Lessons learned on ethics consults during the COVID-19 pandemic carry important implications for future disasters.
Researchers analyzed ethics consultations at Massachusetts General Hospital (MGH) that happened during the first surge of the COVID-19 pandemic to examine the actual ethical issues involving patient care during this period.1 They identified four themes: prognostic difficulty, visitor restrictions, end-of-life scenarios, and family members who could not participate in decision-making because they were ill.
“Many of the patients were incredibly ill, ventilated, proned, with additional organ dysfunction for a prolonged period,” notes Ellen M. Robinson, RN, PHD, HEC-C, a nurse ethicist and co-chair of the ethics committee at MGH.
There were 258 ethics consults conducted in 2019, and 285 in 2020. The number of ethics consults in 2021 increased to 385. During the study period, many services were limited to virtual visits, including chaplaincy and social work. In contrast, the ethics service was present in person.
“Showing up on the units was appreciated by physicians, nurses, and respiratory therapists, who were the primary healthcare professionals who were present,” Robinson says.
The pandemic underscored the need for ethics consultation services and committees to establish a working relationship with public health experts. Consultation services and hospital committees coordinate to manage conflicts while balancing uncertainty of patient values and providers’ obligations in the inpatient setting. However, not everyone is an expert in biostatistics, epidemiology, and public health law.
“To better address patient and providers’ needs in a future public health crisis, clinical ethics and hospital ethics committees must connect and work with public health experts to develop policy, processes, and practices for the clinical setting and community,” says Gavin G. Enck, PhD, HEC-C, clinical ethicist at OhioHealth.
Typically, hospital-based ethicists are not connected with public health experts. To connect with public health experts, Enck suggests inviting these figures to provide in-services to clinicians or ask for their help in developing hospital policies.
Enck believes there is a need for ethics consultation services and committees to standardize the process for resource allocation planning. During the pandemic, many healthcare organizations and state and national departments avoided public discussion of triage and resource allocation.
“This lack of discussion was due to concerns about politics and image. However, neither communicable diseases nor pandemics worry about politics or appearance,” Enck notes.
Enck says engaging in open conversations or a standardized process for resource allocation planning is required to prepare for future crises. Ethicists could jumpstart these talks by hosting in-service and public presentations about triage and resource allocation. “There is a vast amount of empirical and theoretical research on this topic that clinicians and healthcare administrators, as well as the general public, would benefit from knowing about,” Enck says. Ethicists demonstrated remote consultations could be effective, at least to some extent. “In situations with the right technology, such as video conferencing and access to electronic medical records, remote clinical ethics consultations were as effective and successful as in-person consults,” Enck reports.
Going forward, remote ethics consults will benefit patients, providers, and healthcare organizations in rural locations.
“The range of a healthcare ethics consultant or consultation service should not be limited or tied to physical locations,” Enck says.
Although the ethics consult service could conduct remote consults before the pandemic, the practice has become more common since. “Remote consults increased exponentially, especially at the peak of the surges. It is a practice that will likely continue after the pandemic,” Enck predicts.
At the Cleveland Clinic, the ethics team learned several lessons about the consultation process during the pandemic, including the virtual vs. in-person debate. “My own view is that the consultation process is optimal in person. But virtual methods can still be very effective,” says Jane Jankowski, DPS, director of the Cleveland Clinic Center for Bioethics.
Ethicists proved gathering information, coaching clinicians, and providing recommendations all could be handled remotely. The ethicists were fortunate to have had experience managing ethics consultations by phone well before the pandemic. “Because our hospital system is so geographically large, some consultations have to always be handled remotely due to the distance between locations,” Jankowski explains.
For the ethics service, another innovation that is likely to last is scheduling improvements and streamlining intake through a centralized number. Previously, this had been conducted based on geographic location. The ethics service had always managed its consultation service as two distinct services — one service provided coverage for the main campus hospital, another provided coverage for the community-based hospitals. During the pandemic, this changed. All requests were sent to one number and triaged centrally, which worked so well it continues today.
Ethicists are using various smartphone apps that emerged during the pandemic. All ethicists receive secured smartphones equipped with texting and paging apps to contact clinicians, along with tools that notify ethicists if a new order is entered in the patient’s chart for a consult.
The phones also include secure video chat features that allow ethicists to participate virtually with a patient or care team if working on site is not possible. During the pandemic, “for key ethics endeavors, we experienced rich collaboration locally across institutions in our city, across state lines, and even around the globe,” Jankowski reports.
Jankowski hopes that in the future, this can continue. Ideally, bioethics professionals will be called on early to offer guidance on decision-making during disasters or public health crises.
“The profession as a whole provided incredibly important work during COVID,” Jankowski says. “It will be up to us to continue to evaluate what worked, what didn’t, and why in order to be poised to help healthcare rise to the next challenges.”
Ian Wolfe, PhD, MA, RN, CCRN, HEC-C, senior clinical ethicist at Children’s Minnesota, says ethicists were deeply involved in resource allocation policies and decisions.
“We did implement these for things like monoclonal antibodies and vaccines. Despite the many hours we put in to developing hospital resource strategies, they were rarely implemented,” he reports.
For complex ethics consults in pediatrics, it turned out virtual conversations were not realistic. “Many clinical ethics departments worked remotely. There was some ability for this, as many psychosocial and multidisciplinary rounds were all remote,” Wolfe explains.
However, for the more complex consults, it was difficult to communicate effectively over the phone. Wolfe did conduct some virtual consults with families of outpatients for non-urgent cases. Many of these consults involved complex medication decisions that affected quality of life, or parents requesting guidance in difficult decisions around a non-urgent issue. “Virtual consultation also worked well for clinic staff who requested guidance during their busy clinic hours,” Wolfe reports.
REFERENCE
1. Erler KS, Robinson EM, Bandini JI, et al. Clinical ethics consultation during the first COVID-19 pandemic surge at an academic medical center: A mixed methods analysis. HEC Forum 2022;15:1-18.