Park Place Seniors Living
Ethics
in a
Client Centered Model
A Successful Journey
Louise Johnson RN., B.H.Admin
Defining Ethics
Even among the experts, there is no
universally accepted definition of “ethics”
or ethical behaviour.
This is because ethics are culture and
situation-specific: what is seen as ethical in
one situation or culture may not be ethical
in another.
For example, limiting the freedom of another human being would be
considered unethical in most situations. But if the person is a young child;
or a senior with Alzheimer’s, it would be unethical to not limit that person’s
movements, given the risk an unsecured environment poses to his or her
safety.
“We are discussing no small matter but how we ought to live.”
- Socrates, from Plato's Republic, Book 1:352d
Ethics are in the eye of the Beholder
What is defined as ethical choices may be influenced by:
• Acceptance of what is “good” and what is “right” within the broader
culture;
• Conventions within a particular professional discipline;
• Personal belief systems;
• The desired outcome of any action/decision; and
• The situation to which those conventions and belief systems
are to be applied.
Asking individuals or an organizations to make choices based on ethics
is much more complex and requires a higher level of thought than
simply providing checklists, rules, or guidelines. This presentation outlines
how Park Place Seniors Living instituted client-centred ethical decision
making throughout the company’s 11 complex care homes.
Flexible Decision Making
Integrating an ethical choice process into decision making gives
care givers the flexibility to respond better to individual situations
and needs.
Ethics-based decision making can be
attuned to achieving desired end goals,
instead of just following pre-determined
rules. It provides solutions in situations for
which there may be no established rules.
At Park Place, the following shared values
were identified as the end goals of our
interactions with residents, families and
each other. In all our interactions, we
want to maintain:
Dignity, Respect, Trust and Empathy
Maintaining dignity, respect, trust
and empathy across the generations.
Establishing shared goals is a precursor
for ethical decision-making.
noun (plural)/ˈeTHiks/ethics, plural
1. Moral principles that govern a person's or group's behaviour (i.e. Judeo-Christian ethics)
2. The moral correctness of specified conduct (i.e. the ethics of euthanasia)
- Dictionary.com
3. The branch of knowledge that deals with moral principles
Steps towards Ethical Decision Making
• Creating an Ethical Environment
– Establishing a value-driven culture
– Clearly defining desired values
• Ethical decision-making framework
• Teaching the decision-making process
•
•
•
•
– Developing new resources
– Integrating into day-to-day operation
Ethical decision-making in action
Measuring Success
Lessons Learned
Future Direction
• About Park Place Seniors Living
Step 1: Creating an Ethical Environment
Ethical choice is dependent on the culture and environment in which the choice
is made. Therefore, the first requirement for success in making Ethical Choices is
to develop the appropriate Ethical Environment.
Park Place has created the appropriate Ethical Environment by implementing:
• A values based organization with a true commitment to enriching quality of life for
residents and quality of work life for staff.
• Clearly defined and cohesive Mission, Vision and Values statements which
support ethical behaviours and goals.
• Integration of the company’s Mission, Vision and Values in the development of
company policies and operational choices.
• Educational and informational initiatives which repeatedly reiterate the core
values of the company.
Park Place has established a values-driven culture of care.
Step 1: Creating an Ethical Environment
THE MISSION
All photos are Park Place Seniors Living residents or staff – used with permission.
Park Place Mission
PARK PLACE SENIORS LIVING EXISTS TO PROVIDE ENRICHED
LIFE EXPERIENCES TO SENIORS BY PURSUING STRATEGIES FOR
INNOVATION, CREATIVITY AND LONG-TERM GROWTH IN A
MANNER THAT IS SUSTAINABLE AND SECURES
FAIR RETURNS FOR INVESTORS.
The Park Place mission statement underlies the choices made by the company and
balances the responsibility of providing exemplary care with the responsibility to be
financially prudent. Financial stability allows the company to hire and retain the best people,
maintain buildings, and offer enhanced programs.
Step 1: Creating an Ethical Environment
VISION & VALUES
VISION: Guiding Principles
•Treat others with dignity,
respect, trust and empathy
•Involve stakeholders
•Provide appropriate services
•Deliver services that
meet/exceed standards
•Build capacity with
supportive frameworks
•Honour commitments,
agreements and words
•Provide high quality
and exceptional value
•Invest in growth
and sustainability
•Minimize financial risk
VALUES
•Strive to serve our clients with excellence and build strong &
mutually beneficial partnerships
•Attract, hire, retain, develop and deserve the best people
at all levels
•Develop facilities and services that have high quality
and exceptional value
•Be good stewards of the company’s physical, financial
and human resources
•Treat all people with respect, in a manner we would
like to be treated
•Demand the best of ourselves and from others
•Tell the truth and be trustworthy
•Be the difference we wish to see in the industry
•Make sound financial decisions that support our mission; and
•Honour our words, agreements and promises.
