Cases may involve conflicts between the family and clinicians, confusion over the decision-making process, moral distress, or all these factors and more. Still, no ethics consult may ever happen. Sometimes, it is because clinicians have no idea ethics services exist at the organization.
“Development of a vibrant ethics service begins with strong institutional support,” says Leslie M. Whetstine, PhD, a bioethicist at Aultman Hospital and a professor of philosophy at Walsh University, both in Canton, OH.
Whetstine offers several approaches ethicists can use to spread the word:
• Arrange for administrators and unit directors to introduce the ethicist at various departmental meetings. Then, the ethicist can give a brief overview of their role and outline their activities.
• Post information on ethics on the organization’s website. “Showcasing the ethicist’s qualifications and specialization in this medium can reach a broad audience, including patients and their families,” Whetstine says.
• Integrate ethics within the clinical team. “Rounding across units and floors can be particularly helpful,” Whetstine offers. This raises awareness of the ethics service and lets ethicists respond to issues proactively.
• Provide educational offerings, both formal or informal. “This can build an ethicist’s reputation as a resource,” Whetstine says.
Such offerings can be held in conjunction with annual ethics symposia offering continuing education credits, ethics grand rounds, or more intimate ethics “huddles” with small groups. “Huddles can focus on clinical issues the team is dealing with: limits of confidentiality, surrogate decision-making, or even current events,” Whetstine suggests.
• Invite individuals from various areas of the hospital to serve as active members on the ethics committee. “This can foster a collaborative environment that benefits all,” Whetstine says.
Typically, ethics committees draft and review policies, provide medical education, and participate in case consultation. Diverse membership ensures representation from all areas for all these important activities. “Ethics committees are strengthened by membership across various departments,” Whetstine says. “It contributes to the culture of institutional ethics as a whole.”
Ethicists should consider including risk management, legal, human resources, mental health, pastoral care, social work, and critical care. “Some committees require a community member as well to provide an external perspective,” Whetstine adds.
Paul Hofmann, DrPH, LFACHE, an ethics consultant and former hospital CEO, has found it helpful to conduct ethics rounds in ICUs and other clinical units while participating in medical staff grand rounds. He has enjoyed success with some approaches like these:
• Presenting at medical staff, management, and board meetings. Hoffman has given presentations to a wide variety of audiences on an equally wide variety of ethical topics. These include reasons for promoting the completion of advance directives, ethical challenges in making resource allocations in healthcare, and ethics in critical care medicine.
• Preparing an annual report on ethics committee activities. One recent report at a hospital Hofmann consulted for covered an expansive list of issues, including (but not limited to): conversations about organ donations, Do Not Resuscitate orders, and critical care policies; how to handle ethics requests; and a review of controversial proposed legislation that might affect existing facility policies.
• Surveying staff to find out what they know about ethics and what they want from ethics. Recently, Hofmann designed a staff survey for a Program for All-Inclusive Care for the Elderly organization in San Francisco. The brief survey asked respondents these questions such as “Did you know that the organization has an internal ethics committee?” and “Do you know how to refer a case to the ethics committee?”
The survey also asked what respondents believed should be the top three roles of the ethics committee. The listed choices were: to make treatment decisions on ethical matters; to provide consultation and make recommendations on ethical matters, cost control, quality review/utilization review, corporate compliance, review/comment/write policies and procedures related to ethical matters; and to provide education to staff regarding ethical matters. Also, the survey included questions about expected outcomes or results respondents would like to receive from an ethics consultation.
Hofmann says collecting this information is beneficial in several ways. The process reminds recipients of the range of available ethics services and identifies possible gaps in awareness of these activities.
“Having baseline data permits comparisons with results from periodic surveys in the future,” says Hofmann, adding that the process gives staff members an opportunity to submit questions and make suggestions. “Over time, this modest investment should maximize the number of clinicians who have a deeper appreciation for the contribution made by ethics expertise and support,” Hofmann says.
According to Nancy S. Jecker, PhD, the single best way to contact clinicians is through ethics education forums that reach clinical audiences. “If consults can be helpful but are not being called upon, it might also be productive to recruit and train clinical staff from different services to serve on the ethics committee,” says Jecker, a professor in the department of bioethics and humanities at the University of Washington. Most important: for hospital leaders to model the importance of ethics. “This sends a clear message to everyone that ethics matters,” Jecker adds.