By Stacey Kusterbeck
Unlike clinical areas, which are required to track a large number of healthcare quality measures, many ethics programs have little data to demonstrate their effectiveness. One reason is that assessing an ethics consult is not as straightforward as tracking the rate of hospital-acquired infections or surgical complications.
For ethics services, the most common measure of “success” is the number of consults done on a monthly or annual basis. “A larger number or an upward trend suggests that awareness of the ethics consult service as a valuable resource is growing, and that ethics consultants are increasingly welcome as participants in the process of making difficult decisions,” says Robert S. Olick, JD, PhD, associate professor emeritus at SUNY Upstate Medical University’s Center for Bioethics and Humanities.
The number of chart notes made by ethicists also is useful information. “This gauges the institutional presence of an ethics consultation service,” Olick explains. Even informal consults are documented, so the consult service has a record of its activities. A small number of consults, a downward trend, or fewer cases with chart notes from ethicists suggests a lesser institutional presence. “The number and frequency of ethics consults is a handy measure of success. But it is also only a rough measure,” says Olick.
Those numbers are driven by the hospital’s patient mix and range of services. For instance, more end-of-life cases result in more ethics consults. More consults are not always better. “The numbers of consults may also reflect the effectiveness of institutional education about ethical issues — some of which may be provided by an ethics committee, but also is often part of residency training,” notes Olick. Thus, fewer requests for consults could be a good sign — that clinicians are capably addressing ethical dilemmas without assistance.
Unlike clinical areas, there is little oversight of ethics consultants from a regulatory standpoint. “Different societies are trying to put some parameters around what makes a good ethics consultant, and what a consult should look like. Other than that, it’s really just up to the consultant to do a ‘good’ job,” says Katherine Fischkoff, MD, MPA, FACS, an associate professor of surgery and critical care at Columbia University Medical Center. The hospital’s five full-time ethicists prioritize consistency. Although every consult has a unique set of facts, necessitating personalized recommendations, “there are basic frameworks that we can use to apply to every patient,” says Fischkoff.
Columbia’s ethicists created a database to obtain data on consults. Ethicists document who requested the consult, the general theme, recommendations, and the outcome. “At the moment, there are really no criteria on what makes a good ethics consult note. There are people who are trying to think about that, but, for now, there is no actual standard,” observes Fischkoff.
At Columbia, ethicists’ notes serve to document the ethicist’s thought process. The notes also are used for educational purposes, since the notes describe how the complex issues in the case were addressed. Clinicians can review the notes and learn how to manage similar cases in the future.
For example, in a case involving a conflict between clinicians and a family member over whether to withdraw life-sustaining interventions, the ethicist’s recommendation may be to inform clinicians that state law prevents them from withholding or withdrawing treatment over the objections of the family member. Ethicists clarify those requirements to the clinical team. Ethicists also recommend that clinicians focus on the patient’s comfort, continue communicating with the family, and involve palliative care. All that gets documented in the medical record. Since the clinical team changes every week or month, the new team reviews the ethicist’s notes to pick up where the previous team left off.
“Our experience is that people find that really valuable. They really like the notes,” says Fischkoff.
On a weekly basis, ethicists meet to review all of the consults that were entered into the database. This allows ethicists to identify recurring themes. It also ensures that cases are being handled consistently.
“As we got bigger, we realized there was a need for a formalized method for quality assurance. We look at each other’s work, to ensure that our approaches are aligned in these cases,” says Fischkoff.
For additional oversight, consultants report monthly to the ethics committee’s 20 members. Identifying recurring issues coming up in consults allows ethicists to create targeted educational programs for residents and fellows. Recently, ethicists saw multiple consults involving clinicians who wanted to know if providing amputation over a patient’s objection was ethically justifiable. In response, ethicists put together an educational program for vascular surgeons on this topic.
Ethicists still want clinicians to request consults in those cases. “It’s not that we think that surgeons should make the decision alone, but it’s clearly something that comes up. With education, they have a framework in their minds for how to think about it,” says Fischkoff.
Trainees who go to other hospitals can bring ethics expertise with them. “If one of our vascular surgery fellows gets a job in a smaller hospital, who knows what resources they will have?” says Fischkoff.
Similarly, ethicists saw multiple cases involving requests for dialysis at the end of life. In response, ethicists brought together a group of nephrologists and intensivists to provide education on these complex cases. “Ethicists have offered education on moral distress and burnout after seeing these issues come up multiple times during consults,” adds Fischkoff.
