Electronic Orders, Education Boost Requests for Ethics Consults
For a busy clinician managing multiple tasks at once, it might be easier to request an ethics consult electronically than making a phone call. “As an ethics consultation service, we have thought carefully over the past several years about ways to improve access to ethics consultation services for all stakeholders,” says Danielle Novetsky Friedman, MD, MS, a member of the ethics consultation service and associate attending in the pediatric long-term follow-up program at Memorial Sloan Kettering Cancer Center in New York City.
Friedman and colleagues recently implemented an electronic ethics consultation order as an easy, time-saving option. Post-implementation, “we found there was a significant increase in consultation requests placed for patients, in both the inpatient and the outpatient setting,” according to Friedman. In the 17 months before the electronic order was implemented, 108 consults were requested vs. 165 in the 17 months after implementation.1
The previous process started with a phone call, which remains an option for those who prefer this route. The person requesting an ethics consultation called a central number to give basic information regarding the reason for the request and patient demographics. The ethics program coordinator used this information to complete an intake form. The form listed the name and contact information of the requestor, the patient’s clinical background, the ethical issue to be addressed, and the names of other clinicians and support staff involved in the patient’s care. The on-call member of the ethics consultation service contacted the requestor with additional questions before proceeding with the consultation.
Ethicists were concerned that for some clinicians, taking the time to call someone might be a deterrent. “We hypothesized that it would feel less onerous for staff to place an electronic order for ethics consultation, which is in line with existing workflows for other types of consultation within the hospital,” Friedman explains.
The electronic order includes a drop-down list of reasons for requesting the ethics consult (e.g., informed refusal or surrogate decision-making). If requestors want, they can write the reason for the request in an open-text field. “The electronic order is more seamlessly incorporated into the providers’ days, rather than having to making a phone call,” according to Priya Marathe, MD, another of the study’s authors and a pediatric survivorship fellow at Memorial Sloan Kettering Cancer Center.
Most other consults are obtained via electronic orders. “This is similar to what clinicians are used to,” Marathe adds.
Before the new electronic orders went live, ethicists learned about the new method of requesting consults. “There was an educational effort throughout the hospital, so that might be a separate reason the number of consults increased,” Marathe suggests.
Notably, there was no increase in ethics consultation requests from non-medical providers (i.e., representatives, social workers, care coordinators, or patients/families). “This highlights the need to continue to design novel initiatives to improve access to the ethics consultation services for non-medical stakeholders,” Friedman asserts.
The electronic order is an important way to streamline ethics consultation requests. “But additional, broader efforts will be needed in the future,” Friedman says.
Ethicists have expanded educational outreach to non-clinical providers, and also have enabled a feature within the patient portal so patients and families can request ethics consultations. Since non-medical staff cannot request most medical consults, some still might be unaware they can request an ethics consult. “The educational effort was meant to fix that problem. But we may not have quite gotten there yet,” Marathe says.
1. Marathe PH, Zhang H, Blackler L, et al. Ethics consultation requests after implementation of an electronic health record order. JCO Oncol Pract 2022 Jun 24;OP2200174. doi: 10.1200/OP.22.00174. [Online ahead of print].
The electronic order is an important way to streamline ethics consultation requests, but additional, broader efforts will be needed.
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