By Stacey Kusterbeck
“Who requested this ethics consult?” Some physicians ask this question not out of simple curiosity, but because they plan on retaliating against a colleague. Others tell ethicists point-blank to stop interfering with patient care or flatly refuse to cooperate during a consult.
Bryanna Moore, PhD, HEC-C, is unfazed by this behavior. “My response is usually to ask to meet with that clinician one on one, during a time when they are less busy, to explore their understanding of our service and any concerns they may have. They are usually reasonable concerns,” says Moore, an assistant professor and clinical ethicist at the University of Texas Medical Branch.
If the clinician agrees to a meeting, Moore takes the opportunity to explain that ethicists are not there to punish or regulate anyone’s practice, but rather just to support everyone involved in the case. “I will ask if I can spend some time observing that physician’s team, just as an educational activity for me. Sometimes, that opens the door,” says Moore.
Clinicians’ negative views of the ethics service often are rooted in misunderstanding. “Clinicians unfamiliar with ethics consultations or ethics services can easily bring misperceptions about the process into an encounter with an ethics consultation,” says Erica K. Salter, PhD, HEC-C, associate professor and PhD program director of healthcare ethics at Saint Louis University. Here are some examples:
• Some attending physicians perceive a nurse’s request for an ethics consult as an attack on the attending’s ability to make good decisions about patient care.
In the attending’s view, the consult is an unwelcome intrusion on the process of clinical decision-making. An ethicist in this situation can begin by assuring the clinician that an ethics consult does not mean anyone necessarily has been unethical.
Clinical team members may refuse to participate in the consult or decline to be interviewed by ethicists. This prevents the ethics consultant from getting a fully informed view of the case. An ethicist can approach a resistant clinician with the goal of learning what specific experiences, beliefs, or attitudes are motivating the refusal to participate. Where appropriate, the ethicist can correct misunderstandings or answer questions. “Then, the ethicist might explain that an ethics consult will happen, whether they approve or not, and that it’s important to understand the perspective of everyone involved,” says Salter.
Ethicists can assure everyone involved that no one will take over the clinical decision-making. The ethicist might also convey that the clinician’s point of view, whatever it may be, still is a critical piece of information for the ethicist to understand. “This might help the clinician feel heard and ensure that all the relevant information is being gathered,” says Salter.
• Some clinicians do not perceive the case as involving any ethical dilemma or ethical conflict.
Clinicians with this mindset cannot see value in the ethics consult. This especially is common if bedside nurses requested the consult because they disagree with (or do not understand) the decision being made. An attending physician may have additional information about the case. “An ethics consult could still provide helpful clarification and facilitate information-sharing, even if the medical decisions themselves don’t change,” says Salter. However, it also is possible that an ethics consult will uncover options that had not been considered previously. For example, physicians may specify that an aggressive intervention will be done as a time-limited trial instead of a permanent intervention. That may help the whole team feel good about the decision, Salter explains.
• Some clinicians have unrealistic expectations about what ethicists can do.
Clinicians sometimes call ethicists looking for legal advice, to investigate an employee for misconduct, or to convince the patient’s family to do something. “They will likely be disappointed, as ethics consultations do not typically serve these purposes,” says Salter. Possibly, there are other appropriate hospital resources (such as legal counsel, risk management, or a peer review committee). If so, “ethicists should facilitate a warm, respectful handoff,” says Salter.
Some clinicians want ethicists to achieve a certain outcome. For example, clinicians might ask ethicists to “get the DNR” in cases where life-sustaining interventions seem inappropriate. In cases like that, ethicists need to explain their true role. Moore does this by explaining: “We practice active listening, clarify, validate, relay information, redirect, align interests, build rapport, and ideally help everyone figure out a way forward that promotes the patient’s interests.”
Some ethical issues stall at the administrative or systems level, making them hard to address or resolve. “This can lead to a feeling that we did a lot of talking and nothing really changed as a result of everyone’s efforts,” acknowledges Moore. For example, staffing shortages may cause clinicians to feel they are being prevented from providing safe care. “Ethicists can help manage expectations in cases like this by being transparent about institutional ‘hard stops’ such as resource constraints,” suggests Moore.
• Some clinicians assume that ethicists are there to investigate instances of “wrongdoing.”
“Some folks assume that we’re an arm of the hospital’s legal and compliance or human resources departments and that we are there to report instances of ‘wrongdoing’ in the hospital,” adds Moore.
Many clinicians are unaware of the process that ethicists use during consults. “We typically do a lot of meeting with people, listening, and synthesizing information. This work is not always visible to those who are not present during all the steps of our workup,” says Moore.
Correcting misconceptions about the work of ethics is important for many reasons. “Trainees — medical students, residents, and fellows — can inherit this perspective. A culture where open discussion of ethical issues in patient care is shut down can spread,” says Moore.
If a clinician has a negative attitude toward ethics consults, it is likely to discourage others from reaching out to ethicists. “This could lead to fewer requests for consults, even in cases where an ethics consult could be helpful,” says Salter.
To obtain clinicians’ buy-in, just being present on the unit perhaps is most important. “Education, ethics rounds, and informal discussions help ethicists to build a reputation of being available, competent, and helpful,” offers Salter.
Providing short information sessions to hospital units about what ethics can help with is another effective approach. “Leverage existing relationships to create buy-in,” advises Moore. “If there are clinicians within a unit who are OK with ethics involvement, we encourage them to ask skeptical colleagues to give us a chance.”
