Rapid response to ethical crises may REEP’ benefits
Pilot teams in 5 hospitals test probability model
Ethical dilemmas in some respects are no different from the diseases that often foster them: There are certain patterns, certain symptoms, that the ethics consult team or ethics committee sees over and over again. But are bedside ethical dilemmas actually predictable?
Two longstanding ethics committee members think some are, in fact, rooted in the same or highly similar situations and therefore are not only probable, but preventable. This fall, the Rapid Ethics Evaluation Project (REEP) will evaluate this hypothesis with the pilot of a "rapid response" team in five hospitals in the city of Boston and in nearby Massachusetts and Connecticut suburbs.
Better care through ethics
"We see this as really preventive ethics," explains Daniel Teres, MD, a critical care physician, health services researcher, and ethics committee member at Baystate Medical Center in Springfield, MA. "We hope to ultimately improve communication between the doctors and the patient and family, clarify the patient’s preferences, and maybe even shorten the ICU stay."
The concept is for a team of three to four professionals to rapidly respond to a given situation that is deemed either a pink flag or a red flag situations or circumstances that stand out as soon-to-be or immediate sources of ethical conflict.
Team members should include an ethicist and other health care professionals who would be available for consult within 24 hours, says Christine Mitchell, PhD, staff ethicist at Children’s Hospital in Boston. The REEP team might include but would not be limited to members of the hospital’s ethics committee, Mitchell explains.
Mitchell and Teres have designed the pilot to involve an ethicist going on morning rounds and identifying pink and red flag situations. "We have seen these situations over and over again," says Teres, a staff critical care physician for more than 20 years. "They all come down to a lack of trust."
Teres and Mitchell give these examples:
• A doctor talks to the family in the emergency department to gain consent for emergency surgery. He tells one member of the family that the surgeon will call the family afterward. The surgeon is tired, goes home without calling, and another family member from out of town assumes the surgeon was not acting in his loved one’s best interest.
• Family members stop visiting their loved one for two days in a row. They don’t call on the telephone to inquire about the patient. The staff doesn’t trust that the family cares about the patient.
• A mother of a large family is in a coma. She has been unstable and in multiple organ failure for five days. One of the sons lives 3,000 miles away and has not been able to arrange his schedule to fly in to see his mother but is expected this weekend. In the meantime, the staff is concerned because he seems to have peculiar reactions to what his siblings tell him about their mother.
• A baby is born with anencephaly.
• A physician refuses to honor a health care proxy’s decision to withdraw care. He says the surrogate’s decision will not give him time to uncover why the patient did not respond to a certain treatment.
Teres and Mitchell say it’s clear that the first two situations are pink flags and the last two are red flags. The third could easily be either.
"In pink flag situations, it generally is a rule of thumb to make an extra effort early on to have clear and frequent communication with the family," Mitchell says. "Often, the situation is not what it seems."
When family members stop coming for several days, it may mean that the stress is too much or that other family issues have taken precedence. "Why must the family call the unit? In this situation, we would suggest that the nurse call the family and tell them how the patient is doing," she says.
The son who is out of town is getting information about his mother secondhand and may be feeling guilty or left out. Why not have a conference call, Mitchell suggests, so all family members can ask questions and get information about their mother’s care at the same time? Designate a primary care nurse on each shift to be in touch with family members and to initiate such a telephone conference.
See a red flag? Seek outside help
In the case of red flags, Teres and Mitchell agree that these situations call for outside intervention immediately. "When you have a patient who has been in multiple organ failure for five or six days, it is a good idea to get a set of fresh eyes to help the family understand the prognosis," Teres explains. He proposes that the REEP model may be ideal in situations where there is a persistently high risk of mortality. "At this point, it is easier to explain to the family why the patient may die," he says.
These colleagues stress that their pilot work is not scientific research but rather an attempt to determine whether a rapid, preventive approach to ethical dilemmas is possible. The team would not replace an institution’s ethics committee.
"We want to be more responsive to staff and families in the everyday throes of bedside practice and to prevent problems before they happen," Mitchell says.
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