EXECUTIVE SUMMARY
Clinicians sometimes wrongly assume the ethics role is to reprimand, criticize, or convince. To avoid misunderstandings, ethicists can clarify:
• whether they are leading a meeting or participating in one;
• that the root causes of poor communication should be identified;
• that they can help convey the team’s agreement that a particular treatment should not be offered.
Someone must have done something wrong.” Whether they admit it, that is the first thought some clinicians have when they catch sight of an ethicist in the department.
“Sometimes there is an assumption that when you call ethics, you couldn’t figure it out on your own, so you had to call these other people in,” says Anita J. Tarzian, PhD, RN, program coordinator of the Maryland Healthcare Ethics Committee Network in Baltimore.
Heading off such concerns, which are sometimes unspoken, is ideal. Tarzian begins consults by stating: “These days, we are working at a faster pace, and decision-making is more complex. We view ethics consults as a kind of moral timeout. We carve out space to reflect with someone who has a neutral perspective.”
Regardless of how much an institution values ethics, “ethicists are still faced with continually educating others about their role,” says Paula Goodman-Crews, MSW, LCSW, bioethics director at Kaiser Permanente San Diego, and Kaiser Permanente Southern California bioethics program director.
The following are some scenarios involving misconceptions of the ethics role:
• Clinicians sometimes call ethicists because of ongoing communication problems.
A revolving door of ethics consults for the exact same issues does everyone a disservice. “You are enabling the continuation of substandard clinical practice,” Tarzian explains.
A better approach: Address the root of the problem by helping clinicians communicate about a particular issue. “Ethics has to figure out how to be a benefit not just for that individual encounter, but at the institutional level,” says Tarzian.
For instance, a physician’s strong moral distress might be the underlying reason for an ethics consult. “The skilled ethicist will be able to discern the contributing factors and work with the team,” says Goodman-Crews.
Recently, a nurse reported that a physician had not obtained appropriate informed consent from a patient. The nurse wanted the ethicist to talk to the physician about it. “It was with good intent. But she was trying to use ethics as a buffer,” says Steven Squires, MEd, MA, PhD, vice president of mission and ethics at Cincinnati-based Mercy Health. It soon became apparent that the nurse had never spoken directly to her colleague about the concern. “Everybody tries to avoid difficult conversations. But that’s not a reason to call ethics,” says Squires.
• Clinicians ask for help with something outside the purview of ethics.
Squires finds that a “warm handoff” to the appropriate hospital department is best. A curt response, like “That’s not ethics. That’s legal,” comes off as dismissive. Instead, the ethicist can respond: “I understand how needing interpretation of how the law applies to this situation would be troubling. I wonder if our colleagues in legal could help with this?”
• A clinician wants the ethicist to get the patient or family on board with a treatment plan.
“This is a dynamic that sometimes happens, which is a misunderstanding of ethics,” says Tarzian.
Recently, a surgeon asked an ethicist to convince an elderly patient to undergo a procedure that the surgeon thought beneficial. Goodman-Crews explained that the role of the ethicist is not to convince, but to help facilitate meaningful conversation based on established ethical norms.
Some ethics consults are called because the team believes the family’s decision on treatment is harming the patient. Demands for aggressive care for a patient who is not expected to survive discharge from the ICU or regain enough neurological function to ever be conscious again are common examples. It is not necessarily a reason to involve ethics, says Tarzian. The clinical team refers to a multisociety consensus statement for guidance.1
“If the team still gets pushback, you go through the conflict resolution process,” says Tarzian.
This requires the clinical team to concur with the prognosis and appropriate treatment. This way, everyone is on the same page when it is time to communicate with the family. “A lot of time, there is lack of consensus among the team itself as to what options should be on the table and off the table,” says Tarzian.
Ethicists should not merely persuade families to do what the clinicians want. However, they should be of help in conveying that the team is in agreement that a particular treatment should not be offered. “If the team has tried their best and hasn’t succeeded, then the ethicist — who presumably has excellent communication and mediation skills — can give it a try,” says Tarzian.
• Clinicians believe the ethicist is there just to criticize.
“In reality, it’s about how to bring together the different interests that people think are important, and making them jell as much as possible,” Squires says.
Squires invites people to think of him as a member of the team. He then explains that ethics is not out to take over, but simply to offer the best ethics knowledge possible after asking the right questions and getting the right information.
Tarzian offers this explanation: “It’s not our job to tell you what to do. If it’s an issue of medicine, the medical team makes those decisions. What we are doing is facilitating a conversation to figure out what’s the right thing to do, using shared decision-making standards.”
• People are unclear if the ethicist is leading or participating.
“You have to establish the ground rules,” says Tarzian. This means clarifying whether the ethicist is being asked to lead a meeting, or simply be present as a participant.
“The question is, ‘How can I be of service to the team?’ Ethicists need to clarify what their role is,” says Tarzian. “I don’t see that happening all the time.”
• The team thinks the ethicist did a poor job because some of the involved parties are still unhappy.
“There is a perception that if everyone is not happy at the end of the consult, the ethicist hasn’t done a good job,” says Squires.
Many consults are called due to an intractable conflict that’s gone on for days or weeks. “I don’t know of anybody, irrespective of their skill, who can erase all the negative feelings that have been harbored,” says Squires. A more realistic goal is to come to a resolution that everyone can agree to.
REFERENCE
1. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015; 191(11):1318-1330.
SOURCES
• Paula Goodman-Crews, MSW, LCSW, Medical Bioethics Director, Kaiser Permanente San Diego. Email: [email protected].
• Steven J. Squires, MEd, MA, PhD, VP Mission and Ethics, Mercy Health, Cincinnati, OH. Phone: (513) 952-4786. Email: [email protected].
• Anita J. Tarzian, PhD, RN, Program Coordinator, Maryland Health Care Ethics Committee Network, Baltimore. Phone: (410) 706-1126. Email: [email protected].
Clinicians sometimes wrongly assume the ethics role is to reprimand, criticize, or convince.
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