How to write a Bioethics Chart Note:
A. Introduction:
A Bioethics Chart Note tells a story. It tells the reader, and reinforces for the participants, what happened, how it happened, who the players are—patient, family, providers--what their interests are and how the options for care are ethically developed and supported. Clearly much of the perspective presented in this memorandum has been honed over the years in discussions among the MMC staff and in collaboration with Rita Charon, the master of “narrative ethics”.
The bioethics chart note has a plot, and perhaps a subplot. It has intertwining characters some of whom have interacted before and have a history together and some of whom are new to the setting and the issues. How the players perceive the situation and their threatened rights or interests will determine, to some part, how they play out their roles.
The chart note author is also a character in the unfolding narrative; she, too, has a role and interests. Her interest is largely in reaching a consensus that encompasses, to the degree possible, all of the clashing, colliding and conforming values and interests of the other parties. She is the mediator of all of the past and collected history, the present clashes of perspective, needs, wants and desires. It is through her eyes, and in her voice, that the chart notes takes form. That voice should reflect the reality, as far as it can be determined, of the meetings and interaction. When it is the voice of the “bioethics consultant”, that, too, must be clear.
Much of this perspective is not new. It is the documentation of the process set forth in Bioethics Mediation, A Guide to Shaping Shared Solutions, by Dubler and Liebman. It reflects the skills that we all learned from Carol Liebman about framing, stroking, shouldering responsibility, amplifying voices, supporting positions and maximizing options. This document will not repeat all of that wisdom, This is the last step in the clinical ethics consultation experience: how to pass on the a sense of the process and product in a way that is helpful and guiding for the staff that must continue with the patient, the family and each other.
It is also critical to keep in mind that the chart note is a legal document. It is part of the legally discoverable record of the care of the patient in the institution which can be introduced as evidence if the care is ever challenged in a court case. As such the clinical ethics consultant should not offer an opinion in regard to what the law is. That is not the object, the goal or the appropriate stance of the ethics note. The note should be clear about ethical knowledge, ethical principles, ethical perspectives and the weight of different modes of analysis and different ethical exercises in balancing the benefits and burdens of care in the context of the life of the patient. The Clinical Ethics Chart note is just that: it is about ethics. It is about value contexts and value conflicts. It is about mediation and ethical positioning. It is not about what the law is and what the law would demand or permit in the circumstance presented.
This reluctance to state the law is in direct confrontation with the knowledge that clinical ethics consultants must have about what the law is in their jurisdiction. But, in the allocation of authority in major modern medical centers there is almost always an office of legal affairs that has the responsibility and authority to state what the law is or is not in the space of the medical center. These staff are, rightfully, guardians of their powers. There are also offices of risk-management which have the responsibility for assessing risk and determining hospital actions in matters of risk. A clinical ethics consultant needs to be aware of the boundaries of ethics consultation and respect these other institutional voices. The chart note must reflect these divisions of authority and power if it is to have its own sphere of influence. A clinical ethics consultation note is just that: an identification and analysis of ethical issues and opinions. It is not a legal or risk management memorandum.
If the chart note is typed, however, it can be an excellent vehicle for transmitting an ethical analysis of the situation and the options to these other offices. In the MMC model we are committed to a totally transparent process in regard to these other related, allied and coordinate players in the institution. If there is a case that may be of concern to the office of legal counsel or the office of risk management, the chart note will be e-mailed to those offices, but only after it is written and placed in the chart. However do note, Bioethics Mediation [page x] that there are some situations that may not be appropriate for bioethics intervention at all: cases that involve very hostile family members or patients who are threatening to sue; cases in which a suit has already been instituted; or some special circumstance such as, in New York State, certain wards of the state who are living in group homes, as long-term mentally ill or congenitally retarded persons, and decisions about whose care is regulated by special sets of state rules In these cases there may be a request for Clinical Ethics Consultation from the office of legal affairs or the office of risk management but that would be a special matter to be coordinated with these offices.
The CEC chart note has a special place in the medical record. It has an obligation to adhere to standards in the profession. It must be knowledgeable, readable, clear, directive and respectful throughout to patients, family members and the staff. It should lead by example. It should state the narrative, explain the ethical issues, outline the options and state the conclusion, recommendations and future plans. Equally as important, it should educate the reader about the area of ethical knowledge that was involved in the consultation.
