Ethics Committee Core Curriculum
JCAHO 1997
PATIENTS RIGHT AND ORGANIZATIONAL ETHICS
Karen Maricle
The goal of this functional chapter is to promote improved patient
outcomes by respecting each patient’s rights and conducting business
relationships with patients and the public in an ethical manner. The
chapter is divided into two major components: Patients Rights and
Organizational Ethics. Although the 1997 Standards remain
unchanged from those of 1996, there has been a change in the method of
scoring. Historically, when the Joint Commission institutes new
Standards, they "cap" those Standards for a year or two in order to
provide time for organizations to institute measures to be in full
compliance. Prior to 1997 the Standards related to Organizational Ethics
were capped at two. A score of two indicates significant compliance;
therefore, even if there was no evidence of intent to meet the Standard, a
score of two was obtained. In 1997 all Standards related to
Organizational Ethics have been capped at three. A score of three
indicates minimal compliance. A score of three for several related
Standards can result in a Type 1 Recommendation.
I will now present an overview of the 1997 Standards; emphasizing new
intents or areas of increased importance.
The Patients Rights Standards continue to emphasize access to care,
treatment of patients and respect for patients and their families. While
these Standards are requirements, various strategies may be utilized to
achieve compliance. Hospital Ethics Committees, while not required, have
been effective in addressing many of the issues outlined in these
Standards.
RI.1 The hospital addresses ethical issues in providing patient
care
Hospitals must have processes and structures in place to support ethical
decision making and all staff members must be aware of the ethical issues
regarding patient care. Implicit in this Standard is a mechanism for
staff education. The following patients’ rights must be guaranteed:
access to care, care that is considerate and respectful of his or her
personal values and beliefs, informed participation in care decisions,
participation in ethical questions that arise in the course of his or her
care, privacy, confidentiality, security, surrogate decision making and
the right to access protective services. The 1997 Accreditation Manual
defines protective services as the need for protective intervention,
correction of hazardous living conditions or situations in which
vulnerable adults are unable to care for themselves, and investigate
evidence of neglect, abuse, or exploitation. Mechanisms to provide
protective services can include guardianship and advocacy services,
conservatorship, referral to state survey and certification agency, state
licensure office, the state ombudsman program, the protection and advocacy
network, and the Medicaid fraud control unit.
RI1.1 The patient’s right to treatment or service is respected and
supported
The intent of this standard is to provide care that is in response to a
patient’s desire or need, as long as that care is within the hospital’s
ability, its mission and not in violation of relevant laws and
regulations. If a hospital cannot provide required or requested services,
the patient is informed and if medically advisable, appropriate transfer
arrangements are made.. The decision to transfer must not be made solely
for economic reasons.
RI.1.2 Patients are involved in all aspects of their care
The aspects of care that are referred to are informed consent, making care
decisions, resolving dilemmas about care decisions, formulating advance
directives, withholding resuscitative services, forgoing or withdrawing
life-sustaining treatment, and care at the end of life. Hospitals must
also allow patients and their families to express their cultural and
spiritual practices and beliefs as long as this does not interfere in the
treatment of others.
RI.1.2.1 Informed consent is obtained
Treatments or procedures must be fully explained to the patient, and when
appropriate the family. The risks and potential benefits must be
addressed as well as the possible result of nontreatment. Significant
alternatives to the proposed treatment must be shared. Staff members
must also inform the patient of any potential conflict of interest,
including business relationships and relationships to educational
institutions. This Standard includes the requirement of informed
consent for all investigational studies or clinical trials. The hospital
must have policies and procedures in place which ensure that when patients
are asked to participate in an investigational study or clinical trial,
they receive appropriate information upon which to base their decision.
It is essential that patients understand that their refusal to participate
in such trials will not compromise their access to the hospital’s
services
RI.1.2.2 The family participates in care decisions
This Standard requires a surrogate decision maker to be identified when a
patient cannot make decisions regarding his or her care. In the case of
an unemancipated minor, the family or guardian is legally responsible for
approving the care prescribed. The patient also has the right to exclude
any or all family members from participating in his or her care
decisions.
