Evaluation of clinical ethics support needs and service provision at a tertiary hospital in New Zealand

Abstract

Doctors often face ethical challenges in the course of clinical practice. Clinical ethics advisory services (CESS) provide a mechanism for supporting doctors facing these ethical dilemmas. In New Zealand, CESSs are relatively new and have emerged as a clinician-led initiative. This is an exciting time for CESSs in New Zealand, as their availability increases and their systems become increasingly formalised and integrated into the health care system. This thesis is the first in New Zealand to explore the clinical ethics needs of doctors and to evaluate how their clinical ethics needs could be most effectively met. The Capital and Coast District Health Board (CCDHB), comprising a major tertiary hospital and its satellite hospital, is used as a case study. Doctors at CCDHB have had access to a clinical ethics support service since 2010, when the CCDHB Clinical Ethics Advisory Group (CCDHB CEAG) was established. Many of the findings of the research would be applicable to CESSs throughout New Zealand. I developed a methodology to understand the clinical ethics needs of senior doctors at CCDHB and to evaluate how their needs could be better met. In-depth, semi-structured interviews were conducted with 14 senior doctors. The data were analysed using an iterative inductive strategy combining conceptual and normative analysis. My analysis draws on the current international literature of clinical ethics support, as well as my experience as a clinical medical student and my period of observation of the CCDHB Clinical Ethics Advisory Group. This study found that in the absence of formal services, doctors use ad hoc strategies of peer consultation to manage ethical issues. Not all doctors were equally able to access informal support, particularly junior doctors. Many participants were unaware that formal clinical ethics support was available to them and most did not know how formal ethics support worked. Some participants felt that to seek case consultation was to abrogate clinical responsibility and thought that doctors should be able to manage ethical issues themselves. Participants identified a need for improved strategies for clinically relevant ethics education. This study identifies five key recommendations to enhance clinical ethics support at Capital and Coast District Health Board: 1. CCDHB CEAG should formalise its activities, particularly case consultation, using a procedural justice model. 2. CCDHB CEAG should involve clinicians in the process of case consultation to increase user trust and to take advantage of case consultation’s educative value. 3. CCDHB CEAG should allow patients and their families and advocates the option of being involved in the process of case consultation, to ensure that patients feel that their perspectives have been adequately taken into account. 4. CCDHB CEAG should conduct monitoring and evaluation of its service to ensure that it achieves and maintains clinical relevance and normative robustness. 5. CCDHB CEAG should actively disseminate accurate and appropriate information about its aims and processes to all users and potential users to enhance trust in their service and to clarify misunderstandings about their role.