0912P-CONCEPT PAPER ON CLINICAL ETHICAL CONSULTATION SERVICES AT KING FAHAD MEDICAL CITY

Executive summary

This paper presents the rationale and the methodology of providing ethical consultation services to all hospitals and departments at KFMC by the Bioethics Department housed in the Faculty of Medicine. The Department has qualified and competent ethicists with a wide expertise area that includes the Islamic and local cultural perspectives. They can provide their services by responding to normal ethics consultations from any practitioner or by making ward rounds especially in the Main Hospital Intensive Care Unit, the Pediatric Intensive Care Unit, the Fertility Services of the Women's Hospital, and the Rehabilitation Hospital to advise on specific conditions.

1.0  INTRODUCTION

Clinical ethical consultations play a role in clinical quality improvement [1,2,3}. Clinicians encounter ethical problems in their work for which they need professional guidance[4]. Empirical research has shown that hospitals do not fully utilize the clinical ethics consultation services that are available[5]. It is therefore important that clinical ethical consultation services be systematically organized.

2.0 BACKGROUND ABOUT THE BIOETHICS DEPARTMENT

The Bioethics department was established this year. Its mission is to become a leader in bioethics research, education, and clinical ethics services in Saudi Arabia. It also aspires to excel and expand our knowledge and consulting efforts to rest of the Arab world in the future. Its vision is to be one of the leaders of interdisciplinary ethics practice and education in order to create the needed knowledge and skills to improve health care delivery in Saudi Arabia and the Arab world in the future.

The Bioethics Department has 6 specific goals: (a) To link education to research and review the policies and procedures from a bioethical point of view. (b) To support and teach undergraduate students. (c) To support postgraduate educational programs. (d) To encourage and facilitate research in bioethics. (e) To provide ethics consultation services (f) To support clinical ethics activities including continuous medical education related to ethics for health care providers, ethics committees, ethics consultation, and projects related to ethics.

The department plans to undertake various activities in support of ethics education and practice: Education and teaching of medical students and residents, Continuous Medical Education Activities, Ethics Consultation Services, Policy Development & Review, Research Ethics & Ethics Research, and Exchange of ethics experience internationally

3.0  PROFESSIONAL EXPERTISE IN THE DEPARTMENT OF BIOETHICS (CVs attached)

The department has 2 full-time ethicists and a network of collaborating ethicists in and around Riyadh. Dr Abdul Aziz al Kaaba, head of the bioethics department, is a family medicine consultant at KFMC, and a holder of a masters' degree in ethics from Canada. Professor Omar Hasan Kasule has written and taught ethics extensively over the past 15 years and takes special interest in the Islamic perspective of medical ethico-legal-fiqh issues.

The department has got several part-time collaborators whose expertise can be called upon if needed. Professor Dr Jamal al Jarallah is a professor at King Saud University with a long history of publishing and teaching about ethics. Professor Farooq Khan is the chairman of the KFMC Institutional Review Board. Sheikh Khalid Al Shera is an expert in Islamic ethics. Dr  Mahmoud al Rakban is a consultant in Family Medicine and an expert on Islamic ethics.

4.0  METHODOLOGY OF ETHICAL CONSULTATIONS

After approval of this proposal and official introduction of its services to all departments of the King Fahad Medical Complex, the department will prepare a brochure and other more detailed material about the services it can offer. These will be widely disseminated in the hospital and on the city's website. This will be followed by field visits to various wards and departments to meet the staff and explain the services that the department can offer. These familiarization visits will also enable ethicists from the department to appreciate the nature and types of ethical problems that arise in practice so that they can fine tune their methodology.

Special ethics consultation / referral forms will be prepared and will be made available throughout the hospitals. Any physician taking care of a patient can on encountering an ethical issue write a consultation as for any other medical referral and an expert from the center will be dispatched to deal with the problem.

A weekly duty roster will be prepared for the 2 full-time ethicists in the department and will be made widely available throughout KFMC son that normal and emergency consultations can be routed to the right consultant immediately by telephone or pager.

The suggested consultation process will be as follows. A consultant who encounters a problem requiring an ethical opinion will complete the consultation form identifying the patient and describing the problem. The consultation request will be recorded in the patient's chart. The nurse in charge of the ward will send the request to the ethicist on duty and follow up by phone or pager. The ethicist will visit the patient, review the chart, and write his opinion and suggestions. Follow up visits to the patient if needed will be made. In some cases the ethicist may need to hold a conference involving physicians, nurses, and sometimes members of the family to discuss more complex issues.

