Inside Clinical Bioethics: Navigating Complexities in Patient Care

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Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise. 

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an education podcast exploring Cleveland Clinic's Clinical Ethics Immersion Program within its Center for Bioethics. I am your host, Dr. Tony Tizzano, Director of Student and Lerner Health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Margot Eves, Director of Cleveland Clinic's Clinical Ethics Immersion Program here to join us. Margot, welcome to the podcast. 

Margot Eves:

Thank you very much. Thanks for having me here. 

Dr. Tony Tizzano:

Oh, the pleasure is ours. To get us started, could you tell us a little bit about yourself, your educational background, what brought you to Cleveland and your role here at Cleveland Clinic?

Margot Eves:

Absolutely. A little bit about myself, I am actually a native of Ohio, although I spent several years outside Ohio with a little bit of New York mixed in. I have two children, and I have been at Cleveland Clinic for more than 15 years now. I originally came as part of the inaugural Cleveland Fellowship in Advanced Bioethics Class, so I trained here. I left for a couple of years and came back in 2011. The second part of the role, I am a general staff clinical ethicist. I have had the privilege of serving specifically in our west side community hospitals in my first role back in 2011 until 2015 when I came to main campus, as primarily situated here at main campus. 

But I have the privilege and honor of working in all of our community hospitals as well as main campus. I also serve on our institutional review board, and I was given the opportunity to create this program about 10 years ago. 

Dr. Tony Tizzano:

So, you have a broad experience here, to say the least. 

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

So, in today's segment, we'll explore how the Clinical Ethics Immersion Program provides participants with insight and firsthand experience around clinical bioethics in an academic medical center. So, for our audience to have a better understanding, can you provide some context and why have an ethics program in a hospital? 

Margot Eves:

Oh, that's a great question. Our Center for Bioethics began, actually 40 years ago. We were formed in 1984 out of a need to have additional opportunities and thought partners to collaborate when clinicians were facing ethically challenging situations. We will never fully answer the question like just because we can, should we? That's an ongoing question as we innovate in medicine. And so, that actually remains the core reason that we continue to be supported at Cleveland Clinic and a lot of hospitals across the country are growing their ethics programs, because we live in a pluralistic society with differing values. 

And this is one space in which values can really come into conflict, and that's something we can help with. And we can help with creating the space to be thoughtful about how we best provide care to align with patients' values.

Dr. Tony Tizzano:

Yeah, that's well said. You know, as an obstetrician gynecologist, I can tell you, I may have never really understood why I needed you until I did. There's no preparing for it, all of a sudden, you find yourself faced with something, and what do I do? 

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

So, what's a typical example of how you can use Obstetrics, Gynecology, whichever you want that you get contacted? What happens?

Margot Eves:

Oh, uh, it's hard to say what's a typical because we do consultations that arise around pregnancies and health of a fetus prior to birth, to issues that arise postmortem. But that said, we do see a lot of questions rising in this context, what are ethical obligations to this patient? Uh, it seems that there's uncertainty or advocacy for what is the team, the medical professionals believe at this point would be medically inappropriate treatment. And what are our obligations and how do we best create a pathway forward in collaboration with this patient? More often, in some of those cases, the family making decisions on behalf of the patient. 

Dr. Tony Tizzano:

Yeah. Well, I could see where you could run into a sticky wicket here and there. You know, what do you do when you say not in keeping with what the medical personnel feel? When does it become the personal side of what the medical person feels versus what their professional side? I mean, I can see that being juggled as well and trying to bridge that gap. 

Margot Eves:

And that's challenging, right? Because everyone is a human, and most of us have personal beliefs and values, and we also have professional values and responsibilities. So, one of the things that we can do is engage in conversation to help people reflect on whether this is, in fact, rooted in their professional obligations or their personal values. And if the latter, what are their options and is there a pathway forward that allows them to remain true to their moral compass as well and help potentially avoid or mitigate issues of moral distress?

Dr. Tony Tizzano:

That is fabulous, that is so well said, and I can see and think of so many examples. I always like to tell patients, "I work for you, you don't work for me." And the moment that you feel that you and I are not on the same page and are thinking, I want you to feel very comfortable to say and then I'll have to make a decision like, "Oh, I can adjust, or maybe I can adjust, so I need some help-

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

... and call you-

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

... or one of my colleagues." So very well said. What does this program look like, and, and who comes to it? 

