At the Bedside: Teaching Ethics in Real Time

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Introduction

Dr. Holland Kaplan, faculty in the Center for Medical Ethics and Health Policy and the section of General Internal Medicine at Baylor, and Medical Director of Ethics at Benab, presented on the crucial topic of teaching ethics at the bedside to learners.

Her discussion aimed to describe the benefits, identify the role of educators in improving ethical analysis, review frameworks for common ethical issues, and apply an approach to ethics teaching at the bedside.

Challenges of Bedside Ethics Education

Teaching ethics at the bedside is particularly challenging due to several factors:

• Time Limitations: Ethical issues often involve complexity and nuance, requiring significant time that is scarce in clinical settings.
• Lack of Expertise and Training: Many educators have not received extensive formal training in ethics or in how to teach ethical topics, unlike clinical subjects like heart failure or AKI. This can lead to a feeling of lacking expertise and uncertainty about the "right thing to do".
• Complexity and Uncertainty: Ethical dilemmas are often complex, involve inherent conflict, and require gathering substantial collateral information, which adds to the difficulty.
• Perception of Lack of "Teaching Pearls": There is a perception that ethics topics do not lend themselves easily to concise teaching pearls or chalk talks, and a lack of guideline-based consensus can further complicate teaching.

The Case for Bedside Ethics Education

Despite these challenges, there is a strong case for integrating ethics into bedside teaching:

• High Frequency of Ethical Dilemmas: Nearly 90% of physicians report encountering recent ethical dilemmas, and every patient interaction involves ethical or professional duties and value considerations.
• Missed Opportunities: Studies show that while residents frequently encounter ethical issues, faculty often miss the associated teaching opportunities.
• Bridging the Gap: Ethics is typically taught theoretically in medical school but less frequently when trainees witness it in action in patient care.
• ACGME Requirement: Competency in ethical principles is mandated by the Accreditation Council for Graduate Medical Education (ACGME).

Common Ethical Issues and Learning Objectives

Based on frequent ethics consults, common and challenging issues for trainees include:

• Informed consent
• Refusal of treatment
• Patient capacity
• Surrogate decision-making
• Goals of care
• Uncontrolled psychiatric issues contributing to ethical dilemmas, often related to capacity.

Recognizing the absence of a standard, objective list of ethics learning objectives, Dr. Kaplan has developed a list categorized by areas such as decision-making capacity, informed consent, advanced care planning, futility, and end-of-life ethics, which can serve as a roadmap for educators and learners.

Addressing Moral Distress

A critical topic often overlooked is moral distress, defined as "feelings of guilt, sadness, and defeat when we know what our patients need but can’t provide it". This feeling is common among healthcare professionals due to constraints within the "inhumane health system".

Dr. Kaplan suggests a practical approach to managing moral distress, both for oneself and learners:

1. Recognize the Distress: Differentiate moral distress from general emotional distress; it is a conflict between what is felt to be right and what is done due to external or internal constraints, leading to feelings of frustration and helplessness.
2. Identify the Moral Conflict and Constraints: Clearly articulate the right action versus the actual action, and pinpoint the sources of constraint (e.g., institutional pressure, lack of resources, societal policies). Conflicts often arise between principles like non-maleficence (doing no harm) and justice (resource limitations), or professional responsibility and systemic constraints.
3. Identify Available Supports (in the moment): Seek help from ethics services, chief residents, or clinical leadership, who may offer reassurance or system-level resources.
4. Implement Systemic Change (after the fact): Engage in initiatives like ethics morning reports, advocating for protocols, conducting quality improvement (QI) projects addressing causes of moral distress (e.g., AMA discharges), or pushing for policy changes. Providing a venue for discussion is especially valuable, as residents often express a lack of space to discuss distressing cases.

A case example of moral distress involved a 48-year-old man with uncontrolled diabetes, foot ulcers, and homelessness, who returned in septic shock after his prescribed oral antibiotics were stolen due to lack of safe housing. The team's inability to provide a safe discharge plan due to institutional pressures and lack of support options created moral distress.

