Ethical Consultations in the ICU: By Whom and When?* Richard Hall, MD, FRCPC, FCCP Division of Critical Care Medicine Department of Anesthesiology Pain Management and Perioperative Medicine Daliiousie University and tiie Capital District Health Authority Halifax, NS, Canada
C
ritical care physicians deal with stress every day. However, one of the scenarios that produces the greatest degree of moral distress is when the treating team is at odds with the patient or substitute decision maker over the goals of care—an experience that is, fortunately, rare (1). Although such scenarios most often appear when the patient is near the end of life, they may also occur when decisions to provide advanced support, for example, mechanical ventilation or hemodialysis, are being considered (1, 2). It is usually within the context of such confiict that a clinical ethicist is consulted in an effort to mediate the problem (3). But does the involvement of an ethicist lead to improvements in care as a result? Potential benefits cited include improved communication between caregivers and patients (4), an increased frequency of end-of-life discussions with better definition of goals of care (4), a reduction in length of stay (4, 5), and hospital costs (6). Schneiderman et al (5) examined the value of an ethicist's involvement in "value laden confiicts" in a randomized multicenter study. The intervention group had no difference in mortality but reduced ICU and hospital length of stay and reduced use of life-sustaining therapies, which translated into reduced costs of care (6). Swetz et al (2) examined their experience of 255 cases over a 10-year period. They were able to resolve 100% of the issues identified. Nilson et al (3) reported a success rate of 84.9% from review of 53 ethics consultations over a 30-day period. The most common reasons for consultation were confiicts surrounding end-of-life care, advance directives, and withholding or withdrawing life-sustaining therapies. Dissatisfaction with the role of the clinical ethicist in a small minority of subjects in the adult ICU (7) and PICU (8) has also been identified. Given these limited results, it appears that, when conflict arises, the involvement of a clinical ethicist often has merit. So if the involvement of an ethicist is beneficial when a problem has been identified, wouldn't it seem wise to use the ethical consult service in a proactive fashion to try to prevent conflict *See also p. 824. Key Words: ethicist; proactive; reactive The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
from occurring in the first place? Dowdy et al (4) introduced a proactive approach whereby a clinical ethicist actively reviewed patient data for all patients receiving mechanical ventilation for more than 96 hours and then prompted members of the healthcare team on issues including diagnosis, prognosis, treatment objectives and alternatives, availability of an advance directive, capacity to make decisions, availability of surrogate decision makers, and any issues that were not addressed about patient care, preferences, and communication (4). This intervention—as compared with a group of patients examined before the introduction of a chnical ethics service or a group of patients for which the ethics service was consulted on an "as requested" basis—led to improvements in the occurrence and documentation of communications, more frequent decisions to forego life-sustaining therapies, and a reduced length of stay for dying patients. However, there was no direct involvement of the clinical ethicist with patients, their family, or surrogate. In this context, the study by Andereck et al (9) in this issue of Critical Care Medicine is an important contribution. These investigators undertook a randomized clinical trial designed to determine whether the involvement of a clinical ethicist in a proactive (as compared with a reactive) fashion resulted in a difference in the care of patients admitted to the ICU for 5 days. The proactive approach was not associated with a reduction in ICU or hospital length of stay, use of life-sustaining treatments, or cost. How does one reconcile the differences between this study and that by Dowdy et al (4)? The differences might be explained by the difference in populations studied. In the case of Dowdy et al (4), patients had been receiving mechanical ventilation for more than 96 hours and so were arguably a higher risk population (and therefore more likely to benefit from discussions surrounding end-of-Ufe care, advance directives, use of cardiopulmonary resuscitation, etc.) than those studied by Andereck et al (9) for whom the inclusion criterion was presence in the ICU for 5 days. The number of patients receiving mechanical ventilation is not reported, but of those dying, only a minority were receiving mechanical ventilation at the time of study entry. It is also possible that there was a difference in the "culture" of the ICUs with respect to the use of a clinical ethicist in the process of care. In the study by Andereck et al (9), it is likely that the culture in their ICU was one of early consultation to a clinical ethicist upon recognition of a potential problem, given that this is one of the ICUs involved in an earlier study about the successful reactive use of a clinical ethicist (5). Since the study by Dowdy et al (4) involved having the ethicist prompt the treating team to interact with the family (as opposed to the ethicist interacting with the famuy in Andereck et al [9] ), this may have improved the communication dynamic between the team and the family leading to an improved process of care. In the study by Dowdy et al (4), the ethicist identified a potential issue and then brought this to the attention of the treating team for intervention, whereas in Andereck et al (9),
