EXECUTIVE SUMMARY
Ethics consultation requests and case complexity are increasing significantly, ethicists report. Some responses to meet surging demand include the following:
• acknowledging the increasing demands on ethicists;
• sharing recurrent themes with leadership;
• establishing weekly unit-based rounds.
At the same time ethics consultation services are seeing a surge in demand, cases are increasing in complexity.
“There has been a real growth in ethics consult numbers. We are not the only system experiencing this,” reports Ryan R. Nash, MD, MA, FACP, FAAHPM, director of the division of bioethics at the Ohio State University College of Medicine in Columbus.
“There is a desire to have someone who is a bit removed, and not part of the other services, who can just focus on the ethics question and not something else,” says Nash.
At Milton S. Hershey Medical Center in Hershey, PA, there has been an increase in demand every year since the clinical ethics consultation service was established in 2005. Currently, the 550-bed Level I trauma center performs about 65 consults a year. “The peer-reviewed literature supports this anecdote of increasing demand,” says Rebecca Volpe, PhD, director of the clinical ethics consultation service. One 500-bed facility reported an increase in ethics consultation requests from 19 in 1990 to 551 in 2013.1
To manage demand, Milton S. Hershey’s ethics service is continuing to build a strong cohort of consultants. “We inevitably get consults that are borderline ethics,” notes Volpe. If a request is really about a legal concern, ethicists explain, “We’re not the right resource for you. It sounds like you are calling mostly with a question about legal risk. If that’s the case, we suggest calling risk management at this number.”
This helps ethicists manage their workload. “Also, as ethicists we have a specific skill set and we ought not to be practicing outside our scope,” says Volpe.
Historically, ethics consultation services were used less frequently after palliative medicine programs were implemented. “But now growth in ethics demand is happening even in systems with thriving palliative care programs,” says Nash.
As systems grow their clinical ethics services, utilization and case complexity increase. “The degree of difficulty of the consultations is higher,” says Nash. Clinicians sometimes need help identifying the appropriate decision-maker, or resolving conflicts with medical mediation work.
“Clinical bioethics services can do a great deal of good in preventing things from escalating,” says Nash.
Ethics resources vary widely. Organizations may use full committees, subcommittees, independent consultation models, or small teams of several ethicists. “Being nimble is the key to being helpful,” says Nash.
Some systems use nonphysician ethicists, others use only physician ethicists, and some use both. “I think all three models can be successful,” says Nash. Large systems seeing more than 500 consults a year may have four or five full-time ethicists on staff, while others have just one or two. Some work with a strictly volunteer staff. “But if you are getting consults daily, it will make you lose volunteers quickly,” says Nash. “When you have 300 or more consults a year, a volunteer group is not going to work.”
Even if there are several dozen consults a year, volunteer ethicists will feel the strain. “You grow only when there is buy-in, and not just philosophical buy-in, but a commitment of funding and time,” says Nash.
Of Milton S. Hershey’s seven-member ethics consult service, four members take primary call, and three serve as backup. Each person who takes call receives a portion of the .5 full-time equivalents (FTEs) allotted to the service. This covers a small percentage of their salary. “In this way, we demonstrate to both the individual taking call and their division chief that clinical ethics is an activity that is valuable and valued,” says Volpe.
Each of the ethicists is a full-time faculty member with research, teaching, and clinical care obligations. “When the ethics pager goes off, we are without exception in the middle of something else,” says Volpe. Ethicists may be working on a lecture, a research proposal, or facilitating a small group of medical students.
Some institutions use a full-time clinical ethicist model. A single individual takes all calls and does little else in terms of teaching or research. “While I do see the advantages of this system, for me the interplay between teaching, research, and clinical ethics is one of the biggest advantages — and joys — of my job,” says Volpe. The following are some examples:
• clinical cases encountered during ethics consults are used for small group teaching;
• experience in teaching complex ethics topics to students improves ethics consultants’ communication skills;
• research skills improve with exposure to frontline educational and clinical realities.
“Having committed individuals who receive some kind of acknowledgement — for us, in the form of FTE — for their work is important for retaining good people,” says Volpe.
An increasingly pluralistic society is likely a contributing factor to ethics demand. “If you see culture wars among society, there’s going to be culture wars at the bedside,” says Nash. Sometimes cases are so difficult that a subspecialist is needed who has experienced the scenario previously, or is familiar with the relevant literature. “All health professions should have some competence in communication. But they may have gaps and may need assistance,” says Nash.
In Volpe’s experience, institutions without palliative care or psychiatric consult services see higher numbers of ethics consultations. “Our psychiatry consult service performs the vast majority of capacity evaluations that are necessary for patient care,” says Volpe. The hospital also has a strong palliative care service, which conducts most consults involving end-of-life goals of care.
“If neither of these services existed — or they were weak — ethics would be conducting many more consults each year,” says Volpe. “Capacity evaluations and goals of care discussions would likely be under our purview.”
Another institution-specific variable is the degree of investment in ethics. “When institutional culture or leadership does not overtly support ethics, it can be difficult for an ethics consult service to see sustained growth,” says Volpe.
With care becoming more complex, a team approach is used for patient care. As a result, says Volpe, “Institutions as well as individual providers are taking an increasingly inclusive view of services such as clinical ethics.”
For some ethicists, a surge in demand for ethics mirrors the surrounding culture. “In the same way in which our society is struggling with ‘What is the right thing to do?’ we see that same struggle blossoming in the hospital,” says Martha Jurchak, PhD, RN, executive director of the ethics service at Brigham and Women’s Hospital in Boston.
Jurchak says that previously held societal agreements on morality have been “shredded.” “The previous standard of some objective truth is replaced by ‘the truth is what I say it is,’” she explains. “I find we struggle with how to do clinical ethics consultation in a post-moral world.”
Meeting surging demand for ethics consultations, says Volpe, “is no small feat, even for services such as ours that enjoy strong institutional support.”
At the end of an ethics rounds discussion or consultation of a particularly difficult case, Jurchak often says, “OK, this is a really emotionally draining case. An important part of the work is how you take care of yourself after you leave here. You need to pay attention to this to be able to continue to do this hard work.”
Keeping hospital leaders informed on ethics consultation volume also is important. Ethicists at Brigham and Women’s report this information at quarterly meetings with the chief nursing officer and chief medical officer. They make a point of including some compelling stories along with their data. “It’s important that there be some narratives to help the numbers come alive,” says Jurchak.
Establishing proactive interventions, such as weekly unit-based rounds, can help. Jurchak often begins by saying “Who are the patients on the unit this week that you are worried about?”
Talking about an “ethics worry” builds moral community in the organization. “Everyone is sensitive to the ethical aspects of their work, and feels the moral agency to address them,” says Jurchak.
REFERENCE
1. Gorka C, Craig CM, Spielman BJ. Growing an ethics consultation service: A longitudinal study examining two decades of practice. AJOB Empir Bioeth 2017; 8(2):116-127.
SOURCES
• Martha Jurchak, PhD, RN, Executive Director, Ethics Service, Brigham and Women’s Hospital, Boston. Phone: (617) 983-7842. Email: [email protected].
• Ryan R. Nash, MD, MA, FACP, FAAHPM, Director, The Center for Bioethics and Division of Bioethics, The Ohio State University College of Medicine, Columbus. Phone: (614) 366-8405. Email: [email protected].
• Rebecca Volpe, PhD, Director, Clinical Ethics Consultation Service, Milton S. Hershey Medical Center, Hershey, PA. Phone: (717) 531-8778. Email: [email protected].
At the same time ethics consultation services are seeing a surge in demand, cases are increasing in complexity.
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