Margot Eves:

The Clinical Ethics Immersion Program, which we actually call CLEIP, even though it doesn't technically look like that, pronunciation, when you look at the acronym, is oriented toward primarily healthcare professionals or academic professionals that teach bioethics. So, we market and we accept participants from all over the world who are either have secured a clinical ethicist role and would like additional training. Or are serving on ethics committees or otherwise asked by their organization to support ethics consultation service, and they are seeking more training about that. 

Professors, those teaching bioethics that have come to our program have come in order to really ground their teaching in clinical realities. So, kind of bridge that gap between what we might refer to as the ivory tower in a good and thoughtful work that moves our field forward and bridge that with how we are actually providing the care in them.

Dr. Tony Tizzano:

So, there's that-there's that philosophical reality, and then there's the reality at the bedside.

Margot Eves:

Mm-hmm. 

Dr. Tony Tizzano:

And so, these participants, my understanding from our prior conversation, they're kind of joined at the hip with you for a period of time, and so they're getting to see everything.

Margot Eves:

They are. They join us as a group for a four-day intensive where we build skills and identify and practice skills from the beginning of ethics consultation through the end of one and it actually culminates in a full practice consult. Where they are making live phone calls to health care professionals given a very robust fact patterns and roles through the whole consultation. And then they either stay on or they return at another time to spend either two or three weeks in our center doing everything that the ethicists might do. So, they follow on all the ethics consultations and attend our center meetings, attend the other organizational or institutional committee meetings that we might go to during their visit. 

One of the biggest benefits is our volume. We have so many consultations that during a two-week immersion, they can easily see 30 to 40 consultations of varying types. Whereas in many hospitals, say, a 250-bed hospital, if they're on service, they're doing ethics consultation two weeks a month, they still, in the course of a year, may see 30 to 40.

Dr. Tony Tizzano:

Yeah, I could see that. And of course, there also is the added complexity of the sorts of things that would be seen here that you might not see in a community setting or a smaller hospital. Wow, that is a lot in four days. And do I understand correctly that you might come back for yet another four-day shot at this, as you develop your skills?

Margot Eves:

We do allow alumni to return as they would like, as visitors or what have you, but they do their immersion. We then also have a monthly call, uh, collaborative meeting where we are trying to foster the ongoing engagement and the connections between our current CLEIP participants and our alums, such that they have additional resources. And if they're grappling with a difficult consultation, they can always contact us, and we will be thought partners with them. But they also now have a larger network beyond Cleveland Clinic, across the country and the world. 

Dr. Tony Tizzano:

That's fabulous. So, they're doing some of this work, they say, "Gee, I'd like to get a much better clinical perspective and some hands-on experience." They come, they have an opportunity to network and follow up. So, what are some of the examples you might have in front of mind regarding challenges that are brought to your doorstep? 

Margot Eves:

Medicine is complicated and patients find themselves trying to balance what they might want to do with their body, what's being recommended and what their family wants for them. Or family members, find themselves trying to figure out what the patient might have wanted and what the patient is willing to go through and how to best attend to their quality of life based on what the patients defines their quality of life as. But families are complicated, and family dynamics do not typically instantly get better in times of crisis, they might. But, you know, it can exacerbate some of those long held dynamics, and they're doing that in a setting where there's a lot of uncertainty, there's a lot of emotional overlay. 

So, we get a lot of consults requesting support for surrogate decision making and helping people think through and identify and apply values.

Dr. Tony Tizzano:

Help us with that term surrogate decision making. 

Margot Eves:

Surrogate decision making is the concept of when you're making a decision for someone else, you're serving as their surrogate. 

Dr. Tony Tizzano:

Like a health care power of attorney? 

Margot Eves:

Yes, like a health care power of attorney. Now, who might serve as a surrogate can differ from state to state, which, of course, we are very aware of because Cleveland Clinic does operate outside of Ohio. But in Ohio, the recognized hierarchy, which in the statute applies only to end of life, but is guardian, healthcare power of attorney, legal spouse, majority of adult children, parents and then majority of adult siblings, and then any living relative. 

Dr. Tony Tizzano:

Did you list that in order of who they listened to first? 

Margot Eves:

Yes.

Dr. Tony Tizzano:

You did?

