Novel model provides “stat” ED ethics consults

“Otherwise, it wouldn’t happen at all”

A “rapid response” model for ethics consultations in the emergency department (ED) was developed at The Ottawa Hospital in Ontario, Canada, using terminology that ED clinicians familiar with “rapid response teams” can relate to. “We recognized that historically, emergency medicine does not rely on clinical ethics consultation support. We are trying to speak the language of the ED,” says Thomas Foreman, DHCE, MA, MPIA, director of the hospital’s Department of Clinical and Organizational Ethics.

When Foreman and his team looked into what bioethicists could do to support the ED, they quickly learned that clinicians saw ethics consults as a time-consuming process that wasn’t available on short notice. “We set out to see what we could do to change that,” he says. “We had to reconsider the model that was being used.”

In the traditional consultation model, ethicists receive a request, evaluate it, approach the care team, talk with the patient and family, and arrange meetings as needed over a period of days or weeks — none of which is possible in a busy ED. Ethicists agreed to make themselves immediately available to the ED.

“We abbreviated the process to meet the unique needs of emergency medicine practitioners,” says Foreman. “You don’t necessarily need a family meeting in the ED.” Instead, providers were looking for guidance and direction around some of the complex ethical issues that come through the ED. Patients are often transferred to the ED from long-term care facilities, for instance.

“The traditional notion is that you show up in the ED because you want to be treated — otherwise, you wouldn’t be there. The fact is, though, many of these patients don’t want to be treated,” says Foreman. “Does the patient really want us to do chest compressions, or are they here for another reason? The mindset of the emergency physician (EP) needs to change a bit in this situation. The patient is not here to be ‘fixed,’ but we need to do something.”

Three-minute process

Providers sometimes grappled with what to do when patients refused treatment, especially for time-dependent treatments such as thrombolytics for stroke. Bioethicists now help them to determine how to assess the person’s capacity to make the decision, and whether to allow patients to make a decision the provider believes will harm them.

“When the EP calls us, we ask them, ‘What are you unsure about? What can we do to support you and the patient?’ Really, the bottom line is that we allow the ED staff to tell us what their needs are,” says Foreman. “What we have found, most often, is that it’s really about walking the practitioner through the process of ethical decision making.”

Most of the time, providers are already on the right track, but want some reassurance that they’re doing the correct thing from an ethics perspective, he explains. Previously, ED providers had the attitude “We don’t have time to reflect. We’ve got to act or people die,” says Foreman, but now they feel more comfortable having this kind of conversation. Ethicists also had to change their mindset.

“Some ethicists take the approach, ‘I don’t do ethics consults by emergency. If it’s a crisis, don’t expect us to help,’” says Foreman. “I agree that early involvement and being proactive is the best way to avoid ethically contentious situations. But emergency medicine does not lend itself to that.”

Foreman’s office is located near the ED, which allows him to respond on a moment’s notice. Bioethicists developed pocket-sized “trigger” cards to help physicians determine if they need a consult.

Foreman says that bioethicists’ training and experience allows them to offer a rapid, quick session when necessary. “I have a library of scenarios in my mind, so instead of it being a three-hour process, it can be a three-minute process,” he says. “I wouldn’t say it’s the perfect way to do ethics consults all the time, but otherwise it wouldn’t happen at all.”

Ethicists give support

Bioethicists don’t make concrete recommendations, but, rather, help practitioners to decide what they believe is the right direction to go in. Recently, an emergency physician called for an ethics consult on an elderly man who stated that he did not want his percutaneous endoscopic gastronomy tube put back in and wanted to be left alone to die. “The family told him, ‘Don’t listen to him, he is just depressed. Put the tube back in,’” says Foreman, who began by asking the physician whether, based on his assessment, he thought the patient was clinically or situationally depressed. The emergency physician responded that it was situational, which meant he had the obligation to respect the patient’s decision for or against intervention.

“The physician said, ‘Based on that, I’m going to listen to my patient.’ I then told him, ‘If you want me to participate in a conversation with the patient and the family about how you’ve gotten to this place, I’m happy to do that,’” says Foreman. “At times, the bioethicist’s physical presence adds a level of support to the physician and the family, to facilitate a very difficult conversation as a neutral third party.”

In another case, a physician asked for help interpreting the advance directive of a woman transported from a long-term care facility with a gastrointestinal (GI) bleed. “The physician said that on the surface, the advance directive sounded like he should leave her alone and not treat the GI bleed, but it was an easy fix and she’d go back to the same level of quality of life. If it wasn’t addressed, she would bleed to death,” says Foreman. “We walked very quickly through what the physician anticipated was the mindset of the patient. He concluded that he would treat the GI bleed because it was life-threatening but not related to a underlying comorbidity.”

Most bioethicists were taught a “one-size-fits-all” approach to consultations, says Foreman, “but ethics must be dynamic. We must meet the needs as they present themselves, not as we want them to be. There is a perception that if you don’t go through a lengthy process, that you somehow lose quality. I’m not so sure I believe that. The quality of the consult isn’t based on the length of the consult.”

Without access to ethics consults, emergency physicians will face increased moral distress leading to burnout over time, adds Foreman, and if bioethicists do not meet the needs of different care providers, they “will soon become irrelevant.”