The above are Park Place’s Vision and Values and are provided
only as examples. Use your organization’s accepted values as
the basis of an ethical decision-making process.
Step 1: Creating an Ethical Environment
BRINGING IT HOME
At the individual site level, the staff at each home work together to establish site goals
which are consistent with the company Mission, Vision, Values and Strategic Directions.
These Strategic Directions include:
•Enriching Lives of Seniors resident in the home and beyond;
•Embracing a Culture of Learning;
•Maintaining a Culture of Safety;
•Engaging in Ethical Decision Making;
•Establishing an Effective Communication Framework;
•Ensuring Human Resources Allocations support
Work-Life balance; and
•Adhering to the sound financial processes which
support the financial viability of the care home
and the company.
Enriching the lives of seniors,
as shown by this resident’s smile.
Park Place clearly defines desired values as a first step
in making ethical decisions.
Step 2: Ethical decision-making framework
ESTABLISHING GOALS
The key measure of Ethical decision making is not whether a rule is upheld but
whether a goal – such as enriching a resident’s life – is achieved. At Park Place, the
goals are always clearly articulated, visible and front-of-mind for all staff.
The Park Place Resident Bill of Rights is clearly posted in all care homes.
The Bill-of-Rights gives staff an ever-present reminder of resident rights,
which must be respected and honoured.
Park Place core values include treating others with:
•Dignity;
•Respect;
•Trust; and
•Empathy
These values are stressed throughout the company.
Education on upholding these values is provided
to staff, service providers, clients and families.
Dignity must be maintained
so all residents can continue to
enjoy their lives and relationships.
Goals in care are front-and-centre every day in every care home.
Step 2: Ethical decisionmaking framework
THE CARE MODEL
Throughout the company, ethical
decisions are made within
the context of the Park Place
Residential Care Model.
Illustrated at right in a visual,
poster format, the care model
establishes the following five core
commitments to:
1. An Enriching Culture (for seniors &
staff)
2. Follow Standards
3. (Maintain) Holistic Focus
4. Measure Performance; and
5. Continuous Improvement
The Care Model establishes the operational
framework under which the Mission, Vision
and Values are transformed into action.
Step 2: Defining Ethical decision-making
These commitments are honoured
when developing the standards
and policies which govern the
following seven operational areas:
–
–
–
–
–
–
–
VALUE-BASED OPERATIONS
Philosophy
Staffing
Environment
Policies & Standards
Programs
Education
Quality Improvement
By developing this values-based
operational framework, Park Place
Seniors Living created a work and
management environment conducive
to ethical decision making.
A contented resident at
Hilton Villa in Surrey, B.C.
Step 2: Ethical decision-making framework
A VOICE AND A CHOICE
Additional core documents which establish a
framework for ethical decision-making are
known as “Resident’s Day.”
Each resident of a Park Place Seniors Living
home has a Resident’s Day document.
These Resident Day documents are based
on interviews with incoming residents –
and/or family & friends – to determine how
the resident wishes to live in the home.
Residents have a voice and a choice
in their daily care.
The resulting Resident Day document
ensures each resident will be cared for as an
individual with a right to a voice and a choice
in his or her care. A sample is shown on the
following page.
Resident’s Day was identified as a leading practice
by Accreditation Canada in the 2011 Park Place Seniors’ Living review.
RESIDENT’S DAY: A VOICE AND A CHOICE
If an ethical
decision affects
one resident, the
decision made
must fall within
the provisions of
That individual’s
Resident Day
document.
Resident’s Day
documents are
amended as
required to
address resident’s
changing needs.
If an ethical
decision affects
more than one
resident – or the
operation of the
entire care home –
then the combined
Resident’s Day
documents of all
affected residents
must be considered.
Step 3: Teaching the decision-making process
DEVELOPING NEW RESOURCES
Integration of Ethics and Ethical Decision Making across all Park
Place operations began in 2006. The new initiative included
development of materials, policies, procedures and training to turn
ethics into day-to-day reality for everyone.
By 2007, the company had a completed Ethics Resource Manual
which included:
– Code of Ethics
– Terms of Reference
– Consent Policy and Procedure
– Ethical Dilemmas
– Ethics Framework
– Education and Research Function
– Disclosure
– Case Studies
– Articles relating to Ethics issues
Step 3: Teaching the decision-making process
DEVELOPING NEW RESOURCES
The 2007 Ethics Resource Manual is available in each neighbourhood within
every Park Place care home, so staff have an immediate reference should an
ethical issue arise.
Park Place developed an easy-to-follow Ethical and Clinical Decision-Making
Framework Template, which is attached to the agenda of each Professional Practice
Council. This encourages immediate discussion and review of ethical issues as they
occur.
