EXECUTIVE SUMMARY
Regular rounding by ethicists builds trust with clinicians and gets issues resolved earlier. Other benefits include:
• Clinicians learn to use ethical terminology;
• Moral distress is identified and mitigated;
• Other hospital departments prioritize advance care planning and identifying patients’ preferences.
At Michigan Medicine, Janice Firn, PhD, MSW, conducts weekly “preventive ethics rounds” at the health system’s nine ICUs. For both ethicists and clinicians, it is a good chance to build relationships.
“Collaboration is fostered. It doesn’t feel like you have to wait for a huge conflict in order for the ethicist to get involved,” says Firn, a clinical ethicist at the Center for Bioethics and Social Scientists in Medicine at the University of Michigan Medical School.
Ethicists found the preventive ethics approach affected the number and nature of ethics consults. “We’ve identified patient, provider, and system risk factors that, if unaddressed, could result in the need for a formal consult,” says Firn.
All Kinds of Questions
An example would be a patient admitted to the ICU with a diagnosis of severe and persistent mental illness. This could affect autonomy and medical decision-making. “Lack of stable preferences over time could complicate the surrogate’s ability to use substituted judgment,” notes Firn.
Providers may misunderstand how mental health diagnoses affect a patient’s capacity. Additionally, patients with severe mental illness are less likely to have had an advance care planning discussion with providers. “With regular rounding, these issues can be addressed early in the admission instead,” says Firn.
Clinicians who are exposed to ongoing ethics education are able to resolve many issues on their own. “There is a very low bar for asking all kinds of questions,” says Firn. “There is also an opportunity to build a common language.”
Clinicians sometimes experienced a gut feeling something was not right, or thought an intervention was the “right” thing to do. Now, clinicians can describe this feeling using ethical language. For instance, clinicians may believe a surrogate decision-maker is choosing an option that is not in the patient’s best interest. But if the decision is consistent with the patient’s own values, the ethicist can point out that the decision is ethically permissible.
Rounding does not eliminate the need for formal consults. “But they’re happening earlier in the process. They are less contentious and more amenable to resolution,” says Firn.
Most clinicians underwent some type of ethics education as medical students. Seeing ethics applied to actual patients “is a really different thing,” says Firn. “Every time I’m up there, I’m providing education. But it’s case-based, and with teams.”
ICU clinicians voiced a recurring ethical concern, involving patients who can respond verbally and refuse or ask for treatment, but lack decision-making capacity. During ethics rounds, Firn explained why it’s ethically acceptable to provide or withdraw treatment that is consistent with the patient’s expressed wishes, goals, and values.
Although ethics rounds take just 15 to 30 minutes, a surprising amount of ground is covered. Moral distress is sometimes voiced in one way or another. “Rounds act as a way to create moral space for reflection,” says Firn.
Clinicians can debrief as an interprofessional team about emotionally challenging cases in real-time while the case is ongoing. “Unless we create little pauses, the system keeps going. But the system can’t tolerate really long pauses,” says Firn.
Some clinicians thought the ethicist’s role was to tell everyone what was ethically appropriate. They now realize that ethicists consider the viewpoints of stakeholders and identify ethically acceptable alternatives. “Not everybody will participate in a formal consult process,” says Firn. “This gives more people the opportunity to have an interaction with ethics.”
An Uninvited Guest
Weekly medical ICU (MICU) rounding is a chance to briefly teach staff and trainees about relevant ethics, palliative care, and geriatrics issues, according to the authors of a recent paper.1
“I thought of myself as an uninvited guest on the ICU team’s morning rounds. I felt that it was important for me to let them do their work, not interrupting too much,” says Elizabeth K. Vig, MD, MPH, chair of the ethics consultation service at VA Puget Sound Health Care System in Seattle.
When Vig spoke up, she made her points succinctly. “Many of the attending physicians and nurses on the unit already knew me from times when I had done palliative care consults on the unit. I think this helped them trust me,” says Vig, who was present for discussion of about 200 patients per year.
Some potential future conflicts were dealt with on rounds, so they never resulted in formal ethics consults.
“For example, if the team mentioned difficult family dynamics, I’d want to make sure that the patient had designated someone he or she trusts as surrogate decision-maker,” says Vig.
During the first two years after rounding was implemented, the number of ethics and palliative care consults from the MICU increased somewhat. In part, this was because the team was more aware of the relevant ethical issues and the potential for palliative care support.
“Ethics and palliative care are going to be on people’s radar more if someone from those disciplines is standing right there on rounds,” says Vig.
Downstream Effects
It was not surprising that individual clinicians gained ethics expertise. “What I hadn’t thought about before starting the project were the downstream effects,” says Vig.
For instance, a dietician who attended ICU rounds learned about Physician Orders for Life-Sustaining Treatment (POLST) forms. These include a section about preferences for feeding tube use.
“She began encouraging medical teams to consult patients’ POLST forms when deciding about placement of feeding tubes,” says Vig.
Additionally, because of the ethics rounding, hospital staff prioritized reviewing advance directives of newly admitted patients and identifying their legal decision-makers. “This may help prevent ethical dilemmas,” says Vig.
Including someone with ethics knowledge on rounds provides an opportunity to consider ethical issues that arise in taking care of seriously ill people. “Hopefully, this awareness remains when that person isn’t present,” says Vig.
REFERENCE
1. Vig EK. Weekly rounding with the MICU team: Description of a clinical ethics project. Am J Hosp Palliat Care 2019; 36(4):290-293.
SOURCES
• Janice Firn, PhD, MSW, Clinical Assistant Professor, Department of Learning Health Sciences/Clinical Ethicist, Center for Bioethics and Social Scientists in Medicine, University of Michigan Medical School. Phone: (734) 764-5888. Email: [email protected].
• Elizabeth K. Vig, MD, MPH, Associate Professor, Chair, Ethics Consultation Service, VA Puget Sound Health Care System, Seattle. Phone: (206) 277-4361. Email: [email protected].
Regular rounding by ethicists builds trust with clinicians and gets issues resolved earlier with a preventive ethics approach.
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