Gacki-Smith, Jessica MPH; Gordon, Elisa J. PhD
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates that all hospitals have a mechanism for addressing ethical issues in patient care.1 Most U.S. general hospitals (82%) have ethics consultation services available to all health care professionals to serve this purpose.2 As Fletcher and Siegler3 explain, an ethics consultation is a “service provided by an individual consultant, team, or committee to address the ethical issues involved in a specific clinical case…,” the purpose of which is “to improve the process and outcomes of patients’ care by helping to identify, analyze, and resolve ethical problems.” According to one study, the major reasons for requesting ethics consultations were to clarify ethical issues, make management decisions, document support for decisions already made, clarify patient care options, lessen the fear of legal liability, improve communication, and mediate disputes.4 Other studies have shown that the ethical issues most commonly brought to an ethics consultation service concern withdrawing and withholding therapy, resuscitation issues (e.g., do-not-resuscitate), competency evaluation, surrogate decision making (e.g., living wills, advance directives), disagreement resolution, appropriateness of current treatment, and discharge disposition.5,6 These issues pertain predominantly to critically ill patients.
Ethics consultations are touted by bioethicists as useful and/or helpful in medical decision making. Empirical research shows that ethics consultations are effective in reducing hospital days and costs, as well as assisting 70–95% of physicians and nurses in various aspects of patient care.7,8 Despite this generally favorable view of ethics consultations, there is concern about health care professionals getting access to such services.1,9–12 Health care professionals, notably nurses, residents, and social workers, may face barriers to requesting ethics consultations, which studies suggest may be related to the traditional power structures within the medical professional hierarchy.9–11 A national survey of hospital directors (n = 346) found that 19.4% of the 322 hospitals with ethics committees restricted access to ethics consultations to physicians or attending physicians.12 No research has directly examined barriers residents face when they consider requesting ethics consultations. We conducted this study, therefore, to examine factors affecting residents’ and nurses’ use of ethics consultation services. In this article we report residents’ level of awareness, utilization, and perceptions of an ethics consultation service.
The study was conducted at Chicago's Loyola University Medical Center (Loyola), a Catholic teaching hospital. Institutional Review Board approval was granted for the study by Loyola University Medical Center.
Loyola began providing ethics consultation services in 1981. Any person involved in a patient's care, including patients and families, can request an ethics consultation by calling the ethics department and responding to a short intake interview. Ethics consultants respond to calls within 24 hours. Completing consultations requires time to review medical records, hold discussions with the clinical staff and patients and families, and examine patients. Ethics consultants at Loyola provide nonbinding recommendations. The person requesting the consultation is responsible for notifying the attending physician (the leader of the medical team) of the consult. Notifying the attending does not mean asking the attending for permission to pursue the consult. Between January 2001 and December 2002, Loyola had 51 ethics consultation requests: 13 (26%) requested by the attending physician, 12 (24%) by others on behalf of the attending physician, 11 (22%) by residents, 11 (22%) by nurses, 3 (6%) by social workers, and 1 (2%) by a patient or guardian.
We conducted the study over an eight-month period (2001–2002). We delivered a self-administered questionnaire to 229 residents. The questionnaire contained an invitation to the residents to participate in an additional semistructured interview. Because ethics consultations are generally requested for dilemmas arising for critically ill patients, we surveyed residents in Loyola's largest residency programs that care for such patients: internal medicine (n = 100), surgery (n = 47), anesthesiology (n = 37), pediatrics (n = 30), and medicine/pediatrics (n = 15). Residents from all postgraduate years (PGYs) within those programs were included. Of the participants, all transitional PGYs were in anesthesiology, and all PGY-5s were in surgery. Residents were identified through their program's roster. The residents in these programs were 43% of all residents at our institution that year.
Residents were assigned unique identification numbers that were recorded on the questionnaires before the initial distribution. The packets contained a cover letter, the questionnaire, and a return envelope, and they were either placed in each resident's mailbox or handed to them by the authors after they were briefly introduced to the study at routine residency meetings (e.g., mortality and morbidity conferences and morning report). The anesthesiology program's administrative secretary delivered its packets to residents. Three weeks after the initial distribution, nonresponders were sent a second packet. We considered the participants had provided their consent to the study upon receipt of their completed questionnaires.
The two-page questionnaire contained 18 open- and closed-ended questions about residents’ knowledge and use of the ethics consultation service and demographics. The questionnaire also used three measures:
▪ Residents rated their perceptions of how receptive medical team members were to their request for an ethics consultation on a five-point Likert scale (1 = very receptive, 5 = very unreceptive).
