Ethics Consults Depend on Ability to Absorb Multiple Viewpoints
July 1, 2023
Clinicians took on multiple subjective viewpoints — of the staff, of the patient, or both simultaneously — after participating in an ethics consult, according to a group of researchers.1
Investigators interviewed 48 clinicians involved in an ethics consultation. One key theme emerged: The clinicians adopted subjective viewpoints as a result of the consult — of their colleagues, the patient, or both. Clinicians reported taking on the patient’s perspective (42%), the perspective of the clinicians (31%), or both the clinician and patient perspective simultaneously (25%).
“Clinical ethicists are usually called upon only after clinicians have tried all the tools in their toolbelt, but there is still uncertainty on how to proceed,” says Katherine Wasson, PhD, MPH, professor and director of the bioethics and professionalism honors program at Loyola University Chicago.
An important role for the clinical ethicist is to clarify the values people hold that inform their decision-making. Thus, ethicists must develop skills that encourage patients, families, or surrogate decision-makers to openly express these values. These skills do not always come naturally. “Such conversations are not necessarily the type most of us have on a daily basis,” Wasson explains. “It sets out clear skills the ethicist needs to demonstrate, in order to be effective in a consult.”
To help, ethicists can use the Assessing Clinical Ethics Skills tool, which is based on the American Society for Bioethics and Humanities’ Core Competencies for Healthcare Ethics Consultation. When an ethicist receives a consult request, the next steps are to explore the range of perspectives involved, clarify what decisions need to be made, and identify related ethical issues.
“We sometimes have to do a bit of detective work,” Wasson says.
Ethicists talk to each party involved, put the pieces together, and clarify the ethically appropriate options. If the ethicists decide to move forward with a formal consult, the next step is to elicit the views of each stakeholder — the patient (or surrogate decision-maker), the family, and the healthcare providers. Wasson says ethicists do this by asking patients open-ended questions:
• What is important to you?
• What gives your life meaning and value?
• How do you enjoy spending your time?
If patients cannot speak for themselves, ethicists can ask questions of family members: Can you tell me about your loved one? What kind of person is your loved one? What would your loved one say?
“Active listening, where we ask questions and concentrate on the answers, and we listen to understand vs. respond, is vital,” Wasson says.
Ethicists also can repeat medical information about the patient’s current condition to ensure decision-makers understand. Midway through the consult, ethicists summarize the situation and repeat the different perspectives expressed by others. This allows all the participants to feel heard. Ultimately, the ethicist can identify ethically appropriate options and their rationale. “Hopefully, this leads to agreed-upon next steps,” Wasson says.
Ethicists can help clinicians understand the patient or family’s perspective in several important ways, according to Brian H. Childs, MDiv, PhD, HEC-C, professor of bioethics and professionalism and chair of the department of bioethics and medical humanities at Mercer University School of Medicine in Macon, GA:
• Round in the ICU regularly. Ethicists at Mercer round in the ICU every day, alongside clinicians and nurses. By doing this, ethicists can point out pieces of information clinicians might otherwise overlook. “We are able to learn what I call the ‘anthropological’ data,” Childs says.
Clinicians sometimes miss those important pieces of data because they are focused solely on the clinical issues. Ethicists can notice red flags that suggest there is a disconnect between patients and clinicians. “What always perks up my ears is when I hear somebody say, ‘The patient is in denial,’” Childs says. “My response is: ‘Are they in denial, or don’t they understand? These are two different things.’”
Ethicists might find out the real issue is the patient or family does not understand the prognosis. For clinicians, it can appear as though the patient is in denial about the dire situation. If the misunderstanding goes unaddressed, it can result in the patient receiving unwanted, potentially inappropriate, end-of-life care.
“The best thing in this situation is for ethicists to facilitate a goals of care discussion,” Childs offers. “Then, we can determine what the focus is going to be — is it qualitative or quantitative?”
• Listen to the patient’s story. “The main problem with a lot of ethics consults is that it’s just the professionals talking to the other professionals about the patients, rather than talking directly to the patients,” Childs observes.
Unfortunately, clinicians probably do not have enough time to hear the patient’s full story. “Behind every objection to a medical intervention, or every ‘difficult’ patient that I’ve heard being talked about, I’ve found a person who actually has an anthropology, or an aspect of what it is to be a human being, that the medical staff either doesn’t understand or doesn’t know about,” Childs says.
Ethicists can serve as a bridge between the patient and the clinical staff. In one case, two residents contacted ethicists and reported a patient clearly was out of his mind because the man refused medication despite agonizing pain. After speaking with this patient, Childs learned he was a member of the Gullah community and believed that suffering led to redemption. Childs then had to “translate” this information to the residents. He explained the patient was not crazy, but, in fact, was acting in a manner consistent with his religious beliefs. “That’s the kind of thing that an ethicist can do — to spend the time hearing the story and be the translator to the medical team,” Childs says.
Ethicists can gather information from others who know the family well. In some cases, Childs asked environmental services personnel to be part of an ethics consult. In those cases, housekeepers offered insights because they had developed a relationship with the family of an ICU patient. Ethicists also can enlist the help of chaplains.
“There are two entities in academic medical centers that, more than anybody else, have the time to get people’s stories. Those are chaplains and ethicists,” Childs notes.
• Gather all stakeholders in the same room, at the same time, to hear the same information. “That is something that I rarely see anymore,” Childs laments.
Sometimes, the patient, surrogate, and family members are not part of the ongoing dialogue about the treatment plan. “One of the problems we are facing these days is that ethicists and healthcare providers are talking about their patients, rather than to their patients. This is a critical issue,” Childs asserts.
At Childs’ previous institution, ethicists implemented a policy requiring a family meeting for any patient on a ventilator for 72 hours. Ethicists routinely found a way to gather the primary physician, bedside nurses, and family members in the same room. At first, there was some resistance to the policy, since it was challenging for busy clinicians to gather for an in-person meeting. “But then people started seeing, ‘By golly, it works.’ And in almost every case, in what appeared to be an intractable dilemma, people came to an understanding,” Childs recounts.
However, implementing such a policy requires administrative support. The family meetings reduced the time people spent in the ICU, resulting in a cost savings.
In turn, it shortened the time patients were boarded in the emergency department awaiting an available inpatient bed. “That’s not the reason to do it. But it certainly gets the attention of administrators,” Childs says.
RESOURCE
• Neiswanger Institute for Bioethics. Sample demonstration of the Assessing Clinical Ethics Skills (ACES) tool.
REFERENCE
1. Audu A, Hartsock J, Wocial L. Choosing a side: Clinician perspective taking in ethics consultations. J Clin Ethics 2023;34:40-50.
An important role for the ethicist is to clarify the values people hold that inform their decision-making. Thus, ethicists must develop skills that encourage patients, families, or surrogates to openly express these values. But these skills do not always come naturally.
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