By Stacey Kusterbeck
What is the value of an ethics consultation? There is no clear consensus on how to answer this question. “There is a need to recognize the limitations of more traditional clinical metrics for measuring value — and why they can’t be applied to ethics consultation,” according to Thomas May, PhD, Floyd and Judy Rogers Endowed Professor at Washington State University. Clinical areas rely on hard data, such as an increase in the percentage of patients receiving medication in a specific timeframe, to demonstrate quality. For ethics, a “good” consult is much harder to define and is talked about in terms of qualitative, rather than quantitative, data.
“The healthcare industry in general is data-driven, so it is likely that there is a desire for metrics for ethicists. To date, there are no broadly applicable or generalizable data collection methods and tools for clinical ethics,” says Felicia Cohn, PhD, HEC-C, bioethics director at Kaiser Permanente Orange County.
Some traditional metrics are inappropriate for ethics consultation work. “Many of the metrics that are used to measure ethics consultation are looking at things that are focused on some indirect value. That may or may not be consistent with the value that ethics consultation brings,” says May.
To some extent, ethicists’ work reflects organizational priorities. Reduced length of stay is a common example. “Ethics consultation very often does lead to reduced length of stay. But that is not the goal of ethics consultation,” says May.
Many ethics consults involve a conflict over whether life-sustaining interventions should be continued. “When an individual has a limited quality of life and is faced with the prospect of a lot of pain without much reward, most people will choose not to artificially extend those circumstances,” says May. Therefore, the patient and family are likely to decide to withdraw treatment. This results in a shorter length of stay. However, setting a goal to reduce length of stay might be counterproductive to the goals of ethics consultation. “For ethicists, the goal is to determine what is ethically appropriate, not what is cost-effective. No single metric is able to capture the value of ethics consultation,” says May.
Metrics such as length of stay reflect conflicting priorities. For example, shorter inpatient stays might be ethically appropriate for patients and families, but they also are beneficial for the hospital financially. “Artificially imposing a single metric, like length of stay, can actually be dangerous if it leads to decisions or actions that are based on that metric. Shorter length of stay is not the goal we are shooting for. And, if we were shooting for that, it would bring suspicion to the profession itself. So, it’s really important to separate those goals,” explains May.
For ethicists, the challenge is to find a way to demonstrate the value of ethics consultation in a way that does not undermine the purpose of the consultation. “This leads to the necessity of approaching ethics a little differently than we do for some other areas, in terms of measuring value,” says May.
Many hospital departments use Press-Ganey surveys, with increased satisfaction scores identified as a top priority for the organization. For ethics, though, satisfaction surveys can be misleading. “The goals of an ethics consultation is not to make sure that the greatest number of people are happy with the recommendation. It is to make sure that recommendations respect the rights of the person whose interests are most affected,” says May.
May recently consulted on a case of a patient with developmental disabilities who was dependent on family members for activities of daily living. After an acute event, the patient was expected to make a full recovery. The patient considered their baseline quality of life to be very good. In contrast, the family stated that the patient’s baseline quality of life was not worth returning to. A nurse requested an ethics consult to resolve the conflict. The case illustrates the limitations that satisfaction surveys have when used to evaluate ethics consultation. “If you took a satisfaction survey of the parties involved, there would be one nurse who said it was valuable,” says May. All the family members would be dissatisfied, even though ethicists made the appropriate recommendation.
Although satisfaction surveys are of limited value to ethicists, insights from consult participants are an untapped resource. “While the field of clinical ethics has seen rapid growth in the last decade with increased focus on professionalization and competence standards, the area that has not been explored is the experience of the ethics consult requestors,” says Ruchika Mishra, PhD, director of Bioethics in the Program in Medicine and Human Values at Sutter Health.
May and a colleague recently collected narratives of 12 people who had requested and received ethics consultation services.1 These individuals, including patients, family members, and healthcare providers, described their experience with ethics consultation services. “The motivation was to encourage stories from voices not usually heard in the literature: The consumers of ethics consultation,” says Cohn. Cohn, Mishra, and other ethicists analyzed insights gleaned from the narratives.2,3
The narratives demonstrate that anecdotal experiences are one way to assess the value of ethics consultations. “If you are not familiar with ethics, you may wonder: What does ethics do in this situation? Stories can illustrate and make tangible the real value and the real help that ethicists can offer in these cases. It can help people get a handle on exactly what it is that the profession is doing,” says May.
Overall, the narratives depicted a very positive experience with ethics consultation. “The narratives conveyed the emotional distress and turmoil that individuals experience when navigating decision-making in a complex medical situation,” says Mishra. However, some of the stories revealed that people had difficulty accessing ethics consultation. Some were unaware of ethics services or struggled to find contact information. In some cases, families were unable to request the help of an ethicist without going through their physician first. Some physicians obstructed access, believing ethics consultation to be unnecessary or inappropriate.
“Ethics consultation is not widely understood or recognized as a resource, sometimes even within the hospital setting,” says Cohn. “In my experience, people have heard of ethics committees, but do not understand what they do or that they are a resource for healthcare professionals, patients, and families.”
One common misperception is that ethics is consulted because someone did something wrong, necessitating involvement of the “ethics police,” says Cohn.
For ethicists, feedback from requestors is important to counter those misperceptions. “Ethicists can learn the reasons why medical professionals, patients, and families request an ethics consultation, their expectation of the service, the impact of the process and the ethics professional on the requestor and the case, and to get a sense of the value that the ethicist and the consultation process bring to resolving complex medical situations,” says Mishra.
Taken as a whole, the narratives pointed to the need to increase awareness of the ethics service among patients and families, and to educate providers about the role of the ethics consultation service. “There appears to be a great need and appreciation for this work. But it remains a hidden asset that is not readily accessible,” says Cohn. “There is a need to be more transparent about the work hospital ethicists do.”
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
- Craig JM, May T. Receiving clinical ethics consultation services. Narrat Inq Bioeth. 2024;14(1):1-5.
- Cohn F. Understanding clinical ethics consultation: What stories reveal. Narrat Inq Bioeth. 2024;14(1):31-37.
- Mishra R. Clinical ethics consultations: What do requestors say? Narrat Inq Bioeth. 2024;14(1):45-49.