▪ We adapted the Decisional Regret Scale13 to determine respondents’ decisional satisfaction with requesting or not requesting an ethics consultation. The scale has been used successfully in research on decision aids for surgical treatment of breast cancer and hormone therapy, with a Cronbach's alpha coefficient up to 0.92.13,14 We added one item to the five-item, five-point Likert scale instrument. The Scale was used in two different questions: regret about having requested an ethics consultation (Cronbach's alpha with added item = 0.93, without = 0.96) and regret about having not requested an ethics consultation (Cronbach's alpha with added item = 0.78, without = 0.69).
▪ The third measure was a 100-mm visual analogue scale (VAS) on which respondents rated their perception of risk involved in requesting an ethics consultation from “not at all risky” to “very risky.” Scores were the number of millimeters at the mark.
Residents indicated their interest in participating in a semistructured interview on the questionnaire. We collected more information on respondents and on specific questions pertaining to the individual respondent based on their responses to the questionnaire. Interviewing began after all questionnaires were distributed and most were returned.
During the interviews, we asked residents about their perceptions and experiences regarding the hospital's ethics consultation service including descriptions of case studies. By giving residents an opportunity to explain why they did or did not request an ethics consultation, we were able to avoid making potentially incorrect assumptions about access to ethics consultations.
Interviews lasted, on average, 15 minutes and were tape-recorded and conducted in person. Preliminary consent was obtained upon scheduling the interview, and oral consent was obtained after residents reviewed an information sheet about the study.
Descriptive statistics were used to analyze the data. Responses to the short-answer and closed-ended questions were coded and entered into a database using statistical software (SPSS 10.1 for Windows; SPSS Inc., Chicago, IL). The two-sample t test was used to test differences between means. Differences in proportions were tested using the Pearson chi-square test or the Fisher exact test if expected frequencies were less than five. Pearson partial correlation coefficient was used to control for covariance. The Friedman test and Wilcoxon signed ranks test were used to examine how residents ranked individual medical team member's levels of receptivity to the request for an ethics consultation. All tests were two sided and p < .05 was considered statistically significant. Respondents who did not answer a specific question or part of a multidimensional question were excluded from the analyses of that data element.
The tape-recorded interviews were transcribed verbatim. Both authors then analyzed the interview content, systematically searching for themes and repetitions emergent from the data.15,16 The themes were developed by grouping coded segments into larger domains, having both authors review the categorization schema for appropriate thematic fit, and then adjusting and reviewing the schema again until both authors reached consensus. Most respondents gave multiple reasons for requesting ethics consultations and for not requesting ethics consultations when they wanted to. Quotes representing commonly shared views are presented below to provide greater insight into residents’ perceptions about access to ethics consultations.
A total of 135 (59%) residents returned a completed questionnaire, of whom 22 (16%) completed the interview. The response rates according to demographics, PGY, and residency program are presented in Table 1.
Awareness of ethics consultations
Most respondents (76%) reported being aware of the ethics consultation service and had learned about it, on average, two years before participating in the study. Only 21% indicated they knew how to request one (see Tables 2 and 3). Ninety (67%) residents described various avenues for learning about the ethics consultation service, including medical school (19%), direct or indirect experience with an ethics consultation (13%), hospital orientation (12%), word of mouth (12%), other residents (12%), rotation in the hospital (especially in the neonatal and pediatrics intensive care units) (12%), and the attending physician (9%).
Experience requesting an ethics consultation
Most respondents (89%) had never personally requested an ethics consultation. The distribution of residents who called an ethics consultation by residency program and by PGY is provided in Tables 2 and 3, respectively. Of those who had requested a consultation, two (13%) reported feeling hesitant, and none indicated they had experienced repercussions. The 15 residents who requested an ethics consultation rated how receptive each of the medical team members were to their request, and this information is summarized in Table 4. In general, these residents indicated that all members of the medical team were relatively receptive and the ratings were not statistically significant. Surgery residents rated team members as being slightly more receptive to their requests for ethics consultations compared with internal medicine residents.
Wanted to request, but did not request an ethics consultation
Thirteen (10%) residents reported wanting to call an ethics consultation but deciding against it. Based on responses from questionnaires and interviews, most residents reported three main reasons for avoiding the request: The attending physician was against the idea (46%), the resident was unaware of the ethics consultation service at the time (15%), and the resident decided it would not be helpful (15%). These reasons overlap with residents’ perceptions, which are examined further below.
