Ethics Services Taking First Steps Toward Preventive Work
Ethics services often are challenged to keep up with the volume of requests for consults, let alone tackle larger systemwide issues. However, preventive ethics is important work.
“Preventive ethics work, aimed at topics of high institutional concern, shows how ethicists can not only comment on issues but also sometimes prevent them from occurring,” says Tim Lahey, MD, MMSc, director of clinical ethics at University of Vermont Medical Center.
The ethics committee can be asked to address recurring issues, including how clinicians should manage potentially violent patients and balancing the duty to deliver the standard of care with patient autonomy when patients refuse treatment. Committees also might set boundaries on clinician self-treatment and manage requests for non-beneficial care.
The ethics service provides educational outreach to other teams managing these recurring issues. “Also, sometimes, we’re part of teams developing new systems to manage such situations,” Lahey explains. “We work with partners in quality to develop metrics to follow, and adjust systems in response to what those metrics show.”
The work benefits clinical areas. It also benefits the hospital overall in terms of patient satisfaction, risk management, and less burnout. “It demonstrates to leaders that ethicists are important to good institutional function,” Lahey adds.
There is not one consistent definition of what preventive ethics is. “That can be confusing to people,” says Melissa M. Bottrell, MPH, PhD, CEO of San Francisco-based Ethics Quality Consulting.
At some hospitals, just staying involved in writing policies is considered preventive ethics. For ethics services that have never worked on preventive ethics, policies might be an ideal place to start, says Bottrell, former chief of the Veterans Health Administration (VHA) Integrated Ethics program.
In contrast to this limited approach, the VHA Integrated Ethics program focuses broadly around the principles and methods of quality improvement (QI). “Anything from the classic Six Sigma or Plan-Do-Study-Act [PDSA] models, that mindset is about actually intervening to make change. That is the approach that I come from,” Bottrell says.
When it comes to an introduction to preventive ethics, consider a project with a limited scope. “The ethics committee is not a bad place to start to get your feet wet,” Bottrell offers.
Since the ethics committee controls all aspects of the issue, approval or involvement from other hospital areas is not necessary. Examining the quality of consultants’ educational training is one example. “To take a preventive ethics focus, we could do a proficiency assessment, develop an education plan, and use it to drive our practice,” Bottrell suggests. “That is, in fact, a PDSA cycle, and can give the team a handle on it.”
In similar fashion, ethics could review the last few consults. Ethicists could assess whether the consults met best practice standards of what good consults should include, using guidance from the American Society for Bioethics and Humanities.
Another possibility is to examine the last dozen consults to identify common themes, such as putting advance directives in patients’ charts or issues with handoffs between the ICU and stepdown units. By starting with those issues that are squarely within the control of the ethics committee, “the committee can get that experience, and get used to the materials and the methods of QI,” Bottrell says.
After learning some basic QI, ethics committees can move on to organizationwide issues. “Preventive ethics is more looking at the systems issues, so there is a need for a more coordinated systems focus,” Bottrell explains.
It is important for ethics to identify an appropriate issue for which preventive ethics makes sense. Some areas do need attention, but are not necessarily appropriate for an intervention. “It may have to be referred to leadership for more immediate intervention,” Bottrell notes.
There must be a values conflict to require a preventive ethics approach. “Those issues come up all over the hospital. They come up at the boardroom as well as the bedside,” Bottrell observes.
Paying attention to the root causes of consults can reveal the true issue that needs to be addressed. “If a senior manager is calling you because they have an issue that’s driven by an individual patient case, but is actually something broader, that may be your entrée to support them in a small cycle,” Bottrell says.
Ethicists must engage in an upfront conversation with clinical teams first. It is necessary to secure their buy-in before starting. “You cannot walk onto a nursing unit and tell staff to do things differently. That’s just not reasonable,” Bottrell cautions.
When a healthcare institution wants to include ethics within the QI arena, there should be some careful consideration about the infrastructure that is needed to support the effort, says Robin S. Cook, RN, MBA, integrated ethics manager for preventive ethics at the National Center for Ethics in Health Care in Washington, DC. Some institutions have built a strong, centralized QI structure. “Ethics experts should be part of that structure to assist in identification of ethics initiatives and to discuss ethics implications on other QI initiatives,” Cook says.
If the institution works under a more decentralized approach, then establishing a preventive ethics team is best. The team should include someone with QI expertise. “There are many options for identifying potential ethics issues amenable to a QI approach,” Cook says. Determining whether ethics policies are producing the anticipated outcomes is one example.
One hospital was asking for ethics consults on patients who left against medical advice (AMA). It turned out these cases needed a preventive ethics approach. Sometimes, there were hard feelings on the part of clinicians that got in the way of providing the best possible care for AMA patients.
For example, some patients leaving AMA did not receive a discharge plan, or clinicians did not fully check their medications. In some cases, future follow-up outpatient appointments were canceled automatically. “The process was punitive. There was a feeling that patients were rejecting the hospital,” Bottrell reports. In reality, patients were leaving for entirely different reasons. One older patient left AMA not because he wanted to, but because he had to take care of his wife, who was at risk staying home alone. “Yes, the patient is taking risks we would not be advising. But our processes should not be punitive,” Bottrell stresses.
Ethicists worked with clinical teams to identify and address the ethical concerns in AMA cases. “That was done by a committee that had done some smaller scale efforts before taking something on that large,” Bottrell says.
With AMA patients, there were multiple concerns and a clear conflict in values. “Using ethics expertise from the ethics consultation service, the team can develop what is the best ethics practice for addressing patients who wish to leave AMA,” Cook reports.
The team can identify the system issues that are involved. As potential process improvements are developed, it is important to include ethics. “Ethics expertise is needed to assure the best ethics practice is fully defined, and that any strategies that are developed are also ethical,” Cook explains.
That does not mean ethics needs to take the lead on every issue identified. It could be that if it is a legal issue, risk management is better positioned to take the lead. “Ethics can then be a subject matter expert for the ongoing initiative,” Bottrell says.
Overall, the best issues for preventive ethics are “areas that require QI but don’t, right now, have a home,” Bottrell says. Clinical areas might need somebody to help them think about their practices from the ethics perspective. “That’s what the ethics committee is uniquely able to do,” Bottrell adds.
Preventive ethics work, aimed at topics of high institutional concern, shows how ethicists can not only comment on issues but also sometimes prevent them from occurring.
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