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95 6 How to Write a Bioethics Mediation Chart Note Introduction The bioethics mediation chart note has a special place in the medical record. As a subset of a note on clinical ethics consultation, it must adhere to conventions of ethical analysis and standards for best practice in clinical medicine. It must be knowledgeable, readable, clear, and descriptive of the narrative history of the case, compelling in its identification and analysis of ethical issues, and respectful throughout to patients, family members, and the staff. It should lead by example. The chart note should: (1) reflect and discuss the process of the mediation; (2) relate the story of what happened to the patient and how the family and significant others were involved; (3) explain and analyze the ethical issues in the context of the case; (4) detail the options that were generated by the mediation; (5) discuss the consensus reached; and (6) present the agreement as the basis for the recommendations for the future care of the patient. The note should also educate the reader about the ethical issues that were involved in the consultation, as part of the ongoing augmentation of staff knowledge and awareness. This chapter, like others in the book, reflects our heightened awareness of how bioethics mediation relates to clinical ethics consultation. As discussed earlier, it is our contention that many, if not most, clinical ethics consultations involve the resolution of conflicts, and that those involved in the conflict are best served by a mediative approach and the specific techniques and skills that mediation offers. There are times, however, when clinical ethics consultants must address factual or policy questions, or aid in clarification that stops short of intervention as a mediator . The chart note needs to be clear about what the issue or problem was, about the process used in reaching a decision, and about the implications of this consultation for like situations in the future. First, bioethics mediation is a subset of clinical ethics consultation in that it recognizes that the presenting bioethics dilemma is really a conflict and therefore is best addressed with awareness of the dynamics of conflict and with tools for resolution. But it is also a conflict that occurs within a complex institution that provides health care. Thus bioethics mediation must respond to the patient’s values, expressed preferences for health care, needs, wants, and desires, generally as repre- 96 Bioethics Mediation: A Guide to Shaping Shared Solutions sented by the family, and to the understood ethics of providing care as expressed by the care providers. However, the mediation must do so in a context affected by the organizational ethics of providing care as defined by institutional arrangements and policies structured by case law and state and federal regulation. What happens during the consultation is most important, but how it is conveyed and communicated is also critical. Second, more than most consultations, one that carries the label bioethics comes (often mistakenly) with an aura of right and wrong, good and bad, ethical or not ethical—territory that must be addressed cautiously. How issues are resolved in clinical ethics disputes is subject to the same vagaries of dynamics as are other consultation areas of medicine in which there can be good-faith disagreements among equally talented professionals. Professionals of goodwill, skill, and intelligence can disagree about the label and the subsequent analysis that applies in any patient care situation. The recommendation of the clinical ethics consultant or the consensus reached in a principled resolution of bioethics mediation must still be implemented by the care team as part of the plan of care. A clinical ethics consultation, like any other consultation in the care of a patient, is but a recommendation to the attending physician, who is legally responsible for the course and conduct of the patient’s care. A bioethics mediation that reaches a consensus is also a recommendation to the physician. Almost always the physician is a part of the mediation and thus has bought into the process and the outcome as it develops. Third, many on the care team may have been present at the bioethics mediation , but they generally represent only one shift of care providers. In most institutions there are three shifts a day, and all the care providers not present at the mediation need to be brought up to date on what has happened, what the reasoning was for the resolution and the consensus, and what the suggested plan is for patient care in light of the mediation...

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