EXECUTIVE SUMMARY

Teleconsultations can help hospitals meet growing demand for ethics expertise, but also has limitations. Downsides to remote ethics consults include:

• Lack of face-to-face contact with patients and family;

• Inability to follow up with distressed clinicians afterward;

• Technical glitches such as audio problems.


“You should always see the patient.”

“This is one of the first lessons I was taught in ethics consultation,” says Craig M. Klugman, PhD, a professor in the department of health sciences at DePaul University in Chicago.

Face-to-face contact allows ethicists to gauge body language and facial expressions of patients, families, and clinicians. “Often, words alone do not convey the entire story of the case,” says Klugman.

Despite inherent limitations when the ethicist’s input comes instead from a screen or phone, some hospitals are moving toward remote ethics consults. Lack of robust ethics expertise onsite and a surge in demand are contributing factors.

“We are seeing 250 to 300 consults per year and other major medical centers are seeing 300 to 1,000. I wouldn’t have predicted that 20 years ago,” says Ryan R. Nash, MD, MA, FACP, FAAHPM, director of the division of bioethics at The Ohio State University College of Medicine.

Rural or critical access hospitals may lack any ethics expertise. “Finding enough people with the time, training, and inclination to serve on an ethics committee, never mind conduct ethics consults, can be nearly impossible,” says Klugman.

Volume of ethics demand at remote hospitals that are part of newly merged health systems sometimes is too low to warrant onsite ethicists. Some systems employ ethicists to cover a group of hospitals in fairly close proximity.

“But that still leaves a gap between the hospitals that are too far to drive to,” says Nash.

Tele-ethics consults are a possible answer for all these scenarios. “As with all telemedicine, ultimately the program may help reach more patients and clinicians with fewer resources,” says Laura S. Johnson, MD, FACS, an assistant professor of surgery at Georgetown University School of Medicine in Washington, DC.

Meaningful Reflection Needed

Some states have created ethics networks to provide ethics services to rural hospitals, including consultation. “The usefulness of these networks can be expanded through the use of tele-ethics,” says Klugman.

In some ways, tele-ethics is really no different than other types of telemedicine, says Nash. For instance, once a stroke is diagnosed onsite, a remote neurologist can guide the clinical team on the next steps. “The same kind of thing can happen for clinical ethics,” says Nash.

Bioethicists at the Cleveland Clinic occasionally offer input by phone when contacted by ethicists at partner or affiliated hospitals. Ethicists intend to work with other interested hospitals in the system to expand this approach by offering tele-ethics consults.

“We would like to not only provide the service, but also to study the interaction with some meaningful reflection on whether it’s a helpful service,” says Nash.

The following are some potential challenges of tele-ethics:

• The tele-ethicist needs to be able to access the patient’s chart to read and write a consult note.

Many hospitals use different and incompatible EHRs. “This can be a particular challenge,” says Klugman.

Nash sees tele-ethics as superior in some ways to the current peer-to-peer process that sometimes is used at Cleveland Clinic. This is because peer-to-peer consults rely on information gathered by ethicists at the hospital requesting the consult.

“We are often given advance on starting, stopping, or changing medical treatment. We are rendering what some would consider a medical opinion,” says Nash.

If the recommendation is documented sparsely, as in “Dr. Nash from Ohio State says it’s OK to stop treatment,” the nuances of the discussion and thought process are lost. “The danger is that the ethics guidance could be taken out of its original complexity,” says Nash.

It may later turn out that the ethicist was working with incorrect or insufficient information. In this case, says Nash, “the danger is that the ethics opinion may be misused, misperceived, or may be in error.” But tele-ethics consults would require ethicists to gather information on their own and write their own note.

• It is sometimes unclear how tele-ethicists would be compensated.

Many ethics consults are performed on a volunteer basis with no reimbursement, raising the question of how teleconsults would be compensated. “There would need to be a way for a payment of services to make sure that the ethicist is not doing extra work for free,” says Klugman.

• Tele-ethics may not cover informal consults.

Many ethics consults are “curbside” — a clinician spots the ethicist in the hallway and asks a quick question. “These are not formal consults, but are important. Tele-ethics has the disadvantage of not permitting curbside consults,” says Klugman.

It also does not allow for the ethics expert to round with the team. “One solution might be to hold ethics office hours, where the ethicist is available via teleconferencing and people can come in and discuss cases,” suggests Klugman.

In Kaiser Permanente’s Northern California region, regional ethicists sometimes do receive quick calls from clinicians just to clarify policy or legal requirements. “It’s almost the tele-ethics version of a curbside consult,” says Mathew David Pauley, JD, MA, MDR.

• There always will be technical issues.

“Anyone who has tried to do WebEx knows there are technical difficulties,” says Nash. Clumsy interjections, awkward pauses, and equipment failures can immediately increase tension during family meetings.

