Clinical Ethics Consultation

by Mark Hughes, MD, MA

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    00:01 So now I'd like to talk about health care, ethics consultation.

    00:04 There may be times in patient care when it's helpful for either the patient, their family or the members of the health care team to get an additional perspective about how to handle a challenging situation.

    00:18 So health care ethics consultation is often a service provided by many hospitals.

    00:23 Again, it's available for the patients themselves, for their families or their decision makers, any of the clinicians and perhaps other parties where there are these value laden concerns that need to be resolved and, you know, try to figure out how to best take care of the patient. So the goal, when there is a consultation, is to promote ethically sound decision making, when there's either uncertainty or conflict about a course of action. This can be delivered either by a single consultant.

    00:55 There may be a team of consultants or an interdisciplinary committee that meets, gathers all the information, and then discusses things.

    01:04 So what is the role of the ethics consultant? Well, first of all, they're generally going to have some amount of expertise in ethical theory or thinking about clinical ethics.

    01:15 And their role is to clarify the concerns of whoever's asking for the consultation, whoever's putting in that request to make sure that the issues are clarified.

    01:26 They're going to help facilitate communication among all the key stakeholders.

    01:30 They're really going to try to foster an understanding of the clinical situation and what are the issues that are at stake.

    01:38 Their role as a consultant, especially as an ethics consultant, is to then really clarify and analyze what the ethical issues are.

    01:44 There may be medical issues.

    01:46 There may be, you know, decisions that need to be made medically.

    01:49 But the role of the ethics consultant is to really focus on the ethical issues and then ultimately provide some recommendations with some justification for why they're making those recommendations. So let me walk you through the ethics consultation process.

    02:04 So as I said, the first step is usually there's a requester that reaches out to the ethics consultant, and then the job of the ethics consultant is to systematically gather information so that requester, they're going to question them as to what are the ethical issues, Are there other concerns that that are bothering that person, whether it's from the patient perspective or from the team perspective, perhaps they're going to then review the medical record to really understand what the clinical issues are, understand the patient's medical condition, what the treatment options are.

    02:38 Perhaps a little bit about the patient background.

    02:41 You know, who they are as a person.

    02:44 Next, there might be a search for any kind of documents that reflect the patient's values and or preferences.

    02:50 So that might be previous clinical notes where that's been documented.

    02:54 Perhaps the patient has an advanced directive where they've they've either named a surrogate decision maker or perhaps have specified particular wishes about if they were in in a condition, how they would want treatments to be done or not done.

    03:08 There may be orders for life sustaining treatment.

    03:12 You'll hear about that in other lectures.

    03:14 And you're going to look as an ethics consultant for any of those those documents or evidence of the patient's wishes.

    03:22 The next step would be then to interview the stakeholders.

    03:25 So identify who are the important parties that can speak to the issue at hand.

    03:30 Obviously, often that's going to be the patient, their family, other persons in that patient's, in their in their life.

    03:40 Members of the health care team.

    03:42 Again, all of the clinical team members may have a different role and a different perspective about how to handle the case.

    03:50 Often there's going to be a need to facilitate a meeting between those stakeholders.

    03:55 And really when you're gathering people together, really encouraging that, make sure that all voices are heard in that meeting so that you really hear all of the perspectives.

    04:05 Once all that information has been gathered, then the role of the ethics consultant is to deliberate about ethically permissible options.

    04:13 So if this is a team of consultants, maybe they're going to be talking with each other, providing their rationale for why they would make a particular recommendation.

    04:21 If it's a single consultant, they're going to think through all of the issues on their own.

    04:25 They then provide those recommendations to the patient, to the family members, to the team.

    04:33 Hopefully that's done in person.

    04:34 So there's a verbal communication so that if there are questions right on the on the spot, that those can be answered by the consultant.

    04:42 It's also important for the consultant to document this in the medical record.

    04:46 So in the future, how they deliberated, how they made their recommendations is known to future providers and and to the patient as well.

    04:56 And then it's up to the clinicians and the patient again, working in the informed consent process to decide whether they're going to follow through on those recommendations.

    05:05 So they would institute a plan, perhaps have an opportunity to reevaluate how that plan is working, maybe consult the ethics consultant if they need to.

    05:18 So just let me give you one example of where this might happen.

    05:21 Often we might see ethics consultations for patients at the end of life.

    05:26 So the American Medical Association, in their code of medical ethics, talks about the need for seeking consultation.

    05:33 That could either be through an ethics committee or an ethics consultant or any other appropriate resource where there's a need for ethics guidance.

    05:42 And the three instances where they think about this in the AMA code are, first of all, the patient or surrogate.

    05:49 And the health care team just cannot reach an agreement about a decision to withhold or withdraw life sustaining treatments.

    05:56 The medical team might feel that it's appropriate to discontinue a life sustaining treatment. It's not achieving the ends that were hoped for.

    06:04 The patient or their family or their surrogate might disagree with that decision.

    06:09 So bringing in a consultant to hear about the different issues and perspectives.

    06:13 Second, there might be no surrogate available, so maybe the patient lacks decision making capacity. You need to have a decision maker.

    06:22 You don't find anybody that can serve that role and is willing to make decisions on behalf of the patient. So there you have to either use the consultant to then figure out who you seek as a consultant, as a surrogate might need to go in the United States.

    06:38 We might go to court to seek a guardian to speak on behalf of the patient.

    06:43 So that's another place where the ethics consultant can serve a role and help to speak to the ethical issues at stake.

    06:49 And then also, there may be the instances where the physician really disagrees with the decision by a patient or a surrogate.

    06:57 They really feel that it clearly violates the patient's previously expressed values, goals of care or treatment preferences and does not seem to be in the patient's medical interest.

    07:07 They're the the health care team.

    07:09 The physician is reaching out to the consultant to say, I know this patient.

    07:14 I know what they've expressed previously.

    07:17 Their surrogate decision maker seems to be making a decision that's that's counter to my knowledge of the patient and their their values and preferences.

    07:24 So maybe the ethics consultant can help sort out how to resolve that that dispute or that conflict. So those are just a few examples of where you might see the role of an ethics consultant. Not all hospitals have these, but often where they are available.

    07:40 It can be an additional resource for the clinicians and the patients and their families to figure out how to best take care of the patient.

    About the Lecture

    The lecture Clinical Ethics Consultation by Mark Hughes, MD, MA is from the course Introduction to Clinical Ethics.

    Included Quiz Questions

    1. To resolve a value-laden concern
    2. To manage newly diagnosed cancer
    3. To manage hypertension
    4. To resolve a conflict of interest
    5. To resolve a long-standing family dispute
    1. Clarifying ethical issues
    2. Facilitating communication among stakeholders
    3. Providing a recommendation about ethically permissible options
    4. Providing a prescription for amlodipine
    5. Signing DNR and DNI forms
    1. Deliberate about ethically permissible options.
    2. Interview stakeholders.
    3. Have a meeting between stakeholders.
    4. Provide recommendations verbally and in writing.
    5. Provide a court order.
    1. Disagreement about end-of-life care
    2. No assigned surrogate decision-maker
    3. Disagreement about burial location
    4. Uncertainty about the patient's medication list
    5. Resolving mistaken identity

    Author of lecture Clinical Ethics Consultation

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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