EXECUTIVE SUMMARY

Clinical ethics consultation notes are not always included in the electronic health record, but should be included for the following reasons:

• to affect the care of the patient;

• to educate the staff;

• to permit a peer review assessment of the quality of the process.


Ethics documentation isn’t always reviewed by the clinical team, assuming it exists in the medical record at all. A recent paper offers a suggested framework to ensure that clinical ethicists’ notes are included in the electronic health record (EHR).1

“A clinical ethical consultation is an intervention. It is advisory, obviously, but it’s an intervention that is trying to shape care. And it needs to be in the chart,” says Nancy Neveloff Dubler, one of the paper’s authors. Dubler is adjunct professor in the division of medical ethics at NYU Langone Medical Center, professor emerita at the Albert Einstein College of Medicine/Montefiore Medical Center, and consultant for ethics at the New York City Health and Hospitals Corporation.

Ethicists created a template that instructs providers to chart ethically relevant medical facts, ethically relevant social facts, ethical issues that arise, a discussion of those issues, and a recommendation.

“In addition to that, what we built into the ethics format was a set of paragraphs which are short discussions of the most common issues that arise,” says Dubler. These provide some guidance on possible approaches to the consultation and a framework for documentation, “so you are not recreating the wheel on the issue of capacity every time you write a chart note,” says Dubler.

The ethics chart note has these three purposes, says Dubler:

• to affect the care of the patient;

• educate the staff;

• permit a peer review assessment of the quality of the process.

“That’s what we build into our system — and it’s been pretty fabulous,” says Dubler.

The only way to evaluate the quality and the effectiveness of clinical ethics consultations is by reviewing the chart note, according to a previous paper.2 “We put those two things together, and we have taken it to the next step with the EHR,” says Dubler, the report’s lead author.

The chart notes on every ethics consult at New York City Health and Hospitals are sent to a different institution within the system for review. The most interesting notes become the basis of bimonthly meetings for ethics consultants.

“We look at how we do the consults, the issues they raise, and is there something more we need to do?” says Dubler. “We now have the systems in place to do it.”

A reviewer recently noted that a particular consultant’s notes weren’t in the approved format and didn’t include some basic interventions that are expected for every consultation. “For example, you must go and see the patient. Even if the patient is moribund, that is the person that the family sees; and therefore, you must have a sense of what their vision projects,” says Dubler.

There was no indication in the notes that the patient had been seen, nor was there much information about the patient’s social situation. “They were very sketchy. The way it stood, it looked like the consultation was not adequate,” says Dubler. The head of the institution’s ethics consultation service indicated that the consultant was highly skilled but lacked documentation skills. Dubler then met with the consultant and suggested ways to improve how future cases are documented.

“I think that’s a useful intervention because the chart note is what conveys to the rest of the staff what happened,” says Dubler. If the chart note isn’t adequate, the ethicist isn’t giving clinicians the tools they need to think about the care of the patient.

A good consultation that helps to manage conflict is “always in the greater interest of risk management,” adds Dubler. “When there are cases that go to court, it has been noted that a good clinical ethics consultation is often helpful.”

Chart notes are displayed on a screen for the group of about 50 ethicists to review. “Oftentimes, people will suggest ways that a mediation could have been more effective, or make other suggestions about how to improve the quality of the consultation,” says Dubler.

All participants sign confidentiality agreements and no visitors are permitted to attend, including students. “That’s a bit of a loss to me,” says Dubler. “But the office of legal affairs was very concerned, since we are using actual chart notes, that we severely restrict those people who could be part of the review, which is perfectly reasonable.”

The EMR charting facilitates review of the effectiveness, efficiency, and appropriateness of consults. “It has created a dynamic and effective system,” says Dubler. The components are as follows:

• the chairs of the ethics committee designate individuals as having the requisite knowledge and skills to participate in the clinical ethics program;

• clinical ethics consultants are required to write chart notes and send them to be peer-reviewed.

“By critiquing the documentation, you critique the consult,” says Dubler.

Trends also are identified. As part of the peer review process, it was noted that these three scenarios came up regularly in consults:

• the “unbefriended” patient making decisions alone;

• the patient without capacity, or with fluctuating capacity;

• the discharge planning process, in which the patient wants to assume greater risk contrary to what others think is in his or her best interest.

The group wrote algorithms outlining the steps for ethicists to take in addressing these particular scenarios. “We identified issues that should be considered, and in what sort of order,” says Dubler. These guidelines recently became institutional policy. “There is no question in my mind that this sort of rigorous systematic evaluation is in the interest of patients and the institution,” says Dubler.

There is a need for a medical record that speaks to the entire team not just about physiology, but about normative issues related to patient care, says Joseph J. Fins, MD, MACP, FRCP, chief of the division of medical ethics and the E. William Davis, Jr., MD professor of medical ethics at Weill Cornell Medical College. Fins also is director of medical ethics at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City.

“Ethics should not be balkanized. Certainly, the kind of things that end up in an ethics consult can be as dispositive as anything else,” says Fins, one of the paper’s co-authors. These include issues such as whether the patient has capacity, whether aggressive measures will be pursued, and whether palliative care is an option.

“These are at least, if not more, important than the technical details of care,” says Fins. A good template reminds ethicists that there are certain elements that go into a good ethics note. In this fashion, says Fins, “the template might also help to bring standard of consultation up in an organizational, institutional way.”

For instance, if a question comes up about decision-making, others can see at a glance that the patient’s capacity was assessed, who assessed it, and what criteria were used. “The idea is that there needs to be a place for the consultant’s work to be reflected and understood by the entire clinical team,” says Fins.

The work of ethicists is somewhat different from other clinical work, notes Fins. All clinicians face challenges with EMRs being overly templated, and the need to avoid a “check box” mentality may be particularly relevant to ethics, says Fins. Ethicists may need more free text to explain their rationale.

“The goal is not to shed the normative aspects of the work and become reductionistic or overly medicalized, but for our work to be incorporated into the discourse in a way that is compatible with how clinicians communicate with each other,” says Fins.

Ethics documentation that differs from other types of clinical documentation is less likely to be read. “If it’s presented in a way that looks unlike any other medical record note, clinicians won’t understand it, or won’t pay attention to it. And that’s counter to the intent,” says Fins.

Overtly philosophical charting that reads more like a short story is unlikely to be reviewed by the clinical team, for instance. “We’re in a clinical community. The chart is not a place for good narrative nonfiction,” says Fins. “It has to be accessible to other clinicians.”

REFERENCES

1. Sanelli-Russo S, Folkers KM, Sakolsky W, et al. Meaningful use of electronic health records for quality assessment and review of clinical ethics consultation. J Clin Ethics 2018; 29(1):52-61.

2. Dubler NN, Webber MP, Swiderski DM and the National Working Group for the Clinical Credentialing Project. Charting the future: Credentialing, privileging, quality, and evaluation in clinical ethics consultation. Hastings Cent Rep 2009; 39(6):23-33.

SOURCES

• Nancy N. Dubler, Adjunct Professor, Division of Medical Ethics, NYU Langone Medical Center, New York City. Email: nancy.dubler@nyumc.org.

• Joseph J. Fins, MD, MACP, FRCP, The E. William Davis, Jr., MD Professor of Medical Ethics/Chief, Division of Medical Ethics, Weill Cornell Medical College/Director of Medical Ethics, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York City. Phone: (212) 746-4246. Email: jjfins@med.cornell.edu.