Ethics consultation is time-consuming if conducted well, involving multiple conversations and meetings with a variety of clinicians and family members.
“Without time protected for this work, consultants may be expected to make recommendations without having the opportunity to speak with all the stakeholders. Ethicists may struggle to help build understanding among the stakeholders on the recommendations,” says Jennifer K. Walter, MD, PhD, MS, director of the department of medical ethics at Children’s Hospital of Philadelphia.
Allocating protected time for ethics consultation work may result in more pediatric ethics consults.1 Walter and colleagues analyzed ethics consults at 104 children’s hospitals, finding an association between full-time equivalent hours and the number of ethics consults. “Protected time dedicated to ethics can build an institutional education program that helps empower clinicians to discuss ethical concerns before they reach a crisis state,” Walter suggests.
Ideally, ethics consultants have enough time to take a “preventive ethics” approach. “Ethicists can proactively round with clinicians and discuss ethical issues that may not be identified by the clinical team before they lead to a significant values conflict,” Walter explains.
In terms of consult requests, “the data seem to show an ‘if you build it, they will come’ effect of funding ethics work,” says Claire Horner, JD, MA, assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston.
Those with protected (and funded) time to engage in ethics consultation activities seem to consult more often. “It’s not that hospitals with low consult volumes don’t have ethical issues. More likely, consult volumes increase when there is dedicated staff to respond to cases,” explains Horner, clinical ethicist at Baylor St. Luke’s Medical Center.
The opposite also holds true. If there is no protected time for ethics, the work “becomes a kind of extracurricular activity,” Horner notes. “There is a risk that the bare minimum will be done to check the ethics box, so to speak.”
Often, it is a clinician or administrator with a full-time job who also chairs the hospital’s ethics committee. That person will have only so much extra time to dedicate to the ethics role.
“This can lead to unaddressed and unresolved ethical issues in the institution, fewer ethics educational offerings for healthcare professionals, and less time for policy evaluation and development,” Horner warns.
One of the biggest dilemmas in clinical ethics in recent years is making the financial case for ethics resources.
“The question is how to ‘justify’ the need for ethics in the context of the healthcare business model,” Horner explains.
Ethics is not a billable service. Thus, it is difficult to quantify the benefit offered to the institution. It certainly is possible ethics consultation lowers the risk of lawsuits and prevents unnecessary healthcare resource use. “But these metrics are hard to quantify for ethics,” Horner laments.
To further complicate matters, some important metrics used in healthcare do not align with the goals of ethics. For example, there are cases in which the most ethically supportable outcome is to extend length of stay. “Typically, business cases are made based on consult volume. But even that is not necessarily an indicator of value to the institution,” Horner explains.
To make a good case for investing in protected time, ethicists can engage with stakeholders (e.g., department chiefs and clinical leaders) to identify the unmet needs of healthcare providers. Testimonials from healthcare providers who have benefitted from ethics consultation demonstrate direct benefit to patient care.
“It also supports the idea that ethics involvement improves provider morale and satisfaction, potentially preventing burnout and increasing retention rates,” Horner offers.
REFERENCE
1. Weaver MS, Wichman C, Sharma S, Walter JK. Demand and supply: Association between pediatric ethics consultation volume and protected time for ethics work. AJOB Empir Bioeth 2022;Dec 27:1-8.
To make a good case for investing in protected time, ethicists can engage with department heads to identify the unmet needs of healthcare providers. Testimonials from providers who have benefitted from ethics consultation demonstrate direct benefit to patient care.
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