Generally, clinicians are more comfortable asking for ethics consults than in years past. “There are still some services that aren’t, who have never used the services of ethics consultants,” says Wayne Shelton, PhD, MSW, professor of medicine and bioethics at Albany Medical College’s Alden March Bioethics Institute.
Obtaining ethics consultations is no different than other consultation services — with one exception. “It’s important for non-physician team members, particularly nurses and social workers, to be able to call ethicists to discuss their concerns as a preliminary step to see if a full consolation is needed,” Shelton explains.
If nurses or social workers request an ethics consult, the attending physician might become defensive or angry if they have not been informed first. “It’s possible for the ethics consult to be viewed as an outsider in a clinical situation. Physicians may not want to have one more person to deal with in an already stressful situation,” Shelton offers.
Some physicians react negatively to answering questions from an ethicist about the care plan they are providing. The problem is compounded by the fact many people who perform ethics consults are not trained as clinicians. Many are from fields like philosophy and law. Shelton says the best way to counter this is for ethicists to be visible in the clinical setting, show they are “clinically savvy,” and are not there to impose standards of right and wrong.
Ethicists can visibly demonstrate their true role: To help assess complicated situations and create a consensus on how to move forward in the most ethical and beneficial way possible.
“Ethicists who work in hospitals need to be a bit entrepreneurial,” Shelton suggests.
Ethicists can contact department chairs and clinical leadership to express interest in participating in grand rounds or educational forums. Contact nursing leaders to offer in-service training sessions on frequently encountered ethical issues (e.g., how to identify the correct surrogate decision-maker).
Elsewhere, ethicists can join hospital committees to learn more about ethical issues clinicians are encountering. The idea is to gain the support of individual clinicians, the medical staff, and hospital leaders. “With institutional backing from leaders, you can go in with authority. That way, physicians know that you have a right to be there, and over time they become accepted,” Shelton explains.
Typically, ethics consults are requested at times of conflict. “There may be fear of professional scrutiny and being judged negatively for the clinical decisions being made, also raising the specter of medical/legal concern,” says David A. Fleming, MD, MA, MACP, a senior scholar at the MU Center for Health Ethics at University of Missouri School of Medicine.
Conducting a formal ethics consult also presents considerable logistical challenges. “This is especially true when there is an expectation that ‘everyone’ be present to participate in a discussion about goals of care,” Fleming notes.
Ideally, as many stakeholders as possible participate — the patient, family, consultants, and the clinical team. Still, ethicists may need to be flexible and come up with alternatives.
“The logistics of contacting and convening all stakeholders in a timely way and secured space can be very challenging,” Fleming says. Before the situation reaches that point, an early conversation can determine if a formal consult is not needed after all. “Being immediately available for ‘curbside’ discussions, electronically or in person, may thwart greater conflict,” Fleming says.
Ethics has “sort of a PR problem. Health providers don’t always know what we do,” says Aliza Narva, JD, MSN, RN, HEC-C, director of ethics and chair of the ethics committee and ethics consult service at the Hospital of the University of Pennsylvania.
Clinicians are wary of accusations ranging from conflicts of interest to impairment.
“These would be HR problems now. This is an old-fashioned misperception about what ethics does, not a reflection of what we do [today],” Narva stresses.
For ethicists, the challenge is how to convey their actual role: To support the entire team in resolving value-laden conflicts. “What we really end up doing a lot of the time is making sure everyone’s on the same page and operating from the same set of facts,” Narva says. Ethicists find themselves dispelling outdated perceptions. Some people wrongfully believe they need permission to request a consult. “We get the message out any way we can — that ethics is a resource for everyone, and that it’s a supportive resource,” Narva says.
More staff turnover in healthcare has made this harder. “People come in with a very varied understanding of what ethics is,” Narva says.
Although it is possible for clinicians to request consults electronically, ethicists discourage it. “We really like for people to call us, because a lot of the initial information is more easily gathered in a phone call than an automated request,” Narva says. It can become apparent the troubled caller really just needs some guidance in managing a challenging conversation. Sometimes, nurses or social workers are uncomfortable with clinical decision-making and appreciate some coaching on how to bring it up. To field all requests, ethicists take turns covering off-shifts to field incoming calls 24 hours a day, seven days a week. Four ethics consultants sign in to cover the service one week at a time. There are some occasional calls on nights or weekends that turn out to be not urgent.
Other times, the problem involves choosing an appropriate surrogate decision-maker when a patient lacks decision-making capacity, but is stable. Ethicists still respond professionally. “We remember that this is going to impact this person’s willingness to call ethics in the future, when they maybe have a more serious issue,” Narva says.
Ethicists can contact department chairs and clinical leadership to express interest in participating in grand rounds or educational forums. Contact nursing leaders to offer in-service training sessions on frequently encountered ethical issues. Join hospital committees to learn more about ethical issues clinicians are encountering. The idea is to gain the support of individual clinicians, the medical staff, and hospital leaders.
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