Understanding the Process of Clinical Ethics: Committees and Consults

CRAIG M. KLUGMAN

LEARNING OBJECTIVES AND OUTCOMES

Upon completion of this chapter, the reader will be able to:

Explain the three functions of an ethics committee

Describe the history of ethics committees

Explain the process of a clinical ethics consultation

Describe the history of clinical ethics consultation

Understand the knowledge, skills, and experiences necessary to be a clinical ethics consultant

Have awareness of the three forms of ethics consults

Understand the process of ethics facilitation

In most hospitals, registered nurses and other clinicians faced with ethical dilemmas or issues can request an “ethics consult.” As described in Chapter 1, these dilemmas and issues are problems where there is either a conflict of values or a question of what one ought to or ought not to do. The ethics consultant facilitates conversations and deliberations to determine what are the relevant ethical issues, what questions need to be asked, and to assist patients, families, and providers in resolving the issue. “Clinical ethics is a practical discipline that provides a structured approach for identifying, analyzing and resolving ethics issues in clinical medicine” (Jonsen, Siegler, & Winslade, 2006, p. 1).

As a registered nurse, you need to know when and how to call for an ethics consult where you are employed. You also need to understand the process of an ethics consultation and the role of ethics committee (EC) members. Finally, understanding ethical consult services and the skills necessary to conduct an ethics consult will assist you with your role in the process.

CASE SCENARIO

Mr. Ramirez is the youngest of nine children. Because of his developmental disability, at the chronological age of 32 he is at the developmental age of 8. He lives at home with his mother and his 34-year-old brother who are his primary caregivers. Mr. Ramirez has multiple health problems and now has a deep infection in the bones of his big toe that has not responded to antibiotics. His physicians have proposed amputating his toe to try to stop the infection from spreading. If the infection progresses further, it will enter his blood and long bones and kill him. Because of his inability to make choices, his mother is his legal guardian. However, she is in the hospital battling cancer and is unable to assist. His brother says that he wants nothing to do with providing care or making decisions. The majority of the siblings do not want the amputation saying that death would be preferable.

Not knowing who is the decision maker or what to do in this case, the attending physician requests an ethics consultation.

This opening Case Scenario demonstrates both a conflict of values and a question of what one ought to or ought not to do—a difference in values about amputation as well as an inability to move forward because of a lack of an identified decision maker.

Ethics consult services exist in 81% of U.S. hospitals and in 100% of hospitals with more than 400 beds (Fox, Myers, & Pearlman, 2007). However, only 8% of nurses have ever requested a consult (Gordon & Hamric, 2006). Those who conduct ethics consults have backgrounds in medicine (34%), nursing (31%), social work (11%), or chaplaincy (10%). Only 41% have formal training in ethics consultation (Fox et al., 2007).

Ethics consultation serves many purposes in a hospital. Such services increase patient satisfaction, improve employee morale, reduce costs, reduce risk of lawsuits, sustain corporate integrity, maintain the institution’s brand identity, and improve the hospital’s reputation (VA Ethics, n.d.). For nursing, ethics support services are part of professional practice, which is one aspect of the American Nurses Credentialing Center’s Magnet^® Model for excellence in nursing practice and for health care organizations seeking recognition through the Magnet program.

This chapter will examine the two main forms of clinical ethics in a hospital: ECs and ethics consultation services. After defining the history and function of each, the chapter examines the methods of ethics consultation.

Questions to Consider Before Reading On

1. Does your current place of work have an ethics consultation service?

2. Who can call for an ethics consult?

3. Only 8% of nurses have ever requested an ethics consult. What are some possible barriers to requesting an ethics consult?

4. As the nurse caring for Mr. Ramirez, which Quality and Safety Education for Nurses (QSEN) competencies (Box 5.1) are relevant to this opening Case Scenario?

Box 5.1

Process of Clinical ECs and Consults: Relevant QSEN Competencies

Acknowledge the tension that may exist between patient rights and organizational responsibility for professional, ethical care. (Attitudes)

Appreciate shared decision making with empowered patients and families even when conflicts occur. (Attitudes)

Communicate patient values, preferences, and expressed needs to other members of the health care team. (Skills)

Describe basic principles of consensus building and conflict resolution. (Knowledge)

Describe strategies to empower patients or families in all aspects of the health care process. (Knowledge)

Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. (Skills)

Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. (Skills)

Explore ethical and legal implications of patient-centered care. (Knowledge)

Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences/values; information, communication and education; involvement of families and friends. (Knowledge)

Participate in building consensus or resolving conflict in the context of patient care. (Skills)

Value continuous improvement of own communication and conflict resolution skills. (Attitudes)

Source: Cronenwett et al. (2007, pp. 123–129).