RI.1.2.4 The hospital addresses advance directives
Hospitals are required to determine whether a patient has an advance
directive and if not, wishes to implement one. Hospitals must provide
assistance to patients in formulating advance directives. The discussion
must be conducted by an authorized staff member who has specific training
in this area or be the attending physician. If a patient does not wish to
implement an advance directive, this must be indicated in the medical
record. Once an advance directive is executed, hospitals are required to
honor the directive within the limits of the law and the organization's
mission, philosophy, and capabilities. Finally, in the absence of the
actual advance directive, the substance of the directive is documented in
the medical record by hospital staff. This final issue has raised
concern since its implementation in 1996. The concern centers around
the ability of the staff member to capture the true essence of the advance
directive in light of the patient's present condition and limited contact
with the patient. Organizations would be prudent to consult with their
legal counsel regarding this issue.
RI.1.2.5 The hospital addresses withholding resuscitative
services
RI.1.2.6 The hospital addresses forgoing or withdrawing
life-sustaining treatment
Policies and procedures should provide a framework which ensures that the
decision-making process is applied consistently and that lines of
accountability are clear. Hospitals will conform to the legal
requirements of their jurisdiction. Policies and procedures should be
adopted by the medical staff and approved by the governing board.
RI.1.2.7 The hospital addresses care a the end of life
This Standard provides for the appropriate care of dying patients. The
framework used must address the following issues: pain management,
sensitively addressing issues such as autopsy and organ donation,
respecting the patient's values, religion and philosophy, involving the
patient and where appropriate the family in all aspects of care, and
responding to the psychological, social, emotional spiritual and cultural
concerns of the patient and family
RI.1.3 The hospital demonstrates respect for the following patient
needs: confidentiality, privacy, security, resolution of complaints,
pastoral counseling and communication.
When the hospital restricts a
patient's visitors, mail, telephone calls, or other forms of
communication, the restrictions are evaluated for their therapeutic
effectiveness. Any restrictions on communication are fully explained to
the patient and family, and are determined with their participation.
RI.1.4 Each patient receives a written statement of his or her
rights
RI.1.5 The hospital supports the patient's right to access protective
services
This Standard refers to the provision of guardianship and advocacy
services, conservatorship, and child or adult protective services for at
risk populations.
RI.2 The hospital has a policy and procedures, developed with medical
staffs' participation, for the procuring and donation of organs and other
tissues
Policies and procedures for organ and tissue procurement and donation
include the following elements: identification of the organ or tissue
procurement agency with which the hospital is affiliated, criteria for
identifying potential organ and tissue donors, procedures for notifying
the family of each donor of the organ to donate, and for recording their
decision, discretion and sensitivity to the circumstances, beliefs, and
desires of the families of potential donors, procedures for directly
notifying appropriate organ procurement organizations and tissue banks
when an organ or other tissue is potentially available, written
documentation showing that the patient or family accepts or declines the
opportunity for the patient to become an organ or tissue donor and records
of potential organ donors whose names have been sent to organ or tissue
procurement organizations.
RI.3 The hospital protects patients and respects their rights during
research, investigation, and clinical trials involving human subjects
(please refer to consent Standard)
ORGANIZATIONAL ETHICS
RI.4 The hospital operates according to a code of ethical behavior
This code addresses ethical practices regarding marketing, admission,
transfer, discharge and billing, and resolution of conflicts associated
with patient billing.
The code ensures that the hospital conducts
its business and patient care practices in an honest, decent and proper
manner. The code of ethical behavior is driven by leadership and must be
approved by the governing board.
RI.4.3 In hospitals with longer lengths of stay, the code addresses a
patient's rights to perform or refuse to perform tasks in or for the
hospital.
Patients have a right to refuse the work. Work must be appropriate to the
patient's need and therapeutic goals.
Reference: 1997 Hospital Accreditation Standards. Joint Commission
Other Resources:
COPYRIGHT © 1997, UB Center for Clinical Ethics and Humanities in
Health Care
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Last Revised 2/15/97