Margot Eves:

So, that is listed in order of priority, and so most of those are fairly helpful and fairly clear. There are sometimes questions of whether the spouse is a current spouse or not, but you currently in our country are only allowed to have one spouse at a time. So, that is fairly clear. But when you get to majority of adult siblings or majority of adult children, which the adult children come first in priority. If there are seven or eight children, seven or eight children have standing to make decisions, and so they all have equal standing if there's not a designated healthcare power of attorney. So, that is how it opens up to a lot of the dynamics and the potential conflict and the authentic differences related to what people believe the patient would want. 

Dr. Tony Tizzano:

Yeah. Boy, that's a lot. So, refresh what you had said regarding spouse and healthcare power of attorney, who has precedent?

Margot Eves:

Healthcare power of attorney. Only adults- 

Dr. Tony Tizzano:

That's a pill for some people.

Margot Eves:

It is, only adults can appoint a healthcare power of attorney, and you can appoint almost any other adult with decision making capacity. You cannot appoint your doctor, you cannot appoint like there's some other caveats, like director of your residential facility, things like that. But otherwise, you have no obligation to appoint a family member, and you're not obligated to appoint a spouse. Now, many times we see people appointing their spouse or their children, but sometimes we see people who have together in a relationship, chosen to appoint other people and they have reasons for that, and they are aware of that. 

It's only really a big challenge if someone's done an advanced directive or healthcare power of attorney and not informed the person who might otherwise be a default decision maker. 

Dr. Tony Tizzano:

Yeah. 

Margot Eves:

That's kind of where that pill becomes a challenge. 

Dr. Tony Tizzano:

We just, we just redid our trust, and we involved our children and my wife, all five of us were there together. And, you know, we got to hear, "I, I really don't want that or so, and so might be able to do this better. I want to be last in line to make that decision-

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

... and feel free to phone a friend. 

Margot Eves:

Absolutely. 

Dr. Tony Tizzano:

Because I, it's not within my comfort level. Boy, those conversations, and I wonder how often that happens when everyone is on thick ice, because-

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

... you never know. 

Margot Eves:

You never know, and those conversations are hard and uncomfortable to have for many, many people. I will give the personal example of trying to have this conversation with my own father, who tends to think about decisions as quite like yes or no, black and white. And, uh, as we know, in medicine, there's a lot of nuance, and there's a lot of if this, then this, right? And he had a really difficult time in that context having a conversation, because he had very strong views, but they didn't help me incorporate a larger range of what could happen to really give me a sense of how to best honor his wishes. And so, it was a really funny conversation, because it's safer conversation I have all the time. 

Dr. Tony Tizzano:

Okay.

Margot Eves:

And I would have, uh, with basically strangers, and I was having more challenges having the conversation with my own father, whom I've known for my entire life. And yet, so it's difficult for families to talk about those things, and if you don't talk about them, then the people that you have appointed are less equipped and less confident in their decision making. And now I say that all to say, we cannot, and I use healthcare professionals as an example. Someone may have worked in acute care medicine, taking care of patients at bedside for 40 years and they still may not be able to fully anticipate the whole range of scenarios that they or their loved ones might find themselves in. 

So, one I think a healthcare power of attorney or an advanced directive is only as helpful as you make it by having the hard conversations. And is also more helpful if in addition to focusing on various discrete things that you would want or not want, such as a ventilator or resuscitation, CPR. You also talk about those quality-of-life metrics that are important to the individual, because if I know that somebody is pretty good with being fairly immobile, as long as they can talk to their family and watch their favorite TV shows. That helps me understand the recoverability goals. 

Dr. Tony Tizzano:

Right. 

Margot Eves:

Right? What they're reaching for. But if they're the person who, by golly, is not going to accept people in their home doing things in their home for them, then that shifts significantly, potentially, what they are going to be willing to accept, and the uncertainty as to how much they can recover?

Dr. Tony Tizzano:

Yeah. And it's very easy to say it, it's another thing to have a sense, to really make a decision with autonomy and have understanding of all that's being said. And I do this for a number of individuals within our family, and I love it when they say to me, "We go over the detail," and I said, "Well, do you want this? Do you want CPR or resuscitation?" "Only if it's going to work, only if I'm going to be okay after they get it done." And I'm like, "But we need a crystal ball for that." 

Margot Eves:

Right.

Dr. Tony Tizzano:

So, unless you have a crystal ball, so it's tough, and I understand it, and I get it, and it's no fun making those decisions, but so important the work you do.

Margot Eves:

Thank you.

