Case Consultation
Many clinical ethics services, such as Clinical Ethics Committees (CECs), are involved in case consultation, in which a case involving a particular patient is referred to the service for its advice.
It is important to ensure that the service has clear and appropriate processes for receiving, considering and responding to referrals of cases. The service should also have in place suitable processes in relation to any other ethical issues (such as regarding policies) that may be referred by healthcare professionals and managers within the organisation.
Below we describe some of the key issues and questions you should consider when devising your process. Our focus is on case consultation, but some of the topics covered below may help to inform your service’s process for receiving other sorts of referrals (for example, about policies).
In addition to the information provided below, you can download (and adapt) a template referral form, here
Frequently Asked Questions
The service should consider, and make clear, from whom it can receive referrals. Many services only accept referrals from the relevant lead (responsible) clinician. However, some services are willing to accept referrals from others, including from patients or family members. Some services are nevertheless unwilling to receive referrals that are, or are likely to become, part of a complaints process.
The service should also consider in what circumstances, if any, it is willing to receive and advise on a referral that comes from outside of the host organisation. Receiving, and advising on, external referrals may have legal implications, for example in relation to indemnification. UKCEN advises that a service should not seek to provide advice outside its host organisation without the explicit agreement of the host organisation and this should include assurance that such advice is indemnifiable. In general, we understand that such arrangements are possible between many NHS organisations.
The service should have a clear process for making (and receiving) referrals. The process should explain the form in which referrals may be made, for example, whether these are to be in writing or may be made verbally.
Most services tend to receive written referrals, usually using a referral form, into which the referrer enters the pertinent information, such as the essential facts and the ethical question(s) on which the referrer is seeking advice. You can download (and adapt) a template referral form from here.
Even if the service will not receive direct referrals from patients or families, the service should consider whether and how patients or families can feed into the case consultation process (see Who can inform the service’s deliberations?). Referral documentation is likely to form part of the patient record. The service should offer the option for patients and/or families to have input into the referral (at least, in suitable cases). For example, patients and/or families may be invited to supply a written statement or letter, which can be appended to the referral form.
The service should have a process for the secure receipt, logging and storage of referrals that are received. The process should abide by any legal or other obligations (for example, concerning confidentiality, data processing, and data protection).
Referrers are likely to indicate (for example, in the referral form) how soon they need a response. The service should, in any case, have clear time-frames for dealing with referrals.
Some referrals may be able to await the next full meeting of the service. Other referrals may need to be dealt with between meetings, for example, via (secure) email. There may also be situations in which advice is needed urgently. As such, the service should consider whether it needs to have a rapid response process for dealing with urgent referrals. A rapid response service is likely not to involve all members of the service – but, in any case, the service should have a clear process for how such requests will be handled.
Clinical ethics services in the UK typically take the form of a Clinical Ethics Committee (CEC), although some organisations employ Clinical Ethicists – these are individuals who are appointed to advise on the ethical issues arising within a particular organisation or setting.
Whatever form it takes, the service should have clear processes for dealing with referrals, including who in the service will deal with any particular referral. As noted above, some referrals may be discussed by the whole service (or CEC), but there may also be situations in which a referral is handled by a sub-group or even a single member (such as a Clinical Ethicist). Urgent referrals, for example, might be most efficiently handled by a sub-group. In any case, the service should have clear processes for who will deal with referrals, and in which circumstances.
As part of its process for dealing with referrals, the service should have clear processes around any meetings held and minutes taken. For example, it should be made clear who will chair or facilitate the discussion(s) and who will write this up and/or comment on any draft advice. The Chair or Vice-Chair of the service will typically chair discussions, but the service should have in place a process for appointing an alternative chairperson or facilitator in their absence. The service might also wish to consider having in place a rota for writing up the advice generated (for example, ensuring that every member is actively involved in write-up during their tenure).
The service should have clear processes around who can attend and/or inform the service’s work on case referrals. Some services invite the involved professionals to attend; some invite the patient and/or their family (or other support persons) to attend. Whoever attends, the service should make clear its advisory role, and work to ensure that it is a welcoming and safe space for discussion.
In this regard, it is important to note the decision delivered by Ms Justice Russell, in a ruling in 2020. (You can access the full ruling here).
In her ruling, Justice Russell recognised that there will be some MDT meetings in which it is appropriate not to include the patient and those close to them. However, she otherwise emphasised the importance of ensuring that patients can be involved and/or participate in clinical ethics referrals:
“The absence of any prior consultation or participation, cannot be good practice and should generally be unacceptable. Even at hastily assembled meetings there should be notice taken of the views of the patient and/or close relatives which could take the form of some written notes or letter submitted on their behalf. There should be guidance on patient/family participation and a clear protocol of how and when they are informed as to the arrangements being put in place for an Ethics Committee to meet along with being informed as to the outcome.”
Clinical ethics services are therefore urged to ensure that they have clear processes in place for the involvement and/or participation of patients and those close to them.
The service should be equipped to provide the advice sought. Amongst the things to consider here are whether the service will use an ethical framework to work through the case and arrive at its advice. You may also find it helpful to consult the Clinical Ethics Resources, as this section may contain information pertinent to the case in question, which can inform the service’s deliberations.
The service should have clear processes for communicating its advice back to the referrer. Thought should be given to how the advice will be communicated to the patient concerned, mindful that any advice offered is likely to form part of the patient record.
As noted above, the referral process should abide by any legal or other obligations (for example, concerning confidentiality, data processing, and the GDPR).
There may be circumstances in which it is envisaged that advice will be shared outside the context of the referral. For example, if it is envisaged that advice might be shared for research purposes, then there should be clear – and legally-compliant – processes in place for ensuring that there is consent to such sharing, or some other recognised justification for doing so.
There may also be situations in which the work of the service is the subject of a freedom of information request.
It will be helpful to the service, and to future referrers and patients, for the service to seek feedback on its work, so that it can improve the service it offers. At a minimum, the service should endeavour to follow-up on those cases referred to it and, where possible, seek feedback on whether the service was helpful. For further information about evaluating your service, see Evaluation.