Make yourself relevant to clinical areas: Meet providers’ needs for ethical guidance
Don’t limit activities to ICU
As a bioethicist, is your approach too theoretical or removed from the practical issues that face clinicians? “Clinicians generally want someone who can relate to the practical nature of the ethical dilemmas facing them, patients, and families, even if the fundamental principles are conceptual,” says Katherine Wasson, PhD, MPH, director of the Bioethics & Professionalism Honors Program at Loyola University’s Neiswanger Institute for Bioethics in Maywood, IL. “Being able to translate the conceptual foundations of bioethics into practice is vital.”
If bioethicists cannot do this effectively, clinicians may view them as unhelpful or irrelevant, warns Wasson.
“The bioethicist being visible, involved, approachable, and accessible throughout the entire hospital, and all the different clinical services, is vital to making the bioethicist relevant to all clinical services,” says Marianne L. Burda, MD, PhD, a Pittsburgh, PA-based ethics consultant and educator. “All clinical areas have unmet needs for ethical guidance. Therefore, the bioethicist’s activities should not be limited to a few areas of the hospital, such as the intensive care unit [ICU] and other critical care areas.”
Bioethicists can promote greater awareness of ethics issues in all clinical areas, including subspecialties, by leading case discussions and providing informal ethics education on units, argues Burda. “Taking bioethics to the clinical area is one very effective approach,” she says. “These types of activities include participating in rounds and spending time with the different clinical areas that are not always exposed to the bioethicist on a regular basis, such as anesthesia, cardiology, and radiology.”
Clinicians often lack time to attend ethics educational activities, and there may be a lack of support from clinical and administrative leadership or insufficient staffing of formally trained bioethicists, says Burda. In some cases, there is no paid bioethicist or only one bioethicist for a large facility.
“Physicians should continue to have training in ethics in all stages of their career from medical student to attending,” says Wasson. She suggests these approaches:
• Offer to serve on a community hospital ethics committee;
• Provide ethics education for clinicians of all types;
• Ask what ethical issues clinicians have encountered in their practice and discuss ways of addressing them, such as surrogate decision makers and their choices for incompetent patients; and
• Present on ethical issues within a subspecialty at national meetings. “This is a key way to raise awareness and encourage discussion among those clinicians in the subspecialty,” says Wasson. “It denotes that the organization thinks ethics is an important area to be included and addressed.”
Build relationships
Ask clinicians who are ethics committee members and clinicians on hospital committees if they are willing to be educational contacts, suggests Burda. “The more involved the bioethicist is in different clinical areas, the more contacts they can develop,” she says. “These contacts can explain the medical aspects of cases to the bioethicist when needed.” For instance, a bioethicist’s pharmacy or oncology contacts can explain why a particular drug is not an acceptable substitute for treatment for a particular cancer.
Bioethicists working at a hospital or academic medical center can build relationships with clinical colleagues by offering ethics grand rounds and other educational sessions to various departments, says Wasson. “Classic clinical topics include informed consent, confidentiality, ethical decision-making, ethical issues at the beginning and end of life,” she says. “Bioethicists also can use contemporary topical issues such as medicine and social media or direct-to-consumer genetic testing to engage clinical groups.”
At Beth Israel Deaconess Medical Center in Boston, a monthly Ethics Case Conference open to all staff offers a forum for examining cases. “The conference has the dual aim of inviting peer discussion about how these cases were handled by our ethics consultant and learning from these cases about how we might improve the ethical aspect of care, education, and staff support for all of our clinicians,” says Wendy McHugh, RN, MS, a clinical nurse ethicist.
The conference attendees come from all disciplines, with an interactive forum led by a panel of providers involved with the case and an ethicist. “Because it is so difficult for front-line staff to leave their units to attend case conferences, our ethics support service has instituted monthly ethics rounds in 20 different locations,” reports McHugh.
During these informal rounds, an ethicist meets with staff from a particular unit to reflect on current or recent situations involving challenging ethical issues. “Rounds are designed to be interdisciplinary and to foster team collaboration in difficult situations,” says McHugh. “We have rounds in all nine of our ICUs, one of our outpatient clinics, some of our specialty wards and, on a quarterly basis, with our hospitalist group.” Recent discussions covered ways to prevent moral distress, brainstorming ways to approach difficult medical decision-making conversations, or when it may be helpful to consult the palliative care team or the legal department.
“We are also available for a one-time ethics round on any unit to discuss a challenging clinical situation or topic,” says McHugh. The hospital’s Ethics Liaison Program is a way of engaging a larger and more broadly representative group of staff in the medical center’s ethics activities, she adds. Ethics liaisons are selected by department or division chiefs, and serve renewable year-long terms.
“They are invited to a monthly meeting to discuss clinical cases, serve as a contact for the Ethics Support Service within their area, create a project that addresses an ethical issue within their department, and annually review ethics activities or needs within their clinical or administrative area,” says McHugh. “We currently have 60 liaisons. They are encouraged to attend all the ethics educational offerings in the area.”
Training and skills
Lack of understanding and poor communication between clinicians and bioethicists can result in misunderstandings about goals for patient care by all involved parties and medical errors, warns Burda. To communicate effectively with clinicians, Burda recommends taking these steps:
• Attend continuing medical education courses to learn more about the medical issues encountered in the clinical setting;
• Take advantage of grand rounds and lectures at the health care institution or other institutions to learn more about different diseases and medical problems; and
• Obtain training in medical terminology and health care.
“Likewise, clinicians should have a basic understanding of ethics terminology, principles, and concepts to enhance communication with bioethicists,” says Burda.
While bioethicists don’t necessarily have to be “fully fluent” in medical terminology, a certain level of familiarity is important to communicate with those in the medical world, says Wasson. “One element that bioethicists can contribute to clinical ethical discussions is noting when there is too much jargon being used, and asking for clarification,” she adds. “Patients and families often do not understand medical jargon, and it can impede communication on that level.”
Sources
• Marianne L. Burda, MD, PhD, Pittsburgh, PA. Phone: (724) 933-0265. E-mail: [email protected].
• Wendy McHugh, RN, MS, Clinical Nurse Ethicist, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 667-5682. E-mail: [email protected].
• Katherine Wasson, PhD, MPH, Director, Bioethics & Professionalism Honors Program, Neiswanger Institute for Bioethics, Loyola University Chicago, Maywood, IL. Phone: (708) 327-9201. E-mail: [email protected].
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