HEC Forum

, Volume 24, Issue 2, pp 99–114

Functions and Outcomes of a Clinical Medical Ethics Committee: A Review of 100 Consults

Authors

  • Jessica Richmond Moeller
    • Department of Psychiatry and Behavioral SciencesAkron General Medical Center
  • Teresa H. Albanese
    • Health Services Research and Education InstituteSumma Health System and Northeast Ohio Medical University
  • Kimberly Garchar
    • Kent State University
  • Julie M. Aultman
    • Department of Family and Community MedicineNortheast Ohio Medical University
    • Palliative Care and Hospice ServicesSumma Health System and Northeast Ohio Medical University
  • Dean Frate
    • Internal Medicine, Palliative Care and Hospice ServicesSumma Health System and Northeast Ohio Medical University
    • University of Pittsburgh Medical Center
Article

DOI: 10.1007/s10730-011-9170-9

Cite this article as:
Moeller, J.R., Albanese, T.H., Garchar, K. et al. HEC Forum (2012) 24: 99. doi:10.1007/s10730-011-9170-9

Abstract

Context: Established in 1997, Summa Health System’s Medical Ethics Committee (EC) serves as an educational, supportive, and consultative resource to patients/families and providers, and serves to analyze, clarify, and ameliorate dilemmas in clinical care. In 2009 the EC conducted its 100th consult. In 2002 a Palliative Care Consult Service (PCCS) was established to provide supportive services for patients/families facing advanced illness; enhance clinical decision-making during crisis; and improve pain/symptom management. How these services affect one another has thus far been unclear. Objectives: This study describes EC consults: types, reasons, recommendations and utilization, and investigates the impact the PCCS may have on EC consult requests or recommendations. Methods: Retrospective reviews of 100 EC records explored trends and changes in types of consults, reasons for consults, and EC recommendations and utilization. Results: There were 50 EC consults each in the 6 years pre- and post-PCCS. Differences found include: (1) a decrease in number of reasons for consult requests (133–62); (2) changes in top two reasons for EC consult requests from ‘Family opposed to withdrawing life-sustaining treatment (LST)’ and ‘Patient capacity in question’ to ‘Futility’ and ‘Physician opposed to providing LST’; (3) changes in top two recommendations given by the EC from ‘Emotional Support for Patient/Family’ and ‘Initiate DNR Order’ to ‘Comfort Care’ and ‘Withdraw Treatment.’ Overall, 88% of recommendations were followed. Conclusion: PCCS availability and growth throughout the hospital may have influenced EC consult requests. EC consults regarding family opposition to withdrawing LST and EC recommendations for patient/family support declined.

Keywords

EthicsHospital ethics committeeEnd-of-life decision makingPalliative careConsult service

Introduction

The number of hospitals with clinical ethics committees has grown dramatically since the 1992 mandate by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) that all its accredited hospitals implement some means to address ethical concerns (Sexson and Thigmen 1996). By 1998, 100% of hospitals surveyed (with over 400 beds) had ethics committees in place (Fox et al. 2007); however, there are no Joint Commission mandates or federal standards on what functions an ethics committee must perform. Research has identified three primary functions consistent across most of the ethics committees studied (Gonsoulin and Taube 2002; McGee et al. 2002; Youngner et al. 1983) and an emerging fourth function. The first function pertains to policy development. In this role, the ethics committee typically offers recommendations for the implementation or revisions of policies pertaining to patients’ rights and end-of-life decisions. The second role of an ethics committee involves educating healthcare professionals, patients, and patients’ families about ethical issues in health care as well as educating new members of the ethics committee about case consultation. Educational activities performed by an ethics committee may include developing informational pamphlets for distribution, participating in Grand Rounds, or holding educational seminars for hospital staff and for the local community. The third and perhaps most important function of an ethics committee is clinical case consultation. In this role, the ethics committee acts as a consultative service when ethical dilemmas in patient care arise. A fourth function an ethics committee may perform is research as ethics committee members may collaborate on mixed methods research to identify the strengths and weaknesses of the other three functions, and to assess the quality and type of consultation services. This fourth function, while emerging among some ethics committees, should be encouraged so as to strengthen communication and education within and external to the members serving the committee. Although ethics committees world-wide may even provide oversight for behavioral and clinical trials research, separate Institutional Review Boards (IRBs) serve this function in most U.S. research settings (e.g., academic institutions, hospitals and clinics, pharmaceutical companies), including our own clinical setting. The ethics committee reviewed below was designed to perform all three of the primary roles.

