Are Are Clinical Ethics Clinical Ethics
CommitteesCommittees Effective? Effective?
Ronn HuffDirector, HCA Center for Clinical Ethics
Ethics Consultant Group, LLC
ObjectivesObjectives
1. Primary Functions of Clinical Ethics Committees (CEC)
2. Over-emphasis on case consultation3. Effectiveness of case consultations4. Ideas for improvement
Ethics Committee FunctionsEthics Committee Functions
Common ethical issuesCommon ethical issues
Withholding or withdrawing treatmentDo Not Attempt Resuscitation orders (DNAR)Identification of patient’s representativeAdvance directivesMedical futilityInformed consentDetermining decision-making capacityPalliative care issuesConflict resolutionPerinatal & neonatal issuesResearch protocol
2005 HCA survey of Clinical Ethics 2005 HCA survey of Clinical Ethics CommitteesCommittees
106 out of 185 facilities responded 50% of ethics committees meet
(regularly) four times yearly or less65% of CEC’s receive 6 or fewer
consultation requests annually ◦High % of that number report 2 or less
*37% of total CEC time spent on case consultation
Fox Fox et al (et al (2007) survey of 2007) survey of ethics consultation servicesethics consultation services
The average hospital ethics committee receives 3 requests for case consultation per year
“…the fact that many Ethics Consultation Services have a very low level of consultation activity may be cause for concern. Is there sufficient activity to develop and maintain the competencies required for the ethics consultation?”
“If we reflect on how many ethically charged conflicts occur in hospitals each year, it is clear that there is a large, unmet need among patients and their families for help in navigating these conflicts: the ethics consultation system we have in place in the U.S. is not working”
Characteristics of CEC membersCharacteristics of CEC members
Individuals performing ethics consultation
54% female, 90% white
Physicians (34%), nurses (31%), social workers (11%), chaplains (10%), administrators (9%)
Educations of CEC membersEducations of CEC members
5%: fellowship or graduate degree program in bioethics
41%: direct supervision by an experienced member of the CEC
45% learned independently
28% of hospitals have a formal process for evaluating the effectiveness of ethics consultations
Internists & Ethics ConsultationInternists & Ethics Consultation
82% of those surveyed had some prior experience with ethics consultation;
Nearly half expressed some hesitation over using ethics consultation
Physicians main complaints?1. Consults take too much time or make
the situation worse2. Consultants are unqualified
Internists & Ethics ConsultationInternists & Ethics Consultation
Recommendations?
1. Publicity(19% didn’t know consultation service was available in their hospitals)
2. Timeliness of consult
3. Adequate knowledge & training
4. Specific recommendations
What are patients/families saying?What are patients/families saying?
Ethics Consultation Service Evaluation
476-bed teaching hospital near New York City
Questionnaire to clinicians associated with 20 cases referred to ethics consultation service
Was consult deemed “very helpful,” “somewhat helpful,” or “not at all helpful”?
What are patients/families saying?What are patients/families saying?
96% of physicians considered ethics consults either “very helpful,” “somewhat helpful”
95% of nurses considered ethics consults either “very helpful,” “somewhat helpful”
65% of patient or family respondents considered deemed ethics consults either “very helpful” or “somewhat helpful
Primary patient/family complaintsPrimary patient/family complaints
Lack of involvement in decision making process
“We were not kept apprised of events.”
“I feel it (the ethics consultation) wasted precious time I could’ve spent with my dying husband”
Too little, too late?Too little, too late?
“When medical outcome was experienced as unsatisfactory, patients/families rated ethics consultation as ‘unhelpful’… whether or not the consult team supported & advocated for the patient or family’s preferred course of action.”
Difficult outcome compounded by communication gaps
Uneven playing field for patients?Uneven playing field for patients?
CEC members employed by the hospital
Case reviews are multi-party events
CEC and clinical team are colleagues
Resolutions involve ‘best practice’ stds
Consults involve dying or critically ill ptsPrimary stakeholder is often not a
participant
How physicians face ethical difficultiesHow physicians face ethical difficulties
Qualitative analysis of 310 ethically difficult situations described by physicians who encountered them in their daily practice
“The avoidance of conflict, between any parties, emerged as a goal in its own right… often taking priority over other goals.”
How physicians face ethical difficultiesHow physicians face ethical difficulties
If conflict avoidance is the goal, outside help is usually not required
“Conflict seems to be a trigger for ethics consultations, but ethics consultation
appears to be the last resort rather than as a early or primary source of help in
cases of ethical difficulty.”
ObservationsObservations
Many physicians…◦ do not feel the need for outside assistance
with ethically challenging cases◦Seek assistance as a last resort
Patients and families do not appreciate CEC involvement as much as clinicians
Ethics consultation services are often ill-defined & poorly publicized
Effective ethics consultation requires a substantial time commitment
Other ways of ‘doing’ Other ways of ‘doing’ ethicsethics
"To see what is in front of one's "To see what is in front of one's nose needs a constant struggle." nose needs a constant struggle." - George Orwell- George Orwell
The heroic fallacy modelThe heroic fallacy model
Everyday conduct is of greater moral significance than how we respond to special situations calling for extraordinary moral conduct
1. Proactive ethics consultation1. Proactive ethics consultation
Study of 99 ICU patients with 4+ days of continuous mechanical ventilation
Will proactive ethics consultation result in better communication, more decisions to appropriately forego EOL treatments, and reduced length of ICU stays?