Key Ethics Teaching Pearls and Approaches

Dr. Kaplan outlines essential teaching pearls for common inpatient ethics topics:

1. Decision-Making Capacity
   • Pearl: The four elements of capacity are the ability to express a choice, demonstrate understanding, appreciate consequences, and reason based on one's values. These are often memorized but not practically applied.
   • Approach: Ask trainees: "Which elements of capacity are you concerned this patient might not demonstrate?" or "How would you assess if this patient understands their treatment options?". Learners can also complete a formal capacity assessment tool like the Aid to Capacity Evaluation (ACE).
   • Pearl: Potentially reversible causes of limited capacity should be identified and addressed.
   • Approach: Ask: "What are the potentially reversible causes of this patient's limited capacity?" or "How can we optimize this patient's potential for demonstrating capacity?" Consider factors like hepatic encephalopathy, communication barriers (aphasia), comfort in the setting, or interpreter quality.
   • Pearl: Capacity is decision-specific and can vary over time.
   • Approach: Ask: "Do you think the patient has capacity for this decision? What about this other decision?" and "Has anything changed clinically that might affect the patient's ability to make their own decisions?".

1. Surrogate Decision-Making
   • Pearl: Identification of a surrogate decision maker is based on a legal hierarchy, which varies by state (e.g., Texas) or federal setting (e.g., VA). The person at the bedside may not be the legal surrogate.
   • Approach: Ask: "Who is the patient's legally authorized decision maker?" Encourage trainees to look up the state hierarchy or review medical power of attorney (MPOA) forms. Emphasize that the legal decision maker must be "reasonably available" and that others who know the patient well should be involved, even if not the primary legal decision maker.
   • Pearl: Surrogates should make decisions based on the patient's stated wishes (if known), then substituted judgment (what the patient would have wanted), and finally best interests (if little is known about the patient).
   • Approach: After family meetings, ask learners to identify the ethical basis for statements made by surrogates (e.g., "She told me she never wanted machines" – stated wishes; "I think she'd want everything done because she was a fighter" – substituted judgment; "I don't think anybody would want to live this way" – best interests).

1. Informed Consent
   • Pearl: Informed consent is a conversation, not just a signature, encompassing the nature of the procedure, its risks, benefits, and alternatives.
   • Approach: Before a trainee obtains consent, ask them to "walk through" what they will say to the patient about the procedure, risks, benefits, and alternatives.
   • Pearl: The patient must have capacity to engage in informed consent and be free of coercion.
   • Approach: Discussions about informed consent can naturally lead to teaching points on capacity and whether the patient might feel pressured by family or the medical team.

These pearls are illustrated through common scenarios like patients with fluctuating capacity, disagreements in goals of care, unrepresented patients, or those wanting to leave against medical advice (AMA). Example cases include a patient with schizophrenia intermittently pulling out an IV and refusing medicine, an 82-year-old with advanced Alzheimer's and recurrent pneumonia whose daughter insists on aggressive treatment and PEG placement, and a 58-year-old with heart failure exacerbation wanting to leave the hospital AMA.

Integrating Ethics into the Teaching Workflow

Dr. Kaplan suggests several strategies for integrating ethics into daily teaching:

• Transparency and Verbalization: Verbalize your ethical reasoning and thought processes when balancing different factors in a case, using an ethical lens.
• Debriefing: Utilize the moral distress framework during debriefs after ethically challenging situations to check in with the team and address their feelings.
• Recommending Resources: Suggest podcasts (e.g., Core IM, Bioethics for the People) and academic papers (e.g., on discharging AMA or assessing capacity) for further learning, especially when time is limited during rounds. Dr. Kaplan has compiled a compendium of such papers.
• Preventive Ethics Checklists: Proactively address ethical issues on admission by discussing code status, goals of care, and advanced directives (e.g., Medical Power of Attorney forms). Clinical teams discussing the importance of these documents significantly increases patient willingness to complete them.
• Utilize Visual Aids: Refer to diagrams or one-pagers (e.g., flowcharts for guardian appointment, guides for COVID-19 goals of care discussions).

Observations from implementing curricular interventions (e.g., ethics morning reports, Wednesday school curriculum) at Baylor residency indicate that senior residents, once more comfortable, can also be set up to teach the team on ethical topics, such as how to approach a consent conversation or anticipate conflicts in a goal of care discussion. This peer-teaching approach has proven effective.

Take-Home Points

• Teaching ethics at the bedside is feasible and necessary and can be integrated into existing teaching strategies.
• Acknowledge and address moral distress, as it is a prevalent issue among residents, often stemming from hierarchical decisions or systemic constraints. Fostering a safe environment for residents to voice these concerns is important.
• Focus on common and accessible ethics topics such as decision-making capacity, informed consent, surrogate decision-making, end-of-life ethics, and discharge ethics.
• Leverage available resources, including targeted questions, thinking aloud, recommending papers, and podcasts, to enhance ethics education on the wards.

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