DOI:10.1097/CCM.0000000000000089
Critical Care Medicine
www.ccmjournal.org
983
Editorials
the intervention was much more diffuse. As the authors acknowledge, it may be also difficult to demonstrate the utility of the proactive approach if there is no perceived confiict developing in the majority of patients (which would be the expected norm). The value of an ethics consult, that is, the insightful ethical fi'aming and analysis of an existing issue(s) leading to the identification and careful balancing of values-based competing obligations, and the subsequent, collaborative development with all invested parties of pragmatic ways forward, is not possible before an actual ethics issue emerges and requires intervention. Strengths of the study by Andereck et al (9) are that it was a randomized trial design and it was conducted in a unit where the "learning curve" for the intervention should have been short and acceptable to the study participants—both caregivers and patients. Unlike the study by Dowdy et al (4), it heavily involved patients and their substitute decision makers, as well as the members of the healthcare team. The major weakness is that it was a single-center study, which makes the generalizability of the findings problematic. The results in different ICUs may be dependent on other characteristics differing fiom this center including such things as case mix, race, ethnicity, and cultural considerations. So, is there a role for a clinical ethicist in the ICU? Experience and the studies to date would suggest that the answer is yes for problematic cases, and the results suggest that their intervention wül produce some resolution to difficult issues the vast majority of time. From a pragmatic perspective, once a potential confiict is identified, earlier intervention by a clinical ethicist before both sides have developed polarized positions would seem preferable. However, the thorny issue of whether an ethicist should be involved in a proactive fashion before a problem develops has not been resolved. Further single-center studies are unlikely to provide a solution to the question for the reasons outlined
above. Pending a well-designed multicenter clinical trial, I'm just thankful for their expertise on the (rare) occasion I need them.
ACKNOWLEDGMENT The author acknowledges the insightful comments and suggestions of Dr. Jeffrey Kirby, Professor of Bioethics and Lynette Reid, Associate Professor of Bioethics, Dalhousie University, Halifax, NS, Canada.
REFERENCES 1. Johnson LS, Lesandrini J, Rozycki GS: Use of the medical Ethics Consultation Service in a busy ievel I trauma center: Impact on decision-making and patient care. Am Surg 2012; 78:735-740 2. Swetz KM, Croviiley ME, Hook C, et al: Report of 255 clinical ethics consultations and review of the literature. Mayo Clin Proc 2007; 82:686-691 3. Nilson EG, Acres CA, Tamerin NG, et al: Clinical ethics and the quality initiative: A pilot study for the empirical evaluation of ethics case consultation. Am J Med Ouai 2008; 23:356-364 4. Dowdy MD, Robertson C, Bander JA: A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998; 26:252-259 5. Schneiderman LJ, Gilmer T, Teetzel HD, et al: Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized oontrolled trial. JAMA 2003; 290:1166-1172 6. Gilmer T, Sohneiderman LJ, Teetzel H, et al: The costs of nonbeneficial treatment in the intensive care setting. Heaith Aff (Miiiwood) 2005; 24:961-971 7. Schneiderman LJ, Gilmer T, Teetzel HD, et al: Dissatisfaotion with ethics consultations: The Anna Karenina principle. Camb 0 Healthc Ethics 2006; 15:101-106 8. Yen BM, Schneiderman LJ: Impact of pédiatrie ethics consultations on patients, families, social workers, and physicians. J Perinatoi 1999; 19:373-378 9. Andereck WS, McGaughey JW, Schneiderman LJ, et al: Seeking to Reduce Nonbeneficial Treatment in the ICU: An Exploratory Trial of Proactive Ethics Intervention. Crit Care Med 2014; 42:824-830
Quality Improvement Processes: Drilling Down and Stepping Back* Maurene A. Harvey, RN, MPH, MCCM Consultants in Critical Care Glenbrook, NV Don't be afraid of the answers. Be afraid of not asking the questions. —Jennifer Hudson *See also p. 831.
Key Words: healthcare transformation; needs assessment; quality improvement The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippinoott Williams & Wilkins
I
n this issue of Critical Care Medicine, Sarti et al (1) describe the results of their "Comprehensive Assessment of Critical Care Needs in a Community Hospital." The assessment was done using multiple techniques including interviews, observation, questionnaires, simulations, and database searches. Regional leaders, critical care practitioners, and patient family members at a Canadian community hospital and its referral hospital were targeted. The authors are to be commended for the complexity of this rigorously designed study which yielded nine specific areas in need of improvement as well as their causes, impact, and possible solutions. Several quality improvement projects have been implemented as a result of the information uncovered in the study, making their work well worth the effort.
