Making difficult decisions in health care

Clinical ethicist Cecilia Marion knows that no matter who you are when making difficult decisions in health care, it’s important to reflect on the situation before choosing a course of action.

“Our ethics team at Covenant Health helps our colleagues slow down their decision-making when faced with difficult decisions,” says Cecilia. “Slowing down allows them to consider many perspectives, to broaden the picture.”

When planning care for patients, our care teams work hard to see the whole situation. Team members bring different perspectives such as the person’s health, their quality of life, the supports they have at home, their preferences, their understanding and more to the discussion. If they need assistance, they may consult with the Covenant ethics team.

Individuals and teams can request an ethics consult when there is some disagreement about how to proceed, whether it’s within the team or among the patient, resident or family members. Sometimes someone may “feel in their gut” that something does not feel right, says Cecilia. Other times the individual or team may want an external person to look at the situation to make sure they’ve thought through everything.

“We recently led an ethics consult about a patient with diabetes who lives in the community and who will require an amputation that the care team felt should happen right away,” says Cecilia. “The patient did not want to proceed now. The unit manager ensured the patient understood the situation, and the care team requested an outside perspective to help them make the best decision for the health of their patient.”

The team members had done a lot of work, but they were struggling with postponing the amputation, the effect of this decision on their patient’s quality of life and what the patient wanted.

In an ethics consult, the clinical ethicist does fact-finding and facilitates a discussion where all the facts are laid out.

“We provide a forum where the pros and cons, benefits and burdens, possible harm, the patient’s autonomy and our values, especially of compassion and respect, are discussed,” says Cecilia. “We support the care team to ensure they’ve looked at the situation from all angles before they make their decision.”

In this situation, the care team decided that the best course of action was to respect the patient’s choice and autonomy since the patient was capable of making the decision and not to proceed with the amputation at this time.

As part of the ethics consult, the group also discussed ways to mitigate risk if the patient were discharged. They developed a discharge plan that included things like arranging home care, getting the patient into the diabetes clinic more often and educating the people the patient lives with about what to watch out for and how to provide care at home.

In these and other situations, there are steps care teams can take to help them make difficult decisions, says Cecilia.

“When facing difficult decisions, do not make them alone. It’s really helpful to have a conversation with someone else. On the ethics team, we bring our consults back to our team for discussion to gain the broadest possible perspectives. In Catholic health care, there is a clear set of values we work by, so we use the values to help guide our decision-making.

“In health care, we also need to bring humility to decision-making, says Cecilia. “We do not know all, no matter what our role is.”