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Department: ETHICS IN ACTION

The necessity of clinical ethicists for inpatient care

Bertino, Joseph T. PhD; Hurst, Daniel J. PhD

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doi: 10.1097/01.NURSE.0000657020.87064.e9
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HEALTHCARE ETHICS consultations with clinical ethicists have been part of healthcare for about 30 years, but they have become more commonplace in the last decade.1 Consulted about ethical concerns regarding a patient's care, clinical ethicists are members of the multidisciplinary healthcare team and are particularly prominent in larger hospitals or hospital systems. Clinical ethicists come from various backgrounds, and most have advanced degrees such as a doctorate in medicine, philosophy, theology, law, or healthcare ethics/bioethics (see Legal competency needed). Many clinical ethicists also have specific training in the form of an internship or postdoctoral fellowship performing clinical ethics consults.

This article highlights the role of clinical ethicists in the inpatient context, with an emphasis on how they can help nurses and the clinical team improve the quality of patient care.

Multifaceted role

The role of clinical ethicists is multifaceted. They may conduct research, participate in ethics education, and help develop policies pertaining to patient care and organizational ethics. However, clinical ethicists most commonly lead clinical ethics consults. Clinical ethicists typically receive requests for consultations from physicians or nurses when a problem or conflict with a patient arises. Ethical concerns encompass questions about shared decision-making with patients/families/surrogates, end-of-life care, beginning-of-life care, professionalism, privacy and confidentiality, resource allocation, and ethical practices in research and clinical trials.2

Ethical issues are always present, to one degree or another, in clinical encounters between a healthcare provider and a patient or the patient's family/surrogate because care always involves medical and moral considerations.3 With today's medical technology and its ability to prolong life with equipment such as mechanical ventilators or a procedure such as extracorporeal membrane oxygenation, ethics issues have either increased or we have become more acutely aware of them.

Healthcare ethics consultation is defined by the American Society of Bioethics and Humanities as “a set of services provided by an individual or group in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in healthcare.”2 These consults can be performed with just the patient's family or with appropriate healthcare team members present. If a situation is particularly difficult to resolve, the hospital's ethics committee may get involved to find a solution acceptable to all. The chief goal of ethics consultations is to improve care quality through the identification, analysis, and resolution of ethical concerns that arise in the clinical setting.2

While clinical ethicists may have master's or doctoral education in areas such as bioethics, philosophy, or theology, this is certainly not an absolute. Nurses, social workers, physicians, and others can cross over into clinical ethics either full time or in addition to their clinical role. For these individuals, graduate certificates, master's, or doctoral level training is available at several universities, some of which are online.

Case study

To further articulate the role of clinical ethicists in contemporary medical settings, consider the following case.

MH, 58, is admitted to a medical-surgical unit after experiencing a major stroke. He is successfully resuscitated but has an array of medical complications due to his stroke, including a coagulopathy that results in a bilateral amputation of his hands. MH is placed on bilevel positive airway pressure. Although his clinical status stabilizes, the stroke has left him severely cognitively impaired with little hope for recovery, and he cannot make his own healthcare decisions. He is married and has an adult daughter and son-in-law.

MH qualifies for transfer to a long-term-care facility. However, despite the patient's clinical qualifications, nursing staff members are concerned that transfer to a long-term-care facility may not be the best course of action due to his low chances of making a “meaningful” recovery. Rather, many on the healthcare care team believe that transfer to hospice may be a better course of action.

During this time, MH's family indicates to his nurse that they are unsure of what to do, given that he cannot articulate his healthcare choices. The nurse documents this interaction and reports it to MH's attending physician. Because the team notes the discrepancy in recommendations and the difficulties his family is facing in making a formal decision, they contact the healthcare system's ethics consultation service.

The clinical ethicist corresponds with MH's attending physician and nursing staff, then organizes a family meeting consisting of MH's respiratory therapist, attending physician, nurse, wife, daughter, and son-in-law. The clinical ethicist gathers the necessary stakeholders to gain a clearer understanding of MH's values and wishes.

It is clear that his family wants him transferred to a long-term-care facility rather than to hospice. However, after a careful discussion about MH's lifestyle, both the care team and his family develop a refined understanding of what he would determine as an acceptable quality of life. The clinical ethicist asks MH's family to elaborate on what kind of activities he enjoys and what aspects of his life he may have mentioned that he could not live without. The family explains that MH is a carpenter, handyman, and skilled craftsman.

Reiterating these facts provides insights into his values and helps the family come up with a plan of care that is consistent with the patient's values. MH's family ultimately decides to transition him to hospice, where he dies several weeks after his discharge.

Although hospice placement is not always the optimal choice, MH's family members agreed to this option due to the insight they received during the ethics consultation. After meeting with the clinical ethicist, MH's family members were encouraged to think critically about the current medical situation and the important facets of MH's life. They decided that a hospice placement allowed for a venue to promote MH's values and adhere to his wishes, such as spending time with his family and having his symptoms managed in a controlled environment.

This case study demonstrates the eclectic nature of ethics consultation work. Amid discrepancies about a patient's values, clinical ethicists promote shared decision-making among stakeholders.

Valuable tools

Clinical ethicists are key members of the interdisciplinary healthcare team, serving as a resource for medical staff and patients/families in inpatient settings. They have substantial opportunities to improve patient care in various situations. As the case study illustrates, clinical ethicists are equipped with tools to facilitate discussions between caregivers and families; aid overall patient and family understanding of the impact of clinical situations, including institutional constraints; and highlight the importance of individual values, which are especially relevant due to the nature of inpatient care.

Nurses can serve as quintessential ethical stewards by listening, reacting, and adjudicating relevant information about patients alongside clinical ethicists. Collaborative efforts involving patients, nurses, families/surrogates, medical staff, and clinical ethicists promote an ethical environment that improves inpatient care.

Legal competency needed

Although clinical ethicists may not be legal experts, they must be aware of relevant state and federal laws that pertain to their work in clinical settings and establish working relationships with the healthcare system's legal team to constructively approach difficult cases, such as decision-making for minors, patients without surrogates, and guardianship pursuits for vulnerable individuals. However, the difficulty for clinical ethicists in terms of legal constraints often pertains to the moral distress that accompanies ethical decision-making when the legal requirement may not seem like the ethical choice.

REFERENCES

1. Tapper EB. Consults for conflict: the history of ethics consultation. Proc (Bayl Univ Med Cent). 2013;26(4):417–422.
2. American Society for Bioethics and Humanities. Core Competencies for Healthcare Ethics Consultation. 2nd ed. Glenview, IL: American Society for Bioethics and Humanities; 2011.
3. Jonsen A, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw-Hill; 2010.
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