Quality improvement is uniquely challenging in the ethics field because of lack of time, lack of resources, and, to some extent, the nature of clinical ethics itself.
“Ethics committees are tasked with numerous roles — policy review, education, and clinical consultation. Ethicists are often given fewer resources than other consulting teams,” says Jay R. Malone, MD, PhD, HEC-C, medical director of ethics and chair of the Ethics Committee at St. Louis Children’s Hospital.
To streamline data collection, some ethicists rely on consult tracking systems. “Ethics teams should use whatever format they can apply consistently and utilize efficiently to track and review consults,” recommends Malone.
Resources for quality improvement vary widely, with many large academic medical centers having robust ethics programs with multiple full-time ethicists; in contrast, rural or community hospitals typically rely on volunteer ethicists.1 “Notably, some institutions have recently cut their entire ethics programs under post-pandemic financial pressures,” reports M. Jeanne Wirpsa, MA, BCC, HEC-C, program director for medical ethics at Northwestern Memorial Hospital. Thus, ethics programs are under increased pressure to demonstrate their value. “If clinical ethicists do not create our own outcome metrics, we risk having these imposed on us in ways that undermine the integrity of clinical ethics itself,” cautions Wirpsa.
Minimal evidence-based research on how to measure the “quality” of an ethics consult presents an additional challenge. Still another barrier is the lack of standardized tracking tools. Some electronic medical record systems can be adapted to automatically generate reports with relevant patient demographics (such as race, ethnicity, diagnosis, and illness acuity). “But even well-supported programs lack personnel and resources to invest in this level of technical sophistication,” says Wirpsa.
Many ethics programs (including Northwestern Memorial’s) instead design their own templates, relying on local expertise to generate limited statistical analysis. After a second paid clinical ethicist position was added in 2016, Northwestern Memorial’s ethics program began tracking data on every consult. Using a simple Excel format, ethicists designed a tracking sheet that captures patient name, unit, referring source by discipline, and primary/secondary ethical concerns. “We use that limited data set to provide targeted education to clinical specialty areas where we received few consults,” says Wirpsa. Recently, ethicists used the data to identify commonly held misperceptions that only certain members of the healthcare team, and certain units, could request an ethics consult. After providing some targeted education, more consult requests came in from oncology and the emergency department, and also from non-physicians.
There still is no agreed-upon, standardized way to collect data on ethics consults. “Each consult service may use different terms to categorize ethics consultation,” explains Katherine Wasson, PhD, MPH, HEC-C, professor and director of the Bioethics and Professionalism Honors Program at Loyola University Chicago. This makes it difficult, if not impossible, to compare ethics services. Some ethics services may use the term “informal consults” while another refers to “curbside consults.” There may be different criteria for what constitutes a “family meeting.” There also are different criteria for what counts as a competent ethics consult. “We need to agree on the measures used to assess consults. But it is a complex question,” says Wasson. Some ethics services use satisfaction surveys, but such data can result in misleading conclusions. The ethicist may have done an excellent job identifying the ethical issues and options and helping the parties reach an agreement. “Yet, a family member or healthcare professional may not feel ‘satisfied’ with the outcome,” says Wasson.
Some ethics services use metrics that reflect organizationwide priorities, such as reducing the length of stay. There is some evidence that ethics consults can shorten length of stay in cases of intensive care unit patients receiving non-beneficial life-sustaining treatments.2 “But such conclusions cannot necessarily be applied to all ethics consults. Ethicists are resistant to narrow our work and value to this outcome, especially because length of stay is multifactorial and can be complex,” Wasson explains. Wasson says that at a minimum, ethics services should collect these data: the type and number of consults conducted, amount of time spent, who requested the consult, who the ethicists spoke to, who attended meetings, demographic data on the patient, steps taken by the consultant, and ethical issues that were covered during the consult.