Perceptions of the ethics consultation service
During the interviews, we asked residents about their general perceptions of and barriers to the ethics consultation service. From their responses, we identified three main barriers: (1) the perception that the attending physician may become angry at the resident's request for an ethics consultation, (2) the perception that ethics consultations are time-consuming and not helpful, and (3) the perception that ethics consultations may require the medical team to give up control in decision making. Some residents stated that they did not believe ethics consultations would aid in resolving moral/ethical conflicts.
Several residents reported the perception that attending physicians would become angry if they were to request an ethics consultation. Some residents construed the request as tantamount to questioning the attending physician's medical and ethical judgment. They were afraid, therefore, to incur the attending physician's anger because of the attending physician's power over the resident, presumably in regard to performance evaluations. They also expressed fear that their working relationship with the attending physician would be undermined. These concerns are reflected in the following quote:
Yeah, I could see definite fear about calling an ethics consultation on that point because this is somebody who… you definitely have to work with the rest of the month, which in itself, would—may be hard to face after that. If you've had such a disagreement that you are questioning their judgment, as a resident, somebody who doesn't really have much experience… I could see how many attendings would become quite angry about that. And not only do you work with them through the month, but… there's a lot of talk that goes on about residents, and I think your reputation spreads… quite quickly. And I, I would have fears about, if somebody hated me, completely hated me. I would have a lot of fear about what that would do to my reputation around the hospital. (first-year female internal medicine resident).
Some residents stated they perceived ethics consultations to be time-consuming, which deterred using the service, particularly in emergent situations. According to a first-year female internal medicine resident,
[Residents] need to have some sense that something's going to be dealt with quickly … within the next couple of hours. Because usually things are pretty far progressed by the time somebody's even considered calling Ethics, and so I think that … the fact that they might not get feedback in time to do them any good anyways, is something of a barrier.
It is clear that residents experience frustration about delays in medical decision making due to the time required to process ethics consultations.
Some residents maintained a perception that the medical team surrenders some of its decision making control by requesting ethics consultations. According to a fourth-year female surgery resident:
We [surgeons] take care of our patients ourselves completely. You know, like … very little do we consult out. We really are not just surgeons, we're like physicians, we really do all the care…. I've never heard an attending ever bring [an ethics consultation] up, and—although I don't think they'd ever say like, “Absolutely not,” it's just not something we do…. It's a lot more emphasis on, you know, … them being in control of the decision making process … on the trauma service … because we run that service.
The following quote demonstrates a resident's perception that a contradictory decision from the ethics consultation might cast her in a bad light and undermine her medical judgment:
Let's say a case where you have a very young patient who's on life support, but, you know, if they were to get out of it, which would be slim to none let's say, and you think really the best thing would just—to—be to withdraw life support, the family is battling against you because the patient was so young. Well, you call an ethics consult, the risk would be that they would actually agree with the family, even though you thought really against your better judgment. So, you'd be asking a third party to come in, and they might usurp your medical judgment. So that would be risky because then you might end up looking like, you know, a fool or you were trying to be like Dr. Death… (first-year female internal medicine resident).
Because power dynamics were originally hypothesized to influence residents’ willingness to request an ethics consultation, we assessed respondents’ perceived level of risk using the VAS. For the 130 (96%) responders, the average risk score was 20 mm (range 0–78 mm). About a quarter of these respondents (24%) gave a no-risk or 0 mm rating.
On the questionnaire, residents were asked to indicate the kinds of risks to themselves they perceived in calling an ethics consultation. Of the 97 (72%) residents who responded to this question, 45% perceived no risk to themselves. The remaining residents identified several risks that overlap with general perceptions about the ethics consultation service, including: attending physician's anger (19%), negative interaction with health care team members (9%), delay in patient care (7%), adverse effects on personal beliefs and feelings (4%), and the potential for legal repercussions (4%).
Residents were also asked to indicate the kinds of risks they perceived to the patient and/or family in calling an ethics consultation. Of the 88 (65%) responders, 52 (59%) perceived no risk. In fact, two of these residents considered an ethics consultation as beneficial to the patient and family. For those who did perceive some risk to the patient and family, most noted issues related to adverse outcomes to patient care from the ethics consultation process (13%), negative emotional responses from the family to the ethics consultation (10%), and strain on the doctor–patient relationship (5%). For instance, one first-year male surgery resident stated that the ethics consultation process could result in delays in patient care by “prolong[ing] unnecessary or painful treatment while [a] decision [is] being made.”
