Evaluating quality of activity.

Concerns have been raised by a number of authors about the lack of evidence of procedural rigor within CECs. Such a lack of evidence to clearly illuminate their benefit is likely to undermine the ability of CECs to confidently promote their effectiveness in practice.

The UK CEC should demonstrate evaluation of the quality and usefulness of their processes, particularly case review. This starts with identifying clear aims for practice. The manner in which the CEC seeks to achieve the stated aims can then be analysed. Williamson (2007 p3) identifies the need for CECs to be transparent and accountable stating:

“The need to assess the performance and contribution of CECs is

supported by a number of factors. Firstly, evaluation is deemed important to help ensure that ethics services are transparent and accountable ― as far as confidentiality requirements permit”.

What evidence is already available about activity of CECs and how can using a structured approach such as the ASCS approach assist with improving the quality and amount of evaluative evidence available?

There is some emerging evidence about the impact of CEC activity on clinical teams as Pfafflin et al (2009) state “research on or evaluation of ethics

consultation has started to appear in the European literature”. This is not always positive. Evidence available appears to point unsurprisingly to the need for more research in this area. Williamson (2007 pp20-21) identifies that UK CECs are

arranged in an ad hoc way, and that there is a lack of national standards to guide their activity stating:

“Clinical Ethics services in the UK are arranged on an ad hoc basis. The Clinical Ethics Network currently fosters exchange between existing CECs and provides short educational programmes. But in this system ethics education is optional for CEC members, not a requirement. The network has not sought to act as a vehicle to generate national standards or operational procedures for committees. Those involved in establishing the network have acknowledged that committees require evaluation.”

Whitehead et al (2009) surveyed UK CECs to elicit opinions about their case review activities. The fragmented and ad hoc nature of the groups was identified through the survey. Fewer than half of CECs approached responded to the questionnaire sent, but those that did respond showed a very diverse set of roles and functions. Of the respondents 70% indicated their group had at least one member with doctoral-level training in ethics, bioethics or philosophy. The number of case reviews ranged from none in the previous 12 months to 10-15 active cases. The varying numbers of cases, varying structures for ethical review and the lack of funding for a number of groups all demonstrated the diversity that exists between groups. A clinician bringing an issue could not be confident of

standardised practice and a consistency between groups.

Slowther et al (2012) published results of a postal survey sent to the chairs of the 82 clinical ethics services registered with the Clinical Ethics Network in July 2010. From the responses returned (62%), they found almost 30% of the committee chairs spent more than 50% of their time on case reviews. However, they also found a “wide variation in committee processes”. Slowther et al (2012) call for

more research into this area, to enable CECs and the organisations within which they work to evaluate current provisions, and plan for future service development. The Slowther et al (2012) survey identifies that current case review activity is increasing however, there is still insufficient evidence to reassure those using or considering using CEC services on the following points: how do the committees ensure that all of the dangers inherent in case review (as discussed previously) are minimised?; what are the potential benefits?; how is the CEC aiming to adapt its function so as to maximise these identified benefits?

The groups need to urgently consider how they can demonstrate quality and consistency in their processes and outcomes and needs to adopt a model that recognises their supportive not advisory nature and demonstrates how such support is offered particularly with regard to clinical case. The consequences of a CEC not offering appropriate support (and potentially causing harm) by adopting a model that encourages the perception that they are experts in ethical matters, and encourages abrogation of responsibility for a decision, which may be a wrong decision, will have direct repercussions for patients and their families. Therefore it would be unethical for CEC groups not urgently consider auditing the quality of their activities and responding to the results.

Answering the questions above is an achievable goal. All CECs should be striving to develop and evidence a procedural expertise that will assure us as service users that the support given is high quality.

As Childs (2009) states:

“CECs cannot and will not claim to have normative moral guidance and expertise but, rather to have procedural expertise” (p233).

The ASCS model provides a clear goal for practice and an auditable framework for practice. Firstly a standardised pre-requisite education for all CEC members can be identified. Enhanced communication skills, legal awareness training and solution focused training can be offered to all members prior to active group membership. The skills gained through such training and being involved in group post hoc case review activities can enable the CEC member to develop skills to support clinicians to “come to their own wise counsel on what, finally, to do” (Childs 2009 p233).

CEC reflective practice can be analysed and evaluated within the four following areas; (1) the group’s ability to hear the issue brought, (2) their ability to offer support, and ability to promote the service user perspective, (3) their use of systems for introducing and exploring precedent cases and (4) Their use of solution focused questioning techniques. In addition activities in relation to sensitive information gathering, confidentiality, privacy and conflict management can be evaluated.

CECs themselves using the ASCS model will be expected to identify a benchmark standard for good practice within the areas identified above. For example in the Ask phase the CEC would need to demonstrate how they manage the

environment to facilitate dialogue and non-judgemental support, how they

structure their questioning, how they allocate time, and how emotional support is offered.