HEC Forum DOI 10.1007/s10730-015-9273-9

Preventive Ethics Through Expanding Education Anita Ho • Lisa Mei-Hwa MacDonald • David Unger

Ó Springer Science+Business Media Dordrecht 2015

Abstract Healthcare institutions have been making increasing efforts to standardize consultation methodology and to accredit both bioethics training programs and the consultants accordingly. The focus has traditionally been on the ethics consultation as the relevant unit of ethics intervention. Outcome measures are studied in relation to consultations, and the hidden assumption is that consultations are the preferred or best way to address day-to-day ethical dilemmas. Reflecting on the data from an internal quality improvement survey and the literature, we argue that having general ethics education as a key function of ethics services may be more important in meeting the contemporaneous needs of acute care settings. An expanded and varied ethics education, with attention to the time constraints of healthcare workers’ schedules, was a key recommendation brought forward by survey respondents. Promoting ethical reflection and creating a culture of ethics may serve to prevent ethical dilemmas or mitigate their effects. Keywords Ethics consultation  Ethics education  Communication  Preventive ethics  Capacity building  Accreditation Advancing technologies, multidisciplinary care, and evolving financing models have intensified the complexities of healthcare delivery. Many healthcare organizations are increasingly relying on individual ethics consultants and ethics A. Ho (&) Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore e-mail: [email protected] A. Ho  L. M.-H. MacDonald W. Maurice Young Centre for Applied Ethics, University of British Columbia, 237-6356 Agricultural Road, Vancouver, BC V6T 1Z2, Canada A. Ho  D. Unger Providence Health Care, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada

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committees to provide guidance on challenging cases. Recognizing the centrality of ethical behavior for healthcare organizations, The Joint Commission in the United States requires hospitals to have and use a process to address ethical issues or issues prone to conflict (The Joint Commission 2011). In Canada, accreditation guidelines similarly require healthcare organizations to establish ethics programs, tools, or formal processes that can guide staff in ethical decision making (Robblee 2004). Many hospitals now have ethics consultation services, with consultants or committees playing an active role in helping to promote high quality personcentered care. While only 18 % of Canadian hospitals had clinical ethics committees in 1984, this percentage increased to 85 % in 2008 (Gaudine et al. 2010). This is all to the good. However, there are as yet no national or international authoritative standards for assessing the qualifications of bioethicists—those who are distinguished as being uniquely capable of providing ethics guidance on challenging issues. A large survey of ethics consultations in US hospitals in 2007 showed various consultation practices (Fox et al. 2007). The authors put this forward as a compelling reason to standardize consultation methodology and to accredit both bioethics training programs and the consultants accordingly. Echoing such concerns, the American Society for Bioethics and Humanities appointed a Task Force on Standards for Bioethics Consultation to explore these issues (ASBH 2010). We agree that having qualified consultants and ethics committee members is important, and we applaud various efforts to determine and promote the requisite skills and training for ethics personnel. But recent findings in the literature on evaluating the outcomes of ethics consultations compel us to ask whether ethics consultation is the most important element in shaping and improving ethical standards across an organization, or helping staff members deal with day-to-day ethical dilemmas. These questions arose when we conducted a quality improvement survey in 2013. Our multi-site organization in Vancouver, Canada operates 16 sites, including acute care, residential care, rehabilitation, hospice, community dialysis, and addictions facilities. We set out to determine the perceptions of clinicians and administrative staff on the current state of ethics services and the ethical climate of the organization. We asked multidisciplinary health care providers and administrators what ethical dilemmas they most commonly experienced, their preferred resolutions for such ethical dilemmas, their perceptions and experiences with our service, as well as their recommendations for areas of focus, future development, and improvement. One hundred and eighty-three administrators and clinicians responded to the invitation to take part in the survey. Administrators constituted 28 % of the respondents. Other respondents included nurses (22 %), physicians (20 %), and allied health professionals (20 %). The remaining respondents were comprised of secretarial/administrative staff and nurse educators. The most represented service area was administration (32 %), followed by psychiatry ward/mental health (14 %), medical ward (13 %), outpatient clinics (9 %), residential care (7 %), surgical ward (7 %), diagnostic imaging (6 %), emergency room (5 %), and critical care (4 %).

