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Ethics center to standardize ethics consultations
Case consults now done in stepwise fashion
The U.S. Veterans Health Administration (VA) National Center for Ethics in Health Care launched a major ethics integration initiative in 2007, including a new component that seeks to standardize and evaluate the quality of ethics consultations.
One of the challenges to evaluating ethics consults has been that there have been no established standards to measure by, according to Ellen Fox, MD, chief officer for VA Ethics in Health Care. Fox says not only has proof of the effectiveness of ethics committees been primarily anecdotal, but there is also little measurable evidence that ethics consults improve patient outcomes.
"To evaluate ethics consultations, you need to compare them relative to standards, and the standards for ethics consultations have not been clearly defined, and there's not been a great deal of consensus on what constitutes a good consultation," says Fox. In addition, Fox and colleagues pointed out in a 2007 journal report,1 fewer than half of ethics consultants have any formal training, and only one in 20 has a bioethics certification or graduate degree.
With a nod to the fact that an ethics consultation is, by nature, a fluid and dynamic process, VA ethicists have created and put into practice standards by which ethics consultants can assess their own effectiveness, and ethics committees can measure their strengths and weaknesses. The ethics consultation component is one of three that make up the IntegratedEthics initiative.
CASES: A stepwise consult plan
Fox says that there have been standards in place for consultants, but not for the consultation itself.
"We spent a number of years and involved hundreds of people in developing detailed standards for evaluating consultations, and we created a primer that lays out the standards, how you should and shouldn't do a consult," she explains. (The primer, "Ethics Consultation: Responding to Ethics Questions in Health Care," and other materials from the IntegratedEthics initiative are available for download at www.ethics.va.gov/integratedethics.)
The VA ethics center drafted CASES, a step-by-step approach to ensuring that ethics consultations hit all the points that the initiative has set out, Fox says. (See box.) A 63-page primer and two-hour instructional video was created for VA consultants, and ethics coaches are visiting VA medical centers to train consultants on consistently following the process when handling cases.
Fox says the drafters of the IntegratedEthics model looked at hundreds of consults involving different kinds of people, and created a stepwise plan that applies to the majority of ethics consultations seen at VA facilities, Fox says.
The consultation plan is made up of two tracks — the case consult track guides consultants through a comprehensive study of case-related ethical situations that most often are seen at VA hospitals, while the non-case track guides consultants through how to handle questions about health care policy, hypothetical scenarios, and other questions for which a standardized format might not apply.
"We found that in consultations, one of the major mistakes consultants make is skipping steps. This standardizes the steps, but it's a fluid, dynamic process, so we make it clear that there's no set order in which the steps have to occur."
The mainstay in many ethics programs in hospitals is the meeting — a meeting that under the VA initiative is optional.
"We believe that some case consults can be resolved by a group meeting, when you get to a point where you come to a resolution, everything may already be resolved, so the meeting isn't mandatory," says Fox.
When a consultation is over, the consultant then goes to an on-line evaluation tool that measures the consultant's proficiency and knowledge; the self-evaluation then goes to the head of the hospital's ethics consultation service for review.
"This isn't a pass/fail evaluation," Fox explains. "It's a way for the consultant to know his or her level of skills, and for the head of consultation services to make sure the assessment is accurate."
Another piece of the evaluation is what Fox refers to as "a quality improvement tool" for ethics consultations, an electronic means of tracking data such as who requested the consult, what the prompting issue was, and what the outcome was.
'Surprising' consensus on standards
Fox says an unexpected element to the planning for and creation of standards for ethics consultation was the degree to which the many participants and reviewers agreed, considering that some elements of ethics consults can be quite subjective.
"We had a team get together and articulate what we thought the standards are at VA hospitals, hammer out internally what the differences are, and to see what we could agree on," Fox says. "We had many reviewers, many leading exerts in ethics, and we received a lot of very detailed comments, and we were a bit surprised by the extent of consensus."
That's not to say common ground was found on every point, she concedes.
"We had some notable exceptions, where people disagree with the stand we took on some issues," says Fox.
For example, the VA has rejected the use of "curbside consults" — when an ethics consultant is asked for an opinion on a patient who he or she has never examined, and without a formal consultation requested. Curbside consults are considered widespread in medicine, according to the literature, because they're convenient and quick.
"We don't believe in curbside consults on active patient cases, and we strongly emphasize that they're a mistake and that we should never do it," Fox says. "Some people agree with that, and think it's a standard part of some consultants' practice."
The new standards insist that ethics consults include a face-to-face visit with patients, rather than telephone interviews.
"Some consultants work remotely and can't visit, but we feel it's important that they visit the patient," Fox explains.
And as previously mentioned, the VA standards don't revolve around a full ethics committee meeting.
"In some models, some steps of the consult take place during a meeting, and that's different from our standards," Fox says. "Some people think that if you haven't had a meeting, you haven't had a consult. But we find that in many cases, there's resolution before you ever get to a meeting."
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