|Home | About | Journals | Submit | Contact Us | Français|
Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services.
To describe physicians' expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit (ICU).
Physicians responsible for the care of at least 10 patients in ICU over a 6‐month period at a 921‐bed private teaching hospital with an established ethics consultation service. 69 of 92 (75%) eligible physicians responded.
Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal‐training programmes for ethics consultants.
Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law (p<0.03), religious traditions (p<0.001), medicine (p<0.001) and conflict‐mediation techniques (p<0.001). When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important.
Although many physicians caring for patients in ICU believe ethics consultants must possess non‐medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a “medicine plus one” view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established.
Clinical ethics consultation services have expanded considerably in the past two decades,1,2,3 a trend that is likely to continue with evolving accreditation requirements for hospitals to establish formal procedures for resolving ethical disputes.4 Despite the proliferation of ethics consultation services, persistent questions remain about the basic aims of clinical ethics consultation, its methods and the expertise of those who provide such services.5,6,7,8,9
Several recent initiatives by bioethics professional societies have helped clarify pertinent skills and areas of special expertise that ethics consultants should possess.10,11 An important supplement to these efforts to improve the provision of clinical ethics services is clarification of users' views regarding ethics consultation. Clarifying users' expectations may help increase the likelihood that consultants possess the skills most valued by those who request their services. In that regard, defining users' expectations may be of great value to aspiring clinical ethicists, directors of ethics consultation services and hospital administrators seeking to establish ethics programmes. Identifying potential discrepancies between providers' and users' expectations may also be helpful in assessing the quality of existing consultation services and potential barriers to their expansion.
Despite a substantial body of empirical data on clinical ethics consultation,12,13,14,15,16,17,18,19,20 there are limited data on users' views regarding the skills ethics consultants should possess.21 We report results from a survey of physician views regarding the training of ethics consultants.
Subject eligibility was restricted to physicians responsible for the care of at least 10 patients in one of four intensive care units (ICUs) at The Methodist Hospital (TMH) in Houston, Texas, USA, over a 6‐month period from 15 October 2004 to 15 April 2005. These ICUs have an open admission policy, so eligible physicians included both critical‐care specialists and admitting physicians who retain responsibility for medical decisions while their patients are in an ICU. TMH is a 921‐bed private facility that participates in the training of medical students and residents (http://www.methodisthealth.com). Staff in the medical records department at TMH assisted in the identification of 96 physicians who met initial eligibility requirements. Physicians who had ceased employment at TMH and those who self‐reported ineligibility for the study were subsequently excluded, yielding an effective sample of 92 eligible subjects.
TMH has supported an ethics consultation service since 1986 (Baruch A Brody, Director, Ethics Consultation Service, The Methodist Hospital; 1 December 2005). Consultation services are provided by experienced physicians, nurses, social workers, chaplains, bioethicists and lawyers. Before joining the service, consultants receive approximately 10 h of training on institutional policies, legal requirements and consultation techniques. Ethics consultants also serve on the hospital's ethics committee during their tenure on the service and receive additional training in that context. Consultation services are provided upon request via a pager. Individual consultants staff this pager and respond to requests for consultation. In complex cases, a consultant may solicit help from other members of the consultation service.
The survey consisted of 23 closed‐ended, multiple‐choice questions estimated to take no more than 10 min to complete (available from the authors upon request). Survey items were developed by the members of the research team (EC, RRS) in consultation with a subject‐matter expert (Dr Lawrence McCullough). In selecting particular items, the position statement on “core competencies” for ethics consultants developed by the American Society of Bioethics and Humanities was used as a guide.10 Various skills and areas of expertise identified in that document as critical for the performance of ethics consultation were associated with areas of disciplinary training and used in developing individual survey items. The survey instrument was pilot tested in a small sample (n=6), and further refined subsequent to debriefing interviews.
Written surveys were administered between May and August, 2005. Surveys were mailed with a self‐addressed stamped envelope and a cover letter explaining the study. Email reminders were sent to non‐responders 2 weeks after the initial mailing. Surveys were mailed to non‐respondents a second time 2 weeks later. A second email reminder was sent at that time to alert non‐responders of the survey's arrival. Demographic information was ascertained from the Harris County Physician Roster.22
The survey response rate was calculated as a proportion of the effective sample who returned a complete (or substantially complete) survey. Descriptive statistics were used to determine the frequency of specific responses to each question.