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We were struck by the fact that, while 85 % of all respondents have accessed ethics consultation, only 38 % of respondents indicated that an ethics consultation was their preferred means by which to resolve an ethical issue. Fully 59 % of respondents preferred reaching out to someone else: consulting a colleague in their department (42 %), discussing the issue with their supervisor/manager (10 %), discussing with colleagues in another department (3 %), or consulting resources outside the organization (4 %). A further 3 % simply tried managing the issue on their own first. In other words, 62 % of respondents would not opt for ethics consultation as their first method in resolving the issue. There is some variability regarding preferences among disciplines. While 54 % of nurses preferred to utilize an ethics consultation to resolve an ethical dilemma, only 28 % of physicians indicated such preference. Physicians (53 %) showed the strongest preference to consult with a colleague in their own department, followed by allied health professionals (41 %) and nurses (35 %). This is despite the fact that 79 % of all respondents rated the competency of the ethics consultants as ‘‘very high’’ or ‘‘rather high’’, and that 74 % of respondents indicated that having well-trained ethicists was a recognized strength of the ethics service. The bioethics literature also shows the inadequacy of relying primarily on ethics consultative services in promoting ethical reflection and decision making. Almost 30 years ago, when ethics consultation was still in its infancy, Puma et al. (1988) began collecting data and prospectively evaluating ethics consultations. They concluded that consultations were valued and considered ‘‘very important’’ in resolving and clarifying issues. However, looking into the future, one of their questions was the effectiveness of such consults. Given that physicians tended historically to resolve conflicts via informal discussion with colleagues, would ethics consultative services ever prove superior to those methods? In subsequent decades, additional empirical data have brought us closer to some answers. Dowdy et al. (1998) found that clinical ethics consultations decreased the length of stay but not costs in the intensive care unit (ICU). Schneiderman et al. (2003) performed a randomized controlled trial looking at outcomes of using ethics consultation as an intervention when ethical issues arose in an acute care setting. They found reduction in length of stay in the ICU and in the hospital, and concluded that ethics consultations were helpful in addressing treatment conflicts once they arose. But more recent analysis regarding the utility of ethics consultations is less sanguine. Andereck et al. (2014) looked at preventive ethics consults in the ICU (before ethical conflicts arose) and found no improvement in length of stay and costs. They speculated that constant attention from the ethics team—which may be helpful to the general operation of the unit—diluted the effect of the formal consults when they at last occurred. Indeed, in the Dowdy et al. (1998) study, the authors noted the significance of the non-financial aspects of the ethics consultations. Having the ethics consultants available as ‘‘sounding boards’’ had a major impact on overcoming ethical hurdles that cannot be simply reduced to cost reduction related to shorter hospital stays. Consultants’ presence improved communication between team members and patients/families, especially around withholding and withdrawing treatments. It also ‘‘normalized’’ various ethical concepts (e.g., goals of care and the burdens and benefits of treatments) in ongoing care. In a follow-up analysis of

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their 2003 study, Schneiderman et al. (2006) posited that dissatisfaction with ethics consultation processes usually stemmed from the lack of follow up. Fiester (2007, 2014) questions the effectiveness of ethics consultative services in situations when the consultation is viewed as a (brief) intervention with a conclusion and final recommendations. She argues for an ethics intervention in the form of a prolonged mediation or facilitation. We conclude from analyzing these studies that when crisis arises, a wellorganized ethics consultation is often helpful in accomplishing its objectives: resolving ethical dilemmas and reducing burdensome and ineffective treatments, reducing hospital stays, etc. To use a clinical metaphor, for ethical crises an ethics consultation is the correct intervention in the right dosage. But, as per Andereck et al. (2014), having constant access and exposure to ethics colleagues at a hospital or on a unit reduces the punch of, and the need for, ethics consultations in the first place. We argue, apropos our own data, that ethical issues are often discussed contemporaneously, and in a manner that is convenient to the clinicians. It is noteworthy that, more than any other clinical areas, 75 % of our respondents who worked in the Emergency Room—a time sensitive setting—preferred consulting with a colleague in their own department to resolve an ethical dilemma. Aside from crisis situations, clinicians are likely to first reach out to clinical colleagues who are present, as opposed to mounting a formal consultation with the ethics consultants or committees. Speculating more widely, we believe that there is more to promoting ethical reflection and practices, and that ethics consultation should not be our only or even primary tool. There is value added in training care teams on principled ethical reasoning process and guiding them to support each other; but this approach is underutilized. To continue with our metaphor, in ethics as in medicine, an ounce of prevention is worth a pound of cure. But the value of prevention cannot be measured simply by collecting length of stay data and costs statistics—one cannot measure the fallout of a crisis that did not happen in the first place. The key to preventive ethics is access to ethical expertise, ongoing exposure to ethical wisdom, a culture of ethical reflection, and a mechanism for regular team communication (Pavlish et al. 2015). We believe that preventive ethics is not best delivered in the one-time injection of a consultation, but in a continuous infusion of local ethics guidance. Fiester (2014) argues for a prolonged ethics intervention as a facilitated process. Taking this a step further and extrapolating from our own data and the literature, we suggest that it would be useful for ethics services to focus on ongoing education and capacity building. We acknowledge the importance of quality ethics services, including ethics consults that conform to recognized standards and consultants that possess established core competencies. But an ethics consultation service or an ethics committee cannot be present in all areas at all times. Ethics services are subjected to the same resource constraints as every other service, and to put preventive ethics to work, institutions will need to be efficient in this task. Pavlish et al. (2015) recently found that physicians consider ethics skill-building, good teamwork, and creating an ethics-minded culture as important preventive measures. Our findings also suggested that providing general ethics education around the process of working

