Abstract
Bioethics consultations are necessary to ensure excellent patient care and all US hospitals are required to provide access to bioethics consultants for cases raising ethical or moral dilemmas. However, there is a paucity of trained clinical ethicists. While assistance from trained bioethicists may be obtained via telephone or email, such methods of contact do not allow a bioethicist to engage fully with all members of the health-care team, the patient and family members. In two recent cases, rural hospitals contacted our centre for assistance with complex ethics cases. We provided a clinical ethics consultation via videoconferencing. The outcomes of the consultations would probably have been inferior had they been performed via telephone. For example, the non-verbal cues allowed the consultants to have a better understanding of the team dynamics, and led them to ask important questions that directly affected the recommendations which were made. Because patients are likely to benefit significantly from access to bioethicists when ethical questions arise, rural and community hospitals should consider teleconsultation when local ethics committees decide that further assistance is warranted.
Introduction
In the USA, the Joint Commission requires that all accredited hospitals make bioethics consultations available to staff for assistance in managing cases that raise ethical concerns. 1 The American Society for Bioethics and Humanities (ASBH) has identified the core competencies for health-care ethics consultation. 2 Because there are too few trained bioethics consultants to meet current demands, and insufficient resources to support such consultation services, many facilities rely on individuals with little or no formal bioethics training to provide bioethics consultation services. 3
Cases raising ethical concerns are often handled without the assistance of trained bioethicists. However, such assistance may be extremely helpful, particularly when difficult cases raise significant ethical questions. While assistance from trained bioethicists may be obtained via telephone or email, such methods of contact do not allow a bioethicist to engage fully with all members of the health-care team, the patient and family members. Telemedicine can provide a link between community hospitals struggling with complex ethical issues and trained bioethicists at academic institutions. We report two experiences with such consultations, where trained academic bioethicists provided consultation services to local ethics committees at rural hospitals to assist with ethically complex patient care issues. In both cases, we used ordinary videoconferencing units (model 880, Tandberg) at both the academic and the rural hospitals, connected at a bandwidth of 384 kbit/s.
Case 1
Mrs M was a woman in her 70s who underwent exploratory surgery for abdominal pain at a rural hospital approximately 120 km from the University of California Davis Medical Center (UCDMC), the closest academic hospital. During surgery, Mrs M's surgeon found a tumour that he was unable to resect, and he felt that disclosing to Mrs M that she had terminal cancer was not in her best interest. Mrs M's husband agreed, and both planned to withhold information regarding the diagnosis from Mrs M based on their assessment of her best interest.
The surgeon informed the nursing staff that Mrs M was not to be told that she had cancer. This caused significant discomfort among several nurses, who subsequently asked for an ethics consultation. During the hospital's ethics committee's case discussion, members of the committee felt torn between the duty to tell the truth to patients and the principle of beneficence. On the one hand, the duty to tell the truth led several committee members to argue that disclosure of the diagnosis was necessary. On the other hand, many committee members felt that the principle of beneficence supported withholding this information if disclosing it would be harmful to Mrs M.
The ethics committee chair contacted one of the UCDMC bioethicists for assistance, and a videoconferencing link was established connecting the bioethicists with the hospital's ethics committee. During the one-hour consultation, the bioethicist helped committee members, nurses and the surgeon understand the ethical issues pertinent to the case and helped develop an ethically sound course of action. While the surgeon and husband felt that the patient would be harmed by disclosing the diagnosis, it was clarified that decision of how much information should be disclosed should be at the discretion of the patient herself. The group discussed various strategies that would allow Mrs M to guide the amount and type of information she received. On follow-up, the care team and ethics committee members noted that the discussion was extremely helpful and led to meaningful changes in the care of Mrs M. Ultimately, Mrs M stated that she would want to be given complete information, and the surgeon fully explained the findings and prognosis to her.
The use of telemedicine in this case provided significant benefits over telephone consultation. During the consultation, the bioethicist was able to observe non-verbal cues that altered the consultation in meaningful ways. For example, at one point during the consultation the surgeon sat back in his chair with crossed arms indicating a reluctance to follow the recommendation of the consultant. On seeing this posture, the consultant used prior clinical cases to demonstrate how such conversations could be accomplished and also informed the surgeon that he was a practising intensive care physician, in addition to being a bioethics consultant. After this information and examples had been provided, the surgeon became more willing to consider how to follow the recommendations made, as demonstrated by a change in posture and arm position.
Case 2
Mrs Y was a woman in her 50s admitted to a rural hospital with abdominal pain. Her medical care was complicated by severe obesity, multiple endocrine neoplasia type 1 and diabetes. Mrs Y was found to have a spinal compression fracture as the source of her pain, and subsequently developed pneumonia. During her hospitalization, she fell while under the supervision of a physical therapist. The fall caused several significant injuries including soft tissue avulsion on one leg, a fracture of her humerus and additional vertebral compression fractures.
The health-care team, the patient and the patient's husband agreed on a plan of care that included dietary restrictions to produce weight loss. Despite both the patient and her husband agreeing to the plan, the husband repeatedly brought high fat foods to the patient. Because of her intake of fatty foods, Mrs Y's weight loss was insufficient to significantly improve her medical status. She also developed repeated infections leading to multiple admissions for intensive care.
The care team was concerned because Mrs Y and her husband had failed to comply with the agreed weight-loss plan, which had significantly delayed her recovery. Furthermore, Mrs Y was often uncooperative with physical therapy and rehabilitation. The staff had researched the possibility of transferring Mrs Y to a rehabilitation facility. However Mrs Y refused to be transferred because the closest rehabilitation facility was approximately 160 km away. On discussion with Mrs Y's husband, he stated that because the hospital had caused her injuries, the hospital should ‘fix it’ and therefore it was neither his nor his wife's responsibility to follow the care plan.