Dr. Tony Tizzano:

So, I understand also Margot that you function in oversight, looking at research protocols and review boards. Is that something that ethics gets involved with as well? 

Margot Eves:

So, we have a phenomenal institutional review board at Cleveland Clinic. They actually were originally formed prior to the promulgation of the regulations requiring institutional review boards, and they may have been called something slightly different, I don't really know. But this is made up of a wide range of disciplines and specialties and community members on our institutional review board, I am one person who serves on that. And the purpose of the IRB is research oversight, and they look at the protection of human subjects, that is the overarching goal. 

And there's a lot of regulations that they need to, you know, make sure that the research is attentive to and following, and they also look at, are we adequately protecting human subjects and the ethics of the research? So, they do an excellent job, I am one person who also contributes to that, and it is a phenomenal group that get a lot done and are very responsive to researchers. Some of my colleagues in the center also do research. They secure grant funding supporting that research, or, you know, do the research on behalf of the center for very, like shared goals. 

And then there's some of us, at various points, may be invited onto a research team that comes out of a different Institute or, you know, medical discipline. So, some examples of that, our manager of research, Mary Beth Mercer, does a lot of patient experience related research, right? So, she is looped in with quality and patient experience and initiatives to look critically and carefully at those programs and the patient's actual experience. I have colleagues that have contributed to neuro ethics research and also led neuro ethics research. My one colleague is a nurse ethicist who her folk guy for research and for ethics programming is around moral distress interventions. 

And so, she also does research related to moral distress, that's Dr. Georgina Morley through a nursing perspective. And so, there's a lot of ways that we might contribute or support research across the center and for the whole organization. Personally, I serve on the IRB, that is the bulk of what I do in terms of the research ethics. We do offer a research ethics consultation service, and at some point, I also served for a short time with the uterus transplant team.

Dr. Tony Tizzano:

So, there is tremendous depth and breadth-

Margot Eves:

Yes.

Dr. Tony Tizzano:

... here. I mean, as you speak, I'm thinking, "Wow, this is a gamut." So, not just in that, but in, in your encounter with healthcare providers and so forth. Do you have times when, gee, there's no obvious good choice, and what do you do with that?

Margot Eves:

Unfortunately, we do see it. One of the challenges is sometimes that's based in the patient's values, right? People have internally competing values that both cannot be honored in their current context. People who have, uh, the family knows strongly that they never want to be in a nursing home, but the alternative is death. You know, do they continue the support to assess further recoverability, which may mean being in a long-term care hospital or being in a nursing home or other type of long-term facility? Or do they say it's time to focus on comfort and receive hospice care? 

For many, that's two bad options, right? And let me be really clear, I strongly believe in hospice care, they do an amazing work, but if you're not ready to die, or there might be something that you could recover from, that may be two bad options. Another good example of this are with regard to patients who need chronic dialysis, say three times a week. There are two subsets of patients that frequently face no good choice, and that-

Dr. Tony Tizzano:

Yes.

Margot Eves:

... our patients who are undocumented, or our patients who have some history of behavioral disruptions in that setting previously. And there are a handful, maybe more, and care managers certainly know more about this than I do of dialysis centers. They tend to be large organizations with multiple sites, but if you were disruptive or threatening in one site, they're not going to take you back in another site. And to be fair to them, they are also concerned about the safety and experience of their healthcare professionals. But it means that then we have patients who need this three times a week. It is a life sustaining intervention, and they may have no access to it. 

Dr. Tony Tizzano:

Yeah, I get that. And then I must imagine there are times when you have the patient is not responsive and isn't going to be responsive, but the surrogate is not ready, or the family is not ready, and that just has to be tough. So, in another conversation, you had mentioned a concept that I didn't quite grasp, and that was abuse of choice. Could you elaborate a little bit on that and what that means in your profession?

Margot Eves:

So, I worry around choice, in the arbitrariness of restrictions of choice and the opposite end of too much choice. As healthcare professionals, we should be expected to utilize and communicate our clinical judgment and expertise and give solid recommendations. We are ethically obligated not to offer things that do not have a favorable potential benefit versus risk, so we should not be proffering a diner menu. So, that's the example of too much choice. Well, you could do this, this or this or this. What do you want to do? Versus there are three ways we could proceed, I'm going to focus on this way and potentially this way, because these appear to align with what you told me your goals were. 

