual advice/counseling about an ethical issue concerning a patient. - notifying Risk Management of all ethical issues involving patients and families

of 4 IDP E-02-a All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

3. When a Medical Ethics consultant is called regarding a medical ethical situation, the following steps will be used as a guide to resolve the dilemma 4. Medical Assessment This should include as an accurate diagnosis and the patient’s prognosis. It should include the available treatments with their respective risks, benefits and burdens. 5. Patient/Family--Physician Communication The attending physician must ascertain the patient’s values and goals, and present a clear explanation of the medical diagnosis, prognosis, and treatment options. 6. Identification and Clarification of Conflict If there is a conflict between the values and goals of the patient and the values and goals of the physician and health care team, all parties should seek an acceptable compromise. If this is not possible, either the patient or the PSFHS staff should request consultation. 7. Consultation Conflict may be resolved by consultation with the Spiritual Care Department, or by requesting an ethics consultation from the Medical Ethics Committee, or from Care Management Services. All patients with a life threatening illness and their families may request ethics consultations through the Bioethics Committee. 8. Treatment Decisions The patient makes the final decision to accept, refuse, limit or discontinue any medical treatment or intervention. The opinions of the family, physicians, other members of the health care team, and the hospital are advisory only. 9. Implementation Once the final decision has been made to accept, refuse, limit, or discontinue treatment, the physician and health care team should act promptly. 10. All personnel are committed to resolving ethical issues that arise out of individual or group clinical practice issues. Practices that support this are: - discussing a physician practice concern with the unit/department manager, who will gather all pertinent information and report it to the department director. Normally, after review, the director will send the information to the Chief Medical Officer and/or Medical Staff Peer Review for resolution. - discussing a colleague practice issue directly with the colleague when possible. If resolution can not be achieved, referral to the unit/department manager, and then to the department director is the appropriate process. The director will report any “unethical practice issues” in violation of the Colorado Nurse Practice Act to the Colorado Board of Nursing. - notifying Risk Management of all ethical issues involving the clinical practice of caregivers. 11. All personnel will follow processes, which assure protection of the dignity and autonomy of those we serve by: - providing access to all who seek care, including those who cannot afford to pay - advising and educating about patient rights including pain management and palliative care, as well as, the right to refuse treatment - responsibilities and risks regarding health care services - safeguarding confidentiality, privacy, self-worth, dignity and autonomy - adhering to just and non-discriminatory practices - once stabilized, transferring patients who cannot be safely or appropriately treated in the PSFHS facilities - restructuring services to put the patient at the center of attention - supporting interdisciplinary patient care practice/performance improvement - being truthful in all forms of professional and organizational communication 12. All personnel associated with PSFHS will act in ways that merit the trust and confidence of employees. Practices which support this are: - adhering to just and non-discriminatory practices - providing equal opportunity employment and job advancement opportunities - conducting all personal and professional activities with honesty, integrity, fairness and good faith - maintaining confidentiality - continually improving competence and proficiency - exercising responsible stewardship of resources - recognizing/honoring those who live out the Mission and Values in daily practice. 13. All personnel associated with PSFHS will conduct business in an ethical manner for all those we served by: - avoiding conflict of interest in all business practices - respectfully resolving all issues expeditiously with integrity and without harassment - providing itemized billing including dates of service - admitting, transferring and discharging based on patient need and not solely on economics - contracting based upon best bid practices Page 3 of 4 IDP E-02-a All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

- accurately reflecting accreditation and services available in public relations material 14. Appropriate personnel will serve in the development of partnerships with educators, other providers, and payers with ethical behavior demonstrated by: - providing clinical sites for students interested in the health care profession - assisting faculty members with the education and training of students - serving on advisory boards of educational institutions - coordinating with other providers and payers for quality, efficient patient care - working to expedite patient care in a manner which meets the patient’s health needs in a cost effective manner - focusing planning strategies on health maintenance, integration, collaboration, and partnering along the continuum of care 15. Administration will assure that the Centura Health Integrity Program will be discussed and applied to the entire spectrum of health professions in clinical and management services, including, but not limited to, admissions, patient care, marketing, billing, discharge planning, purchasing and partnering. Ongoing communication is evidenced by discussion: - during new associate orientation - at the annual performance review - in the workplace as issues arise - in the formal Medical Ethics Committee as the need indicates 16. The Conflict of Interest and Governance/Conflict of Interest Principles (HR Principle 4-2) will be followed by Board members and all associates. 17. Physicians will follow ethical behavior requirements as further amplified in the Medical Staff Bylaws. 18. Physicians and staff will follow associated practice guidelines relative to specific clinical conditions/situations: - Consents - Advance Directives (Living Will, Medical Durable Power of Attorney) - Do Not Resuscitate status (Life Support treatment, Care of the Terminally Ill) - Refusal of Treatment - Refusal of Blood Transfusion - Organ and Tissue Donations - End of Life Care 19. Basic Principles of Healthcare Ethics . Autonomy: Form of personal liberty, where the individual is free to choose and implement one’s own decisions free from deceit, duress, constraint or coercion. . Beneficence: Acts of mercy and charity; any action that benefits another; primary commitment to the health, welfare and safety of another. . Distributive Justice: Fair, equitable and appropriate treatment in light of what is due or owed persons. . Double effect: A principle used to determine whether an action is morally defensible when the action has more than one consequence usually both favorable and ill. Secondary effects may be foreseen, but can never be the intended outcome. . Non-Malefic: Not to inflict evil or harm. . Paternalism: The belief that one should on the basis of doing good for the patient, limit the patient’s personal autonomy. . Veracity (truth-telling): Binds both the health practitioners and the patient in an association of truth. The patient must tell the truth in order that appropriate care can be provided. The practitioner needs to disclose factual information.

References: Ethical and Religious Directives for Catholic Health Care Services, National Council of Bishops, 4th Ed, 2001. Guidelines for End-of-Life Decisions, Pikes Peak Forum of Health Care Ethics, 2008

Last review facilitated by Kate McCord, CNO

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