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10/12/2016

Clinical Ethics Consultation Services and Expectations: Is It That Much Different From Other Clinical Services?

Two recent presentations at the
2016 Annual Meeting of the American Society for Bioethics and Humanities in Washington,
DC – offered within just a couple of hours of each other – had a similar theme
but approached the issue from different angles. The first presentation was a
case review by David Kappel, MD, a surgeon at the University of West Virginia,
and Valerie Satkoske, MSW, PhD, a bioethics professor at the University of West
Virginia Center for Bioethics and Health Law. The case involved a 75-year-old-man
admitted for surgery. Unfortunately, following the surgery, he was delirious.
The delirium continued for several days. He had to be restrained and fed with a
nasogastric tube. The situation was very upsetting to his family; they were
completely taken aback by this complication. The delirium was so unexpected and
surprising that the family wondered whether or not the patient would have
agreed to the surgery if he had fully understood that the extended delirium
might result. The title of this presentation was: “You Should Have Told Me!
Struggling to Meet the Spirit of Informed Consent.” As one can imagine, the
presenters asked if information about the possibility of an extended delirium
should have be included as a part of the informed consent process. The delirium
was not part of the patient’s and family’s expectations. Of course, even with a
more extensive, informed consent process, the family still may have not been
fully prepared to deal with the complication anyway. Perhaps the answer turns
more on the likelihood of the complication arising in this patient’s case given
the particulars and context? Some complications are more probable than others
given the circumstances?

The second
presentation, titled “I Never Promised You a Rose Garden: On the Necessity of
Not Meeting Expectations Regarding Clinical Ethics Consultation,” was given by
Virginia L. Bartlett, PhD, and Stuart G. Finder, PhD, of Cedars-Sinai Medical
Center. This presentation too dealt with expectations: the expectations those
who ask for a clinical ethics consultation might have of clinical ethics
consultants. The presenters suggested that the expectations might range from
“ethics policeman” to “ethics superhero.” The presentation ended with the
relatively unsatisfactory mechanisms available to evaluate the effectiveness or
helpfulness of clinical ethics consultation services interventions. From the
presentation, it was clear that clinical ethics consultants should be prepared
for not meeting expectations of those who request assistance.

Regardless,
both presentations highlight how important it is for clinicians – whether
physicians or surgeons directly caring for patients or clinical ethics
consultants offering advice or recommendations to colleagues or patients or
families – to understand stakeholder expectations as well as they can. With
doctors and nurses it may be a bit easier: mostly likely the patient wants to
be restored to health or a baseline with the least discomfort and minimal
aggravation. With clinical ethics consultation services, the expectations are
often not this clear. Moreover, with both clinical medicine and clinical ethics
consultation service interventions, there are complications and unintended
consequences. One cannot always fully anticipate which way a case may turn, or
which word or phrase at a particular moment may result in a worse situation
rather than a better situation.

For good or
ill, there is no informed consent equivalent for clinical ethics consultation
services when stakeholders ask for a consultation. The various stakeholders –
when they request a clinical ethics consultation – may or may not know exactly
what they are asking for anyway. But, most likely, what they are asking for is
help with a very troublesome or thorny issue that has ethical implications or dimensions.
In this respect, clinical ethics consultants perhaps should worry less about
meeting expectations than other clinicians, since the goals of clinical ethics
consultation services often times are much less clear – at least when the
consultation is requested – than restoring the patient’s health or previous
baseline with the least discomfort and minimal aggravation. However, may always
be better for the clinical ethics consultant to ask, “How do you think we can
help?” and try to set or reset expectations as well as one can at the beginning
of the process.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.

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