By Stacey Kusterbeck
As Memorial Sloan Kettering (MSK) Cancer Center grew from a single campus in Manhattan to more than 12 outpatient care centers throughout New York City and the surrounding suburbs, ethicists saw the need for an expanded presence. “We recognized the geographic limitations of our Ethics Consultation Service and Ethics Committee to deliver real-time, expert ethics services at all of our locations,” says Liz Blackler, MBE, LCSW-R, associate director of the Ethics Committee and Ethics Consultation Service at MSK Cancer Center.
All MSK locations have access to the Ethics Consultation Service. However, MSK’s Ethics Committee and Ethics Consultants are based primarily at the inpatient Manhattan campus. “To date, for consult requests that have involved sites out of Manhattan, we have conducted the consultations remotely. But we are open and amenable to traveling to the sites if this is in the best interest of those involved,” says Amy Scharf, MBE, project manager of the Ethics Committee and a member of the Ethics Consultation service.
However, there was no getting around the fact that lack of a physical presence of ethicists at far-flung sites put outpatient staff at a disadvantage, compared to their inpatient counterparts. Outpatient providers were less likely to recognize the need for ethics involvement, says Blackler. With growing numbers of MSK patients choosing to receive care at closer-to-home locations, there was a clear need for ethics expertise at those sites.
To create a cadre of local clinicians with knowledge in addressing common ethical issues that arise in cancer care, the MSK Ethics Committee created a Bioethics Ambassador Program. More than 50 staff members have participated in the program to date. Scharf, Blackler, and colleagues recently examined the impact of the program, based on its first two years.1 The third year of the program is underway. Participants attend three day-long in-person sessions, each covering three to four topics, and two two-hour virtual sessions, each covering one topic.
Ethicists surveyed participants before and after the course to assess their bioethics knowledge on topics such as surrogate decisionmakers, bioethical principles, and requests for nonbeneficial treatment. Most (74%) participants reported that the program increased their overall bioethics knowledge, particularly for decision-making capacity. A significant percentage (41%) of participants reported having participated in ethics-related activities, such as training to become clinical ethics consultants, leading ethics-related educational initiatives, and representing Ethics as members of working groups or committees (such as the Institutional Review Board [IRB] and the Medical Aid in Dying Advisory Council).
The program’s success was boosted by clinicians’ willingness to donate six to eight hours each year to develop the curricula and teach the sessions. For example, a palliative care physician presented on symptom management and ethical obligations to alleviate pain and suffering; a medical oncologist presented on autonomy, the right to decline treatment, and requests for nonbeneficial treatment. Some of the instructors are current or former members of the MSK Ethics Committee. Others were not members but had worked in some capacity with the Ethics Committee or Ethics Consultation team on educational programs or ethics consultations. “MSK’s Ethics leadership works very collaboratively across the institution, as do all members of our staff. While it was a significant amount of time that clinicians devoted to the Program, such partnerships are part of the MSK culture,” says Scharf.
The program is open to all hospital staff, both clinical and non-clinical. Nurses and physicians participate, but so do staff from environmental services, security, and hospital administration. Thus, some participants came into the program with considerable ethics knowledge, and others had none at all. Presenters had to tailor the material to meet the needs of diverse participants.
However, participants ended up benefiting from hearing a wide range of viewpoints. Nonclinical staff offered unexpected insights, from the point of view of patients and caregivers. In one session on decisional capacity, a clinical participant talked about being frustrated when an elderly patient with atrial fibrillation demanded to be discharged against medical advice. In response, a nonclinical participant shared a personal experience with local police performing a welfare check after the participant had left an emergency department against medical advice. The participant suspected that the clinical team would have respected the decision to leave more if it had been someone with a clinical background. This resulted in a vigorous discussion on the balance between the ethical duty to care and the dignity of risk.
Not all the sessions were this engaging — some were heavily didactic. While participants were encouraged to keep their cameras on and participate fully in discussions, not all did so. Participants were assigned several articles to review prior to the next session, but instructors did not require any “homework” and did not ask participants to discuss what they had reviewed. Instructors also did not formally assess how much participants were learning. This made it difficult to quantitatively measure the program’s true impact.
Nonetheless, ethicists feel the program has had far-reaching intangible benefits. “We surmise that many participants have leveraged their knowledge ‘under the radar’ through undocumented conversations and guidance to patients, caregivers, and other staff members,” says Blackler.
Ethicists also are noticing more ethics consultations are being requested in outpatient settings. “Although our internal website has always clearly stated that all sites are eligible to receive our services, we do surmise that our Bioethics Ambassador Program participants are contributing to raising awareness with recognizing ethical challenges, and helping staff know how to receive assistance,” says Scharf.
Outpatient clinicians have contacted ethicists for help with advance directives and identifying surrogate decision-makers. Other outpatient ethics consults involved relational autonomy and patients’ deferring decision-making to others. “It is extremely helpful to have these issues resolved in the outpatient setting, when the patient has the time and decisional capacity to thoughtfully work through these questions rather than in an inpatient setting, when their clinical status may likely be more critical,” says Scharf.
Reference
1. Scharf AE, Blackler L, Matsoukas K, et al. Creating a multidisciplinary bioethics ambassador program at a comprehensive cancer center. Camb Q Healthc Ethics. 2024; Oct 14:1-11. doi: 10.1017/S0963180124000343. [Online ahead of print].
As Memorial Sloan Kettering (MSK) Cancer Center grew from a single campus in Manhattan to more than 12 outpatient care centers throughout New York City and the surrounding suburbs, ethicists saw the need for an expanded presence. To create a cadre of local clinicians with knowledge in addressing common ethical issues that arise in cancer care, the MSK Ethics Committee created a Bioethics Ambassador Program.
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