You are here: HomeEducational ResourcesSupport GuideAppendices → Appendix A5

Educational Resources: Appendices

Appendix A5

Issues to consider when setting up a case consultation service

Many clinical ethics committees (CEC) / groups provide ethics case consultation for clinicians within the trust. Case consultation may be undertaken by the whole committee, by a small consultation group, or by referral to an individual member of the committee who then consults with other members as appropriate.

Below we identify some issues that a CEC may wish to consider in providing a case consultation facility.

  • Who can refer cases to the CEC?
  • Process of referral
  • Pro forma referral forms
  • Ethical framework and critical reasoning
  • Who attends the consultation?
  • Writing up the case consultation
  • Disseminating information

Who can refer cases to the CEC?

Generally the Terms of Reference of a CEC / group are not prescriptive about who can refer cases. Some clinicians may be reluctant to refer cases in the belief that the view expressed by the CEC may limit his / her clinical autonomy. It should be made clear that the CEC provides an opportunity for difficult ethical issues to be considered but the view of the committee does not bind the clinician to a particular course of action.

In general fewer nurses and allied healthcare professionals refer cases to a CEC. This may be because any matter for consultation is channelled through the lead clinician. But what if the nursing team are faced with an ethical dilemma that the consultant does not feel merits referral to the CEC? How will the CEC / consultation group deal with referrals when there is conflict in the health care team over the need to make a referral?

Will patients or their families be able to refer cases to the CEC, and will they be involved in the case discussion when referral is by a clinician?

Process of referral

The committee will need a clear process for considering an initial referral, deciding whether it is appropriate for the committee / consultation group to consider the case, gathering of relevant information, convening a consultation meeting, and documenting the discussion.

Pro forma referral forms

It is very useful for a committee to produce a standard form for all case referrals made to it. This should state the name of the referring healthcare professional and clinical details (but excluding identifying information such as name and hospital number).

An example of a pro-forma for case consultation referral is shown in Appendix A14

Ethical framework and critical reasoning

In case consultation the ethics committee / group is being asked to consider the ethical issues arising in a particular case. It should therefore follow some process to ensure that the ethical issues are addressed and the Chair should ensure that all members have an opportunity to contribute to the discussion.

See Section C for ethical frameworks and critical reasoning.

Who attends the meeting?

The committee will need to consider who should be involved in the case consultation. This will include members of the CEC / consultation group, members of the clinical team, patients and their family or informal carers. How extensive should this group be. There needs to be a balance between the need to involve those people who are directly affected by the discussion, and to avoid an unwieldy meeting or delay in providing support. This may differ depending on the urgency and nature of the case.

Writing up the case consultation

There should be documentation of the case discussion for the CEC, including clear reference to the ethical reasoning leading to the conclusion. This will ensure transparency of process and contribute to consistency of decision-making by comparison of case discussions as part of the review process of the CEC. It will also be valuable in terms of auditing the work of the CEC. It may be useful if a form is created for this purpose.

If the case has been considered by a rapid response team and there has not been a full meeting of the CEC then there will be no formal CEC minutes. When the full Committee next meets the case should be presented for discussion so that all members can learn from the experience and give their views.

The patient’s notes should record the referral and the outline ethical advice given.

Disseminating information

The clinician / healthcare professional that referred the case to the committee should be provided with a write up of the case and the outline discussion (ideally in a standard format). This can be used by the health care team for ongoing education. The process of case consultation should include a review of the outcome of the case to both inform future case consultation and for evaluation of the service.

Copyright of Appendix A5 is held by The Ethox Centre.