Comparing those who requested with those who wanted to but did not
When comparing those who requested an ethics consultation with those who wanted to but did not, there were no significant demographic differences (e.g., age, gender, residency program, or PGY status), but the level of perceived risk in calling a consultation did differ significantly (t = 3.868, p = .001; see Table 5). Those who wanted to but decided not to request an ethics consultation rated calling a consultation as more risky than did those who had actually requested one (39 mm versus 10 mm).
All residents who either requested an ethics consultation or decided against calling one completed the Decisional Regret Scale. The residents who requested an ethics consultation reported a significantly lower level of regret in their decision than did the residents who decided not to make the request (17.56 versus 56.44, t = 5.236, p < .0005, n = 25). This difference suggests that those who requested a consultation were more satisfied with their decision than were those who wanted to request a consultation but did not.
Training in ethics
Most respondents (82%) reported having no formal training in ethics. Of the 56 (42%) residents who specified whether they desired such training, only a third (34%) indicated interest. The lack of interest in ethics training is further explained by negative perceptions about ethics education, as the following quote by a first-year male internal medicine resident reveals,
Well, I have had training in the past, and … I don't know how much ethics training helps me … be ethical. To tell you the honest truth, I don't. So, a lot of times we talk about either really abstract things or things that are—seem obvious to me in a lecture. I think it's hard to lecture medical people about ethics because they feel like they need information they can use every single day and … that they couldn't figure out on their own. I feel like some of this ethical stuff … I, I guess it's okay. I think it's useful, occasionally, to present ethical dilemmas and maybe talk them through, but, like, a lecture per se doesn't do it for me.
This was the first study to examine residents’ use and perceptions of an ethics consultation service. We found that residents reported they avoided using the ethics consultation service for three main reasons. The first barrier to use was their fear of making the attending physician angry, which they felt would jeopardize their working relationship. Their fears clearly stem from their subordinate status in the medical hierarchy and in medical decision making. Although residents are responsible for being the primary caretaker for patients, there is the potential threat of reprisal by the attending for their actions.17 Even attending physicians report feeling the effects of the medical hierarchy. In one study, they identified feeling constrained in ethical decision making and consequent moral distress because of limits imposed by their hospital administration.18 Clearly, constraints imposed by the hierarchical structures of an institution on a health care professional's ability to act as a moral agent can generate moral distress, regardless of one's position in the hierarchy.18
Other studies have documented residents’ reluctance to challenge attending physicians’ decisions even when they conflict with their own ethical approach to patient care.19 This reluctance may be compounded by attending physicians’ perceptions of ethics consultations as an intrusion into the doctor–patient relationship and an abdication of their responsibility to the patient.11 Other research corroborates our findings; in one study, 80% of the 36 residents interviewed felt they did not have the power to intervene when they disagreed with how an ethical situation was being handled.20
The second major barrier we found was that almost a quarter (24%) of residents were unaware of the ethics consultation service, most residents (79%) were unaware of how to request an ethics consultation, and 15% of the residents who decided not to call an ethics consultation were unaware of the service. The JCAHO's mandate that hospitals have a protocol to address ethical dilemmas is moot unless people know about the service and how to access it.
The third barrier we identified was residents’ negative perceptions of the service or their perceptions that possible adverse outcomes to themselves or to the patient would result from calling an ethics consultation. Although some of the residents’ perceptions may be accurate, others may reflect misinformation or inaccurate speculation. Clearly, our study's data show that the less experience residents have in calling ethics consultations, the more they imagine adverse consequences of doing so.
To address these barriers, we recommend several policy changes and educational approaches. First, academic medical institutions must ensure that ethics consultation services are made available to residents. Other research has documented the need for such services. For example, one study reported that 71% of residents desired a formal process to resolve ethical disagreements between residents and attending physicians.21 To effectively provide such services, institutions must recognize and be responsible for the culture of authority that inhibits the use of ethics consultation services by residents. Being responsible means establishing mechanisms to ensure that attending physicians support residents’ access to any resources necessary to resolve ethical dilemmas. Other scholars support similar proposals.18
Currently, the policy at Loyola requires residents to notify their attending physician when they request an ethics consultation. If a resident fears possible repercussions from the attending physician, this policy may deter residents from using the service. Establishing a policy that allows residents to contact the ethics service anonymously or without first informing their attending physician may decrease residents’ hesitancy.
