EXECUTIVE SUMMARY

Ethics consults are linked to high satisfaction and more likelihood of consensus, but outcomes used are inconsistent, found a recent study. To justify ethics resources:

• refer to previous studies showing benefits of consults;

• make hospital leaders aware that ethics consults can defuse problems causing dissatisfaction;

• ask risk managers for case examples where ethics involvement averted a possible lawsuit.


Several years ago, Selena Au, MD, attended a presentation on conflict resolution that recommended referral to clinical ethics consultation. A colleague respectfully asked the presenter what “hard evidence” exists that an ethics consult was effective.

“Although I was part of a hospital ethics committee, I could not silently answer the question in my head. Even more so, I realized there was no consensus definition for a consult that works,” says Au, a clinical assistant professor and critical care physician at University of Calgary’s department of critical care medicine in Alberta.

Au and colleagues set out to answer this important question by conducting a review of the literature. They found that ethics consults in adult ICUs are linked to high satisfaction and higher likelihood of coming to a consensus on a clinical decision.1

The review also revealed a lack of standardization in what outcomes are looked at and how they’re reported, says Au, “despite ethics services being ubiquitous across many hospitals.”

Based on these findings, Au would answer her colleague’s original question thusly: “I would say that when an ethical conflict arises, a clinical ethics consult is an appropriate step. The evidence says there may be benefit, and there is low signal for harm.”

More likely, there are benefits to the patient, family, and provider that aren’t being measured. “We haven’t captured the right process measures yet,” says Au. “Our paper is a calling that ethics services must define the processes that make a ‘quality consult’ in a way that’s measurable.”

The effect of ethics consults is inherently difficult to measure. “Not everything that counts can be counted. This has been an ongoing conversation at our institution,” says Tim Lahey, MD, MMSc, chair of the clinical ethics committee at Dartmouth-Hitchcock Medical Center in Lebanon, NH. Hospital administrators typically rely on metrics to justify resource allocation. “This poses a challenge for ethicists wanting to justify FTE support as institutions tighten purse strings,” says Lahey. He suggests the following approaches to justify ethics resources:

• Refer to existing data.

“There are some data that ethics consultation benefits patients and institutions,” notes Lahey. A 2003 study showed that clinical ethics consultation reduced hospital and ICU length of stay, and reduced use of life-sustaining therapies in patients who did not survive to discharge.2

“These results were confirmed in a 2014 study,3 which also showed ethics consultation resulted in improved achievement of goals of care,” says Lahey.

• Create new metrics to assess the real-world effect of ethics consults.

Some examples: The number of patients with advance directives, ICU length of stay, staff burnout rates, and metrics from the shared decision-making field measuring decisional anxiety in patients and family members.

“Stories about times when ethics consultants helped hospital staff make the best out of a challenging clinical situation can be one way institutional leadership promotes improved employee morale,” adds Lahey.

• Build relationships with hospital leaders.

“Most hospital administrators can come to understand that ethics consultants help defuse challenging communications, which aids good patient care and may even avert lawsuits,” says Lahey. A good relationship between hospital leadership and ethics leadership facilitates that understanding. One key mechanism is to have an organizational ethics group that connects ethicists with hospital leaders.

“Having a risk manager say ethics consultation helped defuse a potentially litigious situation is another nice story-based approach,” says Lahey.

Many organizations struggle with how best to evaluate their ethics consultation activities. “Unfortunately, there’s no one-size-fits all solution that is right for all organizations,” says Ellen Fox, MD, president of Fox Ethics Consulting and director of the Altarum Institute’s Center for Ethics in Health Care in Washington, DC.

Ethics consultation evaluation requires thoughtful planning. It must be tailored to each organization’s unique circumstances. “It’s essential to start by determining what the evaluation is designed to accomplish,” says Fox. The following are some examples:

• to demonstrate the value of the consultation service to leadership;

• to ensure that the service is meeting established quality standards;

• to identify and improve specific ethics quality gaps;

• to develop new knowledge that can be published and generalized to other settings.

“For many organizations I work with, a major purpose of evaluation is to demonstrate the value of ethics consultation to leadership in order to get more resources and other types of support,” says Fox. Organizations often assume that it’s essential to evaluate effectiveness — in other words, the effect of ethics consultation on specific desired outcomes.

“But outcomes may not be the best thing to evaluate,” says Fox. Evaluating effectiveness can be very costly and requires a high level of expertise to do well.

“Focusing too much on outcomes that are easy to measure, such as requester satisfaction, can create perverse incentives that tend to compromise quality in other areas,” adds Fox.

Outcomes evaluations may be appropriate for well-funded and highly sophisticated ethics consultation services, or for research settings. “But for most programs, there are better ways to demonstrate value,” says Fox. The following are some possible approaches:

• Demonstrate that there is a perceived need for an ethics consultation service in the organization, and that the service is meeting the need.

“In my experience, very low consultation volume is often a red flag for quality problems,” says Fox. The solution is not to increase awareness of ethical issues or the availability of the service to address them, but to improve the quality of the service to ensure it is consistently adding value.

“Once demand is high, the service can then demonstrate that resources are inadequate to meet the need,” says Fox.

• Demonstrate that ethics consultation is contributing to other organizational priorities.

Some examples: Improving the efficiency of care delivery, reducing organizational risk, enhancing the organization’s reputation, and improving employee morale. “Such contributions can be described qualitatively, without rigorous outcomes studies,” Fox explains.

• Demonstrate that high-quality ethics consultation is an expected part of healthcare delivery, and that the service is meeting quality standards.

“In many organizations, at least some individuals who perform ethics consultations lack the core competencies required to do it well,” says Fox. Ethics consultations don’t always meet accepted quality standards promulgated by the American Society for Bioethics and Humanities, such as appropriate documentation.

“Ethics consultation services can demonstrate tangible results by identifying ethics-related ‘best practices’ they are not meeting, then measuring improvement over time,” says Fox.

REFERENCES

1. Au SS, Couillard P, Rose des Ordons A, et al. Outcomes of ethics consultations in adult ICUs: A systematic review and meta-analysis. Crit Care 2018 Feb 1. doi: 10.1097/CCM.0000000000002999. [Epub ahead of print]

2. Schneiderman LJ, Gilmer T, Teetzel HD. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA 2003; 290(9):1166-1172.

3. Chen YY, Chu TS, Kao YH, et al. To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization. BMC Med Ethics 2014; 15:1.

SOURCES

• Selena Au, MD, Department of Critical Care Medicine, University of Calgary, Alberta. Email: selena.au@albertahealthservices.ca.

• Ellen Fox, MD, Fox Ethics Consulting/Director, Center for Ethics in Health Care, Altarum Institute, Washington, DC. Email: ellenfoxmd@gmail.com.

• Tim Lahey, MD, MMSc, Chair, Clinical Ethics Committee, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Phone: (603) 650-6063. Email: timothy.lahey@dartmouth.edu.