Clinicians may be hesitant to call ethics consults, anticipating a slow, unwieldy response.
“They feel that there won’t be anything of value by doing it. They don’t think ethics can help them care for the patient,” says Edward Dunn, MD, medical director of palliative care for Louisville, KY-based Norton Healthcare.
Ethics consults entail gathering people together, carefully listening to perspectives, and thoughtfully considering the patient’s values and goals. “That kind of dialogue can take some time,” says Hannah I. Lipman, MD, MS, director of bioethics at Hackensack (NJ) University Medical Center. Some clinicians end up wishing they called ethics sooner. To encourage early involvement, Lipman says ethicists must be easily reachable and visible. “It must be widely known in the organization that ethics is an open-access service, meaning anyone involved in the care of the patient can request a consultation,” Lipman notes.
To streamline ethics response times, Norton Healthcare recently implemented a new model of ethics consultation at its five hospitals. “The primary purpose for making this change was to provide a response to the clinician’s ‘cry for help’ in a more timely, robust, and effective manner,” Dunn reports. Years earlier, Dunn was a practicing cardiovascular and thoracic surgeon in another city at a hospital that used the ethics committee model. “It consisted of hospital staff, nearly all of whom were well-meaning but none trained in ethics consultation,” Dunn recalls.
This traditional model was inefficient. Typically, ethics committees meet regularly and respond when someone requests an ethics consultation. “This process was untimely, unwieldy, and rather ineffective,” Dunn says.
Most committee members were not trained in ethics consultation and typically never directly communicated with the stakeholders. In contrast, the new model requires a two-person ethics team to respond to a request within 24 hours.
“When busy nurses or physicians are asking for help due to an ethical dilemma, they need help now, not weeks later when a committee can get together,” Dunn says. Ethics’ response should be just as timely as any medical or surgical subspecialty service, he adds.
Right away, ethicists go to the bedside and begin talking with stakeholders on both sides of the conflict. “There is no time to waste when patient well-being is at risk,” Dunn stresses.
Ethicists meet with the requesting individual and attempt to discern the ethics question. “If we identify a conflict, then we go to work,” Dunn says.
Most ethics consultation requests receive same-day responses. One recent case involved a patient with COVID-19 pneumonia who had been on a ventilator for a month and extracorporeal membrane oxygenation for two weeks. He was not improving, and his wife advised the critical care team that the family wanted to discontinue life-sustaining treatment to allow him to die with dignity. “The critical care team was committed to continuing [life-sustaining] support. Hence, the ethical conflict,” Dunn says.
Ethicists facilitated a resolution, with an agreement to withdraw critical care support. “The family was grateful for our involvement,” Dunn reports. Sometimes, it becomes apparent there is no ethical issue. For example, patients may ask for a different nurse or attending physician because they are unhappy for some reason. “There is no ethics question here,” Dunn notes. Instead, ethicists refer the matter to management of the clinical unit.
Ethicists promoted the new system via email, newsletters, posters, and social media. “Most of these efforts are ineffective,” Dunn laments.
Busy clinical professionals simply do not have time to digest this information. “The most effective way to stimulate interest is by demonstrating our ability to resolve ethical conflicts in real time,” Dunn offers.
When clinicians receive a quick, helpful response from ethics, “word spreads quickly in healthcare organizations, large and small,” Dunn observes. About 50 ethics committee members have taken a seven-week ethics consultation course, which Dunn provides. Participants are a diverse group of social workers, clinicians, chaplains, respiratory therapists, lawyers, and senior hospital administrators. Students attend weekly 90-minute sessions, including role-playing in hypothetical clinical scenarios.
“We take them through the basis of our ethical duties in healthcare, some moral philosophy, and go through many clinical scenarios that have ethical dilemmas,” Dunn explains.
The goal is to build a strong team of people who are interested in ethics consultation. “If demand increases, we want to respond promptly and effectively to support our colleagues, patients, and their families,” Dunn says.
There is no expectation that all the individuals who receive training are going to end up volunteering to handle ethics consultations. “In fact, most of them will not do it,” Dunn predicts. “The hope is for a broader appreciation for clinical ethics in our workforce.”
Informed clinicians will be more likely to seek help from ethics. “We are starting to see evidence of this. We are seeing more requests for ethics consultations, especially from our nursing staff,” Dunn adds.