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through common dilemmas may align more closely with the needs of acute care settings. 64 % of our respondents wanted more ethics education sessions, in more accessible languages, at more convenient times/locations, and tailored to different audiences. This includes education of other front line workers and education sessions on non-clinical subjects (e.g., organizational ethics) to better capture the true scope of ethical dilemmas healthcare workers experience. If the presence of ethicists in acute care settings can enhance communication and ethically sound decision making by acting as ‘‘sounding boards’’ and stimulating ethical reflection, educating and cultivating an interest in ethics in the care teams ought to provide the same benefit. We believe that more energy needs to go into education, with the aim of installing local ethics champions in acute care settings. ‘‘Brown bag’’ sessions that involve co-presenters (e.g., ethicist or ethics committee member plus clinician) may provide more formal, well-rounded, and multidisciplinary discussions of ethical issues surfacing in the clinical setting. ‘‘In-service’’ ethics huddles that provide informal and short discussions on cases arising in a unit can provide ongoing support and reflection opportunities for clinicians in an efficient manner. Involving clinicians in these educational programs may give more ownership and accountability to those at the bedside to engage in these sessions that will be responsive to their needs. These educational fora may be particularly helpful for physicians, who generally prefer consulting their colleagues before reaching out to ethics consultants or committees. As administrators comprised of the biggest group of our volunteer respondents (28 %), this signals their high level of interest and concerns of ethical issues at the managerial level. Organizational ethics discussions as part of the agenda for leadership meetings can offer administrators support in dealing with broader policy and operational issues as well as integrate ethics discussions into their regular work. If people are more apt to reach out to colleagues when ethical challenges arise, we need to ensure that there is a high standard of ethics education among all staff at various levels so they can support each other when the need arises. It is only through comprehensive education that a culture of ethics can be created, and only then that preventive ethics can occur. Acknowledgement We thank Carol Pavlish for her constructive and helpful feedback on an earlier draft. We also thank our anonymous reviewers for their insightful advice.

References American Society for Bioethics and Humanities (2010). Report to the board of directors, American Society for Bioethics and Humanities: Certification, accreditation, and credentialing of clinical ethics consultants. Andereck, W. S., McGaughey, J. W., Schneiderman, L. J., & Jonsen, A. R. (2014). Seeking to reduce nonbeneficial treatment in the ICU: An exploratory trial of proactive ethics intervention. Critical Care Medicine, 42(4), 824–830. Dowdy, M. D., Robertson, C., & Bander, J. A. (1998). A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Critical Care Medicine, 26(2), 252–259. Fiester, A. (2007). The failure of the consult model: Why ‘‘mediation’’ should replace ‘‘consultation’’. The American Journal of Bioethics, 7(2), 31–32.

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HEC Forum Fiester, A. (2014). Bioethics mediation & the end of clinical ethics as we know it. Cardozo Journal of Conflict Resolution, 15, 501–513. Fox, E., Myers, S., & Pearlman, R. A. (2007). Ethics consultation in United States hospitals: A national survey. The American Journal of Bioethics, 7(2), 13–25. Gaudine, A., Thorne, L., LeFort, S. M., & Lamb, M. (2010). Evolution of hospital clinical ethics committees in Canada. J Med Ethics, 36(3), 132–137. Pavlish, P., Brown-Saltzman, K., Dirksen, K. M., & Fine, A. (2015). Physicians’ perspectives on ethically challenging situations: Early identification and action. AJOB Empirical Bioethics (in press). Puma, J., Stocking, C. B., Silverstein, M. D., DiMartini, A., & Siegler, M. (1988). An ethics consultation service in a teaching hospital: Utilization and evaluation. JAMA, 260(6), 808–811. Robblee, J. A., & Heidemann, E. G. (2004). Hospital accreditation and the surgeon: The Canadian experience. The Surgeon, 2(6): 321–326. Schneiderman, L. J., Gilmer, T., Teetzel, H. D., Dugan, D. O., Blustein, J., Cranford, R., et al. (2003). Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial. JAMA, 290(9), 1166–1172. Schneiderman, L. J., Gilmer, T., Teetzel, H. D., Dugan, D. O., Goodman-Crews, P., & Cohn, F. (2006). Dissatisfaction with ethics consultations: The Anna Karenina principle. Cambridge Quarterly of Healthcare Ethics, 15(1), 101–106. The Joint Commission. (2011). Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission.

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Preventive Ethics Through Expanding Education.

Healthcare institutions have been making increasing efforts to standardize consultation methodology and to accredit both bioethics training programs a...
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