Ethicists’ recommendations aren’t always accepted
Clinicians, patients may misunderstand team’s role
A terminally ill patient was in multi-organ failure in an intensive care unit (ICU), and the family opposed the primary physician’s recommendation for a Do Not Resuscitate (DNR) order, which was based on her benefit-to-burden analysis of cardiopulmonary resuscitation for the patient. A subcommittee of the ethics committee was assembled, and met with the family and representative members from the primary clinical service and from the ICU.
"The ethics team ultimately supported writing a DNR order even without family consent, based on the patient’s best interests," reports Martin L. Smith, director of clinical ethics at The Cleveland (OH) Clinic. "Many hours by multiple members of the ethics team were spent on this consult. In the end, the primary physician chose not to write the DNR order."
Role is advisory
Given the advisory role of ethics consult services, an ethics consult team needs to anticipate that its recommendations won’t necessarily be accepted or followed. Typically, after appropriate information-gathering and analysis, the team provides ethically supportable and recommended strategies and options, says Smith.
"The consult process, depending on the case and its complexity, can be very time-consuming and labor-intensive," says Smith. "But ethics consultants need to routinely remind themselves that after all that hard work, their role remains advisory." The primary stakeholders in the case — usually the patient, family, physician, and other clinical team members — are ultimately responsible for their own decisions and are free to ignore the advice of ethics consultants.
Kayhan Parsi, JD, PhD, professor of bioethics and health policy/graduate program director at Loyola University Chicago’s Neiswanger Institute for Bioethics and Health Policy in Maywood, IL, says patients and clinicians might have to be reminded that the bioethicist’s role is typically advisory. "We are not there to go in and make moral pronouncements. We are really there to offer a range of ethically appropriate options," he says. "We are really facilitators, at the heart of it."
While a question such as, "Who is the appropriate surrogate decision maker for this patient?" is fairly straightforward, consults become considerably more complex when the bioethicist is asked to facilitate a resolution regarding a conflict between the family and the clinical team.
If a terminally ill patient is in an ICU setting and has undergone an aggressive treatment regimen, and the clinical team has come to a point at which they believe there is nothing else the team can do medically for the patient, the clinical ethicist might recommend a palliative care approach. "If the patient’s family wants to push forward, the attending always has the discretion to follow our recommendation or not," says Parsi. "We are like any other consultant in that sense. But if they choose not to follow the recommendation, they should have a very good reason, and indicate such in the record."
In some instances, a family member perceives the ethics consultant as having a conflict of interest simply because he or she is employed by the institution. "We have to be very careful to clarify what our role is — that of an impartial third party," says Parsi. "We are there to facilitate dialogue and come to some sort of consensus. We are not there to be the ethics police, or address one view unilaterally."
Clinicians misunderstand role
Some clinicians, based on previous experiences with an ethics consult service, believe that ethics consultants will "take over" the case, to the detriment of the clinical team members’ relationships with the patient or the family. "Clinicians who have less power or authority in health care’s traditional hierarchy, such as nurses or resident physicians, may feel intimidated or threatened by an attending physician if ethics assistance is requested," says Smith.
If ethics consultation can make a positive contribution to patient care and patient outcomes, says Smith, then under-utilization of an ethics consult service means that patients and their families are being denied a valuable resource. "At the Cleveland Clinic, we have initiated what we call embedded ethicists’ with many of our clinical services," says Smith. This means that one of the team’s bioethicists participates in a clinical team’s routine meetings, inter-disciplinary meetings, patient-focused meetings, care discussions, and decision-making.
"We have done this successfully and effectively with our neurology colleagues, with most of our organ transplant services, genetics, pediatrics, and heart failure," Smith says. "Over time, trusting relationships with clinicians are built. Clinicians come to see the positive contributions we can make to their thinking, decisions, and patient care."
Bioethicists also participate in routine inter-disciplinary rounds in most of the organization’s ICUs. As a result, over time, bioethicists become well known by attending physicians, fellows, and residents; by bedside nurses and nurse managers; and by physical therapy, occupational therapy, social work, pastoral care, and case managers. "Mutual trust, understanding, and respect are established," says Smith. "There is little or no hesitancy to request ethics assistance when needed."
Not about winning
If conflict over patient care isn’t successfully resolved, a communication breakdown and loss of trust between any of the parties can occur. "This can stall progress on behalf of the patient, and damage the working alliance with the clinical team, patient, and family," says Jane Jankowski, LMSW, MSB, a clinical ethicist and assistant professor at Alden March Bioethics Institute at Albany (NY) Medical College.
In some cases, a patient’s discharge from the hospital to a skilled care facility is held up because the patient will not consent to a recommended treatment. The family and clinical team can become frustrated if Jankowski recommends that the patient’s preference on the matter should be honored.
"And I get it; this can delay a hospital discharge. There is a lot of pressure to move patients through the system these days," says Jankowski. However, if that patient understands the risks and benefits of what he or she is declining, as well as the consequences, Jankowski is not likely to recommend overriding a patient’s well-reasoned refusal in order to satisfy the preferences of others or pressure to expedite a hospital discharge.
As a clinical ethicist, Jankowski expects to be questioned about why she arrived at the recommendation she did, and is prepared to explain her reasoning. "When there is strong opposition, I find that the most productive response is listening to other views on the situation, and validating the concerns of the team," she says. "This helps the consultation remain a shared, inclusive process."
Flexibility, self-reflection, and a willingness to acknowledge errors are key. "It is important to focus on the purpose of the consultation," says Jankowski. "It is about the patient, not about winning or losing a debate over a theoretical dilemma. This is real — it is someone’s health and welfare at stake."
- Jane Jankowski, LMSW, MSB, Assistant Professor, Alden March Bioethics Institute, Albany (NY) Medical College. Phone: (518) 262-7125. E-mail: JankowJ@mail.amc.edu.
- Kayhan Parsi, JD, PhD, Professor of Bioethics & Health Policy/Graduate Program Director, Neiswanger Institute for Bioethics and Health Policy, Loyola University Chicago Health Sciences Division, Maywood, IL. Phone: (708) 327-9214. E-mail: firstname.lastname@example.org.
- Martin L. Smith, Director, Clinical Ethics, The Cleveland (OH) Clinic. Phone: (216) 444-8720. E-mail: email@example.com.