The formal ethics framework guides staff and
management through a step-by-step ethical
decision-making process. The framework also
addresses issues of consent, disclosure and
research.
Ethical frameworks protect frail elderly residents.
Step 3: Teaching the decision-making process
INTEGRATING INTO DAY-TO-DAY OPERATIONS
The following practices integrate ethical choice into day-to-day work.
•Ethics orientation and staff development sessions provide staff with the
knowledge and skills required to guide discussions when making decisions
on ethical issues;
•All interdisciplinary Care Conferences include a review of care from an ethical
perspective. All members of the care team meet on a regular basis to discuss the
care provided to each resident. Ethical choices made for an individual are measured
against that resident’s wishes, as identified in the Resident’s Day.
•Ethical issues are also discussed at Resident and Family Councils. These
councils promote the collective interests of all residents and provide an avenue for
consultation regarding any changes to policies and procedures.
Step 3: Teaching the decision-making process
INTEGRATING INTO DAY-TO-DAY OPERATIONS
A user friendly brochure about ethics and ethical decision-making
is widely available for use by staff, volunteers, residents and families.
Copies of the brochure are free.
A brochure is freely available to help residents and family understand ethical issues.
The ethics committees uses case-based learning – with identifying details removed
from examples - to transform ethical dilemmas encountered at Park Place into
instructional materials.
Step 4: Ethical Decision-Making in action
Sample of the
step-by-step
Ethical &
Clinical
Decision
Making
Framework
Step 4: Ethical Decision-Making in action
SAMPLE DECISION – the issue
Resident has a diagnosis of Parkinson’s with Speech Language Therapist
repeated assessments, the latest stating “pureed to minced textures as
tolerated, thin fluids by straw (small sips). Sit fully upright. Whole meds, as
tolerated.”
Resident wishes to eat totally minced or cut-up versus puree.
Professional assessment states puree and minced as tolerated, therefore not
agreeing with resident wishes of minced or cut-up only.
The conflict is between two important values: safety vs. quality of life.
Pureed is the safest option but the resident has expressed a clear desire for
minced or cut-up food. The son has signed a release to allow a one week trial
of minced, with staff monitoring.
ISSUE: The resident wishes to eat only minced or cut-up food but the professional
assessment includes pureed food. Which takes precedence: the resident’s wishes or th
professional health advice?
Step 4: Ethical Decision-Making in action
SAMPLE DECISION – the debate
For staff, the conflict is between an obligation to do what is safest versus
increasing the resident’s quality of life.
Resident eats in room alone without supervision and refuses to come to dining
room, making monitoring more difficult. The resident also refuses to move to a
table closer to Nurses to allow closer monitoring.
The son wants the resident to have the quality-of-life choice to eat what she
wants and has signed a Managed Risk Authorization for a one-week trial of
minced or cut-up food.
Possible responses are:
Do nothing?
Change residents’ behaviour – but how?
Consider a policy change
Agreement and understanding of risks
INVOLVED: Those affected by this decision include the Resident, Son/Family,
Dietician, Nurses, Care Aides, Care Coordinator, Physician, Speech/Pathology,
Administrator, Dietary Supervisor
Step 4: Ethical Decision-Making in action
SAMPLE DECISION – options
Under Resident’s Day and the resident-centered care model,
“doing nothing” is not a viable choice since it ignores the
resident’s wishes.
Give cut-up to minced for one week – this honours the
resident’s wishes and permits a trial period to assess the
outcome.
Check the legal authority of son to sign Managed Risk
Agreement to ensure the care home is protected.
Consider Companion Care Assists for meals
GOAL: Honour the wishes of the resident/son within medically safe parameters.
Ensure staff are comfortable with the outcome and revised care plan.
Ensure all stakeholders have an opportunity to discuss the plan.
Step 4: Ethical Decision-Making in action
SAMPLE DECISION – The Outcome
The Resident is considered to be competent to make her own decisions so the
goal is to support Resident’s wishes and to achieve a balance of those wishes
with the professional recommendations.
Staff will monitor at meals which must be in the dining room. The Resident has
some loss of freedom but staff are protected from having to closely monitor in
Resident’s room.
Beverages may be offered in room with a straw i.e. milkshakes and smoothies.
Behaviour Mapping to commence regarding Resident’s feelings of satisfaction
and tolerance of the diet.
The Resident’s swallowing abilities often fluctuate day to day which will
necessitate frequent revisiting of a diet that can be tolerated.
The son will be contacted to review/modify the Managed Risk Agreement.
DOCUMENT OUTCOME: To ensure consistent action, the revised plan will be
documented in the Resident’s Day, Progress Notes, Care Plans, and
Managed Risk Agreement.