ETHICS COMMITTEES

ECs are groups composed of representatives of the disciplines and units at a hospital, which gather to address ethical problems in clinical practice. Ideally members of the committee are not involved with the cases they review. ECs often range in size from 10 to 40 people and may include physicians, nurses, social workers, lawyers, risk management specialists, and administrators. If the hospital has a trained clinical ethicist, then that person will also be a member. Some committees choose to have a community member who represents the morals and values of the community at large. In most cases, EC members are volunteers, not paid for their time or service. Historically, ECs developed as a result of case law and resource scarcity caused by technological development.

Questions to Consider Before Reading On

1. If you have an EC at your work place, who are the nurse members and other committee members?

2. How does one become a member of your ethics committee at your work place?

3. Do you have an interest in becoming a member of your EC? Why or why not?

History

Chapter 1 described the events and trends that led to the development of bioethics. Clinical ECs and consultation grew out of the same trends and interests: abuses in human subjects research, the Civil Rights movement, engagement with the public, and advances in life sciences and health care delivery technology. One such technology was kidney dialysis, a process that became available on a chronic basis with the invention of the Scribner shunt in 1960. However, with an expanded pool of eligible candidates, there was not an increase in the number of available artificial kidney machines. This begged the question as to who would get treatment—and thus live—and who would be turned away—and thus die. Swedish Hospital in Seattle convened the Admissions and Policies Committee of the Seattle Artificial Kidney Center (later known as the “God Committee”). Composed of community leaders, the committee was tasked with determining who would have access to dialysis. This group is considered the first modern EC. Similar committees formed at other hospitals as they were able to offer dialysis and soon thereafter, organ transplants.

In 1976, the New Jersey Supreme Court ruled on the case of Karen Ann Quinlan. Quinlan fell into a persistent vegetative state in 1975 after consuming alcohol and tranquilizers. A year later, her family sued the hospital, which had refused their request to remove her ventilator. In finding that there was indeed a right for the ventilator to be removed, the Court stated that the legal system was not the appropriate place for resolving ethical issues. Instead, the ruling recommended the use of ECs that had appeared in some hospitals:

I suggest that it would be more appropriate to provide a regular forum for more input and dialogue in individual situations and to allow the responsibility of these judgments to be shared. Many hospitals have established an Ethics Committee composed of physicians, social workers, attorneys, and theologians . . . which serves to review the individual circumstances of ethical dilemma and which has provided much in the way of assistance and safeguards for patients and their medical caretakers. (The Supreme Court of New Jersey, 1976)

Functions

As shown in Box 5.2, ECs can have three functions: policy, education, and consultation (Hester & Schonfeld, 2012). In many hospitals, the EC develops, reviews, and implements institutional policies that deal with ethical concerns. For example, policies that deal with surrogate decision makers or advance directives may come under the EC. More recently, policies related to treating Ebola patients and whether staff members are required to assist or volunteer have required review. ECs meet at least monthly and should be supported by upper administration in order to be integrated into hospital operations and not exist just for show. Through this work, the committee supports the institution’s mission, relations with patients, and treatment of employees.

The education role of the committee has two components: of the committee and by the committee. In the first sense, committee members need to be educated on ethics theories, issues, and methods. As stated at the outset, only 41% of committee members have formal training. It is the task of the EC chair and a clinical ethicist—if one exists—to provide continuing education opportunities. In the second sense, the members of the committee are local ethics experts for their discipline and their units. They are expected to take what they learn in the committee and spread that knowledge to their coworkers. Thus, they become a resource about hospital policies that deal with ethics and identify ethical challenges. Committee members can also help advise when a case should be referred for an ethics consult.

Box 5.2

Three Functions of the Ethics Committee

1. Policy review and development

2. Education

3. Consultation

Source: Hester and Schonfeld (2012).

The third role of the EC is ethics consultation. In most hospitals, consults are done by a small subgroup of the committee or by a few individuals. The full committee, however, should regularly review such cases for quality improvement, education, and identifying when new policies may be needed or old ones may require revision. Thus, a case log and case discussion are a part of every scheduled EC meeting. The actual process and history of ethics consultation are addressed in the next section.

Questions to Consider Before Reading On

1. Do members of your EC provide ethics education opportunities?

2. What types of ethics education do you believe are needed in your facility/unit?

ETHICS CONSULTANTS

An ethics consultant (also known as clinical ethics consultant or clinical ethicist) is an individual with specific training who works with care providers and hospital staff to identify, analyze, and recommend resolutions to ethical dilemmas and issues in the course of clinical care. An ethics consultation service is a hospital-based program that assists in addressing ethical issues.

