Improve dynamics of ethics consult meetings
Consider who called for the meeting
Take a critical look at the dynamics of the ethics consult meeting in a debriefing, as a way to improve the process, an expert suggests.
"If the meetings goal is to have all voices heard, then who felt heard and who didn't feel heard?" says Jacqueline J. Glover, PhD, an associate professor of pediatrics at the Center for Bioethics and Humanities at the University of Colorado in Aurora. Glover was member of the core competencies committee/revision committee and task force that developed an education guide for the American Society of Bioethics + Humanities (ASBH) in Glenview, IL.
Ask these questions:
- Whose voice was shut down?
- How did the process work?
- Where are the glitches in the road?
- Did the family feel supported?
How an ethics consult meeting is called makes a difference in how the actual meeting is perceived. "It's not enough to say that anyone can call an ethics consult," Glover says. "You need to consider how that will play out in response."
For example, if a nurse asked for an ethics consult without first letting the attending physician know about the issue or request, then it can create conflict, Glover notes. "If an attending physician receives a call from the ethics committing saying an ethics consult has been called, then it's hard to have that conversation with the physician," she explains.
This type of situation can cause some triangulation in which the physician is defensive about the meeting, she adds. "It's better if the nurse goes to the attending and explains why she thinks an ethics consult would be helpful," Glover says. "If she needs back-up support, then she should go to the charge nurse and work through the channels."
This team approach is less likely to create a confrontational environment in which the attending physician is blindsided by an unexpected call from an ethics consultant, she adds.
Another way to improve the dynamics of an ethics consultation meeting is to structure the meeting around answering the question the ethics consult caller actually asked, rather than answering any perceived expectations. For example, if an ethics consult meeting is called to discuss a specific do-not-resuscitate (DNR) resolution, then the expectations between meeting attendees might be widely divergent, Glover says.
One person might discuss the issue of medical futility when all the person who called the meeting wants is a specific resolution to the case at hand, saying they wanted an answer, not a conversation, she adds. "That's why it's important in the process to somehow clarify why they wanted to call for the consult and to think about what you're doing with the meeting," Glover says. "You can walk into a hornet's nest if you're not attuned to these dynamics."
Also, be aware of the goals of an ethics consult. Each organization can develop its own goals, but a good starting point might be the goals outlined by ASBH in its publication titled "Improving Competencies in Clinical Ethics Consultation: An Education Guide." (See resources, below.) The education guide includes these goals:
- Help the different parties understand the ethical problem, relevant concepts and facts, alternative courses of action, and likely consequences.
- Help the different parties communicate more effectively.
- Help the different parties evaluate moral reasons for different alternatives.
- Help the parties achieve agreement on a course of action.
What was private between a family and doctor or nurse is now public discourse, and what was once private is now more open, transparent, and public, Glover says. "This has great potential to advance our conversation to be more patient-centered and family-centered in the way that we care for patients every day," she says.
Thus, the ethics consultation meeting should reflect this patient-centered and family-centered approach through a reflective process that improves the meeting dynamics, she adds. "Shine a light on your processes, looking at gaps in expectations about why you do what you do," Glover says. "Look at the culture of your institution because the culture of the ethics consult will reflect the culture of your institution, and look at the power dynamics."
Resource
- "Improving Competencies in Clinical Ethics Consultation: An Education Guide" is available for ordering on the web site of the American Society of Bioethics + Humanities at http://www.asbh.org/uploads/files/pubs/EdGuideOrder.pdf. It costs $15 plus $8.75 for shipping and handling.
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