Much of the existing research (Csikai 1998; Gonsoulin and Taube 2002; McGee et al. 2002; Scheirton 1992; Schneider 2000; Youngner et al. 1983) on hospital ethics committees has focused on identifying the primary functions of ethics committees (e.g., policy, case consultation, education), however relatively fewer studies have examined each of these functions in depth (Brennan 1988; LaPuma et al. 1988; Romano et al. 2009; Van der Heide 1994). The present study focuses exclusively on the trends in the consultative function of one ethics committee over its 12 years of service to a 658 bed tertiary care, teaching hospital located in an urban setting.

Established in 1997, the Ethics Committee (EC) at Summa Health System’s (SHS) Akron City Hospital provides clinically based consultative services and currently consists of 20 members, including:
  • Chair appointed by the hospital Board of Trustees

  • Two community members from the hospital Board of Trustees

  • Hospital chaplain

  • Hospital attorney

  • Three nursing representatives (RNs) appointed by nursing leadership

  • Three physicians appointed by the President of the Medical Staff

  • Resident physician appointed by the President of the House Staff

  • Director of Social Work

  • Patient Liaison

  • Four community members (one of whom must be clergy)

  • Two bioethicists.

By design, there are no term limits imposed on the members of the EC. Because there is a learning curve associated with serving on the EC, the desire is to have members with as much expertise and experience as possible serving on the committee. There is roughly a 10% annual turnover rate among EC members due to both personal and work-related reasons such as relocation and retirement. The EC meets monthly to discuss recent ethics consults, review relevant administrative policies, and discuss education efforts related to ethical issues in clinical practice (e.g., Grand Rounds, informational pamphlets). Additionally, EC members are assigned to a quarterly call schedule that responds to requests for consults. The consult call schedule is constructed to assure that at least one nurse, one physician, one member of the clergy and one community member participate in each consult.

The EC at SHS is fairly similar to other hospital ECs based on a survey of 600 hospitals, which was intended to describe in detail how ethics consultation is practiced in general hospitals in the U.S (Fox et al. 2007). There are several key characteristics on which the EC at SHS differs from the majority of other ECs. SHS’s EC has been active longer than most (12 years) only 10% of ECs surveyed have been active for 10 years or more. Annually, the median number of ethics consults performed by ECs in hospitals with 500 or more beds was 15; SHS’s EC performs a median of only 6 per year. SHS’s EC uses a call schedule as do 40% of hospitals surveyed. Only 28% of hospitals reported having a formal process for evaluating ethics consultations, SHS’s EC members received an evaluation questionnaire after each consult in which they participate. EC members are asked to evaluate the process of the ethics consultation and the outcomes; the evaluations are used to provide some assurance that the process includes open discussion and concludes after all issues have been addressed to the satisfaction of committee members. A key characteristic the EC at SHS shares with most other hospital ECs is that clinicians (particularly nurses and physicians) most frequently perform EC duties. The majority (95%) of hospitals indicated that anyone can request a consult; this is now true for SHS’s EC. Results of consultations are provided to all members of the EC; this practice occurs in 73% of hospitals. Finally, the most common form of training for new EC members was formal, direct supervision by an experienced member of the EC. SHS’s EC employs a similar method of training.

In 2002, SHS established a Palliative Care Consult Service (PCCS) with the stated intent to (a) provide supportive services for patients and families facing advanced illness, (b) enhance clinical decision-making during crisis, and (c) improve pain and symptom management for patients. As the majority of the ethics consults were requested for patients in the advanced stages of various illnesses, it was hypothesized post-hoc that the PCCS may have an effect on the functions of the ethics committee and may even reduce the need for its consult services.