1. Baseline group: prior to hospital’s ECS)2. Control group: ethics consultation
optional; available on request3. Proactive group: automatically triggered
ethics consultation by two ethics-trained clinicians with the patient’s care team and patient and/or family)
Care team/family checklistCare team/family checklist
1. Is there an advance directive? In chart? 2. Patient capacity? If no, is proper surrogate
identified?3. Surrogate informed of diagnosis, prognosis,
treatment options?4. MD’s anticipate major obstacles to patient
recovery?5. If patient response to treatment is poor, any
discussion held about withholding or withdrawing treatment?
6. Any unaddressed issues (patient preferences, pain management, consistent, clear communication)?
Proactive ethics consultationProactive ethics consultation
DNR Orders?32%...baseline group39%...control group61%...proactive group
For patients who died… …average LOS was 13 days shorter in the proactive group than in either of the other two groups
Proactive group also showed significantly lower use of other life-sustaining treatments
Why was this effective?Why was this effective?
Preventative; coaching model; focused on quality of clinical communication vs. trouble-shooting model
Targeted to specific patients versus generalized education
Why was this effective?Why was this effective?
Physicians and nurses “express greater conviction that patients and surrogates should be kept informed and involved in decision-making and (can) be approached without stimulating defensiveness, fear, or loss of hope…
Also, discussion of ethical issues between nurses and physicians…appeared less defensive in tone; for example, the mere mention of ethical issues no longer implied wrongdoing.”
2. Policies as Educational Tools2. Policies as Educational Tools
(DNAR policy)
The standard purpose of cardiopulmonary resuscitation (CPR) and other resuscitative measures is the prevention of sudden, unexpected death.
2. Policies as Educational Tools2. Policies as Educational Tools
Withholding/Withdrawal of Treatment policy
Patients have the right to refuse treatments, including life-sustaining treatments. Appropriate and compassionate medical care may in the judgment of the physician call for the withholding and withdrawing of certain life-prolonging treatments either inappropriate or harmful to a patient.
Withholding/Withdrawal policyWithholding/Withdrawal policy
A life-prolonging treatment is medically inappropriate when it provides no meaningful possibility of extended life or other benefit to the patient.
A life-prolonging treatment is medically harmful when the additional suffering or other harm inflicted on the patient is grossly disproportionate to any possibility of benefit.
Physicians may refuse to offer any treatment that is not medically indicated.
Withholding/Withdrawal policyWithholding/Withdrawal policy
Implanted cardiac devices: There is general consensus regarding the ethical and legal permissibility of deactivating implanted cardiac devices in terminally ill patients. These include pacemakers, implantable cardioverter-defibrillators ICD’s, and CRT devices.
Given the clinical context, all three can be considered life-sustaining treatments and may be refused by a patient or patient representative, given that ethics and law make no distinction between withholding and withdrawing treatments.
ICD clauseICD clause
However…
…research to date indicates that clinicians involved in device management generally make a distinction between deactivating a pacemaker and deactivating an ICD or CRT device.
Thus, any request to deactivate an implanted
cardiac device should precipitate a thorough discussion about the consequences and possible alternatives to device deactivation.
3. Additional Ideas3. Additional Ideas
Surrogacy identification processBedside capacity tools, protocolStaff surveys Retrospective consult reviews with staffOpen access to clinical ethics committee
meetings (food, CEU’s, outside speakers)Advance care planning training
Final observationDr. Joanne Lynn (2004)Sick to Death and Not Going to Take it Anymore (2004)
Business as Usual?Business as Usual?
“Continuity of the care plan and care team across time and sites is essential for patients who will be ill and/or disabled for the remainder of their lives. Yet physician and hospital care for those with eventually fatal chronic illness is mostly tied to episodes of acute worsening, and few professionals stay central to the care for the duration of patients’ lives…
“Severely ill patients often see an array of specialists, typically in the office or hospital, though they may also receive many supportive services at home or in nursing facilities. Their doctors are usually only dimly aware of the non-medical services of the patients’ and families’ way of life.
“Patients may be referred from one physician to another, or transferred from one setting to another, without the benefit of a common understanding of their situation or even a common medical record accessible to each provider.
“An error in diagnosing an abscess would be criticized and addressed. But shortcomings that arise from lost advance care plans (precipitating a futile or unwanted attempt at resuscitation or an unnecessary transfer from nursing home to hospital)…are rarely seen as outrageous – or even as medical errors – but are accepted as simply part of how the work gets done.”
DiscussionDiscussion
DiscussionDiscussion
For a copy of this PowerPoint presentation…[email protected]
BibliographyBibliography
Christakis NA. Attitude and Self-reported Practice Regarding Prognostication in a National Sample of Internists. Arch Intern Med. 1998;158:2389-2395.
Fox E et al. Ethics Consultation in United States hospitals: A National Survey. The American Journal of Bioethics, 7(2): 13–25, 2007.
Elliott C. Better Than Well: American Medicine Meets the American Dream, W.W. Norton & Company, New York, London; 2003.
Hurst SA et al. How physicians face ethical difficulties: a qualitative analysis. J. Med. Ethics 2005;31;7-14 doi:10.1136/jme.2003.005835
Jonsen AR et al. Clinical Ethics, 5th Edition: A Practical Approach to Ethical Decisions in Clinical Medicine, McGraw-Hill, 2002.
Lynn J. Sick to Death and Not Going to Take it Anymore: Reforming Health Care for the Last Years of Life, 2004.
O’Reilly KB. Willing but waiting: Hospital ethics committees, AMNews staff, Jan 28, 2008, amednews.com.
Schneider. CE. The Practice of Autonomy, Oxford University Press, 1998.
National Survey of U.S. Internists’ Experiences with Ethics Consultation. J Gen Intern Med 19(3): 251-258, 2004
Report of 255 Clinical Ethics Consultations and Review of the Literature, Mayo Clinic Proc., June 2007;82(6):686-691.
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