Managing ethical issues in patient care and the need for clinical ethics support

Clinical ethics support (CES) is the emerging field of theory and practice concerned with enhancing the ethical quality or ‘ethicality’ of clinical practice within hospitals and other healthcare institutions.^1,2 ‘Ethical quality’ has several interrelated meanings. It can mean that clinical practices are consistent with social norms, such as patient autonomy; it can mean that ethical conflicts over patient care are minimised or appropriately resolved; it can mean that ‘moral distress’ among clinicians is adequately managed; and it can mean that a health organisation has an ethically reflective and engaged culture. With varying emphases between individual services, these elements of ethical quality are the main goals of CES.

CES is typically delivered by a multidisciplinary ethics committee, an individual ethicist or some combination of the two. It aims to provide ‘expert’ ethical input into an organisation’s policies and staff education, and assist with ethically difficult decisions about patient care. CES was initially introduced to help resolve ethical dilemmas and conflict, but it has since evolved to a more ambitious preventative model of fostering an ‘ethical environment’, where the ethical aspects of patient care are routinely and openly considered throughout an institution.^3–5

CES services are an established feature of healthcare in the US and Canada and are becoming so in the UK and elsewhere in Europe and Asia.^6–18 The growth of such services internationally is often taken to indicate a growing perceived need among clinicians for assistance with the many ethical and legal issues they face.^14–17 Although clinicians have always faced complex ethical decisions, the need for CES is driven by factors that have increased the ethical complexities of patient care, such as greater social and value plurality, technological advances and heightened patient autonomy.^19–21 Clinicians have traditionally dealt with ethical issues by keeping their own counsel, turning to trusted colleagues or professional codes of ethics or seeking guidance from religious authorities.²² According to advocates of CES, it is no longer sufficient in a morally pluralistic world to rely on professional opinion and codes to ensure ethically sound patient care: ethical quality requires ethical expertise.^23–26

CES services are currently available in some Australian hospitals, but they have not been widely adopted. According to the few available studies of such services in Australia, their operation has contributed to better patient outcomes, clinician satisfaction and improved ethics literacy across their host institution. ^27–29 Given that observational and experimental studies of CES conducted in the US have also shown positive results,^30–35 it is possible that many Australian clinicians and their patients are missing out on valuable support. This can lead to conflict that is avoidable or unresolved, moral uncertainty and distress and a lack of ethical scrutiny of clinical and administrative policies, processes and decisions.

Herein we report the results of a survey that was conducted as part of a project aimed at developing CES services within public hospitals in New South Wales (NSW), Australia. The project began with a qualitative study in one NSW public hospital, which found that most clinicians regarded their hospital ethical environment as ‘mostly right’, but that difficult ethical issues frequently arose and clinicians were receptive to the idea of CES.³⁶ The aim of the survey was to build on these findings by asking clinicians in the same hospital and an additional NSW hospital about the ethical issues they face, the ethical environment in which they work and whether they supported the idea of additional ethics support.

We conducted a cross-sectional survey of a convenience sample of clinical staff (medical, nursing and midwifery and allied health) in two departments in two large NSW public hospitals. All data were collected using a self-completed questionnaire. The questionnaire included both closed questions with fixed response options and open-ended questions, and required, on average, 15–20 min to complete.

Respondents were asked how often they thought about the ethical and legal implications of their clinical work, whether they had experienced uncertainty or concern about such issues in specified situations during the previous 12 months, how often they experienced uncertainty or concern about certain aspects of patient care (e.g. aggressive treatment), their response to such concern and the frequency and focus of discussions related to ethical issues in their work.

Using a four-point Likert scale, we asked respondents to indicate how strongly they agreed or disagreed with two sets of statements. One focused on the ethical environment of their hospital, the other on their department. Participants’ responses to each set of statements were combined to form a primary scale to indicate their degree of satisfaction with these ethical environments. A total score across all items was calculated. Scores were divided into three equal strata: a score of 7–13 indicated low satisfaction; a score of 14–20 indicated moderate satisfaction; and a score of 21–28 indicated high satisfaction. To be deemed highly satisfied, an individual would have agreed or strongly agreed to most positively worded items. Each scale was evaluated using Cronbach’s α to determine whether it measured the same underlying latent variable (i.e. degree of satisfaction).