Step 5: Measuring Success
EXTERNAL MEASURES
Park Place measures both the company’s ability to create an ethical environment
and the individual ethical decisions made within that environment.
•
To evaluate the company’s Ethical Environment, Park Place measures itself
against Accreditation Canada standards. These established standards are used
across Canada to measure ethics within the health care field.
•
Internally, Park Place maintains an extensive program of Quality Improvement
Measures, which evaluate the provision of care throughout the company
against recognized standards of practice. Quarterly reporting helps the
company flag and investigate any variances in care outcomes.
Step 5: Measuring Success
Ethical issues
are a standard
agenda item for
Park Place
staff meetings.
This ensures
timely review
and assessment
of any issues
which occur.
INTERNAL MEASURES
Continual
on-site
monitoring of
ethical issues
and decisions
proves the
program works.
Step 5: Measuring Success
ANNUAL REVIEWS
Annual Performance/Accomplishment Reviews include consideration of
ethical issues. Included is discussion of ethical dilemmas the staff may have
faced and resolved during the previous year AND/OR discussion of ethical
issues which may arise. Questions asked include:
•Have you faced an ethical dilemma
in the past year related to health care?
•If yes, please share highlights of the
dilemma and how it was resolved.
•If no, state what could be an ethical
dilemma related to health care and
your role in resolving it.
Better care is an outcome of
including ethics in annual reviews.
Step 5: Measuring Success
EXTERNAL PRAISE
In June 2011 Park Place Seniors Living completed a comprehensive
Accreditation Canada review at 10 care homes. The review included a close look by
the six surveyors at how successfully Park Place handled Ethics, which is a priority
practice for Accreditation Canada.
The Accreditation review assessed Park Place’s:
•Ethics
•Ethics framework
•Ethics education
•Effectiveness in resolving ethical dilemmas
In its preliminary report, the survey team
noted, “There is a very strong ethics
framework. Staff know what ethics issues are.”
Accreditation Canada survey team with
(far left) Park Place Owner and President
Al Jina and (far right) Accreditation Coordinator
Louise Johnson.
Lessons Learned
In order to champion ethics, Park Place educated itself by researching various
ethics frameworks and developing an easy-to-read ethics manual for staff. This
manual includes a decision-making framework and terms that “make sense” to
frontline staff.
This resource guide includes a seven step decision-making model with flowchart
and related policies. It is a very practical guide for a long term care environment
and is useful in helping staff understand the role that they play in making ethical
decisions, whether on administrative or clinical issues.
The framework and seven step decision-making process have been used
effectively at all PPSL Homes.
Park Place Seniors Living has also integrated ethical issues into operations by
including Ethics as a standing agenda items on departmental and quality
meetings held throughout the year.
Attaching the ethics reporting template to each meeting agenda encourages staff to
Identify ethical issues and record decisions, experiences, and outcomes. This builds
a larger company-wide pool of experience in handling ethical issues.
Lessons Learned
The combination of print material, readily available manuals, and inclusion of Ethics
as a standard topic in staff meetings has resulted in clear communication to staff on
how to approach ethical decisions.
Management at each home have been able to use the tools to build capacity for
ethical decision making in their specific home.
By developing the ethics process within the framework of the company’s Resident’s
Day and Care Model, the resulting decisions reflect Park Place’s core values and
focus on resident-centered care.
Residents and/or their family members, friends or advocates are involved whenever
there is an ethical issue which affects that resident. Their input is invited.
Throughout, Park Place Seniors Living strives to ensure that every resident’s
wishes are honored.
The best advocates when resolving ethical dilemmas are often the resident,
or a friend or family member who speaks on behalf of the resident.
Future Direction
•Continue to develop an inventory of case
studies, administrative and clinical, as a
resource for all Homes.
•Continue to review ethical issues monthly
at Practice Council Meetings
and Leader Meetings.
•Include Ethics as an agenda item at
quarterly Home Quality Meetings in
each Park Place Care Home
Moving forward with enthusiasm!
•Include Ethics within the program for the
twice-yearly Leaders Forum held with all
care home leaders and executive staff.
About Park Place Seniors Living
Park Place Seniors Living is family owned company, founded, owned and
operated by Al & Jenny Jina. Al is a lawyer by profession and Jenny is a nurse
who specializes in geriatrics and adult education.
Owner Al Jina (left) with a Park Place
resident and her husband.
The company was founded in 1993 with one
small, private Care Home in Nelson B.C. Since
then the company has grown to include 15 sites,
offering a continuum of care from independent
living to assisted living to complex, continuing
and dementia care. All sites are owned and
operated by the company from a small head
office in Vancouver, B.C.
Park Place Seniors Living works in partnership with six regional health
authorities in Alberta and British Columbia.
Enriching the Lives of Seniors
Thank You – Questions?
We are discussing no small matter but how we ought to live.
- Socrates