Give clinicians good reasons to call for ethics consults
Begin with relationship-building
Clinicians often under-utilize clinical ethics consults because they believe these to be unhelpful and time-consuming, but bioethicists can counter these misperceptions with education and by building relationships in clinical areas. To encourage clinicians to call for ethics consults:
- spend time in clinical areas regularly;
- have informal discussions about cases;
- encourage clinicians to call for any challenging case.
The consensus is, "Ethics consults are useless." "They never give us any answers." "They always side with the family."
Clinicians often under-utilize ethics consults because they believe they’re unhelpful or overly time-consuming, says Autumn Fiester, PhD, director of the Clinical Ethics Mediation Program at University of Pennsylvania’s Perelman School of Medicine in Philadelphia.
Unfortunately, there is some truth to these negative perceptions. "Sometimes, people have had bad experiences with ethics consults in the past, and that makes them decide it’s not very helpful," acknowledges Benjamin Wilfond, MD, director of the Treuman Katz Center for Pediatric Bioethics at the Seattle (WA) Children’s Research Institute.
Make your presence known
Clinical ethicists can reach clinicians through presentations, grand rounds, and brochures. However, simply being "present" can have a bigger impact. "Ethicists need to be seen as part of the everyday working environment, not as ancillary or anomalous," says D. Micah Hester, PhD, chief of the Division of Medical Humanities at University of Arkansas for Medical Sciences and clinical ethicist at Arkansas Children’s Hospital, both in Little Rock. He recommends these practices:
- Spend time in clinical areas, either by rounding in the department or informal visits.
- Have regular discussions — weekly, monthly, or quarterly — with different clinician groups. For example, have informal case discussions with house staff and fellows, or start a journal club with a service group.
- Instead of promoting consultations, promote "debriefings" — after-the-event discussions with medical, nursing, and affiliated staff.
"All of these help break down barriers by developing familiarity and comfort with consultants and ethical reflection," says Hester.
Bioethicists at Treuman Katz Center for Pediatric Bioethics have found that when they round on certain units frequently, those units make more calls for ethics consults. "When you are comfortable with people, it makes it more likely they will call you when things get complicated," says Wilfond.
Twice a year at Seattle Children’s, cases from ethics consults are presented at grand rounds by the person who called the consult, with an outside commentator discussing the approach that was taken. This reminds people that ethics consults are useful, says Wilfond.
"Clinicians are more likely to call if they know that the person doing the ethics consult has the appropriate expertise, and is sensitive to time pressures in the clinical environment," says Hannah I. Lipman, MD, MS, associate director of the Montefiore-Einstein Center for Bioethics in Bronx, NY. Here are some practices that can encourage clinicians to utilize ethics consults:
• Remind clinicians that consults can help with any challenging case.
Any ethically challenging case should bring the possibility of an ethics consultation to the mind of clinicians, just as readily as heart-related challenges bring a cardiology consult to mind, says Hester.
In many hospitals, it is commonly "high-stakes" end-of-life and/or critical care cases that generate ethics consults. "But clearly, ethics affects the wide range of medical practices, both in- and outpatient," says Hester.
Since most ethics consults involve end-of-life decision-making, the family and clinical team are often already at loggerheads. "In my view, consults should be called at the first sign that the doctor-patient or doctor-family relationship is breaking down," says Fiester.
• Educate clinicians that consults don’t necessarily need to be formal and time-consuming.
To educate clinical areas on this, Wilfond developed a one-page flyer about the consult service. "Some consults are big meetings and others are conversations," he says. "But even for conversations, we try to do consults in person whenever possible. It’s another way of building relationships."
When a conflict arose within the care team about the best approach for a particular patient, the physician involved was initially very opposed to involving ethics. Wilfond suggested a conversation instead of a formal consult.
After a half-hour discussion, it appeared as though nothing was resolved. "But afterward, the primary nurse and physician ended up continuing the conversation by themselves, and came up with a plan," says Wilfond. "We clearly got things going, but they finished it on their own."
• Be prepared to explain the role of the ethics consultant.
Clinicians are sometimes unsure of the consultant’s role. "They might think we’re going to slow a case down or take control over the care of their patient," says Lipman.
She routinely explains to clinicians that the consultant’s role is primarily that of mediator with ethics expertise, with the goal of bringing parties to consensus, rather than substituting for the primary team. "We help the clinical team and patients and families understand the bioethics implications of the choices in front of them," says Lipman. "We’re there to help support them in understanding the ethics issues."
The team uses consults to teach approaches to common ethics dilemmas, which clinicians can draw upon in future cases. For instance, clinicians often expect a "yes" or "no" answer when they call about complex discharge cases. "We explain that we are not answer-oriented; we are process-oriented," Lipman says. "We tell them the things they need to consider when determining how to honor the patient’s values as much as possible, and still ensure a safe discharge."
Some clinicians avoid ethics consults because they are concerned about a phenomenon known as the "ethics police," says Hester. "That the consultant will swoop in and tell everyone what is right and wrong."
Clinicians may need to be told that ethics consultations aim more at facilitating discussions and clarifying values. Hester informs clinicians that ethics consults can help in these ways:
- Consults can reduce length of stay and costs because protracted problems get resolved earlier than if no consult is called;
- Physicians report that consults aid in clearer communication;
- Patients and families note that they feel more included in their care and appreciate having complex issues simplified for better decision-making.
"What patient isn’t helped when his or her physician better understands what values are being traded on during the relationship?" asks Hester. "If ethics consults can facilitate better communication, the patient is the beneficiary."
- Autumn Fiester, PhD, Department of Medical Ethics & Health Policy, Perelman School of Medicine, The University of Pennsylvania, Philadelphia. Phone: (215) 573-2602. E-mail: [email protected].
- D. Micah Hester, PhD, Chief, Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock. Phone: (501) 661-7973. E-mail: [email protected].
- Hannah I. Lipman, MD, MS, Associate Director, Montefiore-Einstein Center for Bioethics, Bronx, NY. Phone: (718) 920-4630. E-mail: [email protected].
- Benjamin Wilfond, MD, Director, Treuman Katz Center for Pediatric Bioethics, Seattle (WA) Children’s Research Institute. Phone: (206) 884-8355. E-mail: [email protected].