The questionnaire also included open-ended questions asking how clinical ethics could be improved at their hospital and within their department, and fixed-response questions about existing and preferred means of ethics support. Demographic information was also solicited, including age, gender and profession.

Respondents could complete the survey online or as a pen-and-paper questionnaire. The online survey was distributed via an email from the research team that contained a hyperlink to the questionnaire. The email assured anonymity, described the survey and provided an estimate of the time it would take to complete. An email reminder was sent 2 weeks following the initial mail out. The pen-and-paper questionnaire was distributed to potential respondents in person by the clinical support officer or the nursing unit manager. Clinicians were also invited to complete the survey at a pre-arranged meeting.

Data were summarised using descriptive statistics. Proportions are shown as percentages rounded to the nearest whole number. Responses were further analysed on the basis of gender, age, profession and hospital. Associations were tested using Pearson Chi-squared analysis and odds ratios (OR) with 95% confidence intervals (CI). In some analyses, age and profession were dichotomised (21–40 years vs >40 years and medical vs non-medical, respectively). ORs are used to show significant associations, and we report only statistically significant associations (P ≤ 0.05).

This study was approved by the Hunter New England Human Research Ethics Committee (10/12/15/4.12) and the NSW Human Research Ethics Committee (HREC/10/HNE/373).

From the two hospitals, 105 clinicians participated in the survey. The denominator is less than 105 for some items because: 1 – answering was conditional on the basis of preceding question (e.g. If Yes, then…?); and 2 – a small number of respondents did not provide data for some questions. Values are presented with denominator.

Respondent characteristics are listed in Table 1.

Table 1.  Respondent characteristics (n = 105)
Note, seven respondents did not provide data for the first four characteristics; 13 did not provide data for the last. Unless indicated otherwise, data show the number of respondents in each group

We were unable to determine how many clinicians received or sighted the email invitation, or were made aware of the pen-and-paper survey, so were unable to calculate a response rate.

Over half (58/103; 56%) the respondents reported that in the past 12 months they had often considered the ethical implications of their decisions, but a much smaller proportion reported having often been uncertain or concerned about ethics (Table 2). Combining ‘often’ and ‘occasionally’, over half (62/104; 60%) the respondents reported being concerned about what is ethically the ‘right thing to do’ and the majority (74/104; 71%) reported being concerned about the ethics of the decisions and actions of others.

Table 2.  Frequency of ethical uncertainty and concern
Data show the number of respondents in each group, with percentages in parentheses

Respondents were also asked about the legal implications of their decisions (Table 2). Less than half (44/104; 42%) reported often thinking about the legal implications of their decisions. Again, smaller numbers of respondents reported often being uncertain or concerned. Combining ‘often’ and ‘occasionally’, 46 (46/105; 44%) respondents reported that in the past 12 months they had been concerned about what is legally the right thing to do and 57 (57/105; 54%) reported being concerned about whether what other clinicians were doing was legally right.

Respondents were given a list of situations and asked whether they had experienced ethical and/or legal uncertainty or concern related to a particular relevant situation. Experiencing both ethical and legal uncertainty was the most commonly reported category for each situation. Table 3 combines those reporting ethical and/or legal concern in relevant situations. Concern in two situations showed a significant difference according to age. Younger respondents (21–40 years) were more likely to report ethical and/or legal concern at a patient refusing recommended treatment than older respondents (86% vs 61%; OR 3.9, 95% CI 1.4–11.5). Younger respondents were less likely to report being concerned about carrying out an advance directive (8% vs 35%; OR 0.2, 95% CI 0.3–0.9).

