The Role of the Clinical Ethicist: Supporting Patients, Families and Clinicians

Column Author: Stephanie Kukora, MD | Neonatal/Perinatal Medicine, Bioethics | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Column Editor: Brian Carter, MD | Neonatal/Perinatal Medicine, Bioethics; Neonatologist; Pediatric Bioethicist; Interim Director, Pediatric Bioethics | Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

When complex ethical situations arise in clinical practice, often in high-stakes situations with uncertainty, clinical ethics consultation may be helpful to patients, families, surrogates and clinicians. Ethics case consultation is a mechanism for resolving conflict and facilitating communication around treatment decisions when clinician, patient, and family stakeholders are unsure of or disagree about the right way forward.^1,2 When a consult is requested, clinical ethics consultants seek to learn not only the clinical details of the case, but also the values and perspectives of the various stakeholders. With this information, they may then discern what options may be permissible or impermissible in that situation³ and help guide decisions and resolve conflicts.⁴  

Navigating these challenging situations requires a distinct skill set, comprised of not only a foundational knowledge of clinical bioethics but also communication skills to sensitively facilitate conversations and mediate disputes when emotions are high. Likewise, ethics consultants should be familiar with frameworks including feminist and trauma-informed approaches to clinical ethics consultation, which aim to be systematically sensitive to sex/gender inequities, culture, history, power dynamics and marginalization.^5,6 Often, clinical ethics consultants seek to strengthen their knowledge and skills in these realms through coursework, skills trainings and clinical experience. 

HEC-C examination serves to identify and assess a national standard for the professional practice of clinical ethics consultation in health care and meets the National Commission for Certifying Agencies (NCCA) accreditation standard. Its content is based on the core competencies detailed by the American Society for Bioethics and Humanities.⁷ To be eligible for the exam, candidates must also have attained 400 hours of health care ethics experience over the past four years. This may be achieved through performing clinical ethics consultation and other scholarly work, including providing ethics education, ethics-related writings and publications, clinical policy development, ethics-related quality-improvement projects, and other activities.   

In addition to providing clinical ethics consultation and serving on institutional ethics committees, professional bioethicists can offer invaluable expertise for their institution. Newer approaches to preventive ethics, such as “ethics rounds,” have been proposed for addressing ethical concerns that have not risen to the level of a formal consultation.^8–11 Individual clinicians caring for a patient may be troubled by ethical dilemmas or moral distress,¹² but they may not feel empowered to request a consult, or the patient may die, be discharged or transferred before consultation may be completed. In these situations, clinicians may be left with “moral residue,” which over time leads to moral injury, compassion fatigue and burnout.¹³ By having regular check-ins at the bedside in the intensive care units and other clinical environments where ethical stresses often arise, clinicians can get in-time support, with targeted education on how to identify and mitigate moral distress.¹⁴ Additionally, clinical ethics consultants may serve as a resource for interprofessional ethics education,¹⁴ conduct ethics-related empirical research which can guide future normative ethics work and professional guidelines, and assist with drafting of hospital policies related to ethics-related topics including scarce resource allocation, non-beneficial treatment, and withdrawing and withholding of life-supportive technologies or therapies. 

Institutional support for professional bioethicists with additional training and certification through the HEC-C program demonstrates a commitment to an efficient, timely and standardized approach to high-quality ethics support for all practicing clinicians in the health care system. This commitment shows that ethical practice is valued by the institution, and that resolving conflicts and dilemmas with the focus on the patients, families and clinicians is a priority. 

Any community pediatric provider may call the Bioethics Center at Children’s Mercy Kansas City at (816) 731-7154 and request a consult by speaking with Ms. Jennifer Pearl. She can put them in touch with Dr. Carter, the Interim Director, or any other Ethics Consultant (we rotate calls weekly). The on-call ethics consultant is listed in Children’s Mercy Web On Call. Currently, there are six trained and experienced Ethics Consultants. They have all completed the year-long Certificate Program in Pediatric Bioethics at Children’s Mercy Kansas City, and have experience in conducting clinical ethics consults originating from inpatient as well as outpatient settings. 

References:

1. Kesselheim JC, Johnson J, Joffe S. Ethics consultation in children’s hospitals: results from a survey of pediatric clinical ethicists. Pediatrics. 2010;125:742-746. 
2. American Academy of Pediatrics. Committee on Bioethics. Institutional ethics committees. Committee on Bioethics. Pediatrics. 2001;107:205-209. 
3. Mercurio MR, Cummings CL. Critical decision-making in neonatology and pediatrics: the I-P-O framework. J Perinatol. 2021;41:173-178. 
4. Fiester A. Contentious conversations: using mediation techniques in difficult clinical ethics consultations. J Clin Ethics. 2015;26:324-330. 
5. Downie J, Sherwin S. Feminist health care ethics consultation. HEC Forum. 1993;5:165-175. 
6. Lanphier E, Anani UE. Trauma informed ethics consultation. Am J Bioeth. 2022;22:45-57. 
7. Tarzian AJ, ASBH Core Competencies Update Task. Health care ethics consultation: an update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ Core Competencies Update Task Force. Am J Bioeth. 2013;13:3-13. 
8. Foglia MB, Fox E, Chanko B, Bottrell MM. Preventive ethics: addressing ethics quality gaps on a systems level. Jt Comm J Qual Patient Saf. 2012;38:103-AP7. 
9. Epstein EG. Preventive ethics in the intensive care unit. AACN Adv Crit Care. 2012;23:217-224. 
10. Ho A, MacDonald LM-H, Unger D. Preventive ethics through expanding education. HEC Forum. 2016;28:69-74. 

11. Howe EG. Preventive ethics and alleviating care providers’ stress. J Clin Ethics 1993;4:283-286.

12. Hamric AB. Moral distress in everyday ethics. Nurs Outlook. 2000;48:199-201. 

13. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20:330-342. 

14. Firn J, Rui C, Vercler C, De Vries R, Shuman A. Identification of core ethical topics for interprofessional education in the intensive care unit: a thematic analysis. J Interprof Care. 2020;34:453-460.