Relational, Emotional, and Pragmatic Attributes of Ethics Consultations at a Children's Hospital

Abstract

Background: Pediatric ethics consultations are important but understudied, with little known about consultations' contextual attributes, which may influence how ethically problematic situations are perceived and addressed.

Methods: We analyzed data regarding 245 pediatric clinical ethics consultations performed between 2013 and 2018 at a large children's hospital. Prespecified data elements included 17 core problematic issues that initiate consultations, 9 ethical considerations identified by the consultation service, and 7 relational, emotional, and pragmatic contextual attributes of the consultation. The main process measure was the cumulative consultation process, ranging from one-on-one discussions with the requestor, to meeting with the clinical team, separate meetings with the patient or family and the clinical team, or combined meeting with the patient or family and the clinical team.

Results: The most-prevalent core problematic issues were intensity or limitation of treatment (38.8%) and treatment adherence and refusal (31%). Common pertinent ethical considerations were best interest (79.2%), benefits versus harms of treatment (51%), and autonomy and decision-making (46.5%). A total of 39.2% of consults culminated with a meeting with the clinical team, 9.4% with separate meetings, and 8.2% with a meeting with all parties. Common contextual attributes were discord (43.3%), acknowledged dilemma (33.5%), and articulate disagreement (29.8%). In exploratory analyses, specific contextual attributes were associated with the core problematic issue that initiated the consultation and with how the consultative process culminated.

Conclusions: Pediatric ethics consultations have contextual attributes that in exploratory analyses are associated with specific types of problems and, to a lesser degree, with the cumulative ethics consultation process.

FIGURE 1

Prevalence of core problematic issues and pertinent ethical considerations identified in 245 clinical ethics consultations from 2013 to 2018. For core problematic issues, the “other” category included problematic issues such as innovative treatment, disability rights, and child abuse and protection. For pertinent ethical considerations, the “other” category included ethical considerations such as professional obligations, justice, and disparities.

FIGURE 2

Prevalence of contextual attributes and final cumulative consult process identified in 245 clinical ethics consultations from 2013 to 2018. For cumulative process, the “other” category included processes such as referral to the General Counsel’s office, consultation with child protective services, or a full review by the ethics committee.

FIGURE 3

Prevalence of contextual attributes across top 7 core problematic issues in 245 clinical ethics consultations from 2013 to 2018. For each contextual attribute × core problem, *** P < .01, **P < .05, *P < .1.

FIGURE 4

Prevalence of contextual attributes across the 5 cumulative consult processes in 245 clinical ethics consultations from 2013 to 2018. For each contextual attribute × ultimate process, *** P < .01, **P < .05, *P < .1.