CASES is a method developed by the Department of Veteran Affairs (DVA) to provide healthcare administrators with a systematic approach to ethics. As part of the IntegratedEthics (IE) method, the CASES approach coalesces information and strategies from several fields, including:
Organizations that execute the strategy employ an Ethics Consultation Coordinator, who is also an IE Council member, to oversee the following five steps in CASES deployment.
Step One: Clarify
The first step involves learning why a care provider seeks ethics counseling and whether the requesting party truly wants help resolving a concern. After establishing these facts, IE consultants present clients with achievable outcomes by clearly explaining how the process helps to resolve conflicts.
The consultant must work with stakeholders to ascertain what ethics questions lead to justifiable decisions. These critically important questions set the precedent for all ensuing work. After establishing these primary facts, the coordinator gathers the basic information needed to complete work in the next CASES phase.
Step 2: Assemble
During the assemble step, IE consultants gather information from all available sources to build a case overview. Using guidelines from the industry resource “Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine,” consultants outline the universal concerns regarding the current case, incorporating the clinical facts as well as the outcome desired by the patient and other interested stakeholders.
As part of this process, the ethics team must gather all relevant case histories and best practice guidelines, as well as seek counsel from a healthcare law professional. The IE team also networks with subject matter experts on an as needed basis.
Step Three: Synthesize
Here, the IntegratedEthics consultant develops a clear and comprehensive synopsis to present to all stakeholders, sometimes conducting a formal meeting to gather additional information. Next, the consultant performs a detailed analysis.
Ethics consultants might use one of several approaches such as Principlism, Casuistry or other methods of analysis. With the Principlism approach, consultants consider autonomy, beneficence, non-maleficence and justice as it pertains to the case, while the Casuistry approach involves developing a practical, as opposed to theoretical, conflict resolution. Other approaches include feminist, deductivist and narrative analyses.
Ethics consultants develop several resolution options during the course of the case. However, they often resolve issues solely by identifying the appropriate decision-maker in respective ethical conflicts.
Step Four: Explain
During this phase, consultants formally report their findings to appropriate stakeholders, while explaining how the information converged toward a recommended action plan. This includes a written and verbal recounting of the events leading up to the conflict, and plans for moving forward. The consultants also gather and share supporting documentation such as articles, books and other publications.
When the case directly involves a patient, the report becomes part of the patient’s electronic health record (EHR) to aid in accountability as well as legal transparency. Whether or not analyses are placed into a patient EHR, consultants submit all case recommendations to the Department of Veterans Affairs ECWeb database.
Step Five: Support
After explaining the results of the analysis, ethics consultants help organizations follow through with related plans. They also assist with making necessary policy and procedural adjustments. In this closing stage, the consultant reaches out to stakeholders once more. If the stakeholders do not comply with the resulting recommendation, the consultants establish why the stakeholders rejected the proposal.
Significant stakeholder objections might require further research to uncover the underlying issues preventing a consensus and address an adjustment in the recommendation. To aid in making and revising recommendations, consultants regularly review cases to find opportunities for self-improvement and identify institutional cultures and policies that may impede ethical conflict resolutions.
Responding to the Workplace
In her book “Giving Voice to Values,” business professor Dr. Mary C. Gentile discusses the concept of values-driven leadership. The professor’s view concurs with the DVA’s agenda to promote servant leadership, as well as security when presenting ethical concerns, and to demonstrate the courage to take risks when standing up for one’s personal beliefs.
The topics drew so much interest among members that leaders of the Veterans Integrated Service Network (VISN) used them as focal points during their 2016 summit. At the event, the organization revealed they will work with the National Center for Ethics in Health Care (NCEHC) to assist healthcare personnel in navigating these matters. As part of this arrangement, the NCEHC maintains the “Addressing Moral Distress” website.
IntegratedEthics represents an entirely new school of thought in healthcare specific ethics. The practical framework helps ethics consultants apply theoretical best practices to real life cases. By incorporating the complexities and information sources specific to healthcare, the IntegratedEthics method empowers care providers to resolve conflicts systematically and morally.
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