The Bioethics Chart note is a part of a process of Bioethics Consultation Model at any health care institution. On the next page please find the elements of that model:
B. An Institutional Ethics Model:
Institutional Bioethics Consultation Model:
1. Clear indications for a consultation: This can include, among others issues, conflict between and among care providers or providers, patient or family; questions about ethical interpretation or analysis; questions about institutional ethics policy; uncertainty about the ethically appropriate plan of care; questions about the voice of the patient;
2. Regular process for convening care providers [or otherwise soliciting information]:It is the clear preference among experienced ethics consultants that there be an initial meeting among all of the care providers as a first step in the consultation process [see Bioethics Mediation pages x-y]; this meeting permits all of the care providers to hear and challenge each other before presenting an agreed upon medical statement of diagnosis and prognosis to the patient or family members;
3. A standard form for writing in the chart: The chart note must tell the “story”, identify the characters, give the plot, identify the medical options and the ethical weight of each option, clarify the issues in the case, discuss and reference the ethical literature [teach ethical analysis] make clear recommendations;
4. A typed note in the chart:
This is a method for communicating among the care providers—copies of the chart to all--that is shared by e-mail, if that is the culture of the institution, to provide concrete reinforcement of the process and to permit the participants in the conference to review how the issues discussed were relayed to the naïve chart reader [it might also be possible for all of the consultants at an institution to have a shared drive for chart notes];
5. Conception of Bioethics as one voice in a complex institutional system: Bioethics is one of the players in complex institutional systems that include others and especially the Office of the Medical Director—some complex cases require the collaboration of others especially the collaboration of administration, office of legal counsel and office of risk-management—all of these offices have different perspectives and non will dominate at all times—all must meld their voices into set of positions and perspectives that will be comprehensible to the office in the institutions that ultimately decides on difficult and complex clinical cases such as the Office of the Medical Director or other similarly empowered position;
6. A robust QI process: Bioethics consultation as any other service must be subject to a QI process that is, continuous, comprehensive, accessible to practitioners and transparent to the institution;
7. Credentialing and Privileging.
C. The Chart Note:
[Note: Before sitting down to write a chart note review the QI form. It is designed as a quick guide to directing a CEC and as a guide for designing the chart note. It can not replace the depth of knowledge in Bioethics Mediation but can be a quick refresher as a consultation begins. It is always the place to state when the char note is in formation. If all of the points on the QI form have been addressed in the process of the consultations and documented clearly in the note, it will be rated as a quality intervention.]
As you can see from the above Institution Bioethics Consultation Model, bioethics consultation is not a “stand-alone” statue; it is not an isolated object. It is part of the fabric of delivering clinical care to the patient in the context of the family. It is clinical service that clarifies and explains ethical options and the benefits and burdens of these options to the patient, family a members of the medical team. It then communicates these discussions through a chart note that is placed in the patient’s chart and sent, if the culture of the institution permits, to the participating medical staff.
The Template:
The chart note is based on the following template:
Introductory material:
[Note: These are the data that you should be keeping to have a searchable data base that permits gathering aggregate data on the sorts of consultation called over the year, by whom, on what issues. It is the basic data that the person getting the call, or carrying the beeper, should collect. It is also the heading for an electronic medical record.]
Patient’s name, MR#, primary diagnosis______/______/______
Patient’s DOB______Date of hospital admission______Date ICU admission______
Name & position of person who called consult______Unit (service/ICU)______
Name of PCP______
Time and date of consult request______Stated reason for consult______
a.Time and place of the consultation: [See QI Form section A. Participants]
[Note: these paragraphs locate the discussion. They, in effect, set the stage, cramped or spacious, orderly or somewhat chaotic. They may describe a meeting in an empty room in the MICU with staff sitting on beds and on the windowsill. The conditions of the consultation and the participants emerge here.]
Persons present at the consultation including title [housestaff, patient’s attending, social worker for the patient etc.], place of the consultation [in the conference room behind the nurses station].
This descriptive section should explain which staff members were there and which were not and why. If the patient’s attending physician was not there—was she contacted, refused, was present by phone? Were all of the care providers who have been involved in the case and who are necessary to understand the history and the future possible courses of medical intervention present?
[Note: the chart note should never be part of a” chart war” or other hostile interaction. If the attending physician was clear that she would never attend this sort of event, which almost never is the case, then it should be noted that the attending physician was aware of the meeting and could not attend, either by conference call or in person.]
If the patient is able to participate has she been interviewed and if not has she been seen? Respect for patients requires, in this model, that the patient be encountered as part of the process. A CEC should never write a chart note, or even convene a discussion about a patient’s care without having encountered the patient. Sometimes that means trying to rouse the patient and failing to do so. The attempt is what matters.
What was the initial arc of discussion with the care providers? What issues were raised, what disagreements surfaced and what possible resolutions suggested?
b.1.Relevant medical history: [See QI Form Section B. Relevant history]
[Note: this is a more difficult section to write than one might think. For non-medical staff it must be clear to them what the sentinel medical issues are that correlate with the ethical questions. For new consultants who are not medically trained it is best to ask questions, clarify, restate and, in the case of very, very complex medical situations, prepare a draft that can be reviewed by a medical person before placing this section in the chart note.]
Was the medical history of the patient clear? Were sufficient facts provided so that the reader had a sense of the course and development of the illness or condition? Was it clear that there were, or were not, additional medical consultations that needed to be scheduled or facts that needed to be clarified? Were all at the meeting satisfied that the medical facts explained the present status and possible future options for the patient?