Timing of Ethics Consults Varies by Diagnosis, Language, and Ethnicity
June 1, 2024 3 minutes read
Farshid Dayyani, MD, PhD, joined the ethics committee at University of California Irvine (UCI) Medical Center in 2020. Then, the pandemic hit. “We were getting really busy at the medical center with consults, five or six a week. These were very difficult consults,” recalls Dayyani, a medical oncologist at UCI Health and professor of clinical medicine for hematology/oncology at UCI School of Medicine. The hospital is located in Orange County, CA, which has significant Hispanic and Asian populations. “The diversity made it important to look for disparities in what we are seeing with ethics consults,” says Dayyani.
Dayyani and colleagues wanted to know if patient characteristics (language, diagnosis, and race/ethnicity) affected the timing of ethics consult requests or the ethics team’s recommendations. There were limited data showing some racial and gender disparities in delays to obtaining ethics consults.1 The researchers saw the need for a more comprehensive analysis of ethics consults and reviewed charts of all patients seen by the Ethics Consult Service from 2017-2021.2 Overall, the study demonstrated some clear differences and disparities for diagnoses, ethnicity, and language barriers. Some key findings:
• Patients admitted for COVID-19 had longer median times to ethics consults (19 days) from the time of admission, compared to patients with other primary diagnoses (eight days).
• Both COVID-related illness and cancer diagnoses were associated with prolonged time from admission to ethics consult.
• The majority of consults (80%) involving cancer or COVID-related illness involved end-of-life recommendations.
In these cases, ethicists’ recommendations usually involved changing the patient’s code status to “do-not-escalate” care because it was not medically indicated or beneficial, withdrawal of life-sustaining interventions, or switching to comfort care only. “COVID has passed, but cancer has not. The implication here is to preemptively start goals-of-care discussions, before the patient is admitted with a complication from a terminal diagnosis,” says Dayyani.
Conflicts at the end of life are one possible reason for the disparities in timeframes to ethics consults, suggests Dayyani. A common scenario: For a patient with a terminal condition, the clinical team feels continued treatment would be more harmful than beneficial. One patient’s family might be receptive to the idea of a do-not-resuscitate order and hospice. Another family might demand that everything possible be done to sustain the person’s life.
“That might reflect that, culturally, there is less willingness to speak until it’s unavoidable. As a result of failed communication, the ethics consult is delayed,” says Dayyani.
If a patient is getting unwanted, inappropriate care, but waits 20 days for an ethics consult, that patient is potentially being harmed as a result of the delay, adds Dayyani.
In such cases, identifying conflict earlier could facilitate ethics consults. “An ethics consult can be requested by any member of the team — the nurse, the physician, specialists, or hospitalists. Teaching the team to recognize the conflict and escalating it quickly to an ethics consult might shorten these delays,” says Dayyani.
• Ethics recommendations did not differ based on whether the patient had decision-making capacity or not.
“That was reassuring that [individuals who perform ethics consults] are a highly objective group who are really trying to look at the best outcome for the patient from an ethical standpoint,” says Dayyani.
• Spanish-speaking patients had longer median times to ethics consults (20 days) from the time of admission than English-speaking patients (seven days).
This indicates that language barriers could result in delayed ethics consultations. Possibly, clinicians are less likely to initiate prolonged discussions with the family if there is a language barrier because of the need to bring in an interpreter. “So, you try to manage things and delay the difficult discussions, until it comes to a point where you really can’t avoid it anymore. That certainly might be an explanation for these delays,” says Dayyani.
REFERENCES
- Spielman B, Gorka C, Miller K, et al. Gender and race in the timing of requests for ethics consultations: A single-center study. J Clin Ethics 2016;27:154-162.
- Mahadevan A, Azizi A, Dastur C, et al. Characterization of patients requiring inpatient hospital ethics consults — a single center study. PLoS One 2024;19:e0296763.
Farshid Dayyani, MD, PhD, joined the ethics committee at University of California Irvine (UCI) Medical Center in 2020. Then, the pandemic hit. Dayyani and colleagues wanted to know if patient characteristics (language, diagnosis, and race/ethnicity) affected the timing of ethics consult requests or the ethics team’s recommendations. There were limited data showing some racial and gender disparities in delays to obtaining ethics consults. The researchers saw the need for a more comprehensive analysis of ethics consults.
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