The Wilcoxon rank sum test was used to compare respondent assessments of the overall value of the contributions of ethics consultants to the care of patients in ICU. Responses were ranked in the following order: often helpful (highest), occasionally helpful, unsure, and rarely helpful (lowest). Z scores and corresponding p values are reported.
Fisher's exact test was used to analyse views regarding the expertise required if ethics consultants are to contribute effectively to the care of patients in ICU. Two‐by‐two tables were constructed to assess the relative importance of specialised skills and knowledge in ethics in comparison to expertise in: (1) law, (2) medicine, (3) religious traditions and (4) conflict mediation. A variable corresponding to a response of “often helpful” was created, with all other responses combined to create a single “other response” category within this variable. Responses of “unsure” were omitted. p Values were reported.
Fisher's exact test was also used to analyse views regarding the need for advanced disciplinary training in the fields of ethics, law, medicine, theology and conflict mediation. Two‐by‐two tables were constructed by distinguishing responses concerning the formal training of ethics consultants into two discipline‐specific categories, namely, advanced training needed and no advanced training needed. Professional training beyond the undergraduate level was considered advanced training. Responses of “unsure” were omitted. p Values were reported.
All p values are two sided; p values 0.05 were considered significant. All analyses were done using STATA V.9.0.
Completion of the survey was voluntary. Subjects were told that the information they provided would be kept confidential. No compensation was provided to subjects. The study was reviewed and approved by the Office of Research at Baylor College of Medicine, Houston, Texas, USA.
Of the 92 eligible physicians, 69 completed all or a substantial portion of the survey, yielding a response rate of 75%. Respondents were aged 32–75 years, with a median age of 50 years. Most were men. Respondents were board certified in a range of different specialties, although over half of them were specialists in internal medicine or general surgery. Only 5% of respondents were board certified in critical care. Over half of the respondents held academic appointments. Over 90% of respondents were aware that the hospital had an ethics consultation service, but only 13% had served as members of an ethics service. Roughly half of the respondents had participated in the care of a patient for whom there had been an ethics consultation in the past year. Table 11 reports the respondent characteristics.
After a series of initial questions on prior experience with ethics consultation, the survey asked respondents to describe the value of the contributions of ethics consultants to the care of patients in ICU. Of the respondents, 41% described the contributions of ethics consultants as often helpful. Physicians who had cared for a patient for whom an ethics consultation had been called in the past year rated the value of ethics consultants higher than those who had not (z=2.4, p<0.005).
The next series of questions addressed consultants' knowledge and skills in five specific areas: ethics, law, medicine, religious traditions and conflict mediation. The question asked to respondents was: “To contribute effectively to the care of ICU patients, how important is it that ethics consultants possess expert knowledge or skills in [specific area]?” Expertise in ethics was described most frequently as “often helpful” for ethics consultants to contribute effectively to the care of ICU patients (94%). Expertise in law ranked second (81%), followed by medicine (71%), religious traditions (70%) and conflict mediation (65%). The relative ranking of ethics as the area of expertise most frequently described as often helpful was significant in comparison with each of the other areas examined (law, p<0.03; medicine, p<0.001; religious traditions, p<0.001; and conflict mediation, p<0.001). Table 22 reports the distribution of responses.
The survey went on to ask whether the knowledge and skills necessary for ethics consultation can be taught through formal training, whether should there be a formal training process for clinical ethics analogous to clinical residencies or fellowships, and whether, if ethics consultants were required to complete such a programme, respondents would be more likely to use consultation services (table 33).). Most respondents (70%) indicated that they believed the relevant knowledge and skills can be taught through formal training. Most respondents (60%) also thought there should be a formal training programme, analogous to medical residency, that ethics consultants should be required to complete. Despite this endorsement of increased formal training of ethics consultants, however, relatively few respondents (33%) said they would use consultation services more often if there were such a training requirement.