Given that the EC and PCCS both address value issues, work collaboratively, and frequently overlap on cases, it is useful to briefly distinguish the two services here. Since the services work collaboratively, there is no policy specifying that one service should be consulted before or exclusive of the other. The PCCS is more likely to achieve results at the bedside and via family meetings, with greater emphasis on symptom control, spiritual issues and family support. The EC draws upon community resources and a broader interdisciplinary team (such as attorneys, bioethicists, community representatives, and specialty physicians) to address value conflicts which cannot be resolved at the bedside and are more likely to expand to become larger hospital and societal level value conflicts. The EC works to clarify and analyze value conflicts when they arise in clinical care. With this clarification and analysis, problematic situations may be reframed for persons struggling within the health care system such that the value conflict is meliorated. In brief, the EC works to recognize value conflicts, resolve the conflicts when possible while developing recommendations to guide ethical decision-making, and reflect upon the resolution or lack thereof, which commonly takes place during regularly scheduled, monthly meetings. The distinctions between the PCCS and EC are neither precise nor firm; clear boundaries cannot be drawn. Thus a great deal of similarity exists between PCCS consults and EC consults with frequent overlap of issues and patients. Nonetheless the two entities serve two different roles and follow different missions within the organization.

This study retrospectively examined data from 100 ethics committee consults and describes (1) reasons for consult requests, (2) who requested the consults, (3) recommendations offered by the Ethics Committee, and (4) the percentage of recommendations followed. Of particular interest, the authors investigated the possible effects of the implementation of the inpatient Palliative Care Consult Service. Specifically, we sought to identify any changes that occurred in number and reasons for ethics consults as well as the recommendations made by the ethics committee.

Methods

Data were obtained from the Ethics Committee’s database which is maintained for quality review and presented twice yearly to the Health System Quality Committee. This database included data provided in the individual reports for the 100 ethics consults requested from and completed by the Summa Ethics Committee between July 15, 1997 and March 16, 2009. The reports written for each ethics consult included the following information: patient demographics and diagnosis, patient location in the hospital, who requested the consult, type of consult, reason for the consult, number of days required to complete the consult, who was interviewed (e.g., medical staff, patient, patient’s family), recommendations of the EC, which recommendations were followed, the patient outcome, and number of days elapsed before the patient outcome. The data in the EC database are confidential. All identifying patient information, with the exception of the medical record number, is removed. Only the Chair of the EC (SR) and two researchers (JM and TA) involved in this study had access to the database. Descriptive data analyses were conducted including cross-tabulations comparing the most frequent reasons for ethics consults and recommendations by the ethics committee before and after the establishment of the palliative care consult service. Fisher’s exact test was used to test for statistical significance. This study was reviewed and approved by the hospital’s Institutional Review Board.

Description of the Ethics Committee Consult Process

Any patient, family member, staff member or physician may request an ethics consult. Ethics consults are intended to provide direction for the resolution of ethical conflicts or clarification of the operative values in a given situation. In complex situations it is often the case that there are both conflicts of values and practical conflicts as well as ambiguity in both values and facts. Because of the diverse nature of conflicts and ambiguities, ethics consults may be requested unnecessarily in complicated situations lacking value-based conflicts or ambiguities. Due to the difficulty in sorting problems of value from problems of practicality (e.g., conflict among medical opinion, legal questions), as well as the fact that members of the EC are unable to adequately respond to most practical dilemmas, the person requesting an ethics consult is encouraged to exhaust other hospital and community resources aimed at resolving practical dilemmas before an ethics consult is initiated. These other resources include but are not limited to social work, psychology, psychiatry, pastoral care, the patient liaison, the nursing manager, department chair, and the Palliative Care Consult Service. Once all realistic practical interventions have been attempted without resolution, an order for an ethics consult may be requested by any of the individuals noted above. Many concerns that initially came to the EC were resolved with greater emotional, spiritual and administrative support for the family, patient and/or health care providers. This protocol was established in order to be sure that all of the system’s varied resources were brought to bear on the situation. EC members also wanted to be confident that the committee was not intruding unnecessarily into a complex clinical situation with diverse competing voices.

