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Simulated scenarios test, train ethics consultants
Johns Hopkins develops assessment tool
Though some erudite veterans may tell you differently, good ethics consultants are made — not born.
People with the academic and clinical background for service on hospital ethics committees may still have difficulty when it comes to communicating with and dealing with families in crisis.
These are just some of the situations that might require an ethics consult — the convening of an ethics committee or a designated subset of the committee — that meets to resolve a particular conflict.
"It takes time to become a good ethics consultant," notes Eugene C. Grochowski, MD, PhD, FACP, associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, and a member of the ethics committees at Johns Hopkins Bayview Medical Center and Franklin Square Medical Center.
While it’s a given that ethics consults will vary in quality with the skill and experience of individual consult teams, there is no clearly accepted way to evaluate the quality of ethics consults performed and allow people to improve, he says.
Unlike other medical training situations, it’s not practical to let novice ethics committee members observe actual ethics consults and, for similar reasons, it’s not practical to allow more experienced consultants to observe newer consultants performing real consults, either.
"The situation is already very stressful. You have some sort of conflict, or there would be no reason for the attending physician to ask for an ethics consult," Grochowski observes. "The presence of another party in that room, would essentially affect and change the consult process. It just doesn’t lend itself to that kind of situation."
However, if consult teams are allowed to practice using realistic simulations of consult situations, they might be able to improve their skills without any real-world consequences.
After using carefully designed simulations of clinical scenarios to train physicians in the neonatal and pediatric intensive care units, Grochowski and some Hopkins colleagues began to wonder whether a similar technique could be used to train and evaluate ethics consult teams.
They received a grant from the Niarchos Faculty Innovation Fund at the Johns Hopkins University Berman School of Bioethics to conduct a study of two things: 1) could simulations be developed that realistically approximate an ethics consult; and 2) could an assessment tool be developed to evaluate the quality of the consults.
First, they devised a common ethics consult scenario: the daughter of a woman who has suffered a severe stroke wants her placed on a ventilator. The patient previously had told a physician she did not ever want to be placed on a ventilator should her condition warrant it. The physician wants the ethics consult team to "help" the daughter agree to take her mother off the ventilator.
Next, they recruited experienced volunteer actors to develop the characters involved in the simulation. No script is used, Grochowski emphasizes. The actors must improvise while interacting with an ethics consult team.
The test simulation used three actors — a person playing the patient’s daughter, patient’s son, and a real physician playing the role of physician.
"We created in-depth characters, maybe 10 or 15 pages of character development," explains Grochowski. "We know who their kids are, what their kids do, where they go to school, etc."
The research team also asked the actors to open certain windows of opportunity for the consult teams — avenues that might lead to a resolution of the conflict or a breakthrough — to see whether the consult team would pick up on them.
In the scenario, the daughter lived in town, while the patient’s son lived across the country and traveled to see his mother after her stroke. The patient’s husband had died.
The physician had a very strong patient autonomy point-of-view, he adds.
"There were all sorts of different dynamics that we created that were realistic," Grochowski continues. "The patient had been noncompliant with medication for hypertension — she ended up having a stroke. The daughter felt guilty for not coming home immediately when her mother called complaining of a headache. She got there and found her on the floor. She felt the physician was moving too fast, the prognosis wasn’t entirely clear, etc. There were some religious references that a family member would make, and there was a question about how well did the consult team follow up on the use of the religious words."
Once the simulation and characters were developed. The simulation was tested by ethics consult teams from Hopkins Hospital in Baltimore.
"We got four separate consult teams — three or four people on each team — to come meet with our family,’" Grochowski says.
The only instructions given to the teams were to conduct the consult as they normally would. The actors in the simulation responded, in character, to the actions of the consult team.
"Anything that they needed, we would provide — we had charts for them to look at, consult notes from neurology. The neurologist would be available to talk to the family if they wanted," he notes. "The only difference was that the time frame was compressed. If the family needed to meet with someone, we could have that happen right away, rather than waiting for it to be scheduled."
All of the interactions took place in a conference room that had a camera in the ceiling — the consults were videotaped for later review and evaluation.
When the consult was over, participants were asked to write a brief summary of the experience.
"Our first goal was to demonstrate we could create the real feeling of an ethics consult," says Grochowski. "And the consult team members said they felt that way, and the reviewers looking at the tape saw it that way, too. It appeared to them like the real thing."
As the consult teams sat down to write their summaries in the conference room, Grochowski noticed that they spoke about the simulation as if it were a real ethics consult, as well.
"That happened, literally, with every consult team," he says. "When they were sitting down to write, they had spontaneous post-consult discussions. They talked about it in a way you would talk about a real consult, what did they do, what they might have done differently, etc.’ They didn’t say, Gee, those were really great actors. They did a good job.’"
Evaluating the simulations
Just having the videotaped simulation is a good training tool for ethics consult teams and a useful way to help teams improve, Grochowski says.
Because the interactions are videotaped, they are available for both the participating teams and others to review later. The tape can be stopped at certain points, allowing for a discussion.
"You can ask the participants, What were you thinking here?’ Or, what were you trying to communicate just then?’" he says. "In that way, you can get a feel for what they were thinking and how they were working through — or not working through — a particular issue."
At the same time, the second part of their study involves developing a standardized, objective assessment tool to evaluate the quality of the consult.
As part of their research, Grochowski and colleagues used the standards for ethics consultation from the American Society for Bioethics and Humanities (ASBH) to develop an assessment tool.
"We tried to create an instrument — and that is still in its formative stages," he explains. "A lot of it is taken from the ASBH standards book — those were the guiding standards. And we included a lot of communications theory background."
The instrument is a series of questions, covering different skills, designed to evaluate the consult.
"We wanted to look at how well the consult team worked together — whether they worked as a team, or whether it was a group-think sort of thing with one person doing the pushing and everyone else just towing the line," he says. "If you believe that multidisciplinary ethics consult teams are an advantage, then they all have to be heard. And you have to create an environment for that to occur."
Experts review tapes, revise tools
The research team has recruited three nationally known bioethicists, with extensive experience performing ethics consults, to review the tapes using the new assessment tool.
"They watched the first tape using the assessment tool, and then made recommendations about improving the tool," Grochowski says. "We did that through one iteration, improving the tool and then having the experts go back and review another tape using the revised tool."
The researchers hope to go through four revisions of the present tool before exhausting their research funding.
To adequately evaluate the assessment tool, it would have to be used to evaluate several different scenarios, using ethics consult teams from a number of different hospitals — something that will take significantly more time, effort, and money, he adds.
"In order to actually validate it, we would need to use different scenarios and different committees. These things are expensive, however, because it takes time to train the actors, because they are not just learning lines, they are creating," Grochowski explains.
But the researchers do feel they have met their first goal and developed a realistic way to simulate ethics consults for learning and evaluation purposes, he adds.
"Because it is not scripted, what each consult team experiences is different depending on how they interact with the family and what they choose to do in what sequence," Grochowski notes. "And the actors react spontaneously to the consult team. There is a lot of emotion involved. They may get angry and storm out of the room. There are all kinds of possibilities."
• Eugene C. Grochowski, MD, PhD, FACP, Johns Hopkins University School of Medicine, Division of Renal Medicine B2N, 4940 Eastern Ave., Baltimore, MD 21224.