#tweetorial Excited to share my and @agoodbirth paper's on clinical ethics consultation and physician authority, now out in @SHIjournal
https://bit.ly/2ngYU8C 
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We re-examine past conclusions about the role of clinical ethics on physician authority and medical decision-making by exploring:
1) What issues drive ethics consultation, and
2) How issues are resolved
2/13

DRIVERS: We found the primary driver of requests for ethics consultation were disagreements between patients (or their surrogates) and physicians about treatment
3/13

Disagreements were often framed around 2 questions:
Whether a patient was competent to decline tx (cases where Drs wanted to provide tx & patient was refusing) OR
whether a tx was futile (cases where patients/surrogates desired a tx that clinicians did not want to provide)
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RESOLUTIONS: strategies for resolution included establishing clinical details, identifying relevant hospital policies, improving communication, and ultimately, focusing on clinical judgements
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How disagreements R framed often reinforces physician authority thru:
1) foregrounding the clinician's perspective, and
2) tying resolution to key judgements made by physicians: decision-making capacity and futility
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Process & communication strategies also reinforced phys. authority by:
Limiting perceptions of clinical ambiguity
Eliciting goals but limiting patient involvement in choosing particular treatments
Using expert communicators to "shift" goals of care towards less aggressive tx
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In most cases the resolution of problems was found in assent to clinicians' judgements and treatment preferences.
Is this 'good' or 'bad'?
8/13

It depends--it isn't clear that patient-centered care improves medical outcomes (PMID: 20933316) & some argue that done poorly, patient autonomy abandons decision-making onto those less able to understand how choices shape outcomes (see Bosk's excellent All God's Mistakes)
9/13

However, physicians generally approve of paternalistic decision-making more than the public (PMCID: PMC5996773) & more research, including recent research, is needed on satisfaction with ethics consultation
10/13

Key limitations of our study:
1) it was conducted at a single site, and
2) it was limited to analysis of the written record
11/13

Strengths:
1) we examined 156 individual ethics consultations
2) they were conducted over four years by many members of the hospital's ethics committee
3) we focused on what the written record could tell us: how cases were typified & the recommendations given for resolution
12/13

TL;DR: Disagreements, not ethical ambiguity, drive requests 4 ethics consultation (EC). EC resolves conflicts w/ process & comm. strategies, & when conflicts persist, solutions R often focus on clinical judgements, reinforcing role of physician authority in decision-making
13/13