DOI:10.1097/CCM.0000000000000095
April 2014 • Volume 42 • Number 4 984
www.ccmjournal.org
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C
ritical care physicians deal with stress every day. However, one of the scenarios that produces the greatest degree of moral distress is when the treating team is at odds with the patient or substitute decision maker over the goals of care—an experience that is, fortunately, rare (1). Although such scenarios most often appear when the patient is near the end of life, they may also occur when decisions to provide advanced support, for example, mechanical ventilation or hemodialysis, are being considered (1, 2). It is usually within the context of such confiict that a clinical ethicist is consulted in an effort to mediate the problem (3). But does the involvement of an ethicist lead to improvements in care as a result? Potential benefits cited include improved communication between caregivers and patients (4), an increased frequency of end-of-life discussions with better definition of goals of care (4), a reduction in length of stay (4, 5), and hospital costs (6). Schneiderman et al (5) examined the value of an ethicist's involvement in "value laden confiicts" in a randomized multicenter study. The intervention group had no difference in mortality but reduced ICU and hospital length of stay and reduced use of life-sustaining therapies, which translated into reduced costs of care (6). Swetz et al (2) examined their experience of 255 cases over a 10-year period. They were able to resolve 100% of the issues identified. Nilson et al (3) reported a success rate of 84.9% from review of 53 ethics consultations over a 30-day period. The most common reasons for consultation were confiicts surrounding end-of-life care, advance directives, and withholding or withdrawing life-sustaining therapies. Dissatisfaction with the role of the clinical ethicist in a small minority of subjects in the adult ICU (7) and PICU (8) has also been identified. Given these limited results, it appears that, when conflict arises, the involvement of a clinical ethicist often has merit. So if the involvement of an ethicist is beneficial when a problem has been identified, wouldn't it seem wise to use the ethical consult service in a proactive fashion to try to prevent conflict *See also p. 824. Key Words: ethicist; proactive; reactive The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
from occurring in the first place? Dowdy et al (4) introduced a proactive approach whereby a clinical ethicist actively reviewed patient data for all patients receiving mechanical ventilation for more than 96 hours and then prompted members of the healthcare team on issues including diagnosis, prognosis, treatment objectives and alternatives, availability of an advance directive, capacity to make decisions, availability of surrogate decision makers, and any issues that were not addressed about patient care, preferences, and communication (4). This intervention—as compared with a group of patients examined before the introduction of a chnical ethics service or a group of patients for which the ethics service was consulted on an "as requested" basis—led to improvements in the occurrence and documentation of communications, more frequent decisions to forego life-sustaining therapies, and a reduced length of stay for dying patients. However, there was no direct involvement of the clinical ethicist with patients, their family, or surrogate. In this context, the study by Andereck et al (9) in this issue of Critical Care Medicine is an important contribution. These investigators undertook a randomized clinical trial designed to determine whether the involvement of a clinical ethicist in a proactive (as compared with a reactive) fashion resulted in a difference in the care of patients admitted to the ICU for 5 days. The proactive approach was not associated with a reduction in ICU or hospital length of stay, use of life-sustaining treatments, or cost. How does one reconcile the differences between this study and that by Dowdy et al (4)? The differences might be explained by the difference in populations studied. In the case of Dowdy et al (4), patients had been receiving mechanical ventilation for more than 96 hours and so were arguably a higher risk population (and therefore more likely to benefit from discussions surrounding end-of-Ufe care, advance directives, use of cardiopulmonary resuscitation, etc.) than those studied by Andereck et al (9) for whom the inclusion criterion was presence in the ICU for 5 days. The number of patients receiving mechanical ventilation is not reported, but of those dying, only a minority were receiving mechanical ventilation at the time of study entry. It is also possible that there was a difference in the "culture" of the ICUs with respect to the use of a clinical ethicist in the process of care. In the study by Andereck et al (9), it is likely that the culture in their ICU was one of early consultation to a clinical ethicist upon recognition of a potential problem, given that this is one of the ICUs involved in an earlier study about the successful reactive use of a clinical ethicist (5). Since the study by Dowdy et al (4) involved having the ethicist prompt the treating team to interact with the family (as opposed to the ethicist interacting with the famuy in Andereck et al [9] ), this may have improved the communication dynamic between the team and the family leading to an improved process of care. In the study by Dowdy et al (4), the ethicist identified a potential issue and then brought this to the attention of the treating team for intervention, whereas in Andereck et al (9),
