Do Clinicians Follow Ethics Recommendations? Relationships Are Important Factor
Ethicists often make recommendations after a consult — but does anyone actually follow them? “When consulting on an ethical dilemma, a hospital ethicist exists among several actors: Patients, families, healthcare providers, hospital legal counsel, and others,” explains Will Schupmann, a doctoral student in the Department of Sociology at UCLA. Some of those people, inevitably, disagree with ethicists about what to do. Schupmann sought to learn more about ethicists’ ability to enforce recommendations over the objections of others and how the social structure at hospitals supports or diminishes ethicists’ authority. Schupmann conducted in-depth interviews with 31 clinical ethicists in 2021 about how they obtained administrative authority and cultivated trusting relationships.1 Some key findings, based on the ethicists’ responses:
• Ethics consultation services vary significantly in terms of their authority.
Some ethicists receive hundreds of consult requests a year, and clinicians, administrators and attorneys defer to their expertise. Other ethicists get very few consult requests, lack institutional support, and have difficulty getting clinicians to follow recommendations.
• The social structure within hospitals affects the authority of clinical ethics consultants.
At some hospitals, physicians tend to follow guidance from risk managers or surrogates’ instructions over ethicists’ recommendations. In contrast, some hospital attorneys routinely loop in ethics when a clinician seeks legal guidance on a case. “Clinicians and attorneys collaborate with ethicists to come to a mutually agreed-upon solution,” says Schupmann.
• Ethicists’ authority hinges partly on relationships with medical staff.
Ethicists feel the need to prove themselves before certain clinicians will accept their expertise. “Cultivating key connections is essential for ethicists to have a voice in clinical decision-making,” concludes Schupmann.
• Many clinicians view ethics as a compliance entity.
“Ethicists attempt to push back against that reputation, because they think it dissuades staff from calling them,” says Schupmann. Ethicists found ways to assuage people’s concerns about getting a visit from the “ethics police.” One ethicist begins consults by reassuring the clinical team that ultimately, physicians still make the final call on treatment decisions.
• Some clinicians discourage colleagues from involving ethics.
Ethicists actively promote the ethics service and want to see more clinicians requesting consults. However, certain clinicians hinder those efforts by instructing others to avoid calling ethics. Ethicists shared these examples:
- A group of nurses explained to an ethicist that they wanted to call ethics earlier, but were discouraged from doing so by the attending physician.
- A department chair directly told clinicians to never call ethics.
- A nurse feared losing her job after calling ethics to report concerns about inadequate informed consent.
Ethicists work hard to win over physicians (or units) who rarely, if ever, call ethics. Some ethicists make a point of putting in “face time,” while others sent articles of interest to skeptical individuals in the hopes of establishing a dialogue.
• Some ethicists are reluctant to push recommendations too forcefully.
One ethicist considered escalating concerns to the chief medical officer, but worried that the attending physician involved in the case might not call ethics in the future.
• Ethicists who lacked medical training find it harder to obtain buy-in from the clinical team.
Non-clinician ethicists are often viewed as outsiders in the clinical space. One ethicist without a clinical background usually asks a clinician-ethicist colleague to give recommendations to doctors.
Overall, the ethicists who participated in the study found various ways to obtain respect, assert authority, and counter misconceptions about their role. This stems in part from the fact that the clinical ethicist profession is still relatively new, suggests Schupmann. Some medical staff members are unfamiliar with the ethics role, particularly in smaller, non-academic hospitals. “The profession is still in the process of spreading awareness and recognition of their expertise, which is more or less what all professions go through,” offers Schupmann.
Many ethicists struggle with how to inform people about the basics — who they are, what they do, and what they have to offer. “In terms of getting the word out, there’s no real difference between a clinical ethics consultation service and any other service,” says Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai in Los Angeles. Finder has found these approaches helpful:
- Have brochures about the ethics service readily available on units for patients, families, and staff.
- On institutional websites, have a dedicated web page for the ethics service that is easily discoverable using common search terms. The page should outline how the ethics service works, how to contact ethicists, and who can request consults.
- Include reminders about the ethics service in staff-oriented publications and emails.
- Give presentations on the work of ethics at all levels of the organization — administration, clinical leadership, and frontline unit-based staff. Ethicists could give a brief overview at a unit staff meeting, give formal updates at relevant committee meetings, or give grand rounds-style lectures. “Don’t be bashful about reaching out to leadership,” says Finder. “It’s OK to ask for the opportunity to share information about the ethics consultation service.”
- Ask the question: What is the aim of the clinical ethics consultation service? “This a core question for any ethics service,” says Finder. Generally speaking, Finder says that the mission of ethics services is to identify and clarify ethical questions arising within the context of patient care. Ethicists help everyone with a stake in the situation to think through various alternatives, articulate the possible choices and implications, and create space for all divergent voices to be heard. “Any recommendations made by ethicists must be responsive to all of these obligations,” asserts Finder. Involved parties may object if ethics recommendations challenge their beliefs about what is best, right, or good. What is important is that all of the various stakeholders have the opportunity to voice their perspectives. “The ultimate aim is to foster open and honest engagement and develop understanding,” says Finder.
Ethicists should align themselves with the mission of their particular health system, advises Lynette Cederquist, MD, director of clinical ethics and chair of the Hospital Ethics Committee at UC San Diego Health. Ethicists conduct weekly 30-minute rounds to discuss cases in two of the health system’s intensive care units. “This is a great opportunity to create relationships, demonstrate the value of clinical ethics, and incorporate some teaching for staff. Even once-a-month rounds can have a significant impact,” says Cederquist.
Ethicists ask hospital leadership what they are struggling with. “Willingness to help out will go a long way to having the hospital value the ethics service,” says Cederquist.
REFERENCE
- Schupmann W. “We are not the ethics police”: The professionalization of clinical ethicists and the regulation of medical decision-making. Soc Sci Med 2023;322:115808.
Ethicists often make recommendations after a consult — but does anyone actually follow them?
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