Ethics consultation, like other consultation services, involves responding to a request for help. Yet, the role of an ethics consultant goes beyond merely doing ethics consults. There is a growing list of other services that ethics consultants provide—particularly those who have chosen health care ethics as their primary profession. Examples include “ethics coaching,” formal and informal ethics education, running an ethics consultation service, engaging in research or quality improvement initiatives, mentoring other ethics consultants or interns, providing proactive ethics services, etc. Chidwick and colleagues summarize this “model role description for ethicists” in their 2010 publication in HEC Forum (22:1, 31-40).
Institutions that employ an ethicist to run their ethics program are more likely to have proactive ethics services that raise the level of ethics awareness and proficiency throughout the institution. In some cases this increases ethics consultation requests, and in other cases, it decreases them. In general, it is easier to manage and promote the quality of ethics consultation when there is a minimum (and somewhat predictable) number of ethics consults requested, and when there is a formal process for conducting, documenting, and evaluating ethics consultations.
There is a bit of a conundrum here. Those doing ethics consultation as a volunteer service typically have limited time and resources to expand services beyond ethics consultation. Yet, ethics consultation is a difficult service to staff if it is offered 24/7 and serviced by volunteers. This generally results in low numbers of ethics consultation requests. It is then difficult to negotiate with administration to provide more resources to the ethics committee if there is little to show in terms of number of ethics consultations performed. Yet, when ethics consultations are requested, the stakes are often high, so it’s important to ensure that those requesting ethics assistance are actually helped, and not harmed. Read these tips for “How to ‘Sell’ an Ethics Program” to ensure adequate support of the service, written by clinical ethicist MaryLou Lewis, MD, MA, in the Spring/Summer 2011 issue of the MAEC Newsletter.
In 2014, the American Society for Bioethics and Humanities (ASBH) published the first Code of Ethics for healthcare ethics consultants. Currently, ASBH’s Quality Attestation Presidential Task Force is developing a method to evaluate the competencies of clinical ethics consultants. As with other professions (e.g., medicine, chaplaincy, palliative care), graduate programs will eventually become accredited and clinical ethics consultants will then require a degree from an accredited program in order to practice. This has raised concerns about how health care facilities will be able to financially support ethics consultation services. However, others have argued that having at least one “professional” ethics consultant with expert knowledge and skills to run a facility’s ethics program and oversee the ethics committee and other ethics services would be more cost-effective than relying on all-volunteer ethics consultants. See, for example, the VA’s A Brief Business Case for Ethics.
Individual, team, or whole committee. Ethics consultation can be performed by a whole committee, a team, or an individual. There are pros and cons of each. ASBH’s Core Competencies (2011) states: “… [T]he individual consultant model is well suited to situations in which the requester has an urgent need for information. The full committee model may be most appropriate for especially controversial consultations that might establish precedent or end up in the media or the court. The small team model might be appropriate when those requesting the consultation want the opinion of more than one person from the HCEC service, where there may be educational value in involving more than one HCE consultant, or for more complex cases where HCE consultants can share workload tasks.” (See Smith, et al., 2004. Criteria for determining the appropriate method for an ethics consultation (HEC Forum, 16:2, 95-113).
ASBH’s Core Competencies (2011) identifies the following standards of ethics consultation process:
Access. The service should be available to anyone who would benefit from it. This means others must know how to access the service, and those providing the service must be able to respond in a timely manner. Ethics consultation staffing should be mindfully planned before campaigns to increase awareness of the ethics consultation service. It’s important to put thought into the logistics of how an ethics consultation is requested, triaged, and staffed. Ideally, requestors should be able to specify if their request is urgent (i.e., requires a response at 3 A.M.) or can wait (i.e., a request coming in at 3 A.M. can wait until the next day). This directly impacts ethics consultant staffing—particularly off-hours, which can quickly lead to burnout if on-call ethics consultants are over-burdened.
Thorough, systematic process. Ethics committees should have specified processes for each step of an ethics consultation, from initial receipt of the request to evaluation of the consult. ASBH’s Core Competencies (2011) recommends that the following be included in a facility’s ethics consultation policy: The structure, organization, scope, and purview of the ethics consultation service, the designated process for ethics consultation (e.g., when a single consultant versus team or whole committee responds to a request, the advisory nature of recommendations, whether an anonymous consultation can be requested, etc.), how a consult is documented, and how consults will be evaluated for quality improvement. Poor performance in ethics consultation services often reflects lack of attention to standardized processes to ensure that requestors receive a consistent response that actually helps them with the question or concern that prompted their ethics consultation request.
An ethics consultation service should consider utilizing an ethical framework to ensure consistency across consults. Examples of such frameworks include Jonsen, Siegler & Winslade’s 4 Boxes Approach (2010, Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, McGraw-Hill, 7th ed.), Orr and Shelton’s Process and Format (2009, J Clin Eth, (20)1, 79-89), and VA’s IntegratedEthics’ CASES approach.
