EXECUTIVE SUMMARY

Clinicians found debriefing sessions after difficult cases helpful because they permitted the discussion of values, found a recent study. Informal conversations are effective if clinicians need the following:

  • coaching to address a conflict within the team;
  • information on the legal implications of administering sedatives to a dying patient;
  • help understanding their role in a difficult case.

Ethicists sometimes provide debriefings after difficult cases, but not much is known about how helpful these sessions are to clinicians.

Healthcare professionals at a publicly funded children’s hospital in Sweden participated in ethics case reflection sessions on the care of children with cancer. Clinicians reported that the sessions were valuable, mainly because they permitted the discussion of values.1

“The most important finding in this study was that healthcare professionals’ main concern is about striving for common care goals, and creating a shared view of care,” says Cecilia Bartholdson, PhD, RN, the study’s lead author and a pediatric nurse specialist at Karolinska Institutet Childhood Cancer Health Care Research in Stockholm, Sweden.

It would have been understandable if providers saw the sessions mainly as an opportunity to air conflicting views about care. This wasn’t the case. “It was not about participants positioning themselves,” Bartholdson explains. “It was about clarifying professional perspectives.”

The study’s findings suggest that when healthcare professionals have the opportunity to reflect on ethical issues involved in the child’s care, the group is strengthened.

“The model for ethical analysis used during the sessions is preferably guided by a trained facilitator,” Bartholdson notes. An ethicist is an ideal person for this job, she suggests: “The ethicist could guide the sessions when healthcare professionals don’t know the right thing to do in ongoing ethical dilemmas.”

Clinicians often struggle with whether they did the right thing, particularly in cases where there is a poor prognosis and the patient is suffering. However, not all of these clinicians call an ethics consult.

“Creating a forum where it doesn’t have to go to the highest threshold to have a conversation about those cases is really important,” says Timothy E. Quill, MD, FACP, FAAHPM, Georgia and Thomas Gosnell Distinguished Professor of Palliative Care at the University of Rochester (NY) School of Medicine.

The threshold to call a formal ethical consult varies widely depending on the institution. Some have only a handful of consults a year.

If the number of consults is very small, says Quill, “that means the threshold for doing it is really a case where the wheels have fallen off, and there is a horrible outcome.” Often, clinicians worry the ethicist will judge them for doing something wrong, or criticize them in some way. They may fear their relationships with others in the clinical team will be damaged.

Given all the tension surrounding calling a formal ethics consult, Quill recommends “bringing it down another notch.” This gives clinicians an easier way to talk about ethical issues and concerns.

At the University of Rochester, ethicists hold a monthly case conference on several floors. The sole purpose is to discuss ethical issues or concerns in recent cases. “This allows people to talk about uncertainties in these really difficult cases,” says Quill. “It is particularly helpful in places like ICUs that are highly likely to have these kinds of issues.”

Ethicists begin by asking, “Did you have any cases with ethical dimensions, or just cases you felt uncomfortable with, for whatever reason?”

“I will tell you that many of the cases we hear about are strikingly complicated,” says Quill.

Often, good care was provided with a bad outcome, and clinicians are left wondering if they did the right thing. “There are tons of cases to discuss — there is no shortage,” says Quill. “On occasion, you run into a case where there are some real deep ethical issues.”

Open Communication

Having regular conferences opened communication between ethicists and clinicians. “It established that the ethicist understands the clinical situations that regularly go on,” adds Quill.

Clinicians are then more likely to request a consult in the future, if appropriate. Quill makes a point of letting clinicians know there is a middle ground, too. “Having established trust, the ethicist can then explicitly say, ‘There are teaching conferences, there are full consults, but there’s also the gray ones in the middle — something is wrong here, but it feels scary to get into,’” says Quill. If the clinician is not sure what to do, a conversation with the ethicist can help sort through the options.

A formal ethics consult might still be needed. This is often the case if the problem involves a conflict between caregivers. Quill can still coach clinicians privately about their concerns, and provide strategies to address the issue with their colleagues.

“There may be somebody else on the team that they can go to,” says Quill. “Or, it might be trying to approach the problem a different way, or seeing if they can have a direct conversation with somebody.”

Discomfort Over Role

Clinicians may be uncomfortable about some aspect of their role in a patient’s care, but aren’t comfortable saying so. A private conversation with the ethicist can be very helpful. “In talking it through, we can help them understand the ethical principles that underlie the situation,” says Quill.

In one case, a clinician gave the last dose of sedative before a patient’s death. The clinician stated, “I felt like I killed the patient.” The ethicist can begin by informing the clinician that it’s normal to feel this way, but that doesn’t mean the care provided was unethical.

“Clinicians also worry about getting into trouble legally, and whether they need to keep their role a secret,” says Quill. Some worry that by speaking with an ethicist, they’ll get their colleagues into legal trouble.

“These are serious things to worry about,” says Quill. The ethicist can provide information on both ethics and the law. Some of the cases turn out to be ideal for a teaching conference. If one clinician felt uncomfortable with a case, others may have felt similarly.

“Sometimes, these informal meetings are on the threshold of bigger issues,” says Quill.

It may be that a clinician really did give too much medication, for instance. “Then the ethicist has to figure out what kind of advice they could give that’s private, or if it goes over a threshold where they need to do something else,” says Quill.

For instance, if a resident in an ICU administers a rapidly accelerating dose of opioids until the patient’s death, and is not following the proper procedure, the bedside person delivering the dose might be uncomfortable with his or her role. Not surprisingly, clinicians aren’t always comfortable speaking up.

In this situation, a policy is needed, says Quill, “because the current practice is not the right thing to do, and is going to get people in real trouble, both ethically and legally.”

A clinician who reports an issue like this can still keep his or her involvement confidential. “There’s a lot of people involved in these cases, not just a few. You can do it without naming names,” says Quill. The ethicist can explain to the entire department, “It’s come to our attention that there is no set way of doing this, and that sometimes people are being really aggressive. We really need to develop a policy. Here’s one case we are aware of, and I bet there are other cases like this.”

It may be that a policy already exists, and someone is not following it. “Either they don’t know about the policy, or they are aware of the policy and they are not adhering to it for some reason,” says Quill.

It may be that additional steps need to be taken, beyond the scope of ethics. “But one way or the other, these things need to get surfaced,” says Quill. “If they don’t, they fester, and lead to bad care happening.”

REFERENCE

  1. Bartholdson C, Lutzen K, Blomgren K, et al. Clarifying perspectives: Ethics case reflection sessions in childhood cancer care. Nurs Ethics 2016; 23(4):421-431.

SOURCES

  • Cecilia Bartholdson, PhD, RN, Pediatric Nurse Specialist, Childhood Cancer Health Care Research, Karolinska University Hospital, Stockholm, Sweden. Email: cecilia.bartholdson@karolinska.se.
  • Timothy E. Quill, MD, FACP, FAAHPM, Georgia and Thomas Gosnell Distinguished Professor of Palliative Care, University of Rochester (NY) School of Medicine. Phone: (585) 273-1154. Fax: (585) 275-7403. Email: timothy_quill@urmc.rochester.edu.