Some nurses mistakenly believe only the attending physician can request ethics consults. Others do not even know their institution offers an active ethics consultation service. Still others worry about retaliation.
Nurses usually give one of these three reasons when asked why they never request ethics consults, according to Claudia R. Sotomayor, MD, DBe, chief of the clinical ethics consultation service at Georgetown University’s Pellegrino Center for Clinical Bioethics. Ethicists have made a concerted effort to encourage nurses to be comfortable with requesting consults. “When rounding, we talk to the charge nurse directly to make sure they know how to contact us if needed,” Sotomayor says.
Ethicists remind nurses anyone involved in the case can request an ethics consult. “When someone has retaliation concerns, we take the consult on an anonymous basis,” Sotomayor adds.
These approaches have produced results. In 2020, nurses requested 41% of ethics consults. Only 26% came from physicians. At MedStar Georgetown University Hospital, most consults nurses requested involved uncertainties about the plan of care for a patient. “Typically, these are the cases of patients at the end of life where the goals of care are not well-defined. These uncertainties trigger moral distress as well,” Sotomayor says.
Other nurse-requested consults were related to advance directives. Sometimes, there was confusion about the appropriate surrogate decision-maker. In 2021, so far, equal numbers of nurses and physicians have requested consults.
It makes sense nurses would be the ones requesting ethics consults as the provider who spends the most time at the bedside. However, nurses requested an ethics consult less frequently than other providers.1 Researchers surveyed 150 physicians, 35 advanced practice providers, and 109 nurses. Thirty-five percent of these nurses had ever requested an ethics consult vs. 51% of physicians and 63% of advanced practice providers.
“Many have questioned why the statistics on referrals to ethics has been traditionally lower with nurses,” says Blair Henry, D. Bioethics, a former senior ethicist at Toronto’s Health Ethics Alliance. Targeted education to nursing units on how to make an ethics consult request is helpful. “However, there may be a more complicated dynamic at play, which acts as a gatekeeper to getting ethics involved,” Henry says.
Ethicists should offer debriefing sessions on difficult cases as a teachable moment to show nurses how ethicists can help with future cases. Assign unit-based nursing ethics champions and document ethics involvement in the medical record so nurses can review what was covered. “Shift work means a constant rotation of care providers. The notes are a great way to reach all staff,” Henry offers.
Marcia Bosek, DNSc, RN, says nurses often ask questions on end-of-life decision-making and the doctrine of double effect (actions that cause harm as a result of promoting something beneficial, such as relieving pain and at the same time hastening the person’s death).2 Bosek says the best approach is to “become known by nurses and establish professional relationships with nurses.”
As a clinical ethicist, Bosek participated on morning rounds on the ICU and transplant units. It was a chance to engage in real-time ethical problem-solving conversations. “Nurses should request ethics consultation when faced with ethical questions regarding nursing care,” according to Bosek, an associate professor at the University of Vermont department of nursing.
Nurses question how to respond when a patient consistently refuses bathing, turning, and incontinence care, or when a patient demands no nursing personnel enter the room. “In addition, the nurse should seek out ethics consultation when experiencing moral distress,” Bosek says.
The ethics committee at UConn School of Medicine in Farmington provides many education sessions. “The ones that have produced the most bang for our buck have been sessions during National Nurses’ Week,” says Zita Lazzarini, JD, MPH, director of the division of public health law and bioethics.
Recently, nurses attended a session about the work of ethics committees. “Nurses are a very important constituency that didn’t necessarily realize that they had the option to reach out to ethics. Nor did they feel comfortable talking about ethics,” Lazzarini says.
Nurses also acted as an ethics committee, with a case presented and discussed. “That was really well-received,” Lazzarini reports. “After that, we got more requests for consults from nurses.”
- Cederquist L, La Buzetta JN, Cachay E, et al. Identifying disincentives to ethics consultation requests among physicians, advance practice providers, and nurses: A quality improvement all staff survey at a tertiary academic medical center. BMC Med Ethics 2021;22:44.
- Bosek MSD. Involving an ethics consultant. Nursing 2018,48:12-13.