Real-time consults meet needs of ED doctors, but rarely exist

Bioethics’ relevancy is at issue

Ethics consults typically involve intensive care unit patients where issues can be thoroughly examined over a lengthy period of time, but what if a provider has minutes instead of days to make a decision? There is “definitely value” in providing emergency departments (EDs) with access to ethics consults, but the traditional ethics committee consultation process is insufficient to meet this need, says Craig Bates, MD, MS, FACEP, an attending physician in the Department of Emergency Medicine at MetroHealth Medical Center in Cleveland, OH, and a member of MetroHealth System’s Ethics Committee. “The time frames involved in the consultation process are acceptable for other units in a hospital, but not for an emergency physician with a specific question,” he says.

Bioethics consultations in EDs take three forms, according to Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor Emeritus of Emergency Medicine at the University of Arizona in Tucson and co-author of Ethics in Emergency Medicine (Galen Press). These are concurrent “stat” consults, retrospective reviews, and prospective policy and statute production. “Consultations during a clinical situation with ethical implications rarely occur,” he says. “The mechanism for round-the-clock ethics consults rarely exists, even in the most sophisticated institutions.”

Iserson notes that EDs have been described as “battlefields.” “This insight may help ethics consultants understand some of the differences between this medical setting — and the professionals working there — and other areas of the hospital,” he says. “They function at a frenetic pace, and always have limited resources — the most valuable of which is time.”

Stay relevant to clinicians

Individuals who do institutional ethics consultations rarely have the level of emergency medicine experience needed to assist clinicians, according to Iserson. In addition, emergency physicians and nurses might not immediately recognize a situation as an ethical dilemma, might not want others involved in the decision-making process, or might feel comfortable dealing with the issues themselves, as ethics has become more prominent in emergency medicine training, literature, and conferences.

Ethics consultations can promote patient-centered care and sound ethical decision-making, but their application to the ED environment can be challenging because of time constraints and the necessity of rapid decision-making, says Catherine A. Marco, MD, FACEP, a professor in the Department of Emergency Medicine and director of the medical ethics curriculum at The University of Toledo (OH).

“Emergency physicians are trained in, and should be facile in, applying ethical principles to ED issues, such as informed consent, refusal of care, end-of-life decisions, minors and confidentiality, and numerous others,” she says. “Institutional availability of timely ethics consultations may be a valuable asset to emergency physicians for complex or high-risk scenarios.”

Bates says that an effective strategy for ethics consults in the ED includes these components:

• Anticipating common ED issues, so that providers have a “toolbox” of approaches to address problems themselves.

“It is also critical that emergency care providers have a very good understanding of the relevant laws to common situations,” says Bates. These include advance directives, health care power of attorney, durable power of attorney, guardianship, surrogate decision makers, circumstances that impact autonomy of minors, and caring for prisoners or patients in law enforcement custody.

• Exploring ways to give clinicians rapid access to an ethics committee representative who can provide support for challenging situations.

“It is useful for this person to have legal knowledge as well, or to provide access to someone with that knowledge base,” says Bates.

• Discussing challenging cases after the fact.

“Make sure that all sides learn from these cases, and adjust education or available resources as appropriate in response,” says Bates.

Take proactive approach

Discussing scenarios that lead to ethical conflicts in the ED makes it easier to address these in a crisis, says Bates. “This can’t just be at the beginning of the ED visit — it starts in outpatient visits,” he says, adding that while end-of-life issues are a challenging situation for emergency care providers, they are not the most common type of ethical dilemma faced.

Assessing decision-making capacity in patients who refuse treatment is a major part of emergency medicine practice that brings up numerous ethical issues, for instance, and patients in law enforcement custody also present unique ethical challenges in the ED. “Sometimes the only true advocate for their well-being is the health care provider,” says Bates. “The patient and law enforcement can have alternative agendas that cloud their judgment, leaving the health care provider with added responsibility.”

EDs are expected to bring up advance directives at every encounter, but this is very inconsistent with what primary care providers do, adds Bates. “An elderly patient with dementia who consistently sees their primary care provider should have at least some documented discussion about end-of-life wishes on the chart, and the family should have some understanding of that,” he says. “It is very hard to start that discussion fresh, in the heat of the moment.”

Ethicists often find that retrospective ED case discussions are a good way to address bioethical issues, says Iserson. “In the less adrenaline-filled setting of the conference room, clinicians often can more easily identify ethical dilemmas and discuss alternative, ethically acceptable action plans,” he explains.

Ethicists can also routinely attend ED case conferences, or attend conferences on ethically troublesome cases that clinicians have identified, Iserson suggests. “Unless the ethics consultant is also an emergency clinician, a good way to get them involved — and to have them learn more about the nature of emergency medicine practice — is to have one or more of them sit on the institution’s ethics committee,” he advises.

Iserson says the most productive way for bioethicists to positively affect ED practice is to help the clinicians identify recurrent ethical problems that they encounter, such as prehospital resuscitations that neither the patient nor the family desires. “Then work with them to develop institutional or regional policy or state statutes to provide long-term solutions,” he recommends.

Sources

  • Craig Bates, MD, MS, FACEP, Medical Director, Metro Life Flight/Attending Physician, Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH. Phone: (216) 778-2100. E-mail: cbates@metrohealth.org.
  • Thomas Foreman, DHCE, MA, MPIA, Director, Department of Clinical and Organizational Ethics, The Ottawa Hospital, Ontario, Canada. Phone: (613) 737-8899 ext. 19967. E-mail: tforeman@toh.on.ca.
  • Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor Emeritus, Emergency Medicine, The University of Arizona, Tucson. E-mail: kvi@email.arizona.edu.
  • Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine/Director of Medical Ethics Curriculum, The University of Toledo (OH). Phone: (419) 383-6343. E-mail: catherine.marco@utoledo.edu.