Ethics Consults: The Talking Cure
ABSTRACT & COMMENTARY
Synopsis: In this study, proactive ethics consultation led to improved communication, more DNAR orders, and reduced hospital stay.
Dowdy and associates use a before-after study design with historical controls to evaluate the effect of a "proactive ethics consultation" on end-of-life care in an ICU in Richmond. They conclude that this intervention resulted in improved quality of communication, an increased number of "do not resuscitate" orders, and reduced length of stay. (Dowdy MD, et al. Crit Care Med 1998;26:252-259.)
COMMENT BY GORDON D. RUBENFELD, MD
Biomedical ethics consultants are quoted frequently in the newspaper, appear on television, and are interviewed on the radio. They discuss some of the most difficult questions facing our society. Should doctors assist suicide? Who do we save when we can't save everyone? Should we clone grandmother?
What do ethicists know that we don't? How do they know what's right? Most hospitals in the country have ethics committees, and many have ethics consult services. What do these consultants do? Although Dowdy et al were interested in documenting the effect of an ethics consult, I think their article is far more interesting in what it discloses about the nature of ethics consults.
Unfortunately, the study design is too flawed to use in drawing valid conclusions about the effect of ethics consults. Dowdy et al used a before-after design with historical controls during a period (1992-1994) of profound secular change in end-of-life decision making and hospital length of stay that occurred independently of their intervention. Control patients were identified retrospectively using certain discharge codes, while intervention patients were identified prospectively by bedside screening that required physician consent for enrollment. Finally, "quality of communication" was measured by medical record abstraction. This is really a "quality of documentation" measure that, while important, may not reflect the quality of communication between clinicians, patients, and families.
So, while this study does not address the effect of an ethics consult, it does explain how these and other authors conceptualize the ethics consult. Two clinicians "trained in clinical ethics" strictly acted "to facilitate communication" and "to stimulate discussion among caregivers." The ethics consultants did not provide legal information, clinical prediction, or even meet with family members. In fact, it is probably a misnomer to call such an intervention an "ethics" consult. These were communication facilitators, staff mediators, and issue clarifiers. There was no ethicist ex machina who dropped in and told everyone what was right.
Why do intensive care clinicians need a communication facilitator? It is possible that some ICU teams work so well together, respect each other's expertise, and solicit conflicting opinions, so that an ethics facilitator is unnecessary. This is certainly how team care in the ICU should work. But, there is evidence that this is not the case in most ICUs (Asch DA. N Engl J Med 1996;334:1374-1379). Setting shared goals among the providers and clarifying these goals with the patient and family members is the essence of ethical and compassionate medical care at the end of life (Curtis JR, Rubenfeld GD. JAMA 1997;278:1025-1026).
Sometimes, we may just need a little help.