Ethicists at MedStar Washington Hospital Center recently conducted a pilot study to see if tele-ethics consults were feasible for clinical rounds.1 Researchers used videoconferencing to provide real-time interaction between rounding clinicians and a remote clinical ethicist. Not surprisingly, most technical problems involved issues with audio. Of the 30 patient encounters analyzed, 14 were judged to be “inaudible” by the remote ethicists. Adjustments to the microphone improved audio quality. Remote ethicists also reported an obstructed view of the rounding team, addressed by repositioning the camera to more of a bird’s-eye view.

Tele-ethics consults are conducted by phone at Kaiser Permanente’s Northern California region. “The problem is we have hospitals that are super high-tech and some are not. And there are usually only or two rooms where these care conferences normally happen,” says Pauley. Some sites lack the equipment or staff to use videoconferencing.

Technology also can get in the way when consults are performed by phone. As a remote ethicist, Pauley listens to what others say, then interjects when it seems appropriate. Still, silence on the other end can be difficult to interpret.

• Remote ethicists sometimes lack familiarity with the hospital culture and access to available resources.

In recent years, Pauley has moved from serving as an in-hospital clinical ethicist to supporting hospital-based ethicists remotely. “In the past few years, my role has been nearly exclusively a teleconsultant,” he says.

The region’s 21 hospitals do not employ full-time ethicists. Instead, they rely on co-chairs of ethics committees, or small groups of members. “When the case gets beyond them, they call us,” says Pauley. “We are trying to help people do ethics consults from afar. It’s very different — and, in a way, very difficult.”

Typically, ethicists call on many different resources within the hospital — administrators, chaplains, social workers, or clinical leaders. “Knowing how the hospital runs and its culture are resources we would normally have. In my disconnected role from a regional office, I lack that integration,” says Pauley.

• Remote ethicists lose information gained from in-person contact.

“This challenge can be overcome by appointing a person at the remote hospital who acts as the hands of the expert,” says Klugman.

The question becomes: Is calling on a remote clinical ethicist better than employing a nonexpert on site? “It will probably be better than just the local resources doing the best they can to go through the ethics dilemma,” says Nash. “But it should not be replacing the face-to-face interaction.”

Ideally, the outlying hospital would have someone else present with the patient or family. “As ethicists, we often deal with highly charged emotional issues. Videoconferencing handcuffs a lot of our skill set,” says Nash.

During the recent pilot study, researchers were surprised to see that the number of ethics consultation triggers was similar between onsite and remote ethicists, says Johnson.

“We had been concerned that the lack of 360-degree visualization for the remote ethicist would limit their ability to pick up on some of the more subtle body language cues that an ethical issue may exist,” she explains.

Following up after the consult is another challenge. “Ethics consultation has a lot of moving pieces. If you are not integrated enough into the hospital itself, it’s very hard,” says Pauley.

Most of the tele-ethics consults involve the issue of nonbeneficial treatment, which sometimes results in moral distress. Tele-ethicists cannot just walk into the break room with nurses and talk things through.

Nuances such as the need to provide tissues during family meetings and consider where various people are seated can go unrecognized. “People who feel vulnerable don’t like to sit away from the door,” explains Pauley. “It’s the little things that you just learn over time.”

• The tele-ethicist’s recommendations will be conveyed to family by someone else.

Pauley consulted on a recent case with a conflict between a patient’s daughter and wife on who would make decisions. The clinicians were focused solely on who should be the decision-maker when CPR was not an ethically appropriate intervention under the circumstances. “Clarification of the issues was helpful for the physicians — that regardless of what either family member said, it should not be a choice for them to make,” says Pauley.

Pauley was able to assure the team they were ethically justified in not offering nonbeneficial care. But it was up to the onsite ethicists to work with the family and come up with an agreeable plan of care. This brought another limitation of tele-ethics to light: It is one thing to give recommendations, and quite another to convey these to family.

“You can give advice on how to say it, but the person can say it wrong. You are basically sending a missile out to the hospital, because when those things go wrong, they go wrong really badly,” says Pauley.

While some individuals serving on the ethics committees are highly competent clinicians with PhDs in ethics, others are recently appointed and have little or no experience. “It’s the equivalent of helping a layperson land a plane,” says Pauley.

REFERENCE

1. Johnson LS, Brenner DM, Sederstrom NO. Technical considerations for implementation of tele-ethics consultation in the intensive care unit. J Clin Ethics 2018; 29:285-290.

SOURCES

• Laura S. Johnson, MD, FACS, Assistant Professor of Surgery, Georgetown University School of Medicine, Washington, DC. Phone: (202) 877-7347. Email: laura.s.johnson@medstar.net.

• Craig M. Klugman, PhD, Professor, Department of Health Sciences, DePaul University, Chicago. Phone: (773) 325-4876. Email: cklugman@depaul.edu.

• Ryan R. Nash, MD, MA, FACP, FAAHPM, Director, The Center for Bioethics and Division of Bioethics, The Ohio State University College of Medicine, Columbus. Phone: (614) 366-8405. Email: ryan.nash@osumc.edu.

• Mathew David Pauley, JD, MA, MDR, Regional Ethicist, Kaiser Permanente Northern California, Oakland. Phone: (510) 625-3884. Email: mathew.d.pauley@kp.org.