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Be aware of the culture of ethics consultations
Start with asking critical questions
Hospital ethics committees and consultants can improve their own understanding of cultural clashes between the institution and patients/families by first considering the culture inherent in an ethics consult.
"The literature is filled with an important discussion of ethics consultation and a clash of cultures," says Jacqueline J. Glover, PhD, an associate professor of pediatrics at the Center for Bioethics and Humanities at the University of Colorado in Aurora.
Far less has been written about the actual culture of the ethics consult itself, she adds. "We're always aware of the work we do with other people's cultures, but we need to shed more light on this process of ethics consultation and its factors," Glover says. "It's like asking a fish to take a look at its own water – you're the fish, and you need an outsider perspective."
The ethics consult's culture is related to expectations and how listener's and speakers perceive what is being said, she explains. "When a family hears there is going to be an ethics consult, do they say, 'What did I do wrong?" she adds.
Researchers who have studied ethics consults have used participant observers to watch actual consultations and to provide a thoughtful framework for what occurs during these consults, Glover notes. "They observe what people are expecting and what they think is happening," she says.
Hospital ethics committees and consultants who would like to learn more about their own and their institution's ethics culture might follow Glover's advice:
Ask critical questions.
"Turn yourself into an anthropologist, asking critical questions about how you do ethics consults," Glover says. "What is your understanding of what the goal of an ethics consult is? What is your understanding of what goal is for an ethics consult, and what is the patient and family's understanding?"
The chief objectives of an ethics consultation include these:
Identify the goal of ethics consultation.
Describe the gap in expectations among interested parties.
Describe different perspectives in the process of ethics consultation.
Critically analyze barriers to full participation in ethics consultation.
"How do you describe what an ethics consult is to someone else?" Glover says. "How do ethics team members describe an ethics consult to the rest of the team?"
Examine the words used to ask for and describe an ethics consult, she adds.
Practice your "script" for speaking with families and patients.
"I say, 'Hi, I'm Jackie Glover, and I'm a member of the ethics committee,'" Glover says.
Lay people might hear something in the news about government ethics boards and have misconceptions about hospital ethics committees. So the key is to put their worries at ease and prevent cultural misconceptions about the consult. "I say, 'We're part of a team that helps patients and families and providers with difficult decisions,'" Glover says. "I might say, 'We don't make decisions for you, but we can help, and how we help is by making sure all voices are heard and everyone has the same information.'"
Ethics consultants could inform patients and families about what will happen when there is a conflict or disagreement. "If there's a conflict, we look for points of agreement with an overlap of values," Glover says. "We make sure when it's an adult case that the patient's voice is heard.'"
The "script" can change depending on why the ethics consult was called. For instance, if the family calls for a consult, then Glover might say, "I'm here from the ethics committee. Please tell me why you called us."
This is a great way to start the dialogue, she says.
By practicing communication strategies, ethics consultants can reduce the cultural divide in understanding and perceptions. "I have this image of being in a meeting and hearing the language used as bubbles of thoughts appear above each person's head," Glover says. "One person says, 'The expectation is that your baby will have severe developmental issues.' The doctor's bubble says, 'This baby will not walk, talk, eat.'"
The bubble over the head of the parents says, "Maybe our baby won't go to college."
There are big differences in expectations, and different cultural understandings of the language used contributes to these differences, she adds.
Examine ethics consultation processes.
"Look at your processes and behind your processes for who can call an ethics consult and how this ethics problem is described or understood at intake," Glover suggests.
"There are complex contextual features," she adds. "Most ethics committees have a screening and intake process, then an answer or description of the case, and detail who is on the consult service and how they answer the call."
Examine the processes of who is on the ethics team and how they initiate an ethics consult process and then work together. "We usually want the clinician to call the physician, but why are we doing it this way?" Glover asks. "There are hierarchical considerations about who gets heard, and there usually is a complex contextual feature in how the case is described."