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How to avoid ethics consultation pitfalls
Experts should receive financial compensation
Clinical ethics consultations still are infrequent in most hospitals, but their use is beginning to enter ethics board conversations, and it's an area that should be approached with cautious preparation, an expert says.
"If it's done correctly, it's valuable to people who ask for the help," says Anita Tarzian, PhD, RN, an ethics and research consultant in Baltimore, MD. Tarzian also is the program coordinator for the Maryland Health Care Ethics Committee Network, University of Maryland School of Law and an associate professor at the University of Maryland School of Nursing in Baltimore.
When clinical ethics consultations are done poorly, they may take two or three weeks for an answer that essentially boils down to an "It depends..."
This type of consultation adds no value to the process of making a decision, Tarzian says.
Health care institutions can improve their use of clinical ethics consultations by addressing potential pitfalls and writing policies that will enhance the process. Here are some of Tarzian's list of common pitfalls and suggestions for avoiding these:
Pitfall using ethics consult as an add-on. "One major pitfall is that most people are doing this as an add-on to what they're already doing and not valuing the service the way they should," Tarzian says.
Hospitals fall into this trap when they assign a staff nurse, physician, or social worker the additional work of ethics consultation without providing appropriate support.
When done correctly, ethics consultations are time-consuming. They require an expert sorting through facts, meeting with stakeholders, coming up with an ethical analysis and recommendation, and they need proper documentation, Tarzian says.
It's a process that must have institutional support to be done correctly, she adds.
One solution would be for an accreditation organization to give health care institutions an incentive to provide adequate resources so that clinical ethics consultations are done correctly.
"Hospitals could provide resources for people to become properly educated, sending them to conferences or helping them obtain certification," Tarzian suggests. "Hospitals also could pay ethics consultants at the minimum an honorarium for being the lead consultant."
When an appropriate clinical ethics consultation request comes in, it requires the consultant to meet with stakeholders, talk with the medical team, and be responsible for documenting in the consult service's records and the patient's medical record, she explains.
"That person should be paid part of a salary or be paid an honorarium and not expected to do this work as a volunteer," she says. "So there is a need for resources, budget money, and time and respect for their doing quality work."
Pitfall developing competent consultants. "There is this idea that we have not reached a consensus yet on what the standards are," Tarzian says. "Some say we have and some say we haven't."
However, there are some standards available, including the American Society for Bioethics and Humanities' report, titled, "Core Competencies for Health Care Ethics Consultation," which originally was published in 1998. The report has been updated, and the second edition is scheduled to be published this winter.
The report lists basic knowledge competencies and basic skills competencies. The updated edition will have a new section on emerging procedural standards that are not related to the competency of individuals, but cover ethics consultation services' operational policies and procedures.
"Some people say it would be better to evaluate the service and not focus on individuals," Tarzian says. "That's a compelling idea and more consistent with this document."
If a health care institution has a team of people providing ethics consultations, then they could pool their competencies, and one person would not have to be an expert in all areas, she adds.
Pitfall taking away ethical responsibilities from frontline staff. "There is a big concern about what happens if you focus on advanced competency," Tarzian says. "Will frontline health care professionals be replaced with experts from the outside?"
"The concern is this would diminish the ethical climate of an institution if you are encouraging the health care professional to farm out ethical decision-making to some other body," she says.
This concern has been debated with some research weighing in on the side of using professional ethics consultants.
"Some research has shown that if people are more educated about ethics they're more likely to involve ethicists in complex cases and show a higher level of care about ethics," Tarzian says.
Proponents of ethics consults answer that these do not make medicine softer. They say it's a value-added service that enhances the ethical climate of the institution, and, at any rate, it's unavoidable in today's medicine, she adds.
"Medical decision-making has reached a state of complexity that we need people with specialized ethics skills and knowledge to help address ethical questions and dilemmas," Tarzian says.
If done well, clinical ethics experts assist patients and staff in addressing ethical issues and concerns and should bring a benefit to an institution's ethical climate, she says.