Territorial Ethical Decision Making Framework May 2020 Appendix B: Authorities COVID-19 Operations Ethical Decision Making Framework Authorities’ COVID-19 Response Team (ACRT) Page 23 Northwest Territories Health and Social Services Authority Box 1320, Yellowknife, NT X1A 2L9 Territorial Ethical Decision Making Framework May 2020 Introduction to the Authorities COVID-19 Operations Ethical Decision Making Framework Balancing the numerous competing moral obligations during a pandemic at a societal and/or organizational level can be extremely difficult. Because of this unique context, it is critical that decisions are made carefully and expeditiously: based on the best information available, and rooted within a shared understanding of what is important. The values that make up the ethics decision-making tool below are commonly recognized in pandemic planning and familiar to previously developed pandemic ethics frameworks from the 2009 Pandemic Influenza Ethics Framework (Alberta Health Services & Covenant Health, 2009), Alberta’s Ethical Framework for Responding to Pandemic Influenza (AH & AHS, 2016), Provincial Ebola Task Force (BC Provincial Health Office), and Stand on Guard for Thee (Joint Center for Bioethics, 2005). This operational Ethical Decision-Making Framework is intended for use by decision-making groups within the Health Authorities of the Northwest Territories (NWT) and is based on the NWT Territorial Ethics Decision Making Framework. The Territorial Ethics Committee and the Ethicist from Alberta Health Services (AHS) are available to provide support for working through the framework, as required. While using the Framework cannot guarantee an ethical decision, its goal is to ensure that decisions have been made based on a shared and accurate understanding of the relevant information, that the appropriate values have been thoughtfully considered and weighed against each other, and that decisions of such magnitude made by healthcare decision-makers in the public interest rest on ethically and publicly defensible considerations rather than on arbitrary criteria or unchecked biases. The Framework: ● Establishes a set of key values to clarify, justify, and support pandemic-related organizational level decisions; ● Provides a template Decision-Making Form with a values checklist that will ensure consistency and transparency in ethical decision making across the organization; and ● Enables a process for tracking and retention of decisions receiving ethics review and reflection. Who should use and what is the intent? This Ethical Decision-Making Framework is intended for use by organizational level decision-making groups throughout the Health Authorities within the NWT – ideally with support of the Territorial Ethics Committee or the AHS ethicist, but can be used without the direct support of either. It can be used to guide and review prioritization decisions, or other organizational level decisions. Authorities’ COVID-19 Response Team (ACRT) Page 24 Northwest Territories Health and Social Services Authority Box 1320, Yellowknife, NT X1A 2L9 Territorial Ethical Decision Making Framework May 2020 How to use A template form and checklist (Appendix B1) is included to support users to ensure their decisions fulfill the organizations’ value commitments. Initially when looking at the issue, it is important to rate the impact of the decision as compared to the values of the organization. The graph below identifies the importance of the value to the organization and what value it relates to. Tier Specific criteria Does this decision….? Value Theme 1 Minimize the net harm to the public (including through the spread of disease, disruption to healthcare system) Non-maleficence 1 Maximize good outcomes for patients with highest acuity needs(life-saving, long-term impacts of disease, and/or reducing suffering) 1 1 1 1 1 2 Provide healthcare providers with the supports and safety equipment they require in order to discharge their professional obligations and minimize their risk of being exposed to COVID19. And recognize the additional risks or hardships they may be taking on to provide care in this higher risk context. Ensure the policy decision does not create additional access barriers for, or disproportionately impact, those the most vulnerable or already face additional barriers (i.e. lower socioeconomic status, homeless populations, some cultural minorities, etc.) When possible, consult with those groups who will be impacted by the decision (e.g. patients, healthcare workers), and where not possible, strive to pull from pre-existing consultations. Reflect the best available evidence, and ensures any assumptions made are well grounded and defensible Where there is an absence of clear information or evidence, any decision made strives to minimize the risks of harm Ensure less critically ill patients also continue to receive appropriate care 2 Beneficence Safety Justice Transparency, Autonomy, Cultural Safety Non-maleficence Beneficence, Justice, Solidarity, Culture Autonomy Minimize restrictions for staff/patients/public as much as possible, commensurate with the level of risk to public health 2 Confidentiality Respect the confidentiality of medical information of patients and their families 2 Prevent patients from experiencing avoidable harm while waiting Non-Maleficence for a diagnosis of their illness (e.g. patient presenting to ED with co-morbidities that include the screening questions and so does Northwest Territories Health Page 25 Authorities’ COVID-19 Response and Social Services Authority Team (ACRT) Box 1320, Yellowknife, NT X1A 2L9 Territorial Ethical Decision Making Framework 2 2 2 3 May 2020 not receive their cardiac care because a COVID-19 test is pending) Reflect patient values and beliefs as much as possible in healthcare decisions, granting that choices may be limited in a pandemic Provide someone (patient, family, staff, member of public) who is impacted by a decision the rationale and, if possible within the constraints of the pandemic response, the ability to discuss and challenge the decision through the appropriate channels Set clear expectations about what interventions will and will not be provided under which circumstances and the rationale for these decisions Ensure all patients who present with COVID-19 symptoms receive a consistent level of care within the available resources 3 Provide the public with timely, clear and consistent information 3 Foster trust between the NWT Health and Social Services System and our workforces Foster trust of the health and social services system by the public Align with approach taken across organizations DHSS, NTHSSA, TCSA & HRHSSA Allow those closest to clinical decisions to exercise clinical judgement (based on professional knowledge, codes of conduct, college guidelines, etc.) in the difficult decisions they make Align with and/or is supported by decisions in other provinces, territories and federally 3 3 4 4 Dignity Disclosure, Transparency Disclosure, Transparency Justice, patient/family centred Disclosure, Transparency Inclusiveness Transparency Solidarity Integrity, patient/family centred Solidarity Process for Operational Ethical Decision Making For ethics support, make a request via the Director Quality Risk and Client Experience. An ethicist is available to walk you through the process. If not, you have the option of asking the Territorial Ethics team or the ethicist to review your decision after completing the checklist. Step 1 Step 2 Step 3 Step 4 Confirm question Identify who should be involved in the decision (and/or consultation) Develop a draft decision Use the checklist to rate the decision by: ● ● Completing the checklist and ensuring the decision lives up to highest tier values/criteria Ideally, a decision should fulfill all values, but as the context changes during Authorities’ COVID-19 Response Team (ACRT) Page 26 Northwest Territories Health and Social Services Authority Box 1320, Yellowknife, NT X1A 2L9 Territorial Ethical Decision Making Framework ● Step 5 May 2020 an outbreak, it may not be possible to fulfill lower tier values/criteria Include rationale in ‘notes’ column if a Tier 1 value cannot be achieved, and any other values most central to your decision Finalize the COVID-19 Operations Ethical Decision Making Form and submit to the Director of Quality Risk and Client Experience. Authorities’ COVID-19 Response Team (ACRT) Page 27 Northwest Territories Health and Social Services Authority Box 1320, Yellowknife, NT X1A 2L9