Following the order, the EC Chair contacts the physician of record to approve the consult request. Thus, while family members and non-physician staff may initiate a request for an ethics consult (anonymously if necessary), the physician of record was required to approve the request during the period in which data were gathered. This requirement was included in the original policies and procedures of the EC for political reasons; there was originally a widely held but incorrect belief that ethics consults were punitive in nature. The provision was meant to convey to physicians that they would indeed maintain control of patient care and that consults could not be requested arbitrarily. While no ethics consult requests were denied by the managing physician, this aspect of the ethics consult process has been reviewed and altered. Through the presence and work of the EC, physicians’ distrust of the committee has lessened significantly. It is now the case that any person may request an ethics consult and the consult need not be approved by the physician.

Types of Ethics Committee Consults

The EC receives three types of consultation requests: for informal consults, for second opinions, and for formal consults. An informal consult occurs when the Chair of the EC is contacted directly to informally discuss a patient care dilemma without placing a written opinion in the medical record. Most often these informal consults occur when medical staff or others inquire as to the need for the involvement of the EC and/or the availability of other resources to assist the patient, family, and health care providers.

Second opinion consults occur in emergent and urgent situations when an opinion is needed immediately and there is not enough time to perform a formal consult. In such consults, the chair of the EC is contacted directly and renders an opinion within hours without enacting the formal consult protocol. The opinion is noted in the patient chart.

A formal ethics consult requires six to eight members—at least one physician, one nurse, one social worker and one community member—to meet within 48 hours of the initial consult request to discuss the case. For formal consults, data are gathered by a designated member of the EC prior to meeting with the patient/family and physician. A member of the EC is designated as the patient/family advocate and informant throughout the process and clergy are made available at the patient or family’s request. The patient and/or family as well as bedside staff are invited to meet with the EC independently. This EC consultation subgroup deliberates regarding the ethical issues, dilemmas, or ambiguities, gathers any additional information that is needed, and delivers an opinion within 48 hours. The consensus opinion is written in the chart by a physician member and reviewed at the next monthly meeting by the entire EC. All three types of consults were included in the analyses for this study.

As noted by Fox et al. (2007) the methodologies employed in both information gathering and decision making vary depending on circumstances and situation. For example, individual conversations with clinical staff may prove more useful than a simple review of the chart, although in emergent situations the staff may be unable to conference with the member of the EC and the chart may be reviewed, instead. Further, while patients and family members are generally willing to converse with members of the EC, they are occasionally uninterested in participating in a formal consult and information must be gathered through different avenues.

Similarly, the methodology employed in decision-making varies due to different practical factors. Generally, the relationship between clinical staff and patient is conceived and understood using the deliberative model articulated by Emanuel and Emanuel (1992). In this model, the primary relationship from healthcare provider to patient is one of care whereby the healthcare provider empowers the patient (and/or family) to consider, “through dialogue, alternative health-related values, their worthiness, and their implications for treatment.” Clinical decisions are reached through deliberation with the patient with the understanding that the patient’s goals and values may be revised as the case evolves. Given the deliberative nature of clinical decision making, ethical decision making must also be deliberative. The standard across consults is that the patient’s values are respected, although the way in which a recommendation may be reached will be an organic process that includes patient and/or family participation when the patient wishes to be involved; it cannot be consistently described in specific terms (Fox et al. 2007).

Results

Sample Description

One hundred consults involving 98 patients were conducted over a period of 12 years, with two patients each having two separate consults. Slightly more than half of the consults were for female patients (53%). The patients referred for an ethics consult ranged in age from 26 to 93, with a median of 65 years of age. The majority of patients were Caucasian (68%), followed by African American (26%). Patient demographics of the hospital as a whole include 61% female, a mean age of 63 years, 80% Caucasian and 18% African American.