Besides routine consultations, ethicists from the department will join regular ward rounds once a week at services with a high proportion of cases with outstanding ethical issues (ICU, Pediatric ICU, Oncology, and Infertility) This will make the ethical consultations more integrated into the ongoing clinical activities.

Cesides ward consultations, the ethicists will be available to participate in meetings on mortality or morbidity reviews.

5.0  ETHICAL ISSUES COMMONLY ENCOUNTERED

It is expected that the consultations will cover the following broad areas:

1. Informed consent for the incapacitated, children, and mental patients
2. Disclosure of surgical risk
3. Truth telling of patient condition
4. Violent and abusive patients
5. Maternal-fetal conflict
6. Organ transplantation
7. Assisted reproduction
8. End of life issues: artificial life support initiation / withholding / withdrawal
9. Beginning of life issues: stem cells / embryo research
10. Contraception
11. Genetic testing and counselling
12. Objections to routine immunization
13. Research ethics
14. Medical errors

6.0  REFEENCES

1. Opel DJ, Brownstein D, Diekema DS, Wilfond BS, Pearlman RA (Department of Pediatrics, University of Washington-Seattle, USA. djopel@u.washington.edu). Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement . Clin Ethics. 2009 Fall;20(3):220-6.

2. Nilson EG, Acres CA, Tamerin NG, Fins JJ. (Division of Medical Ethics, Weill Medical College of Cornell University, New York, New York, USA. eln2004@med.cornell.edu). Clinical ethics and the quality initiative: a pilot study for the empirical evaluation of ethics case consultation.  Am J Med Qual. 2008 Sep-Oct;23(5):356-64.

3. Nilson EG, Acres CA, Tamerin NG, Fins JJ. (Division of Medical Ethics, Weill Medical College of Cornell University, New York, New York, USA. eln2004@med.cornell.edu). Clinical ethics and the quality initiative: a pilot study for the empirical evaluation of ethics case consultation.  Am J Med Qual. 2008 Sep-Oct;23(5):356-64.

4. DuVal G, Clarridge B, Gensler G, Danis M.Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada. A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004 Mar;19(3):251-8

5. Whitehead JM, Sokol DK, Bowman D, Sedgwick P. (St George's, University of London, London SW17 0RE, UK. m0600174@sgul.ac.uk). Consultation activities of clinical ethics committees in the United Kingdom: an empirical study and wake-up call. Comment in Postgrad Med J. 2009 Sep;85(1007):451-4. & Postgrad Med J. 2009 Sep;85(1007):449-50.

ABSTRACTS

Opel DJ, Brownstein D, Diekema DS, Wilfond BS, Pearlman RA (Department of Pediatrics, University of Washington-Seattle, USA. djopel@u.washington.edu). Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement . Clin Ethics. 2009 Fall;20(3):220-6.

Nilson EG, Acres CA,. Clinical ethics and the quality initiative: a pilot study for the empirical evaluation of ethics case consultation. Am J Med Qual. 2008 Sep-Oct;23(5):356-64. The Institute of Medicine's quality imperatives include the need to provide safe, effective, patient-centered, timely, efficient, and equitable care. Less attention has been paid to quality metrics as they relate to the assessment of clinical ethics consultation and its impact on care. A better understanding of how ethics consultation influences the quality of care might identify opportunities for improvement. A descriptive pilot study, involving 7 hospitals in the New York-Presbyterian Healthcare System, was conducted to identify key elements of the ethics consultative process that might impact clinical and psychosocial outcomes. A majority of consults involved medical or intensive care unit patients and end-of-life decision making; 75.5% had or received a do-not-resuscitate order, 90.6% lacked decision-making capacity, 43.4% had an advance directive. Conflict existed in a majority. Future research should include surrogate decision making, patients on nonmedical services who may have unrecognized ethical dilemmas, and the role of conflict in clinical care.

