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Practices in ethics consults at OHSU
[Editor's note: This is Part 2 of an article that appeared in the April 1, 2009, issue of Medical Ethics Advisor.]
When asked how many ethics consults her team performs annually, or assists in statewide, Susan Tolle, MD, director of the Center for Ethics in Health Care at the Oregon Health & Science University in Portland, explains her team's mission, as well.
"You know, our goal isn't to get as many consults as possible, it's to be useful on the most difficult ones," Tolle tells Medical Ethics Advisor.
As Oregon's lead academic health center, her team holds conferences at smaller hospitals "on a regular basis," she says. "And when we do, we give our policies; we explain their use. Often, they have an active case, but that isn't the reason we were there."
Often, sharing OHSU's already-determined policy helps those hospitals, because that may address that hospital's particular current case or situation.
"Many of [these consults] are more of 'Here's the policy you need to solve your problem, because your problem fits into this situation,'" she says. "And we [smaller hospitals] build the tools to solve it, rather than solving it for you, so that you can continue on."
It's all part of the educational role performed by OHSU in Oregon — "continuous training" and "a lot of teaching them to problem-solve with things that are clearly going to be recurrent," Tolle says.
Ethics partners with palliative care
Since the ethics consult service was formed, the ethics team has begun partnering with its palliative care team, which may be involved in family conferences or "decision-making about goals of care" that the ethics team on its own might have determined in the past.
"The partnering began in about '95 and has gotten stronger and stronger, as our palliative care team has grown," Tolle says.
The palliative care team conducts about 400-500 consults a year. That team, for example, might deal with cases OHSU's Level I trauma center sometimes sees, such as traumatic head injuries, where goals of care discussions might take place over an extended time.
While the palliative care team and partnership with ethics has grown, so have the ethics team's policy writing and education activities.
"That's a given that if you are the state's academic health center, you had better have a pretty robust — both policy side and writing of policies — that solve some of these problems, so you don't keep running into them," Tolle says. "And that you educate about your policies, both within your institution and beyond if you're the lead institution for much of your state."
The ethics consults/cases that the ethics team sees are those with greater complexity.
"The easy consults that we used to get — you know, everybody's in agreement on withdrawal of life support, and we say, 'Yes, this is fine and legal and appropriate' — we don't get those anymore," she explains.
The message from this, she explains, is that "we have taught people how to do the ones that are less conflicted; their skill set has grown. They don't need us for the easy ones; they know how to do them, and so that is, I think, a good thing and a good use of resources and talent."
Logistics of ethics consults
When approaching the ethics consult, Tolle's team typically tries to have two members of different disciplines respond initially — for example, a physician and a nurse, or a social worker and a nurse. And "bedside consult" doesn't necessarily mean that conversations about a patient's care occur literally in the patient's room. Fact-finding occurs in a variety of ways.
"We try to be sure that we get more than one perspective, and it is particularly helpful if there is a conflict between the health care team and the family," she says.
And while that does not occur frequently and is not a majority of their cases, it does occur, she says. One scenario might be that the team thinks that life support should be stopped, "and the family is hoping for a miracle," she notes.
"Then, you want multiple disciplines to be able to spend time with the family, spend time with the team, and if there's a conflict within the team — the nurses and physicians are not in agreement — then having multiple disciplines on your ethics consult team is even more valuable," Tolle says.
Regardless of any given scenario, the goal is always to build consensus among all parties.
"That is absolutely the goal . . . and there may be documents that help you build consensus, if the patient has previously executed an advance directive, or in Oregon and many other states, if they previously had a POLST form that specifically spells out some of their wishes," she says.