DOI:10.1097/CCM.0000000000000089
Critical Care Medicine
www.ccmjournal.org
983
Editorials
the intervention was much more diffuse. As the authors acknowledge, it may be also difficult to demonstrate the utility of the proactive approach if there is no perceived confiict developing in the majority of patients (which would be the expected norm). The value of an ethics consult, that is, the insightful ethical fi'aming and analysis of an existing issue(s) leading to the identification and careful balancing of values-based competing obligations, and the subsequent, collaborative development with all invested parties of pragmatic ways forward, is not possible before an actual ethics issue emerges and requires intervention. Strengths of the study by Andereck et al (9) are that it was a randomized trial design and it was conducted in a unit where the "learning curve" for the intervention should have been short and acceptable to the study participants—both caregivers and patients. Unlike the study by Dowdy et al (4), it heavily involved patients and their substitute decision makers, as well as the members of the healthcare team. The major weakness is that it was a single-center study, which makes the generalizability of the findings problematic. The results in different ICUs may be dependent on other characteristics differing fiom this center including such things as case mix, race, ethnicity, and cultural considerations. So, is there a role for a clinical ethicist in the ICU? Experience and the studies to date would suggest that the answer is yes for problematic cases, and the results suggest that their intervention wül produce some resolution to difficult issues the vast majority of time. From a pragmatic perspective, once a potential confiict is identified, earlier intervention by a clinical ethicist before both sides have developed polarized positions would seem preferable. However, the thorny issue of whether an ethicist should be involved in a proactive fashion before a problem develops has not been resolved. Further single-center studies are unlikely to provide a solution to the question for the reasons outlined
above. Pending a well-designed multicenter clinical trial, I'm just thankful for their expertise on the (rare) occasion I need them.
ACKNOWLEDGMENT The author acknowledges the insightful comments and suggestions of Dr. Jeffrey Kirby, Professor of Bioethics and Lynette Reid, Associate Professor of Bioethics, Dalhousie University, Halifax, NS, Canada.
REFERENCES 1. Johnson LS, Lesandrini J, Rozycki GS: Use of the medical Ethics Consultation Service in a busy ievel I trauma center: Impact on decision-making and patient care. Am Surg 2012; 78:735-740 2. Swetz KM, Croviiley ME, Hook C, et al: Report of 255 clinical ethics consultations and review of the literature. Mayo Clin Proc 2007; 82:686-691 3. Nilson EG, Acres CA, Tamerin NG, et al: Clinical ethics and the quality initiative: A pilot study for the empirical evaluation of ethics case consultation. Am J Med Ouai 2008; 23:356-364 4. Dowdy MD, Robertson C, Bander JA: A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998; 26:252-259 5. Schneiderman LJ, Gilmer T, Teetzel HD, et al: Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized oontrolled trial. JAMA 2003; 290:1166-1172 6. Gilmer T, Sohneiderman LJ, Teetzel H, et al: The costs of nonbeneficial treatment in the intensive care setting. Heaith Aff (Miiiwood) 2005; 24:961-971 7. Schneiderman LJ, Gilmer T, Teetzel HD, et al: Dissatisfaotion with ethics consultations: The Anna Karenina principle. Camb 0 Healthc Ethics 2006; 15:101-106 8. Yen BM, Schneiderman LJ: Impact of pédiatrie ethics consultations on patients, families, social workers, and physicians. J Perinatoi 1999; 19:373-378 9. Andereck WS, McGaughey JW, Schneiderman LJ, et al: Seeking to Reduce Nonbeneficial Treatment in the ICU: An Exploratory Trial of Proactive Ethics Intervention. Crit Care Med 2014; 42:824-830
Quality Improvement Processes: Drilling Down and Stepping Back* Maurene A. Harvey, RN, MPH, MCCM Consultants in Critical Care Glenbrook, NV Don't be afraid of the answers. Be afraid of not asking the questions. —Jennifer Hudson *See also p. 831.
Key Words: healthcare transformation; needs assessment; quality improvement The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippinoott Williams & Wilkins
I
n this issue of Critical Care Medicine, Sarti et al (1) describe the results of their "Comprehensive Assessment of Critical Care Needs in a Community Hospital." The assessment was done using multiple techniques including interviews, observation, questionnaires, simulations, and database searches. Regional leaders, critical care practitioners, and patient family members at a Canadian community hospital and its referral hospital were targeted. The authors are to be commended for the complexity of this rigorously designed study which yielded nine specific areas in need of improvement as well as their causes, impact, and possible solutions. Several quality improvement projects have been implemented as a result of the information uncovered in the study, making their work well worth the effort.
DOI:10.1097/CCM.0000000000000095
April 2014 • Volume 42 • Number 4 984
www.ccmjournal.org
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