The primary diagnoses of the patients for whom ethics consults were requested varied greatly and included Respiratory Failure (14%), Cancer (13%), Stroke (8%), Congestive Heart Failure (8%), Chronic Renal Failure (8%), Trauma (7%), and Dementia (5%), among others. Over time the frequency of ethics consults for patients with renal failure and dementia diagnoses declined in number while trauma cases increased (See Fig. 1). Fifty-five percent of patients resided in the Intensive Care Unit (ICU) at the time of consult, 26% were on Medical Units, and 9% were on the Coronary Care Unit (CCU). The remaining 10% of patients were located in other areas of the hospital including the surgical cardiovascular intensive care unit (SCVICU), other surgical units, rehabilitation, renal transplant unit, and outpatient clinics.
https://static-content.springer.com/image/art%3A10.1007%2Fs10730-011-9170-9/MediaObjects/10730_2011_9170_Fig1_HTML.gif
Fig. 1

Change in ethics consult patients’ diagnoses over time

Consults

The 100 consults reviewed here include 44 formal consults, 30 informal consults, and 26 second opinions. The informal and second opinion consults are less complex than the formal consults and are generally completed within 1 day of the request. On average the formal consults were completed within 2.4 days of the consult request. In most of the cases the consult was requested by the attending physician (63%), or a consulting physician (23%). Five consults were requested by nurses. After data collection, it became apparent some of the consults requested by physicians came at the behest of nursing staff after conversations at the bedside while caring for the patient. This is not represented in the data due to the anecdotal nature of the information. In nine cases, the consult was requested by multiple professionals, specifically: two consults were requested by both the attending and consulting physicians; three were requested by the attending physician, consulting physician, and the social worker; one consult was requested by the transplant team and social worker; one by the Ethics Committee and Department Chair; one by a consulting physician and a nurse; and one by a social worker and surgeon.

Reasons for the Consults

Reasons for the ethics consult could be organized into one of eight general categories: conflict over withholding treatment, conflict over withdrawing treatment, futility issues, decisional capacity of patient in question, wishes of patient unknown, patient non-compliant with medical regimen, issues with DNR status, and other. A total of 195 reasons for the 100 ethics consults were provided. Multiple reasons for the consult request were reported in 47% of cases, and an average of 2 reasons was provided for each consult. The top five specific reasons reported for the ethics consults were: (1) Family opposed to withdrawing life-sustaining treatment (LST), (2) Physician does not wish to provide LST, (3) Patient competence or capacity in question, (4) Issues of futility, and (5) Physician opposed to withdrawing LST. These five reasons represent 62% of the 195 reasons reported for the ethics consults. Table 1 provides the list of reasons given in 10% or more of cases.
Table 1

Number of cases in which each reason for a consult was reported

Reason for consult

Cases N = 100

Family opposed to withdrawing LST

28

Physician does not wish to provide LST

27

Patient competence or capacity in question

27

Futility

25

Physician opposed to withdrawing LST

13

Other

12

DNR

11

Patient noncompliance with medical regimen

10

Patient’s wishes are unknown

10

Recommendations of the Ethics Committee

Depending upon the details of the situation, the committee or chair would make one or more recommendations. The EC attempts to provide both ethically permissible options as well as practical recommendations for persons involved. The practical recommendations accompany a range of permissible options with which the care team, patient, and patient’s family will construct a course of action. A total of 229 recommendations were offered for the 100 consults. On average 2.3 recommendations were made for each case, ranging from 1 to 6 recommendations. These recommendations included: obtain a second medical opinion, withdraw LST, continue LST, provide emotional support (through channels appropriate for the case, such as spiritual care, hospice, and so on) for the patient and/or family, institute a DNR order, proceed with the intervention in question, request a palliative care consult, refer to hospice, initiate comfort care, refer to probate court, and continue with present management. Additionally, for many consult requests the recommendation offered may be that a formal consult is unnecessary, such as in 38% of the second opinion consults and 30% of the informal consults reviewed. In some of these cases an existing policy addressed a situation regarding surrogate decision makers or confidentiality. In other cases legal services or the PCCS resolved the situation with a smaller number of people. In one case a patient’s family did not want him to receive blood for religious reasons; as soon as a committee member arrived at the bedside the patient declared he was a nonbeliever and asked for a transfusion.

