A process for resolving ethical issues in patient care is required for accreditation of hospitals in the United States.1 There are currently no formal or preferred qualifications for providing clinical ethics consultation, resulting in great variability in the composition of consult services and ethics committees.2 The quality of the consultation is directly related to the qualifications of those performing the consultation. Expert guidance by professional bioethicists is absent in many hospital settings, which potentially creates an ineffective ethics committee consultation process. The Joint Commission mandates hospitals to establish a process to consider and educate healthcare staff about ethical issues in patient care.1 Hospital ethics committees over the past decade have been used for the following issues: education about clinical ethics to ensure that everyone is aware of the committee and what it can accomplish and what it cannot; second, providing input into policies around end-of-life care and orders for do not resuscitate; third, assisting with determinations of brain death; and lastly being granted decision-making authority.3 Existing literature recommends the following be incorporated as part of the responsibilities of ethics committees:4
1. educational sessions on relevant ethical issues for staff, patients, and members of the committee;
2. setting annual goals for the ethics committee and regular evaluation of the committee;
3. reviewing the policies proposed by the committee;
4. providing patients and families with brochures explaining the process of treatment decision making, advanced directives, and the role of the ethics committee;
5. providing courses in conflict resolution;
6. educating all staff on the bioethics; and
7. sharing experiences of staff members who have been patients in the hospital.
As there is variation in the expertise and composition of ethics committees and with the availability of advanced technology, the concept of an online video consultation service with a bioethicist may provide the needed expertise to hospitals. The following describes a hypothetical service and how it could be developed and implemented.
CONCEPT OF AN ONLINE BIOETHICIST CONSULTATIVE SERVICE
An online video bioethicist consultation service would serve to supplement hospital ethics committees by providing professional bioethicist services. Using a video platform, the professional bioethicist could be contacted to provide expert opinion and assistance to the local ethics committees on how to proceed with challenging ethical consultations. The service would be similar to online individual counseling services and video interpreter services. An online ethics consultation service would provide bioethicist consultations in an easy and convenient video format (Figure).
AIM OF THE CONCEPT
Currently, there are no online video ethics consultation services. Most online ethics services are focused on the ethics education, not supportive expertise to the clinical bioethics consultation. Providing video conferencing services for a professional bioethicist would be unique to the marketplace. The aim of the concept would be to provide bioethicists consultation and education services using a novel online service to healthcare facilities.
DESIGN AND ACTION OF THE ONLINE SERVICE
An online ethics service would provide subscribing members access to a professional bioethicist including bioethicist's participation during consultations and education of the hospital staff. Employment of an in-house bioethicist is often not feasible in many healthcare organizations. An expert bioethicist consultation through video conferencing would close this gap and supplement hospital ethics committees by providing a professional bioethicist consultation and education services. Access to an online expert bioethicist would enhance ethics consults while allowing those hospitals with existing hospital ethics committees to retain support and function within the medical centers. In addition, collaborating with an online bioethicist would provide continual education to the hospital ethics committee members. In addition, the online bioethicists would provide debriefing discussions to assist staff and ethics committee members dealing with emotionally charged situations. Use models for the service would include lack of bioethicist at the medical facility, during times of vacation of ethics committee members, 1-time consult for a difficult patient case, and 24-hour accessibility-convenience.
ISSUES TO CONSIDER
Healthcare providers and patient and family members would require messaging and support for utilizing a video consultation service. Healthcare teams may not accept an online service because of a perceived lack of personal touch. Participants would need assurances of confidentiality. Messaging to ethics committee members and healthcare providers could include an e-mail introduction, in-person video demonstration with question-and-answer sessions and pamphlets. Final follow-up with these groups would consist of a thank-you e-mail and opportunity to discuss any remaining questions. The rationale for this extensive messaging campaign is because the frontline team would need to embrace and support video ethics consultation services. Patient and family member messaging would include an e-mail newsletter to promote the service. Messaging about benefits of the services including improved access to an independent expert and confidentiality would be provided. Because the service may not be used by all patients and families, a comprehensive messaging plan would not be provided until time of service. At that time, the patient and family would be provided introduction to the bioethicist and opportunity to ask questions about the process.
EVALUATING AN ONLINE BIOETHICIST SERVICE
A new service would require evaluation or proof of concept. This could be done using performance improvement methods. For example, the overall goal would be to utilize the service to provide education and ethics consultations. An initial number of 10 consultations in a defined period would be recommended, with subsequent measuring of staff, patient, and family satisfaction. A tool could be used for such a measure-the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) questions concerning communication with doctors and nurses and annual staff satisfaction surveys. An additional measure would be time to consultation to enable a comparison to existing data before implementation.
THE CLINICAL NURSE SPECIALIST: AN IMPORTANT TEAM MEMBER
The clinical nurse specialist (CNS) is an integral part of the multidisciplinary team in the inpatient setting. When a new consulting service is being considered, the CNS bridges the gap between the existing model and the addition to the model. In the example that has been described above, the CNS would provide the following: develop the nurse's ability and confidence to analyze bioethical issues to enable the nurse to advocate for bioethics consult and increase bioethical applications to timely address ethical issues. The education and ongoing support for the nurse to actively participate in bioethical decision making within the hospital would be enhanced through monthly discussion groups led by the CNS and the CNS serving as a facilitator and educator in the expanding field of bioethics and online consultation technology.
The CNS would engage the multidisciplinary team and provide ongoing assessment of the online bioethics consultation service in the initial testing phase. The final use model for the online service would be determined by the teams using the service and the CNS serving as the facilitator and program manager to ensure all members including the patient and family had their needs met.
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