The survey concluded with a series of 10 questions on discipline‐specific training. These questions examined the nature and extent of formal training expected of ethics consultants involved in the care of patients in ICU. The questions were divided into two parts: the first set of questions asked respondents to suppose that the ethics consultant is working alone and the second to suppose that consultation services are provided by a consultation team. Each of the above‐mentioned areas of expertise were examined in each set of questions (table 44).). In clinical settings, where an ethics consultant is working alone, most respondents (56%) felt the consultant needed to possess, at minimum, a medical degree to contribute effectively to the care of patients in ICU. The frequency with which advanced training in medicine was cited as needed to contribute effectively to the care of patients in ICU was significant in comparison to advanced training in each of the other disciplines examined (law, p<0.023; ethics, p<0.001; theology, p<0.001; and conflict mediation, p<0.001).
In settings where ethics consultation services are provided by a team, >80% of respondents felt at least one member of consulting team needed to have advanced training in medicine. Law ranked second with 60% of respondents citing a need for advanced legal training, followed by ethics (55%), theology (39%) and conflict mediation (28%). However, nearly all respondents (89%) indicated that at least one member of the consultation team should have some training in conflict mediation. Similarly, nearly all respondents (89%) felt at least one member of the team should have some formal training in ethics. With respect to each discipline, respondents indicated that more advanced training should be required for teams than for individuals (law, p<0.001; medicine, p<0.01; ethics, p<0.001; theology, p<0.01; and conflict mediation, p<0.001).
There was strong support for multidisciplinary training of consultants (table 55).). In settings where the ethics consultant is working alone, nearly a third of respondents felt advanced training in at least two disciplines is needed if the ethics consultant is to contribute effectively to the care of patients in ICU. Where ethics consultation services are provided by a consultation team, 68% of respondents felt the team should include members with advanced training in at least two disciplines and over half felt the team should include members with advanced training in at least three disciplines.
Based on our review of the literature, we believe that this is the first study to examine physician views regarding the training of ethics consultants. Four findings are noteworthy.
First, it is clear that physicians who frequently care for patients in ICUs believe ethics consultants need to possess specialised non‐medical knowledge and skills if they are to contribute effectively to patient care. Expertise in ethics and law is viewed as especially helpful, but familiarity with religious traditions and competence in conflict‐mediation techniques are also viewed as highly relevant to ethics consultation. This is consistent with prior research suggesting that interest in obtaining assistance with conflict mediation is a frequent trigger for ethics consultation requests.23 To the extent that many ethics consultants may have little formal training in one or more of these areas, particularly conflict‐mediation techniques,24,25 this finding points to a potential discrepancy between users' expectations and the expertise and skills of those persons who provide ethics consultation services.
Second, although expertise in ethics and law is viewed as particularly helpful in the provision of ethics consultation services, when asked about the formal training consultants should possess, physicians who frequently care for patients in ICU most often identify advanced medical training as important if ethics consultants are to contribute to patient care, irrespective of whether consultation services are provided by a single individual or by a consultation team. To the extent that many ethics consultants have limited medical training,26 this finding points to a second potential discrepancy between users' expectations and the expertise and skills of ethics consultants.
Taken together, these two findings seem inconsistent. If physicians who frequently care for patients in ICU value the consultant's non‐medical expertise in the areas of ethics and law, then why is medical training most often identified as the type of formal training needed for the consultant to contribute to patient care? We believe these two findings suggest that physicians who frequently care for patients in ICU may view the ideal ethics consultant as a physician with additional training or specialised skills relevant to the management of ethical issues. This “medicine plus one” model is consistent with prior research suggesting that 42% of physicians found other doctors to be the most helpful advisors they spoke with in resolving ethical dilemmas.27 There may be other explanations of these findings, however, more information on physician views regarding the relationship between the formal training of ethics consultants and their possession of relevant expertise is needed, especially data on physician views concerning the contributions to patient care made by ethics consultants with limited medical training.
