Due in part to their relative inexperience and incomplete training, pediatric residents are particularly sensitive to the complex medical, psychosocial, and ethical issues that arise in the care of children, particularly those who are critically ill. What may be routine issues to more experienced faculty and staff can be striking and disconcerting to pediatric residents and cause a great deal of personal and moral distress.
Currently, the venues available to Rainbow residents for further discussion of these topics are as follows:
1- Direct discussion with the attending and medical team during rounds
2- Additional informal discussion with the attending or other person within the medical team at another time
3- Ethics consultation
4- Resident Ethics Rounds
5- Informal discussion with a member of the Ethics Center faculty
In the spring of 2005, a survey was sent to all Pediatric and Medicine/Pediatrics house staff in order to evaluate their educational experience in pediatric ethics with respect to formal educational programs, ethics consultation, and an assessment of the ethics environment at Rainbow. Fifty-five residents replied divided evenly among PL-1, 2, and 3 with 55% female and 42% male overall.
Relevant frequencies are noted below:
• 87% would like to have additional opportunities to discuss ethical issues beyond Resident Ethics Rounds
• 93% thought more consults would be helpful for house staff education
• 31% wanted to call a consult on a patient at some time in the last year but were concerned about an adverse reaction from an attending on themselves or their career
• 71% could remember at least one specific patient in the last year for whom an ethics consult would have been very helpful but was not called
• 88% thought more ethics consults in the ICUs would improve their education
• Of the residents who had been involved in the care of a patient for whom an ethics consult was called, 92% felt that the consult was educational and 83% thought it was helpful in the care or management of the patient.
In follow-up discussions about the results of this survey with the chief residents as well as a smaller focus group of residents, they explained that in depth discussion on rounds about ethical topics was either impractical or discouraged, attendings were not always available or approachable for further informal discussion, and ethics consultation was frequently not endorsed. Although Resident Ethics Rounds was one forum for further exploring ethical issues in patient care, this conference was not helpful in addressing immediate questions or concerns about a specific patient. Although residents experience the need to further discuss ethical issues throughout their rotations and training, the circumstances that precipitate a need for further discussion were considered fairly common in the PICU, making it an appropriate place to pilot a new program. What these residents thought would be most helpful was an easy, accessible, non-threatening way to have further discussion with someone who has experience and expertise with complex ethical issues without complicating the care of the patient or jeopardizing their relationship with the attending or medical team.
In the event a resident rotating through the Pediatric Intensive Care Unit wishes to have further discussion about ethical issues relating to a patient in the Unit beyond that which occurs on PICU rounds, the resident may initiate an impromptu ethics forum by contacting the Rainbow Center for Pediatric Ethics. Dr. Anne Lyren or another Ethics Center faculty member will then arrange to meet with the resident(s) as well as any other interested staff to further discuss the patient, their impression, and the reasons for their concern or confusion. The Ethics Center faculty member will seek to help the residents by (1) providing an open, informal forum for discussion of complex ethical issues, (2) helping them identify, clarify and define the dilemma and/or ethical issues, (3) assisting them in gaining deeper insight and perspective on the patient’s case, (4) providing further reading material if applicable, and (5) following-up with the resident. This ethics forum will differ fundamentally from but not replace ethics consultation which will remain a more formal process that often includes the explicit involvement of the entire medical team, patient, and family as well as the Rainbow Babies & Children’s Ethics Committee. Should the resident decide to pursue formal ethics consultation, he or she can request such a consult in the traditional manner. This pilot program will be evaluated by the use of feedback surveys from all residents who rotate through the PICU in the six months following the initiation of the program. Informal feedback will also be solicited and welcomed from other members of the ICU staff.