To identify the skills necessary to conduct a competent ethics consult, Wasson and colleagues developed the Assessing Clinical Ethics Skills (ACES) tool. “It is one way to establish, first, the basic level of quality, and then, to set goals for improving those skills,” says Wasson. The ACES tool is based on the national standards set by the American Society for Bioethics and Humanities. “We have around 1,000 users who have accessed our training videos. Many different ethics committees have used it to train their members,” reports Wasson. According to the tool, these tasks should be covered during ethics consults:
• explaining the purpose of an ethics consult;
• gathering the relevant medical facts;
• exploring each person’s values and the patient’s wishes;
• demonstrating empathetic
listening;
• ensuring that the ethical issues and ethically appropriate options are identified and explained.
“If I haven’t covered all of those areas, I know I’ve missed something and need to circle back,” says Wasson.
Given the uniqueness of clinical ethics work, some ethicists struggle with whether it is even a good idea to assess consults with quantitative metrics. “In doing so, we risk missing, overlooking, or ignoring those activities which are immeasurable,” argues Virginia L. Bartlett, PhD, assistant director for the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles. Instead, Bartlett and colleagues focus on qualitative assessments. Ethicists ask participants open-ended questions after consults, such as “Why did you request an ethics consult?” and “What did you find most important about the ethics consult?”
“This deep-dive quality assessment offers us an avenue of learning what practices and activities are most helpful — and what areas might need more attention,” Bartlett explains.
More than a decade ago, administrators asked Kelly Armstrong, PhD, for data on the ethics consult service. Ethicists had years of detailed case reports. “But we needed a way to translate those narratives into meaningful data, both for persons trained in ethics and for those without that background,” says Armstrong, now director of clinical and organizational ethics at Inova Health System.
Armstrong reached out to ethics services at other institutions and discovered that there was wide variation in how consults were tracked. Some hospitals used very basic approaches, and others collected detailed information. Regardless, it was unclear how any of the collected information could be translated into data that would be meaningful for hospital administrators, or that could be used for quality improvement.
Armstrong set out to create a system to allow ethics services to accomplish these important objectives and developed the Armstrong Clinical Ethics Coding System (ACECS) tool. Armstrong brought the tool to Inova Health System when she joined the staff. The ethics service, which performs more than 700 consults per year, now can compare their data with more than 100 hospitals using ACECS. The system combines multiple types of data on ethics consults, giving additional context to understand what the case was really about.
Many ethics services still only have qualitative data on consults; few can conduct a quantitative analysis of their work currently, says Stowe Locke Teti, DBEc, MA, HEC-C, a senior clinical ethicist at Inova Fairfax Medical Campus. “The field lacks a central epidemiology of ethical issues. Range of presentation, variation, frequency, and distribution are some basic questions we cannot yet answer,” says Teti. “To be a clinical service in modern medicine, clinical ethics has to be more descriptive, more accountable, and more rigorous in QA/QI.”
Armstrong and colleagues have used data collected through the ACECS tool to identify recurring ethics issues that need attention. For example, if a particular unit has a large number of conflict cases, and the average time the consults are requested is more than 30 days after the patient was admitted, this might signal a need for education on the benefits of earlier intervention by ethics. A common example is when family members disagree about the goals of care for a patient who lacks capacity. “Addressing the disagreement early in a forum such as a family meeting, rather than hope the family will eventually agree, usually results in better outcomes,” says Armstrong.
Teti saw the need to visually convey data on ethics consults and developed a data dashboard. This allows ethicists to tell at a glance if there are increases or decreases in highly differentiated case types on specific units. “It allows us to measure the effectiveness of preventative interventions,” says Teti.
Data allow ethicists to talk with specificity about their work in the same way that other hospital units do. “We need to be able to do more than consults. We need to be able to identify trends, develop insights, and measure effects,” argues Teti.
REFERENCES
- Fox E, Danis M, Tarzian AJ, Duke CC. Ethics consultation in U.S. Hospitals: A national follow-up study. Am J Bioeth 2022;22:5-18.
- Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial. JAMA 2003;290:1166-1172.
Quality improvement is uniquely challenging in the ethics field because of lack of time, lack of resources, and, to some extent, the nature of clinical ethics itself.
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