This has the best chance of achieving your goals and addressing the issue for cure or for life extension or for just better quality of life. There is a third option we're not going to discuss today, because it is really not aligning with that, right? Rather than here they all are. Then the restriction of choice comes from a different space of we have clinical judgment and should exercise it. However, if it is within the range of reasonable choices, it should not be withheld from a patient or a family. And where I have observed a shift in space of choice is also in a concept that I started referring to as inappropriate interference with the practice of medicine by non-clinicians. 

And my example is broad in that we see it like in some of how legislation has been coming through. And keeping in mind that legislators are very, very rarely healthcare professionals. There is not space in creating statutes for nuance, they are fairly concrete. And yet, the art and the practice of medicine requires nuance and individuality and adaptability. 

Dr. Tony Tizzano:

Yeah.

Margot Eves:

So, when we think about those legal constructs and overlay, and then think about the other aspects of our society with a kind of a conflation of the, the idea of like potential legal liability versus illegal action. And having less clarity around that, because nobody wants to be sued. 

Dr. Tony Tizzano:

Right. 

Margot Eves:

Lawyers are not, primarily not physicians either. And I say that as somebody who has passed three bar exams, right? Like I don't have any sort of you know, test on my medical knowledge from that process. So, that's where I struggle, and I think it greatly impacts our provision of medicine more. And I, what I've seen over the past 20 years in academic medicine is more and more that way. 

Dr. Tony Tizzano:

And I think we're going to see more. I have this hunch, not sure, but we're not gonna go down that path. So, this has been incredible. What do you see on the horizon if you had, Dr. Stoller always talks about his magic wand. If you had the magic wand. What would be the wish? 

Margot Eves:

Well, the real magic wand would be to fix conflict with a wave of it, but that will never really happen. What I see on the horizon is in our field, really thinking about how to have robust and rigorous professional expectations and standards. Currently, we are very much still in a nascent part of professionalization of bioethics. And it is a challenge because it is an interdisciplinary field, and we value that, and we value the ability to come and bring other specialties and disciplines to the table. So, we want to be inclusive and yet high quality, and so sometimes those can be competing specifically with regard to what are the pathways into the field, and how do we, like is it fellowship training? 

Is it self-education? Is it a certain degree of like, medical professional education, what does that look like? And how do we ensure that it's accessible to continue that interdisciplinarity-

Dr. Tony Tizzano:

Sure. So, a process for certification and credentialing, and what, what are all the pieces? What are the necessaries? What are the, this subset, that subset?

Margot Eves:

Mm-hmm. 

Dr. Tony Tizzano:

That's a lot of work. 

Margot Eves:

It is. Our fellowship directors, Christy Horsberg and Josh Kreitz, are working on efforts around this in two ways, in accrediting training programs and also in establishing some benchmarking for quality of ethics consultation services. And so, you know, for CLEIP itself, how do we remain relevant in that moving space? And how do we continue to foster a network of individuals so that they-

Dr. Tony Tizzano:

Sure.

Margot Eves:

... can increase access to the other thought partners in our center? I can call any of my colleagues anytime to talk through a case, but a lot of ethicists are by themselves. 

Dr. Tony Tizzano:

No, I get it. And this will be a work in process over time, and I am actually gonna be doing another segment down the road where we're going to be talking to those individuals about just that. Well, did I miss anything? Is there something else that you feel our listeners should know? 

Margot Eves:

Just, uh, kind of, uh, in summary, like in our ethics consultation service, we may validate. We may serve as a buffer to help preserve a therapeutic relationship. We may navigate conflict, but I think the most important, in my opinion, others will disagree I'm sure, our role for our service in these challenging or uncertain situations is to be thought partners and collaborators. To bring different perspectives, usually through questions, to help move a patient's care forward in the way that best aligns with that patient's values and meet their professional obligations. 

Dr. Tony Tizzano:

Yeah. I just love the work you do. I've, I've had occasion to use it. The ethicist met with the medical team, and they met with the family, but then they met with us all together. So-

Margot Eves:

Mm-hmm.

Dr. Tony Tizzano:

... they helped us understand, I think they helped the patient's family understand. But then we worked collectively, and I don't think we would have ever arrived with the congruent decision that was made if it weren't for the kind of services you provide. So, Margot, I have to thank you so much. This has been a wonderfully insightful and thought-provoking episode of MedEd Thread. To our listeners, if you'd like to suggest a medical education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of med Ed thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.