The fact that residents in our study learned about ethics consultation services through a diverse array of formal and informal avenues suggests a need for greater consistency in the educational process. Additionally, most residents (82%) reported having no formal training in ethics. We recommend institutions make greater efforts to educate residents about the practical benefits of ethics and the means to address ethical dilemmas. An ideal occasion to inform residents about these services is in the core curriculum. Recent updates to the Accreditation Council on Graduate Medical Education core curriculum require residents to receive education in ethics and/or professionalism.
Presentations by senior residents who have used the service during grand rounds or orientation could be another means to provide less-experienced residents with information about the ethics consultation process, including the time involved, nature of interactions with attending physicians, and personal consequences. Doing so could help dissipate fears. A description of the ethics consultation service including contact information could be printed on wallet-sized cards and provided to residents during such presentations.
Role modeling by attending physicians (perhaps in the form of an educational videotape) could show support for residents’ use of the ethics consultation service. Faculty could describe their experiences and some outcomes of working with residents who requested an ethics consultation and discuss how ethics consultations do not necessarily delay treatment decision making.
We recommend institutions use an educational campaign to eradicate myths and modify negative perceptions of ethics consultations. For instance, the perception that ethics consultations delay the medical decision making process is inconsistent with research, which shows they reduce hospital and intensive care unit days.7 Negative perceptions of ethics consultations may be ameliorated by increasing the residents’ familiarity or interaction with the service. Some scholars have advocated that ethics consultants round with medical teams to become more integrated into the clinical decision making process and prevent ethical dilemmas from developing altogether.22
As part of an educational campaign, Loyola conducts its annual ethics awareness week for all faculty and staff. This program began in 2002 and includes grand round ethics presentations, ethics debates, panel discussions on relevant books, video case discussions, and a medical ethics bowl for medical students. During these events, attendees receive pens, water bottles, and mousepads on which the ethics consultation service phone number is printed for easy access.
Education in ethics is necessary for enabling health care professionals to reason through moral quandaries more systematically. The lack of formal ethics training in most of our sample could help explain residents’ lack of awareness and misperceptions of the ethics consultation service. This rate of training is considerably less than other reports.21 Only one-third of the residents in our study who indicated whether they desired training in ethics responded affirmatively. Other studies show a considerably greater interest (74%) in receiving training in ethics.20
Efforts should be made to appeal to residents and encourage their participation by offering innovative methods of education in ethics, such as those mentioned here. By underscoring how ethics education can better prepare residents to deal with ethical dilemmas and feel more confident interacting with attending physicians during such dilemmas, ethics education may become more appealing.
Several limitations of our study must be noted. First, our results may not be generalizable to residents at other hospitals because hospitals’ policies regarding who is entitled to request an ethics consultation and the procedures for addressing ethical issues vary.23
One might expect Catholic hospitals to differ from non-Catholic hospitals in the range of ethical issues encountered because Catholic hospitals do not offer some reproductive services. However, based on the experience of one author (EJG) as an ethics consultant and member of Loyola's ethics committee, it is apparent that ethics cases pertaining to reproductive issues occasionally arise, which suggests there may be fewer differences than expected.
Our 59% response rate represents the majority of the resident population within the five largest residency programs serving inpatients at our hospital. The views expressed by the residents included in our study may not be generalizable to residents in other programs, especially those treating outpatients.
Although we asked in the survey if respondents personally requested an ethics consultation, some residents who reported having requested an ethics consultation may have done so on behalf of the attending physician. Another limitation is that we did not directly inquire into all residents’ general perceptions about the ethics consultation service on the questionnaire. However, the fact that the risks identified by most of the respondents overlapped with the perceptions elicited from the interviewed respondents supports the pervasiveness of these perceptions among all respondents. Lastly, we did not define “formal ethics education” on the questionnaire, and thus respondents may have had different interpretations of this question. Further research is needed to evaluate the effectiveness of the educational approaches recommended to enhance residents’ awareness of and comfort with using ethics consultation services.
This study showed that several barriers hindered residents’ use of ethics consultation services, including power inequities within the medical hierarchy, lack of awareness, and negative perceptions of ethics consultations. We recommend that health care institutions use innovative methods to educate all employees about the availability of ethics consultation services and how to use them. In addition, institutions should establish mechanisms to give health care professionals in subordinate roles within the medical hierarchy a safe way to access the service to address their moral distress.
We thank all the resident physicians for participating in this study. Mark Kuczewski and Aaron Michelfelder provided insightful comments on an earlier draft of the manuscript, and Jack Corliss provided statistical assistance.