Clinicians frequently struggle with ethical issues, but that does not mean they are going to call ethics.
“In general, the indications for an ethics consult are ‘softer’ than they are for a pulmonary or nephrology consult,” says Douglas S. Diekema, MD, MPH, attending physician and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital.
Providers may not have a clear “trigger” that causes them to think about ethics consultation. “There may also be a psychological barrier to getting an ethics consultation,” Diekema adds.
To some, calling ethics seems like admitting they are deficient in their knowledge of the subject. “In cases involving disputes between individuals on the healthcare team, calling ethics may feel like whistleblowing,” Diekema offers.
When pediatric ethics consults are called, some sort of conflict usually is the reason, often between the parents and the medical team. Parents may refuse to give consent for a procedure or test that the medical team believes is important.
But sometimes, people are uncertain as to the appropriate ethical course of action. Both the parents and the medical team believe that withholding medically provided fluids and nutrition might be the best thing for a dying patient, but are unclear on whether it is ethical to do so. “In these cases, the request is for guidance rather than conflict resolution,” Diekema explains.
Ethicists at Children’s Hospital Colorado suspected that consults were underused and that many ethical issues encountered by hospital staff were going unaddressed. “If you were to query people in the hospital on what is ethics for, it’s for death and dying and decision-making problems. But as ethicists, we know it’s a lot more than that,” says Joel Friedlander, DO, an associate professor of pediatrics at University of Colorado.
To find out if ethical concerns really were going unaddressed, researchers conducted a chart review of ethics consults occurring from November 2013 to January 2014.1 “We set out to answer the question, ‘How good of a job are we actually doing?’” says Friedlander, one of the study’s authors. “We found that our ethics consults were focused on what people classically thought of as ethics — death and dying and those kinds of things.”
The researchers came up with a way to determine what ethical issues were occurring in the hospital and whether these issues actually are addressed during consults. A flyer was posted throughout the hospital, directing people to a website with a 12-question survey.
One question asked participants if they encountered an ethical issue, and if so, to describe it. “It turned out that there were a lot of issues going on in the hospital that the ethics team was not addressing,” Friedlander reports.
Only five ethics consults were documented during a three-month period. Yet, 63 staff members reported having an ethical concern during that same period. Notably, most of these issues involved moral distress in some way. “There are a lot of morally distressing things going on in hospitals that don’t involve death or dying,” Friedlander notes.
The results “were definitely very-eye opening. It was interesting to read about all of these issues happening in the hospital you work in,” says Kelsey Watt, MD, the study’s lead author and an Aurora, CO-based pediatrician. “One thing that I found fascinating is that 80% of participants felt moral and emotional distress regarding what they experienced, yet few sought help in an ethical consult.”
Now, ethicists hold informal classes and rounds in various units to try to address some of these issues. For example, some respondents reported interpersonal problems between doctors and nurses. “The ethics consultant could really have been a third-party intermediary in those cases,” Friedlander suggests.
For ethics, says Friedlander, the results were a “wake-up call. We want to make sure we are applying the same rigor to ethics as we are to GI or neurology or anything else. We want to become better consultants.”
- Watt K, Kirschen MP, Friedlander JA. Evaluating the inpatient pediatric ethical consultation service. Hosp Pediatr 2018;8:157-161.