Many clinical ethics services are seeing a surge in requests for consults. At the same time, they worry about losing resources.
“This has been a challenge with decreases in overall healthcare budgets across the health sector,” says Blair Henry, BSc, MTS (Bioethics), a senior ethicist at Sunnybrook Health Sciences Centre and North York General Hospital in Toronto.
Data on the volume of ethics work can make the difference. Since 2006, a database at Sunnybrook Health Sciences Centre has tracked all the ethics department work. “Our database metrics go beyond just collecting information on consultations,” says Henry, an assistant professor in the department of family and community medicine at University of Toronto.
Ethics also logs its educational activities, debriefings, policy support, committee support, and academic work. Still, numbers showing higher work volume are not enough to support more ethics resources. “A more strategic plan is needed,” Henry says.
Each month, Claudia R. Sotomayor, MD, DBe, drafts a report for administrators with the number of consults and rounds ethicists conduct. “I compare our current information with previous years to show the growth of the activity of the ethics consultation service,” says Sotomayor, a clinical ethicist at Georgetown University’s Edmund D. Pellegrino Center for Clinical Bioethics.
The ethics consultation service created its own database using Microsoft Access. “Our database is very simple, but easy to use. It gives us the tracking information we need,” Sotomayor reports.
At Houston Methodist Hospital, logs for the ethics consultation service date back to 1997. “At that time, they were all handwritten, paper-based logs,” says Joseph Sayegh, MBA, administrator of Baylor College of Medicine’s Center for Medical Ethics and Health Policy. The Baylor ethics center provides clinical ethics services to Houston Methodist and Baylor St. Luke’s Medical Center.
The current database for the Houston Methodist Hospital was developed in 2014, and has gone through several major revisions. “We actually have two platforms that we use,” Sayegh reports.
Houston Methodist uses a web-based application to track ethics consults, which was developed internally. Baylor St. Luke’s Medical Center had been using an Excel spreadsheet to track ethics consults. In 2019, a new database was developed. “Both databases mirror each other in terms of the information collected,” Sayegh says. This allows ethicists to evaluate service lines as a whole or by hospital.
Between the two programs, ethics perform about 600 consults a year. “The goal here is to create a database that allows for streamlined data entry from the consultants, while not being burdensome on them,” Sayegh says.
That means it is crucial to collect the right data. “We have spent the past few year refining that,” Sayegh notes.
The main data points now collected by ethics are: the number of consults, the type of provider requesting the consult, which unit or service the request comes from, and the ethical issue. Ethicists look at these data over a 24-month period, and compare the current 12 months to the previous 12 months. “This lets us identify easily when there is an increase or decline in any of those main buckets,” Sayegh says.
Particular units may request fewer consults compared to the previous year. For example, in 2019, ethicists noticed fewer consults from the medical ICU at one hospital. “That helps us identify the need for engagement with that particular unit to provide more education or face time,” Sayegh says. Data on which topics are cropping up also leads to action. Decision-making issues were arising more often at Houston Methodist and Baylor St. Luke’s, so ethicists gave targeted education on that topic during grand rounds.
At North York General Hospital, surrogate decision-maker concerns make up 20% of consults. “In the coming year, we are doing a lot of education to staff around surrogate decision-maker issues,” Henry reports.
The most common reason for consults is medical assistance in dying. In 2019, 30 consults were called for this reason. “This justified funding a one-year ethics fellowship to support ethics work,” Henry says.
At North York, there were 131 consultations in 2017 with a full-time ethicist in place. The service dropped from full-time status to a 0.5 full-time equivalent (FTE). Consult numbers declined during the next two years, but recently climbed to 102. “However, increasing the consultation numbers was not sufficient to add more FTEs,” Henry notes.
The annual number of consults increased at Houston Methodist from 120 in 2011 to 450 in 2013. Baylor St. Luke’s Medical Center handled about 20 consults in 2017; that number has reached 150 per year. “Both of those spikes in volume were a direct result of a coordinated education campaign for providers, nursing, and hospital staff,” Sayegh observes.
Ethicists promoted the service by attending unit meetings to give quick education sessions, developing and distributing information on the ethics service to units, contributing an active voice in multidisciplinary rounds, and making themselves available for questions. Sometimes, the type of ethics consults changes. “Understanding the reason behind a trend helps tell the story of what is happening,” Sayegh offers.
In 2019, ethicists noted that a significant number of consults involved DNR orders. This was due to a new law that changed how these orders are handled. Ethics proactively provided education sessions on the change, but many formal consults still were requested. “We were able to manage these requests with our current staffing,” Sayegh says. “But we added a tag in the database so we could track the issue.”
If service lines open or expand within the hospital, the consult volume should be noticeably higher, according to Sayegh. If volume remains flat, it is a sign that ethics needs to engage in outreach to that service. “When it comes to telling that story to hospital administration, we have had success by presenting what the volume trends have been and what we think is driving the trends,” Sayegh says.
Ethicists also forecast what they expect for the next several years in terms of volume. “We then try and match that volume to our staffing to see if there is an imbalance, to justify additional resources,” Sayegh explains.
If a new service line is added, ethics normally receives additional funding to increase the FTEs to manage the additional consults. “Based on the data we collect, we can demonstrate the need to support the increased volume,” Sayegh adds.