By Stacey Kusterbeck
Is there a heated conflict on whether to continue life-sustaining interventions for a patient at the end of life? Most clinicians probably would see the need for an ethics consult. On the other hand, clinicians are less likely to recognize many “everyday” issues as ethical dilemmas.
“Failing to identify ethical issues early makes it harder to address them, running the risk of problems escalating to intractable conflict later on,” says Aimee Milliken, PhD, RN, HEC-C, a clinical ethicist and associate professor of the practice at the Boston College Connell School of Nursing.
Everyday ethics issues often came up during case discussions in the pediatric intensive care unit (ICU), recalls Elaine C. Meyer, PhD, RN, MBE, a senior attending psychologist at Boston Children’s Hospital. However, clinicians did not think about requesting an ethics consultation. In one such case, the family became very concerned about their infant daughter’s surgeries for achondroplasia after overhearing the staff questioning the efficacy of the surgery and the parental decision-making process. “This case, replete with ethical issues, generated considerable staff moral distress and parental mistrust and angst. Yet, identifying the problems as ethical in nature or seeking an ethics consult was not the course of action,” says Meyer, a member of Harvard Medical School’s Center for Bioethics.
Everyday ethics issues, such as tension between the family and clinical team, often are the root cause of an ethical conflict. “Frequently, I discover some underlying issue, that, once addressed, allows for a productive, therapeutic partnership,” says Stowe Teti, MA, HEC-C, a senior clinical ethicist at Inova Fairfax Medical Campus. Recently, Teti was consulted about a parent getting angry with a physician in the neonatal ICU. Teti discovered the precipitating factor had occurred days earlier. The parent reported the baby’s distended abdomen, but it appeared that no one took the concern seriously. It turned out to be the beginning of an infection — although successfully treated, resentment lingered. “It led to a breakdown in cordial communication,” says Teti. During the ethics consult, clinicians finally explained that confirmatory lab values were not available when the parent voiced the concern, making it impossible to treat the infection at that point in time. Not feeling heard or listened to, in Teti’s experience, “can be a recipe for outright distrust and conflict. Would you listen to someone who you feel doesn’t listen to you? What if that person wants you to make a life-or-death decision based on the information they are giving you?”
Meyer offers these questions that clinicians can ask themselves to foster basic ethical awareness:
- Do we take patient concerns, values, and wishes seriously enough?
- How do we talk and write about patients? Are we respectful, and able to consider the patient’s perspective?
- Do we uphold patients’ dignity in busy clinical settings?
- How do we respond to seemingly minor breaches of confidentiality in the hallways?
- Are patients truly informed about common procedures?
Nurses may be the only ones to pick up on the fact that a patient misunderstands the risks of a procedure. It is helpful to be able to talk in terms of the related ethical issues — autonomy, beneficence, and non-maleficence. “Ethics can be shrouded in unfamiliar language and processes, and can be experienced as intimidating by some practitioners,” says Meyer.
Clinicians may have a sense that “something isn’t right.” “However, they may not use an ethics framing to describe this problem,” says Milliken.
Meyer, Milliken, Teti, and colleagues interviewed 25 bioethicists on essential ethics skills for clinicians.1 “Expanding clinicians’ working knowledge of ethics holds tremendous promise to identify ethical issues earlier and seek consults in a more preventive, proactive manner, rather than at the eleventh hour,” says Meyer. Through a qualitative analysis of interview transcripts, researchers identified five categories of general skills that bioethicists felt were important for clinicians to have:
- awareness of core values and capacity for self-reflection;
- perspective-taking and empathic presence;
- communication and relational skills;
- demonstrating respect and upholding dignity for all persons;
- organizational know-how.
“The good news is that most practitioners have these general skills within their repertoire, that can be built upon and strengthened,” says Meyer. The bioethicists also provided these examples of how the general skills might translate into clinical practice:
- In the outpatient setting: Clinicians may need to determine how to respond to an unhoused patient arriving late for an appointment, when the clinic has a “strict” policy that after 15 minutes appointments must be rescheduled.
- In a hospital unit: Clinicians may need to respond to a family taking photographs of staff members and posting them on social media with negative comments.
The bioethicists identified these case scenarios that could be used to teach everyday clinical ethics skills:
- Clinicians not heeding patient concerns. One participant reported a case where a patient’s perforated intestine was missed because clinicians were overly focused on the patient’s history of drug use.
- Patients not being fully informed, and who had provided tacit or written consent for procedures that they did not understand or want. In one case, a parent questioned whether clinicians should be administering chemotherapy to a child prior to a bone marrow transplant for a metabolic disorder. For clinicians, it raised serious concerns on whether there was appropriate informed consent.
The authors recommend that ethicists can use the case scenarios to provide ethics education. “The ‘ingredients’ of everyday ethical practice can be presented and unpacked, in small, digestible, educational mini-modules,” says Meyer.
Ethics education could take the form of interdisciplinary ethics rounds, formal simulation exercises, informal role play scenarios, or sessions about specific topics. “In an ideal world, these education sessions would be led by a trained ethicist,” says Milliken. However, formal ethics resources are limited at most hospitals. Ethicists can address this by increasing the available pool of ethics expertise at their institutions. “This might involve formal training of several interested staff members, who can then serve as local experts within their units,” suggests Milliken.
Clinicians’ inability to handle everyday ethics issues can adversely affect patient care, according to study author Robert D. Truog, MD, director emeritus of the Center for Bioethics at Harvard Medical School. “Not all medical errors are technical. Often, patients and families leave hospitals with only vague recollections of the medical details of their care, but with unforgettable memories about their interactions with their doctors and nurses. Some leave with gratitude for the care and compassion they received. But others perceive these interactions as dismissive or even callous,” says Truog. Everyday ethics skills are necessary to avoid these types of “errors,” emphasizes Truog.
Clinicians require both general and ethics-specific skills to be proficient in addressing everyday ethics, says study author Melissa Kurtz Uveges, PhD, MAR, RN. “Given that everyday ethical issues are frequently not recognized by clinicians, clinical ethicists may not receive consultations related to such issues,” says Uveges, a clinical bioethicist and assistant professor at Boston College’s Connell School of Nursing.
For example, clinicians might not view goals of care discussions as an ethical issue, since those conversations are a routine part of care in many settings. Yet goals of care discussions involve patients’ values and preferences, which can sometimes differ from those of the clinical team. “If clinicians begin to recognize such routine interactions as ethical in nature, they can initiate a consultation to a formally trained clinical ethicist, should support be needed,” says Uveges.
REFERENCE
- Meyer EC, Lamiani G, Uveges M, et al. Everyday clinical ethics: Essential skills and educational case scenarios. HEC Forum. 2024; Jul 9. doi: 10.1007/s10730-024-09533-6. [Online ahead of print].
Is there a heated conflict on whether to continue life-sustaining interventions for a patient at the end of life? Most clinicians probably would see the need for an ethics consult. On the other hand, clinicians are less likely to recognize many “everyday” issues as ethical dilemmas.
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