Background: Clinical ethics consultation can promote ethical delivery of care by helping identify ethical questions, frame clinical decisions in the context of values, clarify policies and address the care team’s moral distress. Though hospitalists routinely grapple with ethical dilemmas, there is a paucity of literature on characteristics and value of ethics consults (ECs) in hospital medicine. Most hospitals utilize Ethics Committees, which may be unable to provide timely evaluations. Our study identified themes of consults from a novel bedside Ethics Consult Service, designed to be similar to clinical consult services and provide real-time evaluation and clinically-relevant recommendations. ECs can be requested by the care team, patient or family and are provided within 24 hours.
Methods: This study was conducted under the purview of program evaluation. The ethics team received 48 consults from January 2021-November 2021, 21 of which were from hospital medicine. We abstracted information from the 21 consult notes related to requestor, patient demographics, length of hospital stay (LOS) at time of consult, and presence of decision-making capacity. The Armstrong Clinical Ethics Consultation Coding System 2013© (ACECS) was used to code up to five relevant ethical issues per consult. We then categorized the ethics team’s recommendations.
Results: The average patient age was 70 years. Two-thirds of consults originated from a general medicine unit and one third from a step-down unit. ECs were typically requested by a medical attending or trainee and rarely by a social worker (5%). The median LOS at the time of consult was 31 days (range: 2 – 285). All patients either lacked decision-making capacity (86%) or had unclear capacity (14%). 71% of patients had surrogate decision-makers and none had advance directives. 76% of patients had already received palliative care consults. Most cases raised issues related to substitute decision-making. Issues arose when patient wishes were unclear/unknown (57%), the team had concerns about decision-maker choices (38%) or struggled to determine the appropriate decision-maker (29%). One fourth of patients were unrepresented (i.e., lacked capacity and did not have a surrogate or guardian). The most common recommendation was to conduct a family meeting (43%). ECs commonly involved coaching teams to utilize communication skills (19%) and facilitating discharge plans (19%).
Conclusions: Our finding that palliative care was already consulted in most cases suggests that the role of our bedside Ethics Consultation Service is unique. The most common recommendation was to conduct a follow-up family meeting and 20% of consults recommended communication strategies, illustrating that a major function of ECs is to help teams resolve issues through mediation skills and consensus-building. Most consults involved substitute decision-making for patients who lacked capacity. Median LOS prior to an EC was 31 days and ~20% of consults tackled issues around discharge plans. These findings suggest that earlier ethics consultation may help reduce LOS by facilitating mediation with surrogates, clarifying appropriate decision-makers, and navigating discharge plans earlier. Compared to attendings and trainees, social workers were much less likely to initiate an EC. Given the frequency of issues around unrepresented patients and complex discharge plans, it may be beneficial to raise awareness about the role of EC among all members (e.g., social workers, nurses) of the interdisciplinary team.
