EXECUTIVE SUMMARY

Ethicists at Memorial Medical Center were seeing increasingly complicated cases extending over longer time frames, and created a tool to determine complexity of cases.

  • The group developed a complexity scoring system based on an analysis of more than 500 ethics consults.
  • The study’s findings suggest it is possible to account for case complexity when evaluating an ethics consultant.
  • The researchers recommend that attestation portfolios include several cases of moderate complexity and at least one very complex case.

At Springfield, IL-based Memorial Medical Center, increasing numbers of ethics consultations seemed to extend over longer period of times.

“More seemed to involve patients whose family, living, or financial situations ruled out most commonly adopted solutions,” says Bethany Spielman, PhD, JD, professor of medical humanities and law at Southern Illinois University in Carbondale.

More cases involved the following scenarios:

  • several requests for help over a period of a year,
  • an unusually large variety of professionals,
  • a family member or patient who threatened violence, and
  • a care plan that was in constant flux.

“One of the most complex ethics consultations at Memorial, involving a request for sterilization of a minor, included all of these features,” says Spielman.

Still, consultants had no way to quantify this. “The field of ethics consultation had not yet developed a way of assessing complexity,” explains Spielman, a member of Memorial’s Human Values and Ethics Committee (HVEC).

In 2013, the American Society for Bioethics and Humanities (ASBH) described steps necessary to distinguish qualified ethics consultants from unqualified ethics consultants.1 However, their approach didn’t consider whether a consultant could handle complex cases.

“That seemed like a gap that we could fill,” says Spielman. Memorial’s ethicists set out to create a tool to determine the complexity of cases. They took into account factors such as a history or threat of force, a difficult family or living situation, monetary issues, high levels of emotion, and a large number of professional participants.

Christine Gorka, PhD, director of Memorial’s Clinical Ethics Center, which employs two full-time ethicists and reviews all ethics consultations at monthly HVEC meetings, notes, “The timing was such that using the tool to assess the complexity of problems encountered in our usual practice provided a way to tackle what we considered a gap in the ASBH competencies regarding required skills.”

The group developed a complexity scoring system based on an analysis of more than 500 ethics consults performed during 2013.2 “The study’s findings suggest it is possible to account for case complexity when evaluating an ethics consultant,” says Gorka. “To not consider complexity when assessing an ethicist’s portfolio seems short-sighted.”

Spielman noted the gap between the experience requirements described by ASBH, and what would be required to handle a consult of average complexity at Memorial.

“An individual could almost certainly meet the ASBH requirements that her portfolio demonstrate experience in a ‘range of clinical settings’ with a ‘range of ethical issues,’ and yet be unable to handle a case of average complexity at her own organization,” says Spielman.

The researchers recommend that a minimum level of care complexity be required, and attestation portfolios include several cases of moderate complexity and at least one very complex case.

The qualitative measures of complexity paired up well with the quantitative measures that were used. “The pairing of the two independent measurements helped me feel confident in the tool,” says Gorka. As the number of complicating factors identified in a consult grew, there was a concomitant increase in the amount of time spent on the consult.

“A complex ethics case can arise in any healthcare organization at any time — not just in those that specialize in research or that serve especially vulnerable populations,” notes Spielman.

In Spielman’s view, a process that deems consultants qualified without considering their ability to handle complex cases gives a false sense of security. “Patients, families, and health professionals will be harmed,” she says.

REFERENCES

  1. Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants. Hastings Cent Rep 2013; 43(5): 26–36.
  2. Spielman B, Craig J, Gorka C, et al. Case complexity and quality attestation for clinical ethics consultants. J Clin Ethics 2015; 26(3):231-240.

SOURCES

  • Christine Gorka, PhD, Clinical Ethics Center, Memorial Medical Center, Springfield, IL. Phone: (217) 757-2353. Email: Gorka.Christine@mhsil.com.
  • Bethany Spielman, PhD, JD, School of Medicine, Southern Illinois University, Carbondale, IL. Phone: (217) 545-4261. Email: bspielman@siumed.edu.