Improve ethics consults based on feedback and critique
Prompt follow-up can identify necessary changes
If you are interested in whether consults in the intensive care unit reduce costs, then you might run a randomized trial of whether cases in which ethics consults are offered are more cost-effective than those in which they are not. If your concern is whether a specific procedure is followed when conducting consultations, then a chart review of notes and documentation can evaluate the quality of the process. If you want to know whether consults make participants satisfied, you could do a satisfaction study.
However, "none of this gets at the centrally intractable question of how you measure whether ethics consultation helps people do things in a better, good, or right way," says Paul J. Ford, PhD, director of the NeuroEthics Program at Cleveland (OH) Clinic.
Attention to some combination of process, outcomes, and professionalism constitutes a good approach to effectiveness outcomes in ethics consultation, says Ford. This requires mixed methods, including regularly scheduled peer review of consults; surveys of stakeholders; and demonstration of continuous improvement of policies based on questions that emerge from consultations.
"With these methods, the ethicist can improve her own practice from peer critique, understand gaps in services through stakeholder feedback, and provide institutional change to avoid unneeded consultations," says Ford.
Here are methods that ethics consultation services can employ to improve their own practice:
• Obtain written or verbal feedback from various stakeholders involved in a particular case.
These quality improvement requests focus on various components of the systematic approach to conducting a clinical ethics consultation, such as promptness of the consultant's response, the helpfulness of the consultant, or overall satisfaction, says Adam M. Pena, MA, a clinical research associate at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston, TX.
Other fields of the quality improvement request may address maintaining or facilitating communication between various stakeholders during a consultation, the impact of the ethics consultation on the case, or the process of conducting an ethics consultation, says Pena.
• Conduct a detailed review of the case by senior members of the ethics consultation service and other stakeholders.
This review includes a presentation of the case, a discussion of the various ethical issues involved in the case, and, at times, a review of the consultant's chart notes.
"The discussion helps a consultant sharpen his or her present skill set and identify areas for improvement, such as data gathering, leading family meetings, or ethical analysis," says Pena.
Ethicists need "sounding board"
Having a trusted peer or mentor to discuss cases with can help resolve and improve practice issues, particularly for less experienced clinical ethicists.
"Even those with years of training and practice benefit from having someone to talk with as a sounding board to assure they have a balanced view of the situation," says Jane Jankowski, LMSW, MSB, a clinical ethicist and assistant professor at Alden March Bioethics Institute at Albany (NY) Medical College.
A regular review of cases as a team can also assure that everyone conducting ethics consultation has an opportunity for peer feedback.
"Particularly contentious or precedent-setting cases may warrant review with a full ethics committee to assure that a broader group has an opportunity to provide input," says Jankowski.
To best utilize stakeholder feedback, prompt follow up is required with active participants in a given consultation.
"When feedback suggests that the situation was not helped by the ethics consultant, or that the participant would not seek another consultation, it is important to try to identify in what way the process failed to meet expectations," says Jankowski.
When an ethics consultant or a team of consultants notice a pattern of recurring themes in the course of ethics consultation, this suggests there is confusion or frustration about the issue within the institution.
"Education, policy changes, or procedural suggestions may be proposed to institutional leadership when the ethics consultant feels this will serve the institution and avoid unneeded consultations," says Jankowski.
- Paul J. Ford, PhD, Department of Bioethics, Cleveland (OH) Clinic. Phone: (216) 444-8723 E-mail: Fordp@ccf.org.
- Jane Jankowski, LMSW, MSB, Assistant Professor, Alden March Bioethics Institute, Albany (NY) Medical College. Phone: (518) 262-7125. E-mail: JankowJ@mail.amc.edu.
- Adam M. Pena, MA, Clinical Research Associate, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. Phone: (713) 798-2515. E-mail: Adam.Pena@bcm.edu.