Clinical ethics committees and consult teams exist in various forms and have assisted care providers for several decades. Ideally, the clinical ethicist provides a "structured approach for identifying, analyzing, and resolving ethical issues in clinical medicine."1 Our clinical ethics service at an urban, tertiary, teaching hospital provides ethics consultations to care providers, patients, and their family members.
The most common scenarios prompting an ethics consultation identified by our clinical ethics consult service involve issues of decisional capacity and surrogate decision making, advance healthcare directives, decisions related to withholding or withdrawing life-sustaining treatments (including do-not-resuscitate orders), and conflict resolution/communication problems between caregivers and patient/family. Because a large percentage of patients who are admitted to this institution present through the emergency department (ED), the investigators wanted to study the ethics consultation activity related to this group. Of particular interest was whether or not the issue(s) eventually identified in the ethics consult was present while the patient was in the ED. Although the institution has a general medical center policy related to the calling of an ethics consult as well as a mechanism in place for assistance in the resolution of ethical issues for clinical staff, nurses and other providers in the ED have never formally asked for ethics consultations.
A literature review found few studies focusing on the timing of ethics consultation for seriously ill hospitalized patients.2,3 Furthermore, no data was found regarding the timely utilization of ethics consultation and its clinical relevance to emergency nursing and physician providers. In addition, a review of our own institutional policy on ethics consultation did not reveal any specific provider guidelines as to a screening process for patients who are ethically at risk. The time frame for calling an ethics consult of an identified patient regarding ethical issues was also not addressed in our institutional policy, although it stands to reason that the most useful time to request any type of consult is at the time the issue becomes apparent.
Our study reviewed the nature and frequency of the ethical question(s) addressed by the ethics team, the level of patient acuity and/or complexity, and the time course upon which the ethics consult was requested. Our assumption was that earlier identification of any potential clinical ethics risk might lead to earlier intervention with the clinical ethics consult service and ultimately better overall patient outcomes.
Methods/Study Design
A retrospective medical record review of the 50 hospital inpatients whose charts reflected documentation of ethics team activity during a 14-month period was performed.
Of the 50 patients studied, 18 ethics consultations were performed for patients who initially presented through the ED. We compared this group to inpatients who also received a consultation but were admitted directly (transfers from outside institutions, clinics, etc) to the hospital. Data collection was guided by a survey-based tool. This study was approved by the Institutional Review Board at the University of Illinois at Chicago where it was conducted.
Results
The data from this study suggest that, in general, patients who received ethics consultations and who were admitted to the institution from the ED were seriously ill-they were often admitted to an intensive care unit with multiple diagnoses listed in their medical record. These patients often presented to the ED either disoriented or unconscious, and often without family or friends accompanying them. Most did not have any form of advance directive for healthcare such as a living will or a durable power of attorney for healthcare. The most common reasons for ultimately calling an ethics consult for these patients included end-of-life and/or do-not-resuscitate decision making and surrogate decision making/advance directives. The average time from ED visit to ethics consult was 12 days, with a range of 1 to 52 days. Non-ED patients showed an average time from admission to ethics consult of 23 days, with a range of 1 to 75 days.
A striking finding is that 15 of the 18 patients (83%) lacked decisional capacity on presentation to the ED, and of those 15 patients, 14 lacked decisional capacity at their death or discharge. At the time of ethics consultation, 16 (89%) were unable to make their own healthcare decisions. Of note, our data revealed that 13 (72%) of these patients were cognitively competent before the illness requiring ED services. This was contrasted with the nonemergent group who showed only 3 (9%) individuals lacking decisional capacity immediately before admission. However, 22 (69%) of these patients lacked decisional capacity at the time of ethics consultation. Lack of decisional-making capacity is potentially identifiable in the ED and, from the result of this study, perhaps should be part of a general ethics screening tool.
Interestingly, advance directives for healthcare such as a living will or a durable power of attorney for healthcare were present in only 2 (11%) of patients presenting to the ED and in only 5 (15%) of those directly admitted. In addition, ED patients displayed a higher rate of medical versus surgical admissions (72% vs 28%, respectively). Direct nonemergent admissions showed the opposite with 72% of patients admitted to surgical subspecialties and 28% admitted to medical ones. The categorical ethics consult question trended similarly between both groups.
Discussion
Patients who come to the ED are often in the most vulnerable of conditions. Many present with "particular challenges in moral decision making, especially in situations where insufficient information is available, surrogates are unavailable, or there is conflicting information."4 In this study, those patients admitted to the hospital from the ED who ultimately received ethics consultation were seriously ill, with numerous comorbidities. Thus, the main concern of ED nurses, physicians, and other care providers is to quickly assess and offer appropriate emergency treatment while, at the same time, arranging for institutional support, especially if the patient will be admitted.
Issues related to the lack of decisional capacity in critically ill patients, combined with the lack of an appropriate surrogate decision maker, indicate that early ethics consultation may be useful.
To assist ED staff in identifying appropriate patients for ethics consults, the authors suggest that some process of ethical assessment and/or screening tool be developed for use in the ED and that this process be articulated formally into an institutional policy or formal guideline. A sample ethics screening tool was designed by the authors using ethics risk information gathered from this study (see Figure 1). This sample tool uses the acronym DICE, which would assist ED nurses and physicians in remembering the key issues for at-risk patients: D, Decisional capacity is impaired; I, Interpersonal relationships unknown; C, Complex care plan is anticipated; E, Ethics Consult for assistance. Any type of screening tool would need to be supported by an institutional policy and/or guideline and the appropriate follow-up staff education and training. This tool has not been formally evaluated and would require follow-up research before use within patient care settings. The authors do not suggest that the clinical ethics consultation activity be done in the ED, but rather the use of a screening tool or assessment guidelines would prompt ED nursing and physician staff to contact the ethics consult service as they would any other consulting service for the patient. Actual clinical ethics consultation activity would follow shortly after the patient is admitted to the hospital.
Our sample proved to have a low incidence of advance directives, but this is in line with the overall general population.5,6,7 Although it is impossible to know the potential role of an advance directive on each case, their absence represented a significant opportunity for improvement in assisting patients with such directives in general. It seems reasonable that a higher incidence of advance directives might have truncated hospital stays otherwise lengthened by surrogate decision-making issues.
The difference in days from admission to consultation between groups was interesting data for the team; however, it was difficult to interpret. It is possible that some patients experienced a decline in their health condition prompting ethics consultation later in their stay. In addition, no objective criteria existed for the initiation of the ethics consultation during the data collection period. Consultation was requested at the discretion of the primary care providers. Varying levels of assertiveness on the part of the primary care team may have affected these statistics.
Research of this type is challenging, and we acknowledge factors potentially limiting this study design such as our small sample size. In addition, provider bias cannot be ruled out because there are no objective criteria in place at our institution to help guide healthcare providers in identifying patients who are ethically at risk. Finally, in this setting, confounding variables may be present and difficult to identify.
Conclusion
This study suggests that complex patients admitted to hospitals directly from the ED often present with ethical dilemmas significantly impacting their inpatient care and overall health outcomes. This study shows that issues prompting inpatient providers to call for a clinical ethics consultation are often identifiable when the patient is in the ED. The authors suggest that an objective screening tool, like the example in Figure 1, and policy guidelines used by ED providers may facilitate early participation of the ethics consultant team. Such policy guidelines and screening tool may ultimately impact the overall quality of care for some patients. Our sample ethics screening tool is an attempt to provide a method for uniform patient assessment. However, further research is needed regarding the use of an ethics consult screening tool for this medically and socially challenging group of ethically at-risk patients aimed at rapid and effective interventions.
REFERENCES