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It Takes a Village: Lessons on Multidisciplinary Care from the Practice of Clinical Ethics Consultation

By Currents Editor posted 10-29-2017 23:00

  
Michael_Rubin_Headshot.jpgDaiwai_Olsen_Headshot.jpgBy Michael Rubin, MD (left), and Daiwai M. Olson, PhD, RN, CCRN, FNCS (right)

The theme of this year’s annual meeting is “It Takes a Village.” Every intensive care practitioner worth their salt has learned that they are much more effective if they cooperate with nurses, therapists, pharmacists, surgeons, residents, and consulting physicians. They are all members of the same village. The challenge is that we don’t always know how to best work with each other. Often, we struggle to convince another member of our village that it is in their best interest to find a way to work with us. While we all agree that we have a duty to work for the benefit of the patient, we sometimes disagree over who should do what and when, as well as who needs to bend more than the other. Such interpersonal communication is valued — but it can be a tremendously difficult thing to teach.

Lessons can be applied from the world of clinical ethics consultation to help improve this process. Ethics consultants are called, for assistance, because some decision or conundrum leaves a provider ill at ease and with the perception that someone ought to “do something about it.” Ethics consultants are perceived to have the ability (or at least, some think we should have the ability) to review a situation, identify the ethical violation, and then force the situation to be realigned with what “ought” to be.

In truth, the ethicist has only as much authority as people (patients and providers) are willing to give. What ethicists do have is a specific knowledge set, one that most staff are familiar with but may still require clarification to fully understand. Often, people asking for our assistance have a strong impression about the situation at hand based on a gut instinct. Unfortunately, decisions made on instinct and a powerful moral compass often leave out other important considerations.

Beyond expertise, what makes an ethicist effective is the ability to peel back the layers of the onion and deduce the fundamental conflicts in a particular situation. Furthermore, ethicists have training and experience on how to build consensus amongst people with different opinions.

So, how does one build consensus? First, identify the issues and potential solutions. Next, elicit the views of each stakeholder and develop an understanding of how their background has brought them to their current perspective. The key to this is understanding the cultural influences, religious or spiritual traditions, and family relationships of each individual.

Now let’s turn back to the ICU. Being a good intensivist also requires a specific knowledge set. The intensivist must have a mastery of problems delegated to the intensivist and also possess enough familiarity with the primary disease’s related issues that they know how collaborators (consulting physicians, nurses, pharmacists, etc.) will usually manage them.

I would offer for your consideration that we should approach our colleagues from other disciplines in the same manner that the ethicist approaches the stakeholders involved in an ethics consult. How does their specialty train them to approach patient management issues? What do they see their role as? What are the concerns that they focus on, and what do they expect out of us? Each discipline, whether it be nurse, surgeon, physician, pharmacist, or therapist, has a paradigm, a method of practice and perceptions of the roles of others in the ICU. They are part of their own culture, which may be related to ours, but at the same time is different. Each discipline views the patient from a unique lens.

If we were a conductor managing an orchestra, we need to know who can perform best under what conditions and how their sound blends in with the whole. The conductor recognizes the value of each individual instrument and musician but also recognizes the need for teamwork. To expect everyone just to do their part without recognizing that they have differences leads to disorder and noise. Working in harmony together, well, that gives you Mozart.

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