At Michigan Medicine, surveys were the main way ethics consult quality was evaluated. Participants rated how satisfied they were on a 5-point scale with the consult outcome, timeliness of response, professionalism of the consultant, and usefulness of recommendations.

“But this results in ‘thin’ information that is of limited usefulness,” says Janice Firn, PhD, MSW, HEC-C, a clinical ethicist at the Center for Bioethics and Social Sciences in Medicine at the University of Michigan.

Just asking if people are satisfied with an ethics consult only raises more questions. A participant might be very satisfied, but only because of a hoped-for outcome — for instance, a specific family member was identified as the appropriate surrogate decision-maker. Conversely, someone might rate satisfaction as very low just because they did not like the case outcome. This misconstrues the purpose of an ethics consult. “The process of a consult creates space for appreciating other people’s perspectives. It facilitates dialogue between all the stakeholders,” Firn says.

After participating in an ethics consult, clinicians ideally understand why multiple options can be ethically justifiable. Survey data alone do not reveal those nuances. It also is hard to compare results between institutions. “There aren’t standardized, validated surveys for ethics,” Firn says. “A more robust evaluation of services, through qualitative methods, may provide greater understanding of the value and quality of ethics consultation.”

To address this, Firn and colleagues interviewed 14 healthcare professionals who requested ethics consults in 2020.1 “We wanted to do a more robust exploration of quality, particularly as it related to the intensity of the initial phase of the pandemic,” Firn explains.

To encourage busy clinicians to commit, researchers offered flexible interview times in person, by phone, and virtually. The interviews revealed nuanced information on how participants really felt about the ethics consult process. Clinicians, in general, said the ethics consultant was approachable, responsive, and respectful. Participants offered these additional specifics:

  • Participants talked about how the clinical ethics service fills a gap that otherwise would not be filled. One noted there are clear clinical guidelines for treatment of conditions, such as atrial fibrillation, but nothing comparable for how to resolve a complex ethical dilemma.
  • Participants said involvement in the consult enhanced their own skills in handling difficult conversations.
  • A few participants admitted to concerns about stigma associated with consulting ethics. These clinicians observed others on the team might interpret consults as something that are “policed” for bad behavior.
  • Clinicians expressed the need for greater visibility of ethics services.
  • Participants perceived the value of consults as creating “moral space” for analyzing and reflecting on ethical problems. 

This concept has been described in the literature.2 “But little has been done to demonstrate it empirically. It was gratifying to see empirical evidence of ‘moral space’ in our data,” Firn shares.

Participants talked about the chance to slow down in a fast-paced care setting to clarify points of medical and ethical uncertainty, and to confirm the right course of action.

Last year, ethicists at UC San Diego Health developed a new system to gather ongoing feedback on consults. “When we complete a consult, we have an automated system that sends the requestor a questionnaire,” says Lynette Cederquist, MD, director of clinical ethics and chair of the hospital ethics committee.

The survey asks the requestor to rate on a 1 to 5 scale (ranging from “poor” to “excellent”) whether the ethicists made the requestor feel at ease, respected the requestor’s opinions, gave useful information, explained details well, clarified decisions that had to be made, specified the right person to make decisions, described possible options, resolved disagreements, was easy to contact, and was timely. “In the past year, we have received 31 follow-up survey responses out of 197 consults and advisory calls. It’s about a 15% response rate,” Cederquist reports.

Most responses rated ethics as “good” or “excellent.” Only four out of the 31 responses included some “fair” or “poor” ratings. “We have been mostly reassured by all of the positive feedback,” Cederquist says.

One clinician commented: “At times, it would be helpful to have ongoing daily input from ethics, rather than more of a one-shot deal.” Another clinician noted that talking through a case and hearing immediate feedback was what was really needed most. “About half of our calls end up being advisory, without proceeding to a formal consult,” Cederquist shares.

One respondent indicated a desire for more follow-up on cases after the initial consult. The ethics service deliberated on whether this would be possible. In the end, it was not feasible. “We do try to check in on active cases,” Cederquist notes. “But we do not feel we are adequately staffed to provide a lot of ongoing follow-up on a regular basis.”

There is much debate over the best way to assess the quality of ethics consultation. “There is a bit more agreement than in the 1980s when clinical ethics really began to get off the ground. But the field of clinical ethics is not unified,” says Stuart G. Finder, PhD, MA, director of the Center for Healthcare Ethics at Cedars-Sinai in Los Angeles.

This remains the case, despite movement toward certification of ethics consultants. “The field is still quite young, and the internal norms are yet to be finalized,” Finder observes. In other healthcare fields, outcomes are more clear-cut. Quality is measured by whether a stroke patient received medication in a specific time frame, or whether a patient was discharged to an appropriate setting.

“In contrast, ethics consultation is concerned with addressing the full range of moral dynamics encountered in taking care of patients. This is not easily reduced to simplistic metrics,” Finder laments.

Some ethicists believe numbers are what matters most. They focus on how many consultations are conducted annually. Other ethicists are more concerned with outcomes, satisfaction scores, or the diversity of stakeholders served. “Data can be created about almost anything. It’s easy to slip into quantitative thinking, especially when there are real financial matters at stake,” Finder offers.

Many clinical ethicists must demonstrate to hospital leadership that their work produces a worthwhile return on investment. “Literally, next year’s funding for ethics may depend upon showing data that argue for continued financial support,” Finder says.

However, using qualitative methods can reveal how nurses, physicians, social workers, directors, and administrators view the ethics service. For instance, follow-up questionnaires with open-ended questions can be sent to participants in ethics consults (both clinicians and patients or their families).

“These insights can then help shape practical agendas for education, institutional engagement, and allocation of resources,” Finder explains.

REFERENCES

  1. Kana L, Shuman A, De Vries R, Firn J. Taking the burden off: A study of the quality of ethics consultation in the time of COVID-19. J Med Ethics 2021 Apr 2;medethics-2020-107037. doi: 10.1136/medethics-2020-107037. [Online ahead of print].
  2. Jones J, Strube P, Mitchell M, Henderson A. Conflicts and confusions confounding compassion in acute care: Creating dialogical moral space. Nurs Ethics 2019;26:116-123.