How ethics consultants communicate with stakeholders in an ethics consultation is also critically important. It goes without saying that excellent communication and mediation skills are essential. An important area of consideration is clarity when holding formal meetings during ethics consultations. It should be clear who is running the meeting and what role the ethics consultants are playing (e.g., ethics experts? Mediators? Facilitators?). If more than one ethics consultant is involved, a “lead consultant” should be identified and should serve as moderator for a formal meeting (unless the consultant has agreed to serve a different role and allow someone else from the treatment team to facilitate the meeting). Formal meetings involving patients and families should be handled with particular care. The ethics consultant as meeting facilitator should establish ground rules (e.g., that everyone’s voice is valued, that what is discussed in the meeting should be held in confidence, etc.) and level power imbalances (e.g., if the patient or family members are present, have them speak first). In most cases, the ethics consultant(s) should meet first with the health care staff involved in a consult before conducting a formal group meeting with the patient or family member(s) present. This helps avoid the situation when staff contradict each other in front of the patient/family, or learn facts for the first time that influence their opinions about the best course of treatment for the patient. Helping bring the treatment team on the “same page” is a valuable service the ethics consultant(s) can provide.
While some favor putting all stakeholders—patient/family included—in one room from the beginning to “get to the heart of the problem,” this may expose the patient/family to unnecessary stress and confusion. For example, consider the case of a 76 year old man who has been in the surgical intensive care unit (SICU) for the past four months after initially undergoing a leg amputation for an aggressive infection. Say that a nurse requests an ethics consult because he believes the patient is dying and the family is “in denial.” But when members of the treatment team meet, the consulting infectious disease physician thinks the patient is improving, the surgeon opines that another amputation that would either save the patient’s life or lead to the patient’s death—and since death without the surgery is inevitable, it’s worth a try to amputate again, and the hospitalist and nurse thinks the patient’s death is imminent, with or without surgery. Generally, it’s better to have a formal group meeting first with the members of the treatment team to gather facts and identify what the initial (and actual) ethical issue(s) are. If a formal meeting with the patient’s family is arranged, the ethics consultant(s) can establish in advance the goal of that meeting to further ensure that everyone remains “on the same page.” This can also be done by meeting with each stakeholder individually, but that approach generally takes more time. Also, disagreements about goals of care and methods to achieve them, as demonstrated in this case, are usually better resolved by facilitating a conversation with members of the treatment team in one room.
Notification of a case consultation. If an ethics consultation is requested for help in caring for a particular patient and the responding ethics consultant decides it is appropriate for ethics consultation (e.g., rather than risk management), the attending physician and patient’s surrogate decision-maker should be notified. Some thought should be put into how this is done. Some people may misinterpret what “ethics consultation” means. They might think they have done something wrong if an “ethics committee” has been consulted. The ethics consultant might explain that an ethics consultation is a way to help staff take a bit more time and get a bit more help to figure out the best way to care for a patient whose healthcare needs are complex. Some ethics consultation services call themselves by a different name, partly for the purpose of not scaring off requestors or those they serve by their name! This is an extreme solution. It’s usually sufficient to simply reassure those being notified that an ethics consultation doesn’t mean anyone did anything wrong, but is a way to help make sure that those making decisions for the patient have all the support they need.
Adequate documentation. All ethics consultations should be documented in the ethics consultation service’s records. Case consultations should also be documented in the patient’s medical record. Dubler and colleagues suggested the latter as a way to gauge the credentials of ethics consultants in their paper, Charting the Future: Credentialing, Privileging, Quality, and Evaluation in Clinical Ethics Consultation, published in The Hastings Center Report (2009, 6, 23-33). They wrote (p. 27): “A clear format should govern a first intake note, the body of the chart note and a final summary note, if required. If the chart note format tracks the elements of an established QI [Quality Improvement] tool it will provide readily available material for later organizational evaluation and scrutiny. A clear format for a CEC [clinical ethics consultation] chart note will be recognizable and will encourage the reader to expect a detailed ethical analysis, which is applicable to this case and to like cases in the future.”
While the components of an ethics consultation chart note may differ from one institution to the next, what’s important is to include enough information to tell the “story” of the patient featured in the consultation and to inform those reading the note about the ethical issue(s) involved and what options considered in the course of the consultation were considered ethically justifiable. Ethics consultants should be mindful of avoiding role confusion by writing appropriate chart notes. For example, it would be inappropriate to write, “Pull feeding tube” in an ethics consultation chart note. That would be a medical order. However, it could be appropriate to write, “Based on the reasoning provided above, it is ethically justifiable to stop Mr. Jones’ tube feedings.”
Ethics consultants at facilities using an electronic medical record (EMR) should work with the IT staff to ensure that they have the ability to enter ethics consultation notes in the EMR.
Evaluation, quality review and process improvement. Ethics committees should keep a record of their activities—including ethics consultations—for two main reasons: (1) to demonstrate the value of their services to administration and accrediting bodies, and (2) to improve their services. VA’s Integrated Ethics program provides several resources to assist in this process, including “A Brief Business Case for Ethics,” which describes how integrating ethics throughout a health care organization, with a focus on quality improvement, can benefit the organization. ASBH’s Core Competencies for Healthcare Ethics Consultation has a section on evaluating the quality, access, and efficiency of healthcare ethics consultations. Ascension Health also has tools to evaluate ethics committees.
Literature searches. It’s often said that “good ethics starts with good facts.” Toward that end, it’s helpful to learn what is already known about a topic by searching published literature. To hone your database searching skills, view this PubMed tutorial.