Monday, September 21, 2015

Rethinking Formation for Diversity & Inclusion

by Patrick, McCruden, D.Bioethics, MTS
Senior Vice President, Mission Integration
CHI St. Vincent

Serving as a Mission executive in catholic health care I’ve long been fascinated with a tension that exists between our desire to have diversity in our workforce and our commitment to the formation of our leaders and co-workers into a particular charism or vision of catholic health care. Many health systems have formal programs to increase diversity in hiring and respond to the diverse cultures of our patients and co-workers. Hiring a diverse workforce entails diversity not only of gender, color, culture, etc. but a diversity of ideas, values and beliefs that flow from these characteristics. However, many formation programs stress adherence to a set list of values, beliefs etc. often rooted in the tradition of the founding order(s). I think a recognition of the historical roots of this tension and a concerted effort to revamp formation programs will enhance the ability of our diverse community in catholic health care to work together for the care of our patients.

In 1982, my first job in Catholic health care was in a hospice run by the Hawthorne Dominican sisters. I didn’t realize it at the time but I was given a glimpse of Catholic healthcare that was all but extinct.  The hospice’s administrator, director of nursing and almost all the nurses were Dominican sisters. From the early times of the church down through the middle of the twentieth century, religious orders cared for the sick and operated hospitals principally with the labor and leadership of the members of the order. These communities of women shared a common tradition and commitment to a vision of healthcare interpreted through the particular charism of their founders and handed down through the formation of new members of the order.

By the time I had my first full time job in Catholic healthcare five years later the hospital where I worked only had one member of the founding order who served as the VP of Mission Effectiveness. This was the new norm. It was accepted wisdom that employees and especially leaders would be “formed” into the vision of the hospital’s founders. In a sense the formation of leaders and staff replaced the formation of novices and sisters. Through these programs the founding orders sought to ensure that the identity of the institution would be maintained and that decisions would be made consistent with the charism of the order.

Today very few catholic hospitals are sponsored by one religious order. Most are part of large health systems and loyalty to a particular order’s charism is now being replaced by loyalty to the values and mission of the new entity. Often these values are articulated in a manner that are translatable to a workforce that is growing increasingly diverse. This seems to me to be a positive development and a movement away from formation analogous to religious formation towards a more dialogical approach seems necessary.

The Canadian communitarian Charles Taylor has argued that human diversity is part of how we are made in the image of the triune God .  Truly acknowledging this diversity and recognizing it as a part of God’s plan is therefore fully “Catholic” and transforms the Gospel mandate to “go and make disciples of all nations” (Mathew 28:18) from a  “unity-through-identity” understanding to a “unity-across-difference” understanding .  Thus, we do not have to make physicians, co-workers and leaders into replicas of the amazing women who started these hospitals or close approximations to the same through formation programs in order to be faithful to our Catholic identity. We do have to ensure that our actions as Catholic healthcare are always faithful to a Gospel rooted in agape love.

In our developing relationships with our diverse workforce we must engage in dialogue around the languages and practices that can unite us across our ideological differences. Without doubt there will be practices that the Catholic health system will demand of anyone who wishes to become a part of the ministry including the respect for innocent life, compassion and a willingness to serve the poor. Apart from these essentials there will be a need for dialogue. I feel certain that there will be common themes of reverence, gratitude, forgiveness that cross all cultures and traditions. In faith we believe that in serving the sick and the poor we encounter Christ and this encounter cannot help but be transformative and we need to invite our diverse workforce to encounter this transformation with faith in the Holy Spirit.

Friday, September 11, 2015

Just care for patients in different neonatal intensive care units: a tenable goal?

By Dalia Feltman, MD, MA

One look at a healthcare billboard will reveal that hospitals want to appear unique—one touts superior surgical care; another state-of-the-art cancer treatments.  Quality of medical staff and the array of services offered are not what I mean here by “equal opportunities.” What I’ll examine in detail using two neonatology studies is the variation of initiating and withdrawing life-sustaining treatments for critically-ill newborns between medical centers. I’ll argue that from a principlist standpoint, because extremely premature or critically-ill newborns are completely incapable of autonomous decision-making, and beneficence and non-maleficence are extremely difficult to judge, the remaining principle, justice, is an especially important goal for these patients.

