Levels of Consultation
There are three levels of ethics clinical consultations.
Level I Consultation
Level one of consultation involves responding to relatively simple questions and requests for assistance and can be facilitated by any consultant member of the ECS. Level I consultations may be managed by the Consultant alone or with the assistance of another member of the ECS at the discretion of the Consultant. Level I consultations do not require ongoing involvement or acknowledgement in the medical record of the ethics consultation. Further education and literature may be provided to the person requesting the consultation, as may be deemed helpful to further understanding of the requestor. Documentation of the consultation is submitted for tracking and quality review using the Consultation Report Form. The completed form is filed in the office of the ECS Chair.
Level II Consultation
Level two of consultation requires facilitation of the decision-making process with members of the health care team, patients, and/or family members. Level II consultations are managed initially by the Consultant (primary), who confers with another member of the ECS (secondary) regarding the issues and recommendations.
The primary Consultant, after completing their initial assessment, confers with a second member of the ECS regarding the issues and recommendations. The Consultant is responsible for assuring notification of all parties about the consultation request, including the attending physician if applicable. The attending physician may decline to participate in the consultation process, but does not have the authority to prevent the consultation review from proceeding. The Consultant coordinates information gathering from the patient's medical record, physicians, clinical staff (nurses, social work, etc.) house staff, the patient, and family members as indicated. The Consultant documents his/her findings and recommendations in the patients medical record (Progress Note section). The Consultant continues to follow the consultation at least weekly, or more frequently, as indicated, until the case is resolved. Documentation of the consultation is submitted for tracking and quality review using the Consultation Report Form, which is filed in the office of the ECS Chair.
Level III Consultation
Level three of consultation requires a full Clinical Service review. Level III consultations are performed when there are issues that cannot be resolved through a Level II consultation. The primary and secondary consultants involved in the case determine the need for a Level III consultation. The Level III process is coordinated and facilitated by the primary Consultant. The Consultant is responsible for notifying all parties involved in the case of the need for a level III review. Consent from the parties is needed before a Level III consultation may proceed. The primary Consultant is responsible for coordinating and/or supervising extensive data gathering, documentation, and a written case presentation for the convened ECS.
The primary Consultant facilitates the Level III consultation session. Attendance at the sessions will consist of at least four members of the ECS (Level III panel). At least one member in attendance should be a physician. Selected non-ethics consultants will be invited as appropriate. Only members of the health care team who are involved in the patient's care will be invited to attend. The patient and the family will be invited to participate.
In the presence of the Level III panel, the primary Consultant will present a brief summary of the case. The panel may decide to have members of the health care team, patients, and/or family present during the consultant presentation or may choose to involve them individually in the discussion. The case presentation shall consist of all information gathered including interviews with the health care team, patient, family, and the record review. Anyone present may provide additional information in an orderly fashion. When appropriate, the patient and/or family is/are excused and members of the health care team are invited to provide additional information. The health care team is the excused and the patient/family is invited back to provide additional information. The patient/family is then excused. The Ethics Consultation members (panel) will then review the information presented as a means to identify and then a address the ethical issues using a standardized acceptable framework. The duration of a Level III consultation session is one to two hours. All information discussed, with the exception of agreed to recommendations, is strictly confidential.
Level III consultation requires documentation in the medical record. This is done through a handwritten comprehensive summary of the session prepared by the primary Consultant. In addition, the primary consultant will submit to the ECS Chair a completed Consultation Review Form for quality improvement purposes. Appropriate ethics literature should be referenced in the summary document, with a listing of all pertinent data gathered and reference in the Level III review process.