Many times, Trevor M. Bibler, PhD, has read these words “Ethics said” in a clinical colleague’s notes, followed by some inaccurate statements.
One bedside nurse documented that “Ethics said it is OK to restrain the patient until morning.” The opposite was true: The ethicist had stated that the team was not justified in restraining the patient. “But I wanted to talk with the attending for additional information before moving further,” Bibler recalls. “Somewhere, the message was lost.”
In other case, a cardiologist documented that a patient was “cleared from an ethics perspective.”
“We do not ‘clear’ patients,” Bibler notes. In that case, the ethicist had been told that the patient was going back and forth on her decision to move forward with a left ventricular assist device (LVAD) evaluation. During a conversation with the ethicist, the patient explained that she wanted to complete the evaluation but was not committed to accepting or rejecting the LVAD. The ethicist confirmed with the team that they were justified in continuing an evaluation, but said nothing whatsoever about the patient being “cleared.”
“Without my own note documenting my actions, there could be confusion about nearly every aspect of the consultation,” says Bibler, assistant professor of medicine at the Center for Medical Ethics and Health Policy at Baylor College of Medicine, Houston.
When Bibler sees false or misleading statements on what ethics said or did, he usually calls the person who documented it. “I tell them that my analysis or plan isn’t what they have documented,” Bibler explains. “I ask that the next time they are at the computer that they amend the note.”
Many problems can occur if ethics consults are documented sparsely or not at all, says Ariel Clatty, PhD, a clinical ethicist at UPMC Presbyterian Shadyside Hospital. One issue is that there is no documented resolution to an ethical concern. “It could cause liability to medical staff with no ethics consultation documented if the case were to proceed to court,” Clatty offers.
Lack of documentation hinders the ethics service from knowing how it is performing. Clatty says this information, if consistently documented, helps with quality improvement efforts: Which service line is requesting consults, what the consultations are for, discharge rates before and after a consult is placed, and length of stay.
Documentation of the ethicist’s actions, assessments, analysis, plan, and recommendations allows anyone reviewing the chart at any point to “have some sense of the ethicist’s involvement, in their own words,” Bibler says.
Notably, every other clinical consultation service documents their actions in the patient’s chart. The same is not true of hospital administrators in risk management, operations, or the legal department, all of whom occasionally give input on specific patients. “The ethicist risks being seen as an administrator rather than clinical consultant, if they do not document their involvement in the way other clinical healthcare professionals do,” Bibler explains.
Ethics notes differ somewhat from clinical documentation, since they focus on ethics issues and recommendations. “But if we are going to call ourselves clinical ethicists, then we are relevantly similar to other clinical consultation services,” Bibler offers.
According to Bibler, measuring the quality of an ethics service depends mainly on two determinations:
- whether recommendations are in line with ethical standards;
- whether clinicians follow those recommendations.
“Without proper documentation, these two essential aspects of the ethicist’s work would have to rely on word-of-mouth or internal documentation,” Bibler adds. Some ethicists actively avoid documentation of their involvement. The concern is that it will expose the institution legally because some may perceive ethics involvement as a signal that something went terribly wrong with a case.
This concern is unfounded, Bibler says. It is based on a misunderstanding of the ethics role as someone who ensures the hospital is meeting compliance-related requirements: “But this is an inadequate and mistaken understanding of how ethicists operate.” Bibler says that if anything, ethics involvement should be a positive thing from a risk management perspective. “It makes more sense for the institution to want to show that when ethical conflicts or questions arise, they have a team who can address these issues,” Bibler shares.
At Houston Methodist Hospital, ethicists treat every consultation as a formal request. All requests are documented. The only exception is general questions about policies, such as the state surrogate decision-making hierarchy, that do not involve patient specifics.
“Our default is to leave at least one note,” Bibler says. “I can’t recall the last time I didn’t leave at least one note in the patient’s chart.”