A complete list of the recommendations and the number of cases in which each recommendation was suggested and followed is presented in Table 2. Approximately 88% of the 229 recommendations offered by the Ethics Committee were followed. Some of the recommendations had higher compliance rates than others (range: 60–100%). The recommendations with 100% compliance included: proceeding with the intervention in question, continuing life-sustaining treatment, providing emotional support for the patient and/or patient’s family, and initiating a palliative care consult. The recommendations with lower compliance rates included referral to hospice (60%) or probate court (63%), and withdrawing treatment (70%).
Table 2

Recommendations suggested by the EC: number of cases in which each recommendation was made and the number of times the recommendation was followed

Recommendations suggested

Number of cases (number of times followed)

Emotional support for patient/family

37 (37)

Comfort care

35 (30)

DNR

32 (30)

Withdraw treatment

30 (21)

Continue present management

23 (20)

Formal ethics consult not necessary

20 (19)

Obtain 2nd opinion

13 (12)

Continue LST

12 (12)

Referral to hospice

10 (6)

Proceed with intervention

8 (8)

Probate court

8 (5)

Palliative care consult

1 (1)

Patient Discharge Outcomes After the Ethics Consult

The discharge outcome for almost half of the patients (N = 48) for whom an ethics consult was generated was death. Twenty-four patients were discharged to an extended care facility after the ethics consult, 20 patients were discharged home, 5 were discharged to the hospice inpatient unit, and 1 patient was discharged to another unspecified facility.

Impact of the Palliative Care Consult Service

The data regarding ethics consults were analyzed in two groups: consults occurring prior to and consults occurring after the Palliative Care Consult Service was established, each group covering approximately a 6-year span. An equal number of consults (N = 50) made up each group, suggesting that the implementation of the PCCS did not affect the number of ethics consults requested. Generally, the data were very similar; however, two notable differences were observed. First, several of the reasons for requesting the ethics consult decreased in frequency when compared pre- and post-PCCS establishment. For example, “Family opposed to withdrawing life-sustaining treatment” was provided as one of the reasons for the ethics consult in 42% of cases pre-PCCS compared to only 14% of cases post-PCCS. Similarly, “Patient decision capacity in question” was provided in 42% of cases pre-PCCS compared to only 12% of cases post-PCCS. See Table 3 for comparisons. Second, it was observed that two of the most common recommendations suggested by the EC prior to the PCCS being established were offered considerably less often after the emergence of the PCCS. Specifically, “Provide emotional support for the patient and/or family” was recommended in 68% of cases pre-PCCS versus only 6% of cases post-PCCS. Also, “Initiate a DNR order” was suggested in 44% of consults pre-PCCS versus only 20% of consults post-PCCS. See Table 4 for comparisons. Possible explanations for these changes are discussed in the next section.
Table 3

Reasons for requesting ethics consults pre-and post-PCCS

Most common reasons given for requesting ethics consults

Pre-PCCS (%)

Post-PCCS (%)

Fisher’s exact test

1. Family opposed to withdrawing LST

42

14

p = .002

2. Patient decision capacity in question

42

12

p = .003

3. Futility

30

20

p = .254

4. Physician does not wish to provide LST

38

16

p = .013

The top 4 reasons pre-PCCS and top 4 post-PCCS

Table 4

Ethics committee recommendations given pre- and post-PCCS

Most common recommendations of the ethics committee

Pre-PCCS (%)

Post-PCCS (%)

Fisher’s exact test

1. Emotional support for patient/family

68

6

p = .000

2. Initiate DNR order

44

20

p = .010

3. Comfort care

38

32

p = .532

4. Withdraw treatment

28

32

p = .828

The top 4 recommendations pre-PCCS and top 4 post-PCCS

Discussion

The present study retrospectively examined data from 100 ethics committee consults and described (1) reasons for consult requests, (2) who requested the consults, (3) recommendations offered by the Ethics Committee, (4) the percentage of recommendations followed, and (5) trends preceding and following the implementation of an inpatient Palliative Care Consult Service (PCCS) focusing on whether any changes occurred in the number of and/or reasons for ethics consults as well as the recommendations made by the ethics committee.