Often, ethics consults are requested for reasons that do not relate to clinical ethics. For example, some consult calls are reporting a colleague doing wrong, aiding someone who is having problems with a supervisor or peer, or helping a patient who “just does not understand how sick she is.” None of these are ethical issues. This delineation is confusing, especially when posted signs tell people to call an “Ethics Hotline” if they see people stealing staplers, misusing resources, or treating patients badly. In some institutions, ethics services are located under the mission department and thus become connected with the idea of pastoral care. Ethics consultation is not medical or nursing review, risk management, compliance, palliative care, or pastoral care. The reason people call for an ethics consult with these concerns or questions is because there is often no clear information on how to deal with these issues or a designated department that has responsibility.

Ethics consultants are also not an “ethics police” out to catch people in wrongdoing. Ethics is about value disagreement. Consults are most often called because an uncertain situation is encountered. For example, for assistance in making a decision regarding patient care, for help interacting with a difficult patient or family, for advice on legal or administrative questions, for an “emotional trigger” in the case, or for help “thinking through an ethical issue” (DuVal, Sartorius, Clarridge, Gensler, & Danis, 2001). Consults are most often about end-of-life care (advance directives, do-not-resuscitate orders, futility, withholding or withdrawing treatment), identifying a surrogate decision maker, patient autonomy, informed consent, and conflicts between parties. Less common reasons for consults are questions of genetics, abortion, substance abuse, religious and cultural issues, professional misconduct, confidentiality, and truth-telling (DuVal et al., 2001; Fox et al., 2007; McClung, Kamer, DeLuca, & Barber, 1996).

Question to Consider Before Reading On

1. Ethics consults are most often called because an uncertain situation is encountered. Have you or a class peer or colleague experienced a situation in which a consult might have been helpful but was not initiated?

The next section examines the history of ethics consultation, the areas of core knowledge, and essential skills that a clinical ethics consultant brings to resolving a case.

History

As scholars from medicine, law, philosophy, and theology began studying the ethical issues raised by new medical technologies, they worked to incorporate this material into medical and nursing curricula. In 1972, only 17 medical schools offered ethics courses but by 1976 that number had risen to 56, although only 6 had a required course (Veatch & Sollitto, 1976). A 1977 survey found that two thirds of nursing schools integrated ethics into their teaching, but did not offer separate required or elective courses (Aroskar & Veatch, 1977). One of the reasons for the lack of stand-alone courses was the lack of nursing specific materials.

Once they were teaching in health professional education environments, these scholars found themselves interested in issues in real-world practice. Across the United States, bioethics scholars began entering the hospital and helping health care professionals to think about difficult ethical challenges. Among the early practitioners were two philosophers: Albert Jonsen at the University of California at San Francisco and Ruth Purtilo at the University of Nebraska (Aroskar & Veatch, 1977).

These new consultation services ran into early philosophical challenges. Physicians who also practiced ethics believed that only physicians could resolve these dilemmas. Nonphysicians, who included philosophers and theologians, believed that only outsiders could bring in ethical theory and neutral perspective. In 1982, a philosopher, attorney, and physician—all involved with clinical consultations—coauthored the first edition of Clinical Ethics, a book that described ethics consultation and suggested a method for thinking about these challenging cases (Tapper, 2013).

As of 1983, 4.3% of hospitals had ECs and all of those had over 200 beds (Jonsen et al., 2006). A 1983 report by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research stated that hospital ECs should be an important body in making decisions for incapacitated patients (Youngner, Jackson, Colton, Juknialis, & Smith, 1983). In 1985, the Department of Health & Human Services called for the creation of “infant care committees” to facilitate decision making in care of impaired newborns. This action was a response to a series of cases involving the deaths of newborns with severe health problems where parents refused treatment. Ultimately, this led to the Baby Doe rules and established an abuse hotline to report when newborns were not given care.

Also in 1985, a group of individuals who identified themselves as ethics consultants gathered at the National Institutes of Health. This meeting led to the formation of the first professional organization, the Society for Bioethics Consultation (now part of the American Society for Bioethics & Humanities), and defined the function of the clinical ethics consultant.

In 1992, the Joint Commissions for the Accreditation of Hospital Organizations (now The Joint Commission) released a statement that all hospitals should have a mechanism for resolving ethical issues. Today, Joint Commission accreditation has 24 standards related to ethics, patient rights, and organizational responsibilities. The American Medical Association adopted a statement in support of ethics consultation in 1997. And in 1999, Medicare regulations (64 Fed Reg 36060) required that institutions that receive federal funding had to inform patients of the availability of ethics consultation.

As a result of these events, 81% of all U.S. hospitals now offer these services.