Third, it is clear that physicians who frequently care for patients in ICU expect ethics consultants to possess advanced training in multiple areas, whether they are working alone or as part of a team. This suggests a need to consider how reasonable users' expectations of ethics consultants may be, especially in settings where ethics consultation services are provided by a single individual. This finding also suggests a need to consider whether the provision of ethics consultation services via a team approach may be more consistent with users' expectations. If the knowledge and skills identified by users as critical in providing effective ethics consultation are so varied and multidimensional that no single individual should be expected to possess them all, then this may argue in favour of team‐based consultation services—although other considerations, such as cost or time, may argue against such an approach.28 This finding may also support the design of training programmes in which aspiring clinical ethicists receive multidisciplinary training in those methods most immediately relevant to clinical ethics consultation,29 from a single programme, in contrast to being trained more extensively in multiple traditional programmes such as in philosophy, law, medicine or religious studies.
Fourth, our findings suggest that a significant proportion of physicians who frequently care for patients in ICUs are uncertain about the formal training that should be required of ethics consultants. This most likely reflects the relative novelty of ethics consultation services. In addition, while physicians who frequently care for patients in ICU are well positioned to assess the requisite skills needed to provide effective ethics consultation, they often are less well prepared to assess the formal training required to establish competency in those skills. As clinical ethics services expand and consultation methods become more standardised, it is likely that user expectations regarding the formal training and credentialing of ethics consultants will become better defined.
This is the first empirical study of physician views regarding the training of ethics consultants. As such, it has a number of limitations. Physicians recruited for the study were employees of a single, large teaching hospital with a religious orientation to care and may not be representative of physicians working in ICUs at other institutions. Most respondents were men, which may have introduced a gender bias. Eligibility for the study was limited to physicians responsible for the care of at least 10 patients in ICU over a 6‐month period. This criterion was selected to help ensure that eligible physicians recently had been in clinical contexts often associated with substantive ethical issues, but could have biased the results to reflect the unique demands of advising on ethical challenges at the end of life, thereby limiting the potential generalisability of the results we report to other settings in which ethics consultation occurs. In addition, the survey did not define expertise in ethics, law, religious traditions or conflict mediation. Finally, although the response rate in our study was comparable to, or better than, that of similar surveys,30 response bias is still a possibility.
These considerations suggest that our findings should be viewed as preliminary. In that spirit, we hope the results we present can serve as a helpful guide to others interested in examining these issues in future studies of broader scope. Examining physician views regarding the training of ethics consultants in a larger, more diverse sample would be especially helpful because such a study might reveal regional differences and would allow for comparisons between respondent characteristics and preferences regarding the training of ethics consultants. In addition, qualitative studies would be valuable, as they might provide additional insight into respondents' preferences for particular types of expertise and would permit exploration of the relative value physicians place on access to multiple disciplinary perspectives (eg, in comparison to having more convenient or timely access to individual consultants trained in a single discipline). It would also be useful to examine the views of other people who may solicit ethics consultation—for example, nurses, hospital administrators, and, perhaps, patients and their families. Finally, physicians' preferences regarding the training of ethics consultants might be assessed in relation to satisfaction with consultation services provided by individuals with varying types of disciplinary training.
Our findings are consistent with a conception of ethics consultation as an activity that often involves the introduction of diverse disciplinary perspectives into patient care. Although physicians who frequently care for patients in ICU believe that ethics consultants need to possess non‐medical expertise in ethics and law if they are to contribute effectively to patient care, many of these physicians place a very high value on medical training as well. Physicians caring for patients in ICU often expect ethics consultants to possess multiple advanced degrees, suggesting a “medicine plus one” view of the disciplinary training of an ideal ethics consultant. However, a sizeable proportion of these physicians remain unsure about the formal training that should be expected of ethics consultants. As clinical ethics consultation continues to expand, clear expectations regarding the training of ethics consultants should be established to ensure some level of consistency across medical institutions and services. These expectations should reflect both providers' and users' perspectives on the expertise required to do ethics consultation well. Empirical studies of physician views can contribute to ongoing professional initiatives to enhance consultation practices by clarifying what the potential users of clinical ethics consultation services value most about the contributions of ethics consultants.
We thank Drs Marion Danis, Sarah Hull and Lawrence McCullough for their thoughtful comments on earlier drafts.
ICU - intensive care unit
TMH - The Methodist Hospital
Competing interests: None.