Reasons for Consult Requests

The evolution of medical technology has greatly affected decisions to limit medical care at the end of life. Similar to other studies (Brennan 1988; Gonsoulin and Taube 2002; LaPuma et al. 1988; McGee et al. 2002; Romano et al. 2009; Youngner et al. 1983) the large majority of the ethics consults reviewed here involved end-of-life issues. Specifically, the top reasons for consult requests were: patient’s family opposed to withdrawing life-sustaining treatment, physician does not wish to provide life-sustaining treatment, patient competence or capacity in question, and issues of futility. The term “futility” is notoriously imprecise and often overlaps with concerns regarding LST. Further, we understand that withdrawal of LST may not be morally distinguishable from withholding LST. Nonetheless, the data collected reflect the perception of persons requesting the ethics consult rather than the academic understanding of the ideas and actions. While futility, withdrawal of LST, and withholding LST are dissected and discussed in theoretical circles, many clinicians, patients, and the families of patients often hold a different perspective. The distinction between withdrawal and withholding LST is often felt to be quite real by families making such decisions, and many clinicians do not recognize the numerous definitions of futility. Consequently, different reasons are given for requesting the consult even though the distinctions between reasons may be academically unsupported.

The decline in the number of EC consult requests after initiation of the PCCS for issues surrounding withdrawal of life sustaining treatment deserves comment. Nearly half of all requests for PCCS assistance are for patients residing in Critical Care beds with the majority of these requests having to do with end-of-life (EOL) decision making. Given the mission and work of the PCCS, some of the cases regarding withdrawal of life sustaining treatment may have shifted from the EC to the PCCS and contributed to this decline. More remarkable is the volume of such cases identified through the PCCS database growing to several hundred per year by the time the service had matured (Radwany et al. 2009).

EC consults for patients with renal failure and dementia declined over time while palliative care consults for these patients increased, particularly for patients with renal failure. The initiation of the PCCS; development of Non-Beneficial Treatment and Competence/Decision-making policies by the EC (discussed in more detail later); and the opening of the Acute Palliative Care Unit may have played a role in these changes. EC and palliative care consults for trauma patients increased over time which may have resulted, in part, from palliative care and ethics educational sessions provided to surgical house staff and Trauma staff beginning in 2003.

Who Requests Ethics Consults

It is particularly noteworthy that despite the EC’s efforts to increase awareness of its availability, function, and access, no clinical consults were formally requested by patients or family members. This requires further investigation given the resistance to those multiple attempts at education and promotion via the hospital intranet, inclusion of EC information within the patient handbook and in-hospital television. Similarly, the small number of consults initiated by nursing staff has concerned EC members. While many requests actually filter from family through bedside nurses to the attending before a consult is formally initiated, policy changes are being made to try to allow and encourage direct initiation of EC consults by non-physician staff, patients and families. Given that medical practice relies heavily on team-based approaches, which can ultimately provide comprehensive patient care, additional conflicts in values and opinions may arise and require guidance and resolution through formal ethics consultations. Therefore, encouraging initiation of EC consults by non-physicians may not only empower team-members who have historically been subjected to hierarchical decision-making, but also allows for conflict recognition and resolution that may be ignored or challenged by physicians.

Ethics Committee Recommendations

Multiple reasons are likely to exist for the decline in recommendations by the EC to initiate a DNR order and provide family support after PCCS implementation. For example, EC consults occasionally overlapped with PCCS consults which usually have laid the groundwork for family support as well as for decisions regarding attempts at resuscitation. Eighteen of the 50 clinical consults (36%) which occurred since the implementation of the PCCS service, had both an ethics consult and at least one PCCS consult. In 12 cases, the PCCS consult was initiated before the ethics consult. In four cases, the PCCS consult occurred after the ethics consult, and in two cases, the ethics consult and PCCS consult occurred on the same day. Additional explanations for the decline in recommendations to initiate a DNR order could be the culture change among medical and nursing staff regarding the acceptability of DNR orders which took place due to PCCS and EC initiated educational activities as well as the PCCS presence throughout the hospital.

Recommendation Compliance Rate

Despite the seemingly high overall compliance rate of 88%, it is unclear how typical this is of ethics committees in general. No research studies to date have reported compliance rates for ethics committee recommendations. LaPuma and colleagues (1988) cited this omission as a significant limitation to their own study. These researchers only analyzed the compliance rate for one specific recommendation: establishing a DNR order. Their observed 92% compliance rate is very similar to the 94% reported for this EC regarding this particular recommendation.

