It Takes a Village: Lessons on Multidisciplinary Care
from the Practice of Clinical Ethics Consultation
By Michael Rubin, MD, and Daiwai M. Olson, PhD, RN, CCRN, FNCS
Michael Rubin, MD
Daiwai M. Olson,
PhD, RN, CCRN,
FNCS
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.
ETHICS COLUMN
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