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Family assessment tool expands ethics consults
Hospitals might improve their ethics consultation processes if they design and use a brief ethics family assessment tool to determine families' and patients' values, two ethicists say.
"We have questions we ask families at admission, and they're very important questions to ask," says Heather Fitzgerald, BSN, RN, interim nurse ethicist at The Children's Hospital in Aurora, CO. "But they don't help us get closer to an understanding of the specifics of each unique family system and the context for each family with whom we are engaging."
Asking patients and families specific ethics and values questions in the first meetings would be one strategy for improving communications between the medical team and patients and families, she says. "We commonly encounter communications breakdowns," Fitzgerald notes. "Part of why the ethics team is consulted is because there is some failure of communication or a difficulty of communication, whether it's between family members or between the family and the hospital team."
People with different values have different ways of viewing a patient's care. "There is some place where communication has not been fully functional," Fitzgerald says. "While it may seem simple to say we need to communicate more effectively, one of the key pieces we've found missing is a deep understanding of the family system."
Hospital ethics committee members and ethics consultants need to understand the family's values and what they are bringing to decision-making. One way to find out these things is by designing a family assessment tool, Fitzgerald adds. "Maybe we need to flesh out the questions we ask," she says. For example, an attending physician might ask patients about what they've learned about their condition rather than simply asking if they have any questions.
Also, an ethics family assessment tool could be incorporated into the ethics consultation process. For example, long-time ethics consultant Jackie Glover, PhD, has developed five questions designed to elicit answers that will help explain a particular patient's or family's values and goals in care. "Early on I realized it was so important to take a values history, so I started every ethics consult with these five questions to really have a sense of rapport and understanding," says Glover, who is an associate professor of pediatrics at the Center for Bioethics and Humanities, University of Colorado in Aurora. Glover does consults at the University of Colorado Hospital and at The Children's Hospital, both in Aurora.
Questions such as the ones Glover uses can help the ethics consultation process obtain a deeper understanding of the family context, Fitzgerald says.
An assessment tool might use some of the good questions Glover asks so successfully in her consults, she adds. "I call this taking a values history," Glover says. "Who is this family? How do they make decisions?"
It's essential to understand a family's values, but it's not useful to ask them directly what their values are because they likely will not know how to answer that question, she adds. "Questions are great prompts," Fitzgerald says. "So if clinicians are going to have conversations with families, they can prompt themselves with these or similar questions." Here are Glover's questions:
What is your understanding of your family member's condition?
The answers to this question could highlight family dynamics and areas of stress. "How do they make decisions?" Glover says. "Who needs to be there when we talk about the patient's condition?" For example, it could be the family is huge and the grandparents are the ones to talk to, she adds.
How has the illness affected your family? Follow-up questions might include, "What are you going through? What's most important to you?" she says.
What is most important to you in the care of your child (family member)? A follow-up question is, "What are you hoping for?" Glover says.
What do you fear the most? The next question would be similar, but stated differently: "What do you want to avoid?" Glover says.
What are your family's sources of support and strength?
"If it's a family of faith then they might say their faith is getting them through it," Glover says. "Or maybe they have a tight-knit family who is here for them."