Palliative care fellows at the University of Washington are asked routinely for feedback at the end of their fellowship. Many said they did not receive enough ethics education.

At that point, palliative care fellows received some lectures on ethics topics, but did not receive any other formal ethics education. Elizabeth K. Vig, MD, MPH, developed a one-month ethics rotation. “Fellows were given the chance to do independent study work on a topic of their choice,” says Vig, chair of the ethics consultation service at VA Puget Sound Health Care System. For example, one fellow wrote about a case for publication involving a patient with dementia; another led an advance directive workshop with small groups.

Vig led a quality improvement project on the ethics rotation. Of 28 recent fellowship graduates who completed a survey, half reported encountering ethical dilemmas on a daily or weekly basis.1 “I was surprised that so many of them encounter ethics issues often in their current jobs,” Vig reports.

Respondents offered suggestions on how to improve ethics education for future fellows. Some identified topics they wish they had learned more about during fellowship, including feeding tube use in dementia. Several recommended future fellows spend more time with ethics consultants on active cases and attend more ethics committee meetings.

Interestingly, 86% of palliative care fellows reported their colleagues asked them questions about ethics because of their palliative medicine training. In light of this, says Vig, “palliative care fellowships should make sure fellows are equipped to handle the frequent ethics issues they’ll encounter.”

The variety and number of ethical challenges palliative care clinicians face “is very large, indeed,” notes Janet L. Dolgin, PhD, JD, co-director of the Hofstra University Bioethics Center in Hempstead, NY. Some ethical questions relevant to palliative care include who should make decisions and how to manage pain appropriately at the end of life.

An increasing number of Hofstra’s palliative care clinicians (physicians, nurses, and social workers) choose to attend a two-semester clinical bioethics program. “Students engaged in palliative care work bring important insights to our classes,” Dolgin says.

In practice, palliative care clinicians see how patients, family members, friends, and clinicians respond to a patient’s discomfort, to pain, and to the dying process. Ethicists are trained to mediate disputes among stakeholders. “In turn, ethicists benefit by observing palliative care clinicians provide hands-on medical care to very ill and/or dying patients,” Dolgin observes.

Ethics consultants and palliative care clinicians are “obvious partners in the task of caring for patients in pain,” Dolgin adds. These patients confront important questions about medical care, sometimes without decision-making capacity. “The skills of each group, when combined, are of great potential benefit to patients and their families,” Dolgin explains.

Palliative care specialists are asked to help in many of the same situations as ethicists. Family members who want “everything” done are a common example. “We are often embroiled in the care of patients asking for potentially nonbeneficial treatments,” says Rebecca A. Aslakson, MD, PhD, division chief of critical care anesthesia at Stanford University Medical Center.

Palliative care providers often are unaware of relevant ethical principles, such as nonmaleficence in the case of treatment offering no benefit to patients. An extremely in-depth explanation probably is unnecessary. “Palliative care providers don’t need the ’31 Flavors’ of these ethical principles, but rather need the ‘vanilla and chocolate’ of what the principle is, where it came from, and why we use it,” Aslakson explains.

When palliative care was introduced into hospitals, some ethicists worried providers would no longer see the need for ethics consults. “We haven’t found that to be the case. Our clinical ethics consultation workload has continued to grow,” reports Evan G. DeRenzo, PhD, assistant director of the John J. Lynch MD Center for Ethics at MedStar Washington Hospital Center in Washington, DC.

Today, ethicists handle about 450 consults per year. “Our ethics center has been advancing our education mission as it applies to palliative care,” DeRenzo says.

For several years now, palliative care fellows, including physicians, nurses, and social workers, have been offered a credited ethics elective. “Having the palliative care fellows rotating with us is an eye-opener for them, and is a big help to us,” DeRenzo says.

By the time ethics is called, palliative care fellows usually are involved with the patient already. “They provide us insights into where the intrafamily conflicts are,” DeRenzo says. This allows ethicists to build trust and relationships faster. Meanwhile, palliative care fellows gain ethics expertise.

“They learn to pick up brewing ethics problems sooner than they ordinarily might,” DeRenzo observes. “The special aspect of our program is that we teach at the bedside.”2

Palliative care observes how ethicists gather facts, both from conversations and the medical record. “Palliative care fellows learn how to sort the relevant clinical ethics facts from the mass of data available,” DeRenzo notes.

In the 2020-21 academic year, the ethics rotation will become a requirement for palliative care fellows. So far, four palliative care fellows have participated. Two to four will be participating each year. DeRenzo says this is a “wonderful expansion of the ethics center’s reach into patient care, and produces ethically advanced clinicians throughout the hospital.”

REFERENCES

  1. Vig EK, Merel SE. Ethics education during palliative medicine fellowship. Am J Hosp Palliat Care 2019;36:1076-1080.
  2. DeRenzo EG. “Building clinical ethics expertise through mentored training at the bedside.” In: Watson JC, Guidry-Grimes LK, eds. Moral Expertise: New Essays from Theoretical and Clinical Bioethics. Switzerland: Springer Nature; 2018, pp. 289-304.