There is overwhelming evidence that clinical ethicists provide tremendous value for patients, care teams, and hospitals…
There is overwhelming evidence that clinical ethicists provide tremendous value for patients, care teams, and hospitals. Where once clinical ethicists were only available at research and training hospitals, now, almost every hospital in the U.S. with more than 400 beds has one. This is because professional ethicists—especially those with advanced degrees in ethics and fellowship training—have consistently demonstrated the value of having access to experts in ethics advising. Here are four ways clinical ethicists improve patient outcomes.
Better patient care. A central way ethicists help is by promoting patient-centered care. Many clinical ethics consultations are, at their root, questions about what the appropriate plan of care is for a patient. Sometimes the clinical team isn’t sure. Sometimes the patient’s substitute decision-maker isn’t sure. And, on occasion, patients themselves can be unsure about what to do.
In these situations, the ethicist can help the clinical team in providing care that the patient wants and will benefit from. The main way this happens is by determining the patient’s values. Ethicists are experts in elucidating patient values, either from the patient themselves or, if the patient can’t communicate, from their substitute decision-maker. The ethicist can then work with the medical team to match values and treatment proposals as much as possible. In one study, 60 percent of participants reported that a clinical ethics consultation led to a clarification of the patient’s values, and the consultation led to a change in the plan of care a third of the time.
Increased physician and staff confidence. When the right path is obvious and there’s no disagreement, there’s no need for a clinical ethicist. However, in some cases, it’s far from clear what should happen. An ethical issue is defined by a conflict in values, which makes it difficult to figure out what the best way forward is. All the values are important—e.g., we should care about both patient autonomy and the patient’s best interest—so it’s only by careful analysis that the most ethically acceptable option can be determined. This type of ethics analysis is a skill best provided by professional ethicists. They have the training to assess complex situations and work with the clinical team, patient, and family to determine the best way forward.
Having access to clinical ethicists makes a difference for the clinical team. The study cited above found that, even though the plan of care changed only a third of the time, 75 percent of participants in the study (i.e., members of the clinical team) found that their confidence in the plan of care increased. Lacking confidence in a plan of care is a source of moral distress, or the inability to act on one’s core moral commitments. Among other negative outcomes, moral distress contributes to burnout. As one study found, “Moral distress, resulting from therapeutic obstinacy and the provision of futile care, is an important issue among critical care providers’ team, and it was significantly associated with severe burnout.”
Resolving disagreement. An ethics consultation is often appropriate when there is disagreement between the care team and the patient or surrogate about the plan of care. A common scenario is that a patient’s surrogate is requesting tests or procedures that aren’t medically indicated, or demanding that “everything be done” when the patient would be better with comfort care. As these situations develop, families will occasionally make threats, such as contacting the media or a lawyer.
It’s not the direct goal of a clinical ethicist to prevent these outcomes. While the ethicist is employed or contracted by the hospital, they aren’t public relations or legal risk mitigation experts. However, since the goal of an ethics consultation is to identify and pursue the most ethical outcome, a clinical ethicist can be a valuable person to involve when disagreements arise, since a primary goal of an ethics consultation is to resolve disagreement for the benefit of the patient. Evidence shows that ethics consultations make it four times as likely that clinical consensus will be achieved. A different study found that 87 percent of physicians, nurses, patients and surrogates agreed that ethics consultations were helpful in addressing conflicts about treatment.
Providing more efficient care. The final element, which is helpful for both hospitals and patients, is that clinical ethics consultations decrease hospital length of stay. One study found a decrease of two and a half days for ICU length of stay, while another found a decrease of about four and a half ICU days. A third study found a decrease of about three days. Yet another study concludes as follows:
Our findings demonstrated that [ethics consultations] were associated with reduced consumption of medical resources as indicated by shorter entire ICU stay, entire hospital stay, and shorter ICU and hospital stay after the occurrence of the medical uncertainty or conflict regarding value-laden issues. This study also showed that [ethics consultations] facilitated achieving a consensus regarding the goal of medical care, which conforms to the goal of [ethics consultations].
The evidence overwhelming supports the value of having access to a clinical ethicist. Care becomes more patient-centered, the care team is more confident about the plan of care, disagreements are less likely, and length of stay is decreased while patient and surrogate satisfaction increases.
The reason smaller hospitals don’t have clinical ethicists isn’t because they don’t see the value of having one. Rather, it’s because a full-time, permanent ethicist position is financially infeasible. Compass Ethics provides a solution in the form of remote consultations. In many cases, the quality of the consultation can be as high as one performed in-person. This is especially true as Covid-19 has accelerated the rise of telehealth solutions. There’s no longer a barrier to expert ethics advice.