Whitehead JM, Sokol DK, Bowman D, Sedgwick P. (St George's, University of London, London SW17 0RE, UK. m0600174@sgul.ac.uk). Consultation activities of clinical ethics committees in the United Kingdom: an empirical study and wake-up call. Comment in Postgrad Med J. 2009 Sep;85(1007):451-4. & Postgrad Med J. 2009 Sep;85(1007):449-50.  OBJECTIVE: To identify the consultation activities of clinical ethics committees (CECs) in the UK and the views of CEC chairpersons regarding such activities. METHODS: An anonymous, password-protected online questionnaire was sent by e-mail to 70 CEC chairpersons. The questionnaire contained 14 items. RESULTS: Of the 70 CECs contacted, 30 responded (a response rate of 43%). There has been an almost fourfold increase in the number of CECs in the past 7 years. Over half of the CECs that responded had considered three or fewer active cases and three or fewer retrospective cases in the preceding year. Eighty percent of chairpersons felt that the number of active cases considered by their committee was too low. Seventy percent of CECs had rapid response teams. Aside from low consultation caseloads, chairpersons identified a number of concerns, including education and training of members, composition of CECs, low profile and lack of funding and support. Although most respondents believed there is a need for clinical ethics support in the NHS, many noted the limited use of the services, even after efforts to increase the visibility of their CEC. CONCLUSION: Despite a sharp increase in the absolute numbers of CECs across the UK, the number of cases considered by the majority of CECs is low. The findings presented here suggest we must reflect on the reasons for such low caseloads and pause to consider whether the committee model is most appropriate for the UK context.

Nilson EG, Acres CA, Tamerin NG, Fins JJ. (Division of Medical Ethics, Weill Medical College of Cornell University, New York, New York, USA. eln2004@med.cornell.edu). Clinical ethics and the quality initiative: a pilot study for the empirical evaluation of ethics case consultation.  Am J Med Qual. 2008 Sep-Oct;23(5):356-64. The Institute of Medicine's quality imperatives include the need to provide safe, effective, patient-centered, timely, efficient, and equitable care. Less attention has been paid to quality metrics as they relate to the assessment of clinical ethics consultation and its impact on care. A better understanding of how ethics consultation influences the quality of care might identify opportunities for improvement. A descriptive pilot study, involving 7 hospitals in the New York-Presbyterian Healthcare System, was conducted to identify key elements of the ethics consultative process that might impact clinical and psychosocial outcomes. A majority of consults involved medical or intensive care unit patients and end-of-life decision making; 75.5% had or received a do-not-resuscitate order, 90.6% lacked decision-making capacity, 43.4% had an advance directive. Conflict existed in a majority. Future research should include surrogate decision making, patients on nonmedical services who may have unrecognized ethical dilemmas, and the role of conflict in clinical care.

DuVal G, Clarridge B, Gensler G, Danis M.Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada. A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004 Mar;19(3):251-8. OBJECTIVE: To identify the ethical dilemmas that internists encounter, the strategies they use to address them, and the usefulness of ethics consultation. DESIGN: National telephone survey. SETTING: Doctors' offices. PARTICIPANTS: General internists, oncologists, and critical care/pulmonologists (N = 344, 64% response rate). MEASUREMENTS: Types of ethical dilemmas recently encountered and likelihood of requesting ethics consultation; satisfaction with resolution of ethical dilemmas with and without ethics consultation. RESULTS: Internists most commonly reported dilemmas regarding end-of-life decision making, patient autonomy, justice, and conflict resolution. General internists, oncologists, and critical care specialists reported participating in an average of 1.4, 1.3, and 4.1 consultations in the preceding 2 years, respectively (P <.0001). Physicians with the least ethics training had the least access to and participated in the fewest ethics consultations; 19% reported consultation was unavailable at their predominant practice site. Dilemmas about end-of-life decisions and patient autonomy were often referred for consultation, while dilemmas about justice, such as lack of insurance or limited resources, were rarely referred. While most physicians thought consultations yielded information that would be useful in dealing with future ethical dilemmas (72%), some hesitated to seek ethics consultation because they believed it was too time consuming (29%), might make the situation worse (15%), or that consultants were unqualified (11%). CONCLUSIONS: While most internists recall recent ethical dilemmas in their practices, those with the least preparation and experience have the least access to ethics consultation. Health care organizations should emphasize ethics educational activities to prepare physicians for handling ethical dilemmas on their own and should improve the accessibility and responsiveness of ethics consultation when needed.