Updated core competencies for consults are important milestone for bioethics

Field is at pivotal juncture

While the field of bioethics has traditionally embraced a diversity of approaches to clinical ethics consultations, there is now a general consensus for the need to agree of some basic standards in order to evaluate the quality and impact of the service.

“We are certainly in a state of transition. The train to professionalize health care ethics consultants has left the station,” says Anita J. Tarzian, PhD, RN, program coordinator at the Maryland Healthcare Ethics Committee Network in Baltimore. Tarzian chaired the task force to update the American Society for Bioethics and Humanities’ Core Competencies for Health Care Ethics Consultation report, and is lead author of a manuscript summarizing that report (To view the manuscript, go to: http://bit.ly/15W0jy1).

The original 1998 Core Competencies report discouraged any move toward certifying individual ethics consultants. The 2013 report recognizes the value in having individuals functioning as expert ethics consultants who are held accountable to quality standards, though it doesn’t endorse any particular approach.

The second edition of the Core Competencies clarifies various concepts described in the first edition, reframes the distinction between clinical and organizational ethics, expands on how to evaluate ethics consultation services, and introduces “process standards” for how to perform ethics consultation. “The ethics consultation knowledge and skills tables are essentially the same, but additional skills were added,” says Tarzian. These include quality improvement and evaluative skills; the ability to communicate and collaborate effectively with other responsible individuals, departments, or divisions within the institution; the ability to access relevant ethics literature, policies, and guidelines; and the ability for at least one member of an ethics consultation service to effectively run the service.

“The bottom line is that if someone has an ethics question or concern and calls for an ethics consultant’s help, the person responding should actually be able to help, and we should know how to evaluate whether that happens,” says Tarzian.

Pressure toward professionalization

Some bioethicists have post-graduate degrees in ethics and health policy, while others have only brief exposure obtained at a week-long ethics seminar. “There is also now a willingness, at least, to consider the certification of individuals who regularly perform ethics consultation. This is a contentious issue. Even the existence of ‘ethics expertise’ is a hotly debated topic,” says David M. Adams, PhD, MLS, a clinical ethicist at Pomona (CA) Valley Hospital Medical Center.

The latest Core Competencies report contains a new section devoted entirely to criteria for the evaluation and assessment of ethics consultation, including proper documentation and follow-up. Some have expressed concern that the additional standards may be overly burdensome for smaller hospitals without the same level of resources.

“In academic centers, we have access to a lot of people with formal ethics training. Community hospitals might not have access to people with the same level of training or expertise, but who are still making valuable recommendations,” says Keith M. Swetz, MD, MA, assistant professor of medicine at Mayo Clinic in Rochester, MN.

The creation of competencies and core requirements could exclude individuals with a wealth of clinical and ethical experience, but who don’t meet a certain certification standard. On the other hand, if certification criteria do not ensure that consultants have sufficient knowledge of clinical day-to-day realities confronting clinicians who request an ethics consultation, then certification would fail. “The new guidelines do a nice job of not necessarily mandating, but suggesting and being somewhat flexible in terms of what ethics teams and consults can actually look like,” says Swetz.

The field of bioethics is grappling with how to retain its historic roots in a plurality of disciplines. Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles, CA, notes that the original Core Competencies took the approach of an agreed-upon consensus at a time when the field of bioethics was in an earlier stage of its evolution. “It was not initially pursued to created standards that would be imposed on other people. But once it was done and put out there, some people viewed it that way,” he says.

The 2013 Core Competencies seek to identify “emerging standards” as opposed to a definitive set of standards. “This is an important document that helps further that effort in a field that draws from many different disciplines,” says Finder. “But by definition, once you create the standards, you are going to cut someone out.”

The challenge is how to create standards that are inclusive but also create some sense of boundary, says Finder. “I believe the value is to help us continue to ask important questions, and to provide a means for being accountable for the kinds of skills and judgments that we who do this kind of work hold as crucial,” he says.

Andrew Courtwright, MD, PhD, a physician at Massachusetts General Hospital’s Institute for Patient Care in Boston, MA, says what is most notable about the core competencies report is what is not included. Namely, there is no call for formal Health Care Ethics Consultation (HCEC) accreditation to ensure that the consultation competencies are actually being met.

“The ‘professionalization’ of HCEC has been a longstanding controversy in bioethics. The fact that the task force did not recommend formal credentialing or accreditation means that this will remain an active debate,” says Courtwright.

As the role of HCEC services is increasingly formalized in official hospital policy and state law, particularly in areas such as unilateral medical futility decisions, there will be increasing external pressure toward professionalization in a manner similar to other ancillary clinical hospital services, predicts Courtwright. “As this happens, I expect that hospital administrators and legislators will use the task force core competencies as a template for accreditation and credentialing expectations, if not adopt them outright,” he says.

Lack of outcomes data

Looking forward, the task force’s emphasis on quality improvement processes and establishing research priorities could have the most long-term impact on bioethics as a field. “There remains a significant dearth of empirical data on the practice of ethics consultation and its impact on patient care,” Courtwright says. “The task force’s call for better understanding of the current state of HCEC will help improve these services.”

As bioethics in general, and clinical ethics consultation in particular, become more established, the imposition of standards for education and practice of clinical ethics is inevitable, says Stuart J. Youngner, MD, Susan E. Watson Professor and Chair in the Department of Bioethics at Case Western Reserve University in Cleveland, OH.

“On the one hand, no robust method for determining how to measure outcome exists. On the other hand, clinical ethics consultants have a very real effect on the lives of patients, families, and health professionals,” says Youngner. “As bioethics enters deeper into the real world of clinical medicine, it is encountering a host of real-world dilemmas.”

The bottom line, says Tarzian, is that the practice of each ethics consultant doing it his or her own way needs to be replaced with a more standardized approach. This will allow for better internal quality improvement evaluation and research across practice settings. “We are in dire need of research to identify what types of outcomes are most valued and how they are best achieved,” she says. “We need to agree that some level of standardization is needed across facilities in order to compare apples to apples.”

Reference

1. Tarzian AJ & ASBH Core Competencies Update Task Force. Health care ethics: An update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ Core Competencies Updtate Task Force. The American Journal of Bioethics 2013;13(2):3-13.

Sources

• David M. Adams, PhD, MLS, Clinical Ethicist, Pomona (CA) Valley Hospital Medical Center. Phone: (909) 869-3574. E-mail: dmadams@csupomona.edu.

• Andrew Courtwright, MD, PhD, Massachusetts General Hospital, Institute for Patient Care, Boston, MA. Phone: (919) 699-1729. E-mail: acourt1500@gmail.com.

• Stuart G. Finder, PhD, Director, Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles, CA. Phone: (310) 423-9636. E-mail: stuart.finder@cshs.org.

• Keith M. Swetz, MD, MA, Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN. Phone: (507) 284-9039. E-mail: Swetz.Keith@mayo.edu.

• Anita J. Tarzian, PhD, RN, Program Coordinator, Maryland Health Care Ethics, Baltimore. Phone: (410) 706-1126. E-mail: atarzian@law.umaryland.edu.

• Stuart J. Youngner, MD, Susan E. Watson Professor and Chair, Department of Bioethics, Case Western Reserve University, Cleveland, OH. Phone: (216) 368-6196. E-mail: sxy2@case.edu.