Ethicists have another resource to turn to for challenging dilemmas: A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. “We wanted to contribute to where we thought there was a huge learning gap, where a lot of consultants could really enhance their skills,” says co-author Courtenay R. Bruce, JD, MA.

Authored by the American Society for Bioethics and Humanities (ASBH) Clinical Ethics Consultation Affairs Committee, the book is one of the resources recommended for individuals preparing to take the ASBH’s Healthcare Ethics Consultant-Certified exam. In a recent paper, the authors described how and why the book was developed.1

Existing resources do a good job of covering bioethics topics. “But where they fall short is, they cannot provide the experiential learning — what it’s like to actually do ethics consultation,” says Bruce, an associate professor at Houston Methodist’s Institute for Academic Medicine

Some teaching materials do provide case studies. Typically, the case is presented, then the reader is asked to analyze it. This gives the impression that cases unfold in a linear fashion and that the facts remain as they are at the onset of the case.

“The reality is cases rarely, if ever, unfold neatly. New facts are introduced all the time as the case evolves,” says Bruce.

To reflect the real-life experience of addressing an ethical dilemma, the authors introduced new facts to the 12 featured cases — nine involving adult patients, three involving minors. “We present part of the case, then embed a question and change the facts up. You are making decisions all along the way,” says Bruce.

One case begins with two family members at the same hierarchical level and asks which one should be the surrogate. Further along, another person enters the picture when end-of-life care decisions need to be made. A patient interview is conducted, but the ethical issue remains unresolved. Thus, another family meeting should be called.

Co-author Jane Jankowski, DPS, explains, “To mimic the real process, you have to stop and think before you take another step. We are asking people to apply their knowledge of ethics at various points in the case.”

Less Variation Is Goal

Ethics resources typically do not include procedural elements or specify the types of consultative activities that are used to manage cases such as patient interviews or family meetings. “All those activities that we do are rarely discussed,” says Bruce.

Ethicists may wonder what they should be looking for when determining whether a family meeting was productive, for example. “To do consultation well, and to really be accepted in the hospital, we think the clinical ethicist really must master those procedural elements,” says Bruce.

Although the book is aimed toward clinical ethicists, much of the material is applicable to clinicians. How to conduct a family meeting, or how to elicit patient understanding, says Bruce, “should be a core skill.”

Expertise of clinical ethicists varies even within the same institution. “To try to reduce that variation, we thought it was important to lay out some standards,” says Jankowski, an associate staff ethicist at the Cleveland (OH) Clinic’s Center for Bioethics.

A consistent procedural approach is necessary to ensure quality. “It’s OK to have different styles. But if you’re approaching cases very differently — such that it affects your analysis — I don’t think that is appropriate,” says Bruce.

Reducing variation is an overarching goal in healthcare to improve patient safety and the overall quality of care. “We see that all over the place, in core measures and performance measures,” says Bruce. “This is definitely a step in that direction.”

REFERENCE

1. Bruce CR, Jankowski J, Chanko BL, et al. The work of ASBH’s Clinical Ethics Consultation Affairs Committee: Development processes behind our educational materials. J Clin Ethics 2018; 28(2):150-157.

SOURCES

• Courtenay R. Bruce, JD, MA, Institute for Academic Medicine, Houston Methodist. Phone: (713) 798-4929. Email: crbruce@bcm.edu.

• Jane Jankowski, DPS, Associate Staff Ethicist, Center for Bioethics, Cleveland (OH) Clinic. Phone: (216) 789-9280. Email: jankowj@ccf.org.