Possible Effects of Policy Changes

In addition to providing case consultation and education, Akron City’s EC develops new policies in regard to bioethical issues and assists in their implementation and review. Two policies in particular may have directly impacted the EC’s consultation function: the Non-Beneficial Treatment Policy and the Guidelines for the Management of Patients Lacking Decisional Capacity. The Non-Beneficial Treatment Policy outlines a stepwise process for physicians to follow when the patient’s treating physician and the patient or patient’s family disagree with respect to a decision to discontinue or withhold treatment because the treatment is not medically beneficial in the opinion of the physician. Specifically, the attending physician is instructed to initiate three actions prior to initiating an ethics consult: schedule a meeting with patient and/or patient’s family to discuss the patient’s medical condition, treatment options, prognosis, and concerns of all parties involved; initiate a palliative care consult; and consult for a second medical opinion from another physician. Thus this policy may have decreased the number of consults requested in which the patient’s family is opposed to withdrawing LST and/or where the physician does not feel a specific treatment will help the patient by offering an alternative and clearly defined pathway to resolving such disputes before they rise to the level of EC consultation.

The guidelines for management of patients lacking decision-making capacity were developed with the advice and guidance of the local probate court. This policy provides guidance in managing situations when a patient is incapacitated and has no advance directives and no family to make decisions. The policy outlines the hierarchy for determining who has the authority to make treatment decisions for patients lacking decisional capacity, provides resources for locating family members, guidance for decision-making in an emergency, and steps to take to initiate the guardianship process, as applicable. These guidelines may have decreased the number of consults requested where the patient’s competence or capacity was in question.

Study Limitations and Suggestions for Future Research

This study has several limitations. First, although cause and effect relationships between changes in EC consults and PCCS implementation have been presumed, there is no conclusive evidence to support our assumptions. Such evidence would require a more detailed retrospective and prospective analysis further supported by both quantitative and qualitative data from consultation participants on both services. A project of this magnitude will be considered for future research. Second, the linkage between policy developments and EC consult changes also remains purely hypothetical, and would be a project that would yield important future data.

Third, the current study did not attempt to elucidate the determinants of compliance and noncompliance with EC recommendations. This too would clearly be an area that should be considered for further investigation. While feedback from participants in each EC consult and feedback from clinicians who requested PCCS consults (Radwany et al. 2009) has been consistently positive; we have not obtained feedback systematically from individuals participating in both, nor has follow up feedback 6 or 12 months post-EC consultation been obtained. In addition, we have presumed that stable EC membership with low turnover improves the quality of consultations, though no such proof exists. Further research is needed to examine the efficacy of ethics committees as well as the determinants of success (which itself is not well defined) (McGee et al. 2002; Scheirton 1992).

Only one other study has reported the amount of time it took to complete the ethics consults from the time the consult was requested. LaPuma et al. (1988) indicated that all formal ethics consults were completed within 1 day of the request. However, it is noteworthy that this study (LaPuma et al. 1988) employed an ethics consultant as opposed to a committee model to address each ethics consult request; the ethics consultant gathered information and interviewed all the necessary individuals before providing a recommendation within 24 hours. Thus, no other study has documented the turnaround time for ethics consults using a formal hospital ethics committee.

Finally, this study has stimulated a re-analysis of the ethics consult process given that 100% of the consults were initiated by hospital medical staff. It is extremely concerning and suspect that no ethics consults were formally initiated by patients or patient families. As a result of this retrospective analysis, the ethics committee is discussing additional ways to relay information about the ethics committee and ethics consult process to patients and families, as well as ways to empower patients and families to utilize this service if needed.

Conclusions

Since the development of the PCCS, changes have occurred in the reasons for EC consults and the recommendations that result. Nonetheless the Palliative Care Consult Service and Ethics Committee continue to collaborate addressing common issues, while retaining distinct and independent roles in serving patients, their health care providers and the community. Further research should help to define and analyze the benefits and workings of hospital ethics committees as well as their interactions with the growing number of palliative care services.

Acknowledgments

This study was partially funded by the Summa Foundation and the Department of Internal Medicine, Summa Health System.

Copyright information

© Springer Science+Business Media B.V. 2012