Accessing ethics resources is challenging at many hospitals and health systems. However, the situation can be especially dire in rural locations.
“We have a long-standing mission on the Duluth campus of the University of Minnesota Medical School to train future providers of medical care for rural Minnesota residents and American Indians,” says Catherine A. McCarty, PhD, MPH, MSB, HEC-C, affiliate faculty at the University of Minnesota Center for Bioethics.
McCarty and colleagues wanted to understand what ethics resources would be available to students who chose to practice in rural Minnesota.1 The researchers surveyed 74 rural physicians. Fifty-nine percent reported they could access an ethics committee. Of those ethics committees, only 43% were available 24 hours a day, seven days a week.
The physicians’ central ethics dilemmas were end-of-life care and vulnerable adult patients. Thirty-eight percent of physicians stated they would use tele-ethics if available. The authors suggested the small percentage could be due to the fact the survey was conducted before the pandemic, when tele-ethics became more common. “There is not a lot of positive things to say about COVID, but one good thing to come out of it was an increase in availability, acceptance, and coverage of tele-services,” McCarty says.
For ethics education, physicians preferred online group-learning. Ethicists can help by making consult services available through telehealth, and by providing ethics education remotely so busy clinicians can access it at any time. McCarty finds prerecorded, asynchronous modules work well for basic healthcare ethics concepts. Live educational offerings, such as webinars, work well for more complex topics because they allow for Q&As and some discussion. “Rural providers should learn if there are formal ethics consultation resources available in the healthcare organization, and to avail themselves of continuing ethics education,” McCarty advises.
Healthcare providers might be unaware of all the ethics resources available to them. “We as ethics committees need to do a better job of letting providers know about ethics services that are available and how to access them,” McCarty says.
If healthcare providers are part of larger systems, they most likely will be able to access ethics services remotely. “If they are in a small practice, they usually rely on their partners,” McCarty notes.
Some former students practice in rural or small independent practices without access to ethics services. They contact McCarty for guidance. McCarty previously met with members of the healthcare team and family members in person, but that tends to happen via videoconference or phone now.
“I joke when I am teaching that if we could get interprofessional ethics education into all health professional programs, perhaps we could put me out of a job as an ethicist — and that would be OK,” McCarty says.
Many ethical dilemmas rural healthcare providers encounter are similar to other settings, such as issues with surrogate decision-makers.
“However, what we see in terms of clinical ethics questions stemming from rural environments is that they often are far more focused on relationships between patients and providers,” says Thomas D. Harter, PhD, director of the department of bioethics and humanities at La Crosse, WI-based Gundersen Health System.
A Gunderson physician, with access to Harter as the system medical ethicist, recently asked for guidance. The physician wanted to know how to advise his Amish neighbor about a boy in the community who had a possible tumor. The Amish neighbor wanted to know if the boy’s parents would be forced to accept treatment they did not want if they brought him to the hospital.
“The medical doctor didn’t know how to answer his neighbor, so he called me to ask in the hope that I could provide some education that he could discuss with the neighbor and the family of this boy,” Harter recounts.
Harter explained to the physician that if the minor was diagnosed with a treatable cancer, the family refused the recommended medical treatment, and the child was hospitalized, there likely would be a push to seek court-ordered treatment. Therefore, Harter advised the physician to tell the family to deeply consider whether they would want to bring the child to the hospital since treatment could be sought against their wishes.
Rural providers also grapple with ethical issues related to access to resources and triage decisions. Some rural pharmacies lack access to certain medications or vaccines. Harter was involved in a discussion about possibly closing a rural dialysis facility because there was not enough staff to keep it open.
For many smaller hospitals or health systems, it is simply impractical to hire an ethicist. Ideally, a larger health system would employ dedicated clinical ethicists specifically for its smaller affiliated hospitals. “But large health systems may not want to invest in hiring an ethicist whose primary focus is rural ethics consultation,” Harter says.
Targeted education can manage ethics questions that are relatively straightforward. “But this is insufficient when rural hospitals have a dynamic case that merits having a seasoned expert ethicist to provide consultation,” Harter says.
For more complex cases, rural healthcare providers need access to an expert ethicist. “There are different models for this to happen,” Harter reports.
One example is the Rural Wisconsin Health Cooperative, which pools the resources of smaller hospitals. Meetings target areas in which expertise may be lacking at each hospital.
“Clinical ethics is one of these target areas,” Harter says.
Some of these hospitals recently entered into a contractual relationship with Gundersen, with Harter providing ethics consultation. Consults happen on site or remotely, depending on the question asked and the urgency of the situation. If the conflict is between providers, Harter likely would handle it remotely.
One such case involved a question of whether to offer a medically indicated abortion at the institution before starting chemotherapy or discharge the patient to undergo the procedure at a different facility, then readmit the patient to the other hospital for cancer treatment. Harter addressed that case remotely.
If the case involves a conflict between patient and providers, Harter usually travels to the hospital to meet with the involved parties in person. In a recent case, a family wanted to continue full treatment measures against the patient’s known wishes in their advance directive and against the providers’ medical recommendation. Harter traveled to the hospital to meet with the providers and family.
By meeting the providers at smaller hospitals face to face, ethicists can help build a trusting relationship. “This helps them to be comfortable with seeking an ethics consultation in difficult cases,” Harter says.
Harter also meets quarterly with representatives of about 20 rural acute care hospitals to provide ethics education. In turn, the representatives educate staff and members of ethics committees. In Harter’s experience, providing ethics education remotely feels too “distant.”
“By providing the education in person, I have the opportunity to develop a flourishing relationship with rural providers,” Harter says. “They remember me as a resource when the need for ethics consultation arises.”
REFERENCE
1. McCabe BS, Christensen R, McCarty C. Clinical ethics concerns of rural healthcare providers. Journal of Regional Medical Campuses 2023;6(1).
For many smaller hospitals or health systems, it is simply impractical to hire an ethicist. The Rural Wisconsin Health Cooperative pools the resources of smaller hospitals. Meetings target areas in which expertise may be lacking at each hospital, including clinical ethics.
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