The hospital's ethics committee had been consulted. However they were unable to analyze the ethical issues fully and were unable to assist in developing a realistic plan of care. The hospital's risk management department therefore contacted the Program in Bioethics for advice. Because the hospital is so far from the UCDMC, it was not possible to meet in-person for a bioethics consultation. We therefore scheduled a videoconference where two bioethicists from UCDMC could meet the hospital's ethics committee and care team and discuss the case.
A brief case summary and outline of the hospital course was provided to the two bioethics consultants via email prior to the meeting. During the one-hour meeting, the bioethicists were able to provide meaningful assistance that improved patient care. The bioethicists noted that both the patient and her husband seemed to have significant secondary gain from her continued hospitalization, and that unless a care plan could be established that both Mrs Y and her husband truly felt was in her best interest, it was unlikely that they would comply with the rules made by the hospital staff. The consultants also discussed the need for the hospital to formulate a plan regarding payment for the hospitalization and to make a decision about how long they would cover the patient's care without reimbursement. The consultants explained that in order for Mrs Y and her husband to make important decisions regarding her care, they needed specific information regarding their financial liability.
On follow-up contact with the rural hospital's ethics committee, we received the following comments: ‘The discussion was very helpful and provided validation for many of the issues we had discussed, perceived, or have had difficulty as an entire team placing our finger on the underlying issues… One of the best analyses was segregating into financial, clinical and ethics groups. I was successful in holding a mediation with patient, family and professional mediator yesterday. We hope to have reached an agreement by next week so the clinical group can work on goal setting… [O]n behalf of our care team I wish to extend our sincere gratitude for consulting on this complex case. We live in beautiful surroundings, so what we lack in resources of specialists, we gain in looking out our windows everyday and feel so fortunate to have you graciously provide your consultation.’
The use of telemedicine in this case was important in providing excellent consultation services. During the video meeting, the consultants were able to see all members of the rural hospital's ethics committee and the treating team. This allowed the consultants to ensure that any members of the team who appeared to be reluctant to speak were given the opportunity to voice their opinions and concerns. Via telephone, the consultants simply would not have known that these individuals were in attendance. However, the consultants were able to engage care providers whose input was vital and would have otherwise gone unheard.
Discussion
Rural and community hospitals are often unable to provide onsite coverage for a wide range of subspecialty services. 4,5 It is therefore not surprising that over half of those who provide bioethics consultation at community facilities have no formal training in providing such services. 3 It is likely that those without formal instruction fail to meet minimum competencies as outlined by the ASBH. 2 Thus the ability of ethics committees in rural and community hospitals to consult with bioethicists who have formal training and experience in clinical bioethics is essential to provide excellent patient care.
Bioethics consultations often involve a threshold determination of whether an apparent moral dilemma is genuine and hence constitutes a situation in which honouring one duty entails the violation of another one of equal gravity, or whether the dilemma is actually illusory because the two duties are not commensurate or alternatively that in fact there is no conflict of duty. In Case 1, the institutional ethics committee viewed the situation as a genuine dilemma between commensurate duties of truth-telling (respect for individual patient autonomy) and beneficence/non-maleficence and could not reach a consensus on how to resolve the dilemma. The teleconsultation assisted the committee in recognizing that benefit and harm are intrinsically value judgments and the patient's values should ultimately govern information disclosure. When offered appropriate information about diagnosis and prognosis (the essential elements of informed consent) the patient elected to exercise her right to receive it. 6
Sometimes the circumstances giving rise to a request for a bioethics consultation require the development of a strategy for engaging the care team, patient and family in a process that will result in adherence to a plan of care. Such was the situation in Case 2. While implicit agreement had been reached with Mrs Y and her husband, their subsequent behaviour undermined the viability of the care plan and the goal of enabling the patient to leave hospital. The teleconsultation assisted the ethics committee and treatment team to mediate the apparent impasse through reformulation of mutual responsibilities for a successful therapeutic outcome. 7
Because bioethics consultations often rely on group interactions, which may require the participation of patients, patient representatives, family members and friends of the patient, a face-to-face consultation is generally preferred. When in-person consultation is not possible, videoconferencing provides an excellent alternative because it allows the group dynamic to be understood (for example, the consultant can see where participants choose to sit during the meeting, where participants look when others are talking, how non-verbal cues influence the group discussion, whether participants' facial expressions indicate agreement or disagreement with what is being said) and open conversation to occur. Compared to telephone consultations, videoconferencing incorporates telepresence and nonverbal communication which improves communication and patient/provider satisfaction. 8,9
Although bioethicists may find that leading a consultation via telemedicine requires some practice, we believe that this method is far superior to simple telephone calls because it allows the consultant to see the non-verbal cues (e.g. changes in posture, facial expressions and gestures) that are essential in understanding the subtleties of complex bioethics consultations. This is particularly important in bioethics consultation because non-verbal communication from participants may be pivotal in understanding ethical dilemmas and crucial in developing plans that will be supported by all. In the two cases presented, the outcomes of the consultations would probably have been inferior had they been performed via telephone. For example, in Case 2 the consultants were able to view the postures of the nurses, including times when some would fold their arms in front of themselves, which is an important non-verbal cue that people were feeling uncomfortable with what was being said. Such non-verbal cues allowed the consultants to have a better understanding of the team dynamics, and led them to ask important questions that directly affected the recommendations which were made. Because patients are likely to benefit significantly from access to bioethicists when ethical questions arise, rural and community hospitals should consider teleconsultation when local ethics committees decide that further assistance is warranted.