Conflicts between family members and clinicians are known to be a frequent reason for ethics consults in the adult setting.1 However, less is known about conflict in pediatric ethics consults. Aleksandra Olszewski, MD, and colleagues analyzed pediatric ethics consults from 2008-2019.2 Perceived conflict between families and clinicians was an issue in 44% of the consults. “Given this — as well as the unique role of the ethics consultant as an outside person invited to gather perspectives, determine best actions, and support communication — clinical ethics consultation offers an opportunity for conflict mediation,” asserts Olszewski.
In a previous study, Olszewski and colleagues found greater odds of clinical ethics consults among pediatric patients who were Black, and also among patients with public or no insurance.3 “We know there are disparities in presence of conflict, communication challenges, and conflict management approaches in pediatrics,” says Olszewski, a pediatric critical care fellow at Ann & Robert H. Lurie Children’s Hospital in Chicago. The researchers wanted to know more about the factors that led to conflict in pediatric ethics consults. Clinician-family conflict was more common for these ethical dilemmas:
- informed consent/parental permission;
- assessment of benefit/harm;
- cultural considerations (such as religious reasons for disagreeing with brain death evaluations);
- limitation of life-sustaining treatment.
“Understanding that certain topics are more likely to be associated with conflict can help ethics consultants develop nuanced approaches that are topic- and context-specific,” says Olszewski. Knowing which topics are more likely to have conflict helps ethicists to do more preventive work, with targeted education for clinical teams. During ethics rounds in the ICU, ethicists can discuss cases with a focus on proactively addressing conflict. “Ethicists can offer support to clinical teams facing challenging cases, and determine preventive interventions to reduce conflict or improve its management,” suggests Olszewski.
Clinical ethics consultation is just one resource for mediating conflict, however. Clinicians often reach out to ethicists only after the conflict becomes intractable. “Thinking about what other resources are available, and what resources should be available, is a key consideration for clinicians,” asserts Olszewski. With conflict mediation training, clinicians can address some conflicts without the need for a formal ethics consult. “Institutional protocols and policies ought to be considered, given how common conflict is and how much more common it is becoming.”
Not all conflicts are ethical dilemmas. “What clinicians consider to be ethical dilemmas is quite subjective. Ethicists may be asked to consult on topics that don’t neatly fall into the ethical dilemmas we are taught,” says Olszewski.
Moral distress is a common example. The most ethical action is known, but cannot be taken, so there is no ethical question. Other known situations leading to ethics consultation include emotional triggers (such as frustration or feeling uncomfortable about a situation), or wanting help interacting with difficult patients or surrogates.4 Those cases involve conflict, but there may not be an ethical question. “I think ethics gets called when things are hard, even if there isn’t a decision to be made,” says Olszewski.
Ethicists can still offer support with those cases. However, the ethicist’s role is less clear-cut. “What is our role in conflicts that don’t have clear ethical dilemmas?” asks Olszewski. “This is an interesting discussion and debate to have amongst clinical ethicists.”
Clinicians can’t call ethicists for every single conflict. When is an ethics consult necessary? It depends on how much conflict mediation training the clinical team has, and how comfortable the clinical team is with their ability to address the conflict. “Currently, there is very little guidance on this at individual institutions or in the literature,” says Olszewski. Standardized approaches to conflict management would be very helpful, adds Olszewski.
Given the prevalence of conflict in both adult and pediatric ethics consults, the study authors recommend ethicists make continued efforts toward improving conflict mediation skills. The American Society for Bioethics and the Humanities recognizes conflict resolution skills as a core competency for healthcare clinical ethics consultations.5 Ethicists may benefit from structured conflict mediation and mitigation education, including simulation-based training. “Ethics consultants may benefit from the expertise and training from institutional experts, such as social work and security teams, or external experts,” adds Olszewski.
There is a bigger picture, as well. With a better understanding of the kind of family/clinician conflicts that are happening, institutions can identify the need for improvement. For example, clinicians may be continually frustrated with family members who are rarely at the bedside. Ethicists can help to pinpoint the underlying reason family is unable to be present.
“That might lead to improved policies about family bedside presence or improved resources to support families to do so,” says Olszewski.
By tracking the type of conflicts that come up during consults, organizationwide ethics can be supported. If ethicists recognize recurrent themes and trends, “this may help identify interventions to reduce conflict incidence and improve its management,” offers Olszewski.
- Cho HL, Grady C, Tarzian A, et al. Patient and family descriptions of ethical concerns. Am J Bioeth 2020;20:52-64.
- Olszewski AE, Zhou C, Ugale J, et al. Frequency of perceived conflict between families and clinicians at time of clinical ethics consultation in hospitalized children. AJOB Empir Bioeth 2023;Sep 27:1-6. doi: 10.1080/23294515.2023.2262958. [Online ahead of print.]
- Olszewski AE, Zhou C, Ugale J, et al. Disparities in clinical ethics consultation among hospitalized children: A case-control study. J Pediatr 2023;258:113415.
- DuVal G, Sartorius L, Clarridge B, et al. What triggers requests for ethics consultations? West J Med 2001;175:24-30.
- Tarzian AJ; ASBH Core Competencies Update Task Force 1. Health care ethics consultation: An update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ core competencies update task force. Am J Bioeth 2013;13:3-13.
