ICU team members vary widely in their ability to apply ethical concepts, according to the authors of a recent study.1
“Often, pregraduate education seems to be a focus. But simulation in the classroom is not the same as real-life clinical practice,” says Janice Firn, PhD, MSW, the study’s lead author and a clinical ethicist at the University of Michigan’s Center for Bioethics and Social Sciences in Medicine.
The ethicists interviewed 12 professionals from medical and surgical ICUs to gauge what they knew about medical ethics. The study started shortly after the ethics program received funding in 2016, says Firn: “We began thinking about how we could be of service to the institution.”
Ethicists already knew that most consult requests came from the ICU. Less well-understood were the somewhat different perspectives of the various interdisciplinary team members. “Social workers, nurses, and physicians have different professional training. Codes of ethics are similar, but the priority is somewhat different,” Firn notes. These differences shape how ICU professionals think about an ethical dilemma — or even whether something is viewed as an ethical dilemma at all.
The researchers wanted to know more about how ICU team members viewed ethics. They asked those members to consider some ethically challenging cases. “We found really wide variation between the units, within the units, and also within and between professions,” Firn reports.
It became apparent that team members lacked a common language to talk about ethical problems. “If you have similar terminology, it’s at least a good starting place,” Firn offers.
Then, team members can discuss some possible ways to move forward. “If teams can’t have a dialogue around ethics, it can lead to poor outcomes for patients and dissatisfaction for providers,” Firn says.
Based in part on the study’s findings, ethicists began “preventive ethics” rounds in the ICU. “That is a space to target some of the areas we found were lacking,” Firn notes.
It gives ethicists a chance to model the correct language to describe ethical issues; concerns are taken more seriously. Previously, providers made vague statements such as, “The plan of care doesn’t make sense. What are we doing?” Now, providers express the same concern differently, such as: “I am worried about how we balance supporting this patient’s autonomy with our obligation to avoid harm.”
Firn says conversations are most beneficial when they are facilitated by someone aware of hierarchies within various professions. That could make someone reluctant to bring up a concern.
“We want to build an ethical culture, with an opportunity for personal reflection for folks,” Firn explains. “It’s also an education piece to get at the most frequent topics we are seeing coming up in consults.”
A recent case of a young patient’s parents requesting additional chemotherapy at the patient’s end of life was an opportunity for ethics education. The clinical opinion of the healthcare team was that chemotherapy would be toxic for the patient. But they were uncomfortable withholding it, given the parents’ strong desire for the treatment. “The idea of not offering further chemotherapy in this circumstance is well-established. But actually saying ‘no’ to grieving parents’ requests feels very different for providers,” Firn says.
Ethicists outlined the reasons why withholding chemotherapy is an ethically justifiable action. They discussed nonbeneficial treatment, medical futility, autonomy, and providers’ obligations for beneficence and nonmaleficence. “We explored the deeper ‘why,’” Firn recalls.
Creating ethical language to support the clinical decision helped the healthcare team feel less moral distress about withholding chemotherapy. “It gave them greater confidence when speaking with the parents about the decision,” Firn adds. This type of ethical reflection will help providers deal with future cases. “We are trying to be a smoke alarm rather than a fire extinguisher,” Firn says.
Identifying specific areas of need for ethics education can be handled in several ways, according to David A. Fleming, MD, MA, MACP, co-director and scholar at University of Missouri Center for Health Ethics:
- Systematic random or selective case review using established quality improvement techniques. “Though time-intensive, this is an excellent evidence-based approach,” Fleming offers;
- Periodic patient and multidisciplinary provider surveys;
- Simply asking, “How can I help?” This allows ethicists to identify learning opportunities “on the spot while facilitating discussions about actual events in the ICU,” Fleming notes;
- Conducting regular ethics rounds in clinical areas where moral conflict often occurs (like the ICU). “This can be useful as long as clinical teams are welcoming to consults strolling through the unit when they haven’t actually been consulted and it is not intrusive,” Fleming adds.
Ethicists should take advantage of opportunities to mentor and instruct whenever that door is opened. “But do so without being overbearing or authoritative,” Fleming cautions. “Allow opportunities for open exchange of ideas, questions, and concerns.”
In Fleming’s experience, questions about medical futility and limiting aggressive treatment are by far the most common reasons for ethics consults. Ethicists educate care teams on the importance of early discussions on prognosis and treatment preferences. “We have found that our ICU teams have become much more facile in dealing with the moral complexities and minimizing conflict,” Fleming says.
Role-modeling demonstrates how to handle difficult discussions successfully. “Offer to meet with team members, either formally or informally, when there is the luxury of time and space to delve more deeply into complex issues,” Fleming suggests.
Formal didactic sessions can be informative. “Brief informal communication is often the most productive in building expertise for dealing with ethical concerns,” Fleming says.
- Firn J, Rui C, Vercler C, et al. Identification of core ethical topics for interprofessional education in the intensive care unit: A thematic analysis. J Interprof Care 2019:1-8.