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…huff@ethicsconsultantgroup.com

BibliographyBibliography

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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.

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