Cast a wide net when obtaining feedback on clinical ethics consults
It can result in system-wide improvements
Obtaining good feedback on clinical ethics consultations can be challenging, acknowledges G. Kevin Donovan, MD, MA, director of the Pellegrino Center for Clinical Bioethics at Georgetown University Medical Center in Washington, DC.
"People are anxious to get your input when the problem is presenting itself," he says. "But once it's resolved, they tend to move on."
Donovan says it's worthwhile to make an effort to "broaden the feedback sources" for ethics consults. For instance, ethics consultations often involve two parties with differing viewpoints. Feedback from both parties would be valuable — not just the individual who requested the consult.
"It's frequently difficult to get feedback from the other party," says Donovan. "The patient may no longer be alive, and the patient's family may not be readily available or may not be interested in being contacted at home."
Bioethicists typically interact with patients and families in the context of an individual ethics consultation, and then never have any further interaction with them.
"Because our interactions with patients and families tend to be 'one and done,' there are a number of methodological issues associated with seeking feedback from them," says Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles, CA. Here are some approaches to obtain feedback from various parties involved in ethics consults:
Professional colleagues — nurses, physicians, and social workers.
Both objective and subjective questions should be asked, says Finder. For instance, individuals can be asked to rate the consult's effectiveness, and also to write a sentence or two about what they understood to be most important about the involvement of ethics consultation in the situation.
Others who provide ethics consultation.
This feedback is most easily obtained via regularly scheduled "case review" sessions, says Finder. Ethics consultants can discuss what they did, how it was received, and any challenges they encountered.
"The key to this kind of peer review is the ability and willingness to speak directly and explicitly with our clinical ethics colleagues about our own strengths, weakness, and room for improvement," says Finder.
Such discussions may be especially challenging, however, when ethics colleagues are not only also professional colleagues in other contexts — such as physicians in different specialties — but also with roles at different power levels in the institution — such as a physician and social worker.
"To engage in this kind of peer discussion requires clear ground rules that promote honest and open conversation," says Finder.
The ethics committee.
At Georgetown University Medical Center, feedback that is discussed internally among ethics consultants is also reported back to the institution's ethics committee. "So not only can we tell them about our feedback, but the committee can also tell us their feedback," says Donovan.
The committee has suggested ways to do more preventative ethics by rounding in the intensive care unit to identify ethical problems before they become a crisis, for example.
In addition, ethics consultation reports include the question, "Are there opportunities here for looking at systemic changes?
"Consults can bring to light certain endemic problems for which we can take a more preventative approach," says Donovan. "Those can be brought up with the appropriate nursing service or administration."
Broader issues identified
As a result of obtaining feedback from key stakeholders, ethics consultants are often better poised than others in the institution to identify key ethical considerations particular to the institution, according to Finder.
"In other words, the same kinds of skills necessary for engagement in specific patient care situations may also be useful in identifying broader issues associated with patient care more generally," he says.
The processes by which ethics consultants seek feedback may serve a greater purpose than simply improving clinical ethics consultations, he explains.
"It may also bring to light gaps, challenges, and other systemic dimensions of patient care that, now brought to light, demand attention," says Finder. "When such issues are uncovered or encountered, the role of the ethics consultant bifurcates."
The primary focus is still on helping the patient and providers in the particular situation, but there is also an obligation to work on the larger issue that was uncovered.
"This latter work may or may not be within the scope of the ethics consultation service," Finder says. "If not, what is required is to take what has been discovered to those within the institution who are in a position to address such problems."
For instance, critiquing the medical decision-making of a patient's physician is typically the responsibility of the medical staff peer review process.
"If serious issues are encountered in the midst of ethics consultation, however, the ethics consultant does have a responsibility to report to the appropriate medical staff representative that there may be medical staff issues needing to be addressed," says Finder.
- G. Kevin Donovan, MD, MA, Director, Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC. Phone: (202) 687-1122. E-mail: firstname.lastname@example.org.
- Stuart G. Finder, PhD, Director, Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles, CA. Phone: (310) 423-9636. E-mail: Stuart.Finder@cshs.org.