EXECUTIVE SUMMARY

Ethicists at Indiana University surveyed clinicians about their experience with ethics consultation. Findings include the following:

  • Most clinicians reported the consultation helped clarify the values of the individuals involved.
  • About a third said the patient’s plan of care changed as a result of the ethics consultation.
  • Ethicists used the positive results to underscore the value of the service to hospital leaders.

In Lucia D. Wocial, PhD, RN’s experience, systematic quality assurance for ethics is performed “rarely, if at all,” due mainly to lack of time and resources. Many consultation services rely on volunteers, with no organizational supports to conduct regular quality monitoring of their activity.

“Without resources, it is unrealistic to expect volunteers to add this to the list of other duties,” says Wocial, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health in Indianapolis. Lack of clear criteria on which to measure quality are another obstacle.

Yet, ethicists are being called to consult on increasingly complex cases involving a new category of patients — the “chronically critically ill,” says Wocial. Many patients have multiple comorbidities with chronic illnesses that have no clear trajectory. People live with heart failure and chronic obstructive pulmonary disease much longer, for instance. “But they have the need for hospitalization periodically long before they are on a clear downward trajectory where it is clear that they are dying,” Wocial explains.

This is complicated by situations with no clear surrogate decision-maker, where surrogate decision-makers are themselves in frail health, or when there is conflict among them.

“Probably the biggest challenge is when a patient’s medical illness is complicated by a psychiatric illness, sometimes undiagnosed,” says Wocial.

When evaluating the quality of ethics consults, Wocial says the following are important questions:

  • Does the consult occur in a timely fashion?
  • Is there evidence that ethicists follow a standard process once their help is requested?
  • Do ethicists keep a record of their activity?
  • What was the outcome on the patient’s plan of care after the ethics consultation?
  • What was the effect on the members of the healthcare team, the patient, and the patient’s family?

“It is also important to have a transparent review, with discussion about cases and consult team activities in an open forum,” adds Wocial.

Wocial and colleagues recently conducted a study to assess clinicians’ experience with ethics consults.1 They concluded that ethics consultation offers meaningful support when clinicians face ethically challenging cases.

“The impetus was, in part, the ASBH core competencies and publications that suggested ethics consultants had an obligation to demonstrate the value of their work — and a genuine desire to evaluate our service,” says Wocial.

Researchers interviewed 123 clinicians who initiated an ethics consultation, were interviewed during the course of an ethics consultation, or were present at a patient care conference attended by an ethics consultant. Some key findings include the following:

  • More than 60% felt the consultation helped clarify their own values, and those of the patient and family.
  • Only 32% indicated the patient’s plan of care changed as a result of the ethics consultation. “However, 75% indicated their confidence in the plan of care increased as a result of the ethics consultation,” says Wocial.

The group used the positive results to underscore the value of the service to hospital leaders. “The hope is that we can identify meaningful metrics that would result in increased resources to sustain the quality work made possible by the grant to do the study,” says Wocial.

REFERENCE

  1. Wocial LD, Molnar E, Ott MA. Values, quality, and evaluation in ethics consultation. AJOB Empirical Bioethics 2016; 7(4):227-234.

SOURCE

  • Lucia D. Wocial, PhD, RN, Nurse Ethicist, Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis. Phone: (317) 962-2161. Email: lwocial@iuhealth.org.