At Cedars-Sinai Medical Center in Los Angeles, ethics consult requests come from all units and disciplines across the health system. This was considered when evaluations of the service were collected as part of a quality assessment effort.

“We began with a recognition that both the reasons for why clinicians request consultation, and what they find valuable in the ethics consultation, may vary widely,” says Virginia L. Bartlett, PhD, assistant director of the health system’s Center for Healthcare Ethics.

Ethicists really wanted to find out what mattered most to the people who asked for their help. They found some unexpected variations between the requests for ethics consults and the retrospective reports from the clinicians who made the request. Some said they called ethics because of a conflict with a physician. As the situation progressed, it became apparent that there were broader communication issues within the team.

“What was most surprising was that clinicians found the support of the consultation valuable, regardless of outcome,” says Bartlett.

Next, ethicists considered how they will evaluate ethics consults going forward. A recent paper describes their efforts to solicit, analyze, and understand retrospective evaluations of the service.1 “We continue to explore and evaluate how we seek feedback from our colleagues, and how that shapes our practice, education, and outreach,” says Bartlett.

Differing Perspectives

Cheyn Onarecker, MD, MA, says one important question needs to be answered before setting out to assess ethics consults: “What does it mean to have an effective consultation?” Possible responses to this question vary depending on who is answering, and include:

• the medical team was satisfied the consultant (or committee) helped move the family or patient in a certain direction;

• the hospital is satisfied because expensive treatments could be stopped, or length of stay was shortened;

• the family was satisfied because they felt heard, and the consultant agreed with them on how to proceed.

Each of these measures shows how effective ethics was in the eyes of various parties. “But I think most of us in clinical ethics are also thinking more about the quality of the consultation itself,” says Onarecker, chair of the healthcare ethics council at Trinity International University’s Center for Bioethics & Human Dignity in Deerfield, IL.

The process, the personnel, and the actual content of the report probably are not considered by people who ask for help from ethics; however, these things are very important to ethicists themselves. “The stakes of a consultation can be high. We are often making recommendations regarding life and death,” says Onarecker.

A poorly performed consultation presents significant negative consequences for patients, families, the medical team, support staff, and the institution. Onarecker says the following are important questions to ask about the process of performing the ethics consultation:

• Was the consultation conducted in a timely manner?

• Was the process fair and inclusive of input from all interested parties?

• Did it result in a useful entry in the medical record?

• Have the personnel involved been trained adequately? Are they supported by the institution? Are they given sufficient time to provide consults?

• Are recommendations consistent with recognized ethical standards?

• Is there a review process to continuously improve the effectiveness of the consultation service?

Multiple tools are available for ethics committees to evaluate their services. Still, the issue of evaluating the effectiveness of consults continues to be a source of ongoing discussion at conferences and in the ethics literature.

“Hospitals were given the mandate to create ethics committees before we had any guidance,” says Onarecker. The training necessary to be a consultant, instructions regarding the process of conducting an ethics consultation or managing a consultation service, and who should be on the ethics committee, all were unclear.

“Fortunately, we are making up some ground in these areas,” says Onarecker. “But we still have a lot of work to do to ensure consistent high-quality ethics consultations are being performed.”

REFERENCE

1. Finder SG, Bartlett VL. Discovering what matters: Interrogating clinician responses to ethics consultation. Bioethics 2017; 31:267-276.

SOURCES

• Virginia L. Bartlett, PhD, Assistant Director, Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles. Phone: (310) 248-8199. Email: virginia.bartlett@cshs.org.

• Cheyn Onarecker, MD, MA, Chair, Healthcare Ethics Council, The Center for Bioethics & Human Dignity, Trinity International University, Deerfield, IL. Phone: (405) 272-7494. Email: cheyn.onarecker@ssmhealth.com.