What do you know about effectiveness of ethics consults? Data are often lacking
Good outcomes aren't enough
In order to demonstrate the effectiveness of clinical ethics consultations, it's not enough to show good outcomes — for example, that patients and staff are satisfied. "You have to show that the outcome was better than it would have been without the ethics consultation," says Ellen Fox, MD, director of the National Center for Ethics in Health Care for the Department of Veterans Affairs (VA).
This requires comparing groups that received an ethics consultation with similar groups that did not. "You also have to figure out ways to control for other factors that could affect the outcomes," says Fox. "This sort of study requires a lot of expertise, a lot of money, and a very large volume of consultations."
What to measure
There have been several empirical studies of ethics consultation and how it is practiced, including a large national study of ethics consultation in U.S. hospitals.1
However, none of the studies demonstrated effectiveness. "To demonstrate effectiveness, you need to measure outcomes," says Fox.
The American Society for Bioethics and Humanities' 2010 Core Competencies for Health Care Ethics Consultation includes a section on evaluation. Fox co-authored an article on what outcomes should be measured to demonstrate that ethics consultation is effective.2
"First and foremost, an effective ethics consultation service should improve patient care by ensuring that the health care organization and its staff are consistently adhering to the highest standards for ethical practice," says Fox.
For example, ethics consultations should ensure that patients' preferences for life-sustaining treatment are appropriately and sensitively discussed, documented, and honored.
Ethics consultation should increase patients' and families' satisfaction with their health care experience, adds Fox, and reduce moral distress and employee burnout.
"Unfortunately, however, this sort of effectiveness research on ethics consultation has been limited," she says. "Evaluating ethics consultation quality is a lot easier than demonstrating effectiveness."
Determining how ethics service affects patient care is a challenge, says Blair Henry, an ethicist at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. There are many confounding factors that could influence such an evaluation, given the complexity of care environments.
Many ethics consult services send a quick survey to the involved clinicians after a consultation, with open-ended questions asking for feedback. "This may get at elements of process quality, but not outcomes," says Henry. "A more robust evaluation process is needed to properly illustrate the impact of ethics consultations on patient care."
Some have suggested that a randomized, controlled trial design is required, says Henry, but "the uncertainty of which tools might be used to measure outcomes, and the impossibility of using a non-intervention, or even a placebo arm, make this methodology problematic."3
Clear standards needed
It may be premature to try to demonstrate the effectiveness of an intervention, says Fox, before there are clear standards on how the intervention should be performed. "That's why we have been focusing our efforts on establishing standards and measures for ethics consultation quality," she says.
The VA uses these approaches:
- The ethics consultation services ask for feedback from those involved in a consultation.
Each of the VA's health care facilities has an ethics consultation service, with about 2,000 consults each year. "We receive feedback on about a third of those consults, which is a number we're very proud of," says Fox.
- Ethics consultants document consults in a standardized way.
The VA uses an internally developed web-based database called ECWeb. This system captures information on who is requesting ethics consults; how often ethics consultants visit the patient; and what percentage of consults are about surrogate decision making.
"Data like these help us target activities toward high-priority issues," says Fox.
- The National Center for Ethics is developing a tool to evaluate the quality of ethics consultations based on written consult records.
Once this tool is validated, it will be posted on the VA's website for others to use.
"Tools like this will enable us to relate ethics consultation to a number of important outcomes such as ethical practices, patient satisfaction, and employee morale," says Fox. "Ultimately, we hope to demonstrate the effectiveness of ethics consultation with respect to all of these outcomes."
"Separate, elitist world"
An ethics committee in the field of health care can be said to have reached maturity when it becomes a necessary piece in the organizational chart of a medical institution, according to Rogelio Altisent, chair of professionalism and clinical ethics at the University of Zaragoza in Spain.
"For this to occur, the label that it is only a group of ethics enthusiasts must be eliminated," he says.
Bioethics is still seen by many clinicians as a "separate, elitist world that is interested in philosophy and in 'splitting hairs,'" adds Altisent. "This is probably because most health care professionals have received little academic training in this field."
Clinical bioethics should not be used only for cases with very complex ethical problems, argues Altisent.
"Ethics should also be the engine that drives us to dedicate the necessary time to each patient — to treat seemingly unpleasant patients with patience; to make an effort to give elderly, deaf, or psychiatric patients information they understand; to analyze treatments from the perspective of efficiency; and to avoid criticizing colleagues in front of patients," he says.
The classic functions of ethics committees are receiving queries about cases with ethical problems, providing ethical recommendations, and providing bioethical education. "I believe there should be a fourth function — that of promoting research aimed at understanding the real needs of their field of action," he says.
Ethics committees should play an active role outside the walls of meeting rooms, says Altisent, in determining what really concerns professionals and patients from an ethical perspective.
The efficiency of ethics committees must be evaluated the same way as other services, adds Altisent, utilizing a qualitative methodology. "Otherwise, ethics committees can become distorted by their members' own interests," he says.
- Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: A national survey. Am J Bioeth 2007;7(2):13-25.
- Fox E, Arnold RM. Evaluating outcomes in ethics consultation research. J Clin Ethics 1996;7:127-138.
- Chen YY, Chen YC. Evaluating ethics consultation: Randomised controlled trial is not the right tool. J Medical Ethics 2008;34(8):594-597.
- Rogelio Altisent, Chair of Professionalism and Clinical Ethics, University of Zaragoza, Spain. E-mail: email@example.com.
- Ellen Fox, MD, Director, The National Center for Ethics in Health Care for the Department of Veterans Affairs (VA), Washington, DC. Email: firstname.lastname@example.org.
- Blair Henry, Ethicist, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Phone: (416) 480-6100, ext. 7178. E-mail: Blair.email@example.com.
- The VA designed an Ethics Consultation Service Proficiency Assessment Tool that enables leaders of ethics consult services to evaluate the collective competencies of their service and identify opportunities to improve the service. The tool is available at http://1.usa.gov/1jF5KsW. A standardized Ethics Consultation Feedback Tool is also available at http://1.usa.gov/1bxkRB8.