Table 3.  Proportion of respondents reporting uncertainty or concern in relevant situations
Data show the number of respondents in each group, with percentages in parentheses

Respondents were asked about the specific causes for their ethical concern or uncertainty. The most frequently indicated cause(s) for concern were: (1) whether the patient is receiving the treatment they really want (63/102; 62%); (2) the quality of the information the patient is being given, and how (62/103; 60%); (3) whether the treatment is too aggressive (59/102; 58%); (3) being restricted by resources in providing the care or treatment it was believed a patient needs (57/102; 56%); (4) patient preferences and whether choice is being respected (52/102; 49%); (5) concern that the personal values of clinical staff may be inappropriately influencing patient care (27/100; 27%); and (6) concern regarding the appropriateness and quality of care generally (22/101; 22%). There were no significant differences according to gender, age, profession or hospital.

Respondents were asked what they do when they are uncertain or concerned about the ethical implications of a clinical situation. Most (96/105; 91%) indicated they would ask for the opinions of colleagues; approximately two-thirds indicated they would raise the issue in a group forum (68/105; 65%) or consult a relevant guideline (64/105; 61%); 39 (39/105; 37%) indicated they would meet with the patient and/or family and allow them to decide; 29 (29/105; 28%) indicated they would consult with a clinical ethics committee or other source of ethics expertise; and 23 (23/105; 22%) indicated they would discuss the situation with their partner or close friend. There were no significant differences according to gender, age, profession or hospital.

Respondents were asked ‘How often is what you usually do not helpful in addressing your uncertainty or concern?’. Sixty-nine (69/105; 66%) respondents indicated that their actions were ‘never’ or ‘rarely’ helpful, 18 (18/105; 17%) indicated that their actions were ‘occasionally’ helpful and four (4/105; 4%) reported that their actions were ‘always’ helpful.

Respondents were asked to agree or disagree with set of statements about their hospital. As indicated in Table 4, a large majority of respondents agreed to strongly agreed with the positive statements and disagreed with the single negative statement (‘This hospital is too ready to accede to external political demands’). The statements were scaled and a summary score estimating the individual’s satisfaction with the ethics of their hospital was derived (see Methods). The scale was evaluated using Cronbach’s α (0.87). Sixty-five (65/99; 66%) respondents indicated they were highly satisfied with the ethical environment of the hospital, whereas 33 (33/99; 33%) indicated moderate satisfaction. Only one respondent indicated low satisfaction. There were no significant differences between medical and non-medical respondents or according to hospital.

Table 4.  Respondents’ degree of satisfaction with the ethical environment of their hospital and department
Data show the number of respondents in each group, with percentages in parentheses

Respondents were asked to indicate their agreement with a set of statements about their department (Table 4). The ethical environment of the department was also explored by scaling the statements and by estimating individual respondent satisfaction. The scale was evaluated using Cronbach’s α (0.82). Twenty-two respondents (22/98; 22%) indicated they were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) indicated moderate satisfaction. Two respondents indicated low satisfaction. There were no significant differences between medical and non-medical respondents or according to hospital.

Respondents were asked whether they believed that clinicians are usually comfortable handling the more common clinical situations involving ethical issues. Most (71/105; 68%) answered ‘Yes’; nine (9%) answered ‘No’ and 17 (16%) answered ‘Don’t know’. When they were asked ‘Are there some ethically complex or challenging situations where more support might be helpful?’ most (72/105; 69%) responded ‘Yes’. These respondents were then asked to identify what they felt may be helpful.

Table 5 shows what types of support respondents indicated would be most helpful. The three most commonly preferred types of support were protocols and guidelines (44/72; 61%), having ethics or legal issues covered in routine clinical meetings (42/72; 58%) and having an ethics or legal expert available for advice (39/72; 54%).