Because newborns lack autonomy, we rely on parents and physicians to make medical decisions in their best interests.  This means weighing benefits and burdens of treatments to maximize beneficence and non-maleficence. However, for newborns whose survival or neurodevelopmental outcomes are ambiguous, life-sustaining treatments such as breathing support, chest compressions, and cardiac medications may seem burdensome. The difficulty in finding beneficent, non-maleficent options is of interest in many neonatology bioethics inquiries. However, evidence that some neonatal intensive care units (NICU’s) are more aggressive in providing life-sustaining treatments than others leads to a different arena of questions, concerning whether justice is a tenable goal for these patients.

Treatments after birth
Based on high chances for death and neurologic impairment, being born at 22 to 24 weeks’ gestation is considered “periviable.”  Professional guidelines from groups such as the American Academy of Pediatrics (AAP) advise: 1.) For babies born into circumstances incompatible with survival, comfort care rather than delivery room resuscitation should be provided; 2.) For a baby with high chances of poor outcome, best estimates of survival and morbidity should be conveyed to parents to inform their decision on resuscitation; and 3.) When good outcomes are likely, resuscitation is indicated with continued reassessment of treatment benefits in collaboration with parents.1

Revasy, et al. examine outcomes for extreme preterm infants born at 24 hospitals.2  While not representative of all NICUs, this is a robust sample of nearly 5000 preterm infants born between 22 and 26 weeks with an impressively high percentage of patients followed until 18-22 months. These authors report survival and neurodevelopmental outcomes for the entire sample of 22-week preterm infants as worse than for the subgroup of patients receiving life-sustaining treatments. Similar trends were noted for each gestational week until 25 and 26 weeks, because babies born 25 weeks and older all received active treatment. None of this is surprising, since we know these babies’ immature lungs require support to survive past a few hours or days. Furthermore, the more mature the baby, the more the benefits of treatment outweigh risks, so life-sustaining treatments are provided. What has been impressive, however, to the authors and the neonatology community, is the fact that, controlling for other patient factors, the hospital itself was what most predicted provision of life-sustaining treatments vs. comfort care, and therefore mortality and morbidity (for without survival there can be no morbidity). The earlier the gestational age of the baby, the more profound the inter-hospital variability, until 25 weeks.

Treatments before death

Another article compared circumstances around deaths of NICU patients in four centers—two Midwestern, one Canadian, and one in the Netherlands.3  In all but one center, most “unstable” neonates died with life-sustaining treatments withdrawn. That same outlier center had higher rates of babies dying after chest compressions than the other three. No baby died in the delivery room at that center, while the other three reported similar rates of deaths in the delivery room.

Directions for future study

Equal opportunities will only be possible when we understand why hospitals have such different rates of providing life-sustaining treatments. What options are offered to parents?  Do parents’ cultural differences account for hospital variability? How do obstetricians influence these decisions?

One might argue that if there’s no clear-cut answer on what’s in a certain type of preterm infant’s best interests, why strive for uniformity? To ensure NICU patients receive a just experience, options of comfort care and offering life-sustaining treatments need to be consistently explored with parents in truly shared decision making. A new clinical report from the AAP encourages institutions to create approaches to threatened deliveries at 22 to 24 weeks.4  One possibility for institutional variability is that centers have created strategies to promote just opportunities for their patients. If so, these studies are a call to foster another level of agreement—across hospitals. Otherwise, it may only be where the ambulance brings a prematurely-laboring woman that might determine her baby’s outcome.

Dalia Feltman, MD, MA, is a 2015 graduate of the Loyola MA program in Bioethics and Health Policy.  She is a neonatologist at Evanston Hospital in Evanston, IL and a Clinician Educator at the University of Chicago Pritzker School of Medicine, Chicago, IL

  1. Batton DG.  Antenatal counseling regarding resuscitation at an extremely low gestational age.  Pediatrics 2009;124:422–427.
  2. Rysavy MA, Lei L, Bell EF, Das A, Hintz SR, Stoll BJ, et al.  Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants.  N Engl J Med 2015;372(19):1801-11.
  3. Verhagen AA, Janvier A, Leuthner SR, Andrews B, Lagatta J, Bos AF, Meadow W.  Categorizing Neonatal Deaths: A Cross-Cultural Study in the United States, Canada, and The Netherlands.  J Pediatr 2010 Jan;156(1):33-7.
  4. Cummings J, AAP Committee on Fetus and Newborn.  Antenatal Counseling Regarding Resuscit