EXECUTIVE SUMMARY

Ethics consultations are categorized by institutions in a surprisingly heterogeneous way, found a recent study. Standardizing this could:

• help people determine what kind of cases ethics should be routinely called for;

• compare how often consults are called at different institutions;

• identify specific areas for which clinicians need education;

• facilitate research on ethics consult services.


Ethics consultations are categorized in a surprisingly heterogeneous way, found a recent analysis of 30 articles.1 The researchers identified 27 unique typologies, each containing five to 47 categories. The most common categories were do not resuscitate orders, capacity, withholding, withdrawing, and surrogate or proxy. Only 26% of the typologies (seven of 27 unique typologies) contained the five most common categories.

“We were very surprised by how heterogeneous the typologies are,” says Armand H. Matheny Antommaria, MD, PhD, one of the study’s authors.

Around the same time, the hospital’s clinical ethics consultation service at Cincinnati Children’s Hospital Medical Center had begun systematically documenting its own consultations. “Conducting a systematic review to see how other services had approached the problem of characterizing their consultations seemed the next logical step,” says Antommaria, director of the ethics center.

There is a pressing need for the field of ethics to develop a standardized typology that a wide variety of consultation services can use, according to Antommaria. “This will allow scholarship within the field to advance. In particular, it will facilitate comparisons between services and institutions,” he explains.

Cincinnati Children’s has yet to adopt a typology to characterize ethics consultations. These are characterized in terms of demographics, such as the patient’s age, the primary service, and the requestor’s credentials, role, and group. “We summarize the ethical issues with a brief narrative description,” adds Antommaria.

This is currently feasible at a children’s hospital that performs about 60 consultations a year. “We are approaching the point of having sufficient documentation to qualitatively analyze the ethical issues on which we have been consulted,” reports Antommaria.

Ethicists already demonstrate the value of ethics to administrators, based on consultation volume and diversity of groups requesting consultations. “Describing the impact of several different consultations on patients, families, and providers has been valuable,” says Antommaria.

Identify Ethics Value

Clinical ethics consultation services have become commonplace in the hospital setting. Yet empirical research on the effect of such services on patients, healthcare workers, and hospital systems remains limited, notes Elizabeth Chuang, MD, MPH, FAAHPM. There is significant variation in how ethics services are organized and how consults are requested. “There are many important empirical questions to ask about this variation,” says Chuang, clinical ethics research faculty at the Montefiore Einstein Center for Bioethics in Bronx, NY.

What is the “right” amount of ethics consultation remains an open question. The same is true as to which cases ethics should — or should not — be routinely called. “Studying variations between institutions can help us start to think about how to standardize ethics consultation,” says Chuang. However, a common language is needed. This would allow ethicists to compare consultation services across institutions and allow similar types of consults to be grouped together.

“It would be interesting to see if different institutions routinely request a certain category of consults while others do not,” says Chuang.

This could inform outreach efforts to expand ethics consults. It also could reveal a pressing need to educate clinicians on ethical issues. For instance, clinicians might routinely call ethics for help identifying the most appropriate surrogate, determining capacity, or decision-making for patients who lack capacity and do not have a surrogate.

“In addition, looking at trends over time in categories of ethics consultation might identify emerging issues with new medical technology or new clinical challenges,” says Chuang.

Paving the Way for Ethics Data

The focus of Chuang’s research is healthcare disparities — particularly, differences in how clinicians communicate with patients of different ethnic, racial, and cultural groups from their own.

“If we could systematically categorize ethics consultation types, we could look at whether clinicians are more likely to request particular types of consults for different ethnic, racial, and cultural groups,” says Chuang. This could pinpoint areas where better training in cross-cultural care could improve care and reduce conflict.

Standardizing how ethics consults are categorized would pave the way to making data on ethics consultations available for health services researchers. Some are developing sophisticated methods to examine the effects of changes in healthcare delivery. “It would be beneficial for clinical ethics to be a part of this trend as it may help identify the value of clinical ethics consultation services for health systems and patient outcomes,” says Chuang.

REFERENCE

1. deSante-Bertkau JE, McGowan ML, Antommaria AHM. Systematic review of typologies used to characterize clinical ethics consultations. J Clin Ethics 2018 Winter; 29:291-304.

SOURCES

• Armand H. Matheny Antommaria, MD, PhD, Lee Ault Carter Chair of Pediatric Ethics, Cincinnati Children’s Hospital Medical Center. Phone: (513) 636-4939. Email: armand.antommaria@cchmc.org.

• Elizabeth Chuang, MD, MPH, FAAHPM, Montefiore Einstein Center for Bioethics, Bronx, NY. Email: echuang@montefiore.org.