Table 5.  Types of support respondents believed would be most helpful
Data show the number of respondents in each group, with percentages in parentheses

Most of the clinicians surveyed for this study were sometimes to often troubled by the ethical and legal implications of their own clinical decisions and those of their colleagues. Respondents were most concerned about situations that are known to be ethically and legally sensitive, such as end-of-life care, medical errors and patient privacy.^37–42 Patient autonomy appeared to be the most common source of concern. The five situations that were most commonly reported to be troubling were (in rank order) a patient refusing recommended treatment, disagreement among staff, a patient requesting a treatment of uncertain value, aggressive treatment of a terminally ill patient and a patient requesting treatment outside hospital guidelines. The first, third and last of these situations are related to managing patient preferences and choice. Patient autonomy was also prominent in what respondents indicated were the specific causes of their uncertainty and concern: whether the care a patient is receiving is really what the patient wants, concern about the information a patient is being given and concern about patient preferences being respected and staff inappropriately influencing care.

The majority of respondents appeared to be satisfied with the ethical environment of their hospital and their department. At the hospital level, most respondents indicated being highly satisfied that policies and procedures were ethically appropriate; patients’ interests generally have priority and the values upheld at the hospital mostly reflected their own personal and professional values. Although fewer clinicians indicated being as highly satisfied with their department as they were with the hospital, most still indicated a general satisfaction with the ethics of their department and that ethical issues are attended to appropriately, openly and inclusively.

Most respondents indicated that they were generally comfortable dealing with the ethical issues they face and, similar to the findings of other studies,^6,42 when they are uncertain or concerned they are most likely to talk to their colleagues. Raising an issue of concern at a group forum was also commonly reported, as was consulting a relevant guideline. Although these actions were generally considered helpful, over two-thirds of respondents indicated that additional clinical ethics or legal support would be helpful. Protocols and guidelines, having clinical ethics feature in routine clinical meetings, continuing education and training and having an individual clinical ethics or legal expert available for advice appeared to be most preferred options for further support. A clinical ethics committee was among the least preferred options.

Although talking to colleagues or consulting a relevant guideline or policy can help address ethical uncertainty or concern, it does indicate that clinicians are largely relying on traditional approaches to dealing with ethical issues. As discussed in the Introduction, these approaches are increasingly considered inadequate for ensuring ethical quality in the context of a more socially and morally diverse contemporary society. Given that the social factors that make clinical work more ethically and legally complex are evident in Australia, the scarcity of CES means most Australian clinicians are currently left to navigate their way through complex ethical issues with little specialised support.

Ethical tensions and difficulties that may arise anywhere in a hospital (from the bedside to the boardroom) are not always recognised and acted on as such and, even where recognised, may be considered too hard and avoided. Left unrecognised or overlooked, ethical issues can block communication, create uncertainty or distress about treatment goals and ultimately undermine quality care. A clinical ethics support service providing assistance with policy development, staff education and difficult cases can foster an ethically aware environment where issues are addressed and uncertainty and distress minimised.

Clinician satisfaction with the ethical environment does not indicate that ethical quality is consistently achieved. As one prominent clinical ethicist has observed: ‘Doctors and other healthcare professionals are seldom widely educated in ethics, and no matter the length of their experience, they are by no means guaranteed to have ‘ethical perspicacity’.’⁴³ The majority of the clinicians we surveyed appeared to recognise this by indicating that additional support would be helpful in working through ethical and legal concerns that face them in their day-to-day work.

Responses to this survey were drawn from a non-random sample in which female respondents were clearly over-represented. The findings are also susceptible to social desirability bias (i.e. respondents may have tended to provide what they saw as the most socially appropriate response, instead of what they truly believe). These considerations reduce the generalisability of the findings.

The results of our survey support our qualitative findings reported elsewhere,³⁶ namely that most clinicians see the ethical environment of their hospital and department as ‘mostly right’, that troubling ethical and legal issues frequently arise and that, although these are considered to be generally adequately managed, further support in dealing with these issues would be welcome. CES can take the form of an individual clinical ethicist, a multidisciplinary clinical ethics committee or a hybrid of the two. Which type of support is the most suitable and what functions (e.g. case consultation) should be undertaken are questions that require further investigation. Helping clinicians to provide ethically sound patient care should be a priority of public hospitals in NSW and elsewhere in Australia.

The authors declare no competing interests.