Ethics Knowledge Gaps Exist on Assessing Capacity, Identifying Surrogate Decision-Maker
Ethicists at Rush University Medical Center often observed both trainees and staff demonstrated limited understanding about important medical ethics topics. These knowledge gaps were particularly apparent with assessing decision-making capacity and determining a healthcare surrogate.
As a clinical ethicist, Gina Piscitello, MD, had been involved in multiple ethics consults involving those specific issues. Piscitello and Ruthe Ali, a medical student at Rush Medical College, decided to assess baseline ethics knowledge, attitudes, and skills of medical trainees and staff. They surveyed 93 internal medicine residents, palliative fellows, social workers, medical and pre-medical students, chaplains, and advanced practice providers.1
Fifty-four percent of participants demonstrated good baseline knowledge of the four principles of bioethics. However, just 5% knew how to determine an alternate decision-maker. Only 14% knew how to assess decision-making capacity.
“This is concerning, given that these tasks are frequently required in patient care. Lack of skill in performing these tasks may place patient autonomy at risk,” warns Piscitello, assistant professor of palliative medicine, hospital medicine, and an ethics consultant at Rush University Medical Center in Chicago.
If medical teams fail to correctly assess capacity, patients could end up undergoing unwanted treatment. For example, patients might respond to clinicians with an answer that is inconsistent with his or her preferences, which might be caused at that moment by a state of delirium. “It is important in these situations that clinicians fully assess decision-making capacity,” Piscitello says.
Clinicians must determine if patients can understand the question, state a choice, appreciate the risks and benefits, and rationalize why their decision aligns with their care preferences. The fact that few participants understand decision-makers and surrogates carries important implications for the ethics field. “Hopefully, this will open up the conversation to say: ‘We do really need education in this area,’” Ali says.
After completing the survey, participants attended a one-hour, case-based discussion on medical ethics. After, participants were surveyed again to evaluate the success of the educational intervention. Participants’ self-reported skills in determining an alternate decision-maker increased from 5% to 50%, and self-reported skills in assessing decision-making capacity rose from 14% to 71%. “These findings support the need for curriculum interventions to improve basic knowledge, attitudes, and skills in clinical medical ethics,” Piscitello says.
However, there was a discrepancy between what the participants self-reported and their actual knowledge. Participants were less skilled than they reported. The finding suggests a one-hour ethics intervention alone probably is not enough to provide expertise. “We can create these case-based discussions, but are we actually equipping people with the skills to carry this out?” Ali asks. “That is something we need to address in the future.”
Ideally, clinicians would be sufficiently educated to determine decision-making capacity or surrogate decision-makers. “It is important to continually assess that clinicians possess sufficient knowledge and skills in clinical medical ethics — and if not, to implement education or system changes to improve these areas,” Piscitello says.
REFERENCE
- Ali R, Piscitello G. Improving knowledge, attitudes, and skills of medical clinicians and trainees in clinical medical ethics. Am J Hosp Palliat Care 2022; Mar 31:10499091221084675. doi: 10.1177/10499091221084675. [Online ahead of print].
Clinicians must determine if patients can understand the question, state a choice, appreciate the risks and benefits, and rationalize why their decision aligns with their care preferences. The fact that few participants understand decision-makers and surrogates carries important implications for the ethics field.
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