By Stacey Kusterbeck
Some ethics programs are facing the possibility of full-time employees (FTEs) or protected ethics time being decreased. In extreme cases, ethics programs potentially could be eliminated altogether. At a previous hospital where Sarah J. Russe, DBe, MA, HEC-C, worked, ethicists were unable to avoid their program being cut, despite their best efforts. The ethics program had started in the 1990s and was very well-established, most recently staffed with two full-time clinical ethicists and one coordinator. Ethicists conducted more than 400 consults per year.
“In hindsight, I don’t know that there’s anything we could have done differently,” says Russe, now a clinical ethicist at Northwestern Memorial Hospital. Ethicists had close relationships with hospital leaders and communicated regularly about their work and value to patients, families, and staff. Ethicists also were very active participants in institutional quality improvement efforts, and developed metrics to show how the ethics service supported institutional goals. “Nonetheless, sometimes the financial pressures are, unfortunately, insurmountable,” says Russe.
There are ways to make healthcare ethics consultation more efficient and cost-effective, according to Jason Adam Wasserman, PhD, HEC-C, a clinical ethicist at Corewell Health William Beaumont University Hospital and founding director of the Center for Moral Values in Health and Medicine at Oakland University William Beaumont School of Medicine.
A preventive ethics focus, such as educating clinicians about best practices, is one example. “Eventually, this will yield fewer consults for less complicated issues,” predicts Wasserman. Additionally, some consultation services have successfully stratified parts of the clinical ethics consultation process. Ethicists train designated frontline staff to assist with some tasks involved in ethics consultation, such as information-gathering. These staff either have some protected time for this function or perform it as part of a service commitment within their existing role. “This frees up the full-time clinical ethics consultant to focus to a greater degree on analysis and recommendations that require greater training and expertise,” says Wasserman.
These approaches can make ethics consults somewhat more efficient. “However, most ethics consultation services are already running comparatively lean — and probably just are not good candidates for cost savings,” acknowledges Wasserman.
The underlying issue is that the effect of ethics consultation on cost savings often is indirect and difficult to measure. “The primary goal of ethics consultation is not cost savings, but more ethical practice. But this doesn’t always appear convincing in a world hyperfocused on the financial picture,” says Wasserman.
Lack of recent data showing the financial effect of ethics work makes it easier for hospital leaders to view ethics as a line item in a budget that is easy to cut. Some ethics programs have multiple FTEs. “There are less expensive ways to conduct healthcare ethics consultation,” says Mark Navin, PhD, HEC-C, professor of philosophy at Oakland University and clinical ethicist at Corewell Health. Training volunteer ethics champions can reduce costs, since the volunteers can do activities such as information-gathering and, presumably, reduce FTEs. “But I suspect that most hospitals will have to pay something if they want to receive quality healthcare ethics consultation,” says Navin.
Some ethics services are successfully using an all-volunteer model. Constance Holden, RN, MSN, is a member of the ethics consultation team and ethics committee at Boulder Community Health. “For 30 years, we have had an all-volunteer ethics consultation service,” says Holden. The service performs about five consultations per month. Ethicists mostly are retired hospital employees who have received special training. Five members of the team are retired nurses, two are retired physicians, one is an ethics professor, and one has a longstanding academic interest in ethics. “The nine members share call; come in for ICU [intensive care unit] rounds and consultations; and talk to members of the palliative care team, staff, and providers throughout the hospital,” says Holden.
Over the years, ethicists have attempted multiple times to pay staff to make up at least part of the ethics service. “But it has proven impossible for staff to free up the amount of time in a day or week that it takes to address a complex consultation,” says Holden.
Hospitals nationwide are attempting to trim their budgets in response to economic challenges, such as decreased reimbursement and inflation, reports Lindsay Semler, DNP, RN, CCRN, HEC-C, executive director of the Ethics Service and co-chair of the Ethics Committee at Brigham and Women’s Hospital.
Hospitals may cut ethicists’ FTE hours or reduce protected time for ethics work if a volunteer model is used. Ethicists may be given an increased workload without a commensurate increase in salary. For instance, an ethicist who used to cover one hospital might be asked to cover several hospitals. Hospitals may combine previously separate ethics programs and people into one systemwide ethics service.
“This would lead to a more limited ability for an ethicist to form and maintain relationships with clinicians, as well as reducing education offerings and other ethics work,” observes Semler.
If ethicists get very few consult requests, it could appear to hospital leaders as though cutting the ethics program would not have much of a negative effect. To counter this perception, Semler emphasizes that ethicists do much more than consults. Tracking all ethics work (such as informal consults done over the phone, rounding on units, and providing education) is valuable if hospital leaders challenge the need for FTEs. “You have something to point to to show that ethicists don’t just do consults — there are so many other things that we do,” says Semler.
