Clinical Ethics Consultation in Practice, With Aliza Narva, JD, MSN

In this Q&A, Dominic Sisti, PhD, from Penn Medicine, speaks with Aliza Narva, JD, MSN, the director of ethics at the Hospital of the University of Pennsylvania, about her path from law and nursing to clinical ethics consultation and how ethics services function in practice at Penn Medicine.

Narva discusses the interdisciplinary process behind ethics consults, including chart review, engagement with care teams, and conversations with patients and families. She also outlines common sources of ethical conflict, particularly end-of-life decision-making and clinician moral distress, and reflects on a complex, prolonged ICU case that shaped her perspective on balancing policy, compassion, and family dynamics.

This Q&A is a snippet from our latest episode of Medical Ethics Unpacked, all about clinical ethics consultations. Watch the episode here: Medical Ethics Unpacked: Clinical Ethics Consultation in Practice

Sisti: Why did you gravitate towards ethics consultation after receiving your JD from Pennsylvania Law School and your bachelor’s and master’s degrees in nursing from Penn?

Narva: It started with having a humanities undergraduate degree. Before I went to law school, I was an American studies major at Occidental College in Los Angeles, and I really was focused on and interested in civil rights. I had this idea in undergrad that I would go to law school, and I would end up studying constitutional law and practicing, and that is not what happened to me. Like so many people who go to law school, I ended up coming out with massive debt and sort of got funneled into a large corporate firm where I felt really bored but also anxious, which was a particularly bad combination for me. After a couple of years of practicing corporate law, it became clear to me that I was going to need to do a different thing.

I started to go back to parts of my undergrad education that I had really loved, and then I had worked for 2 years after college in a women's health clinic, and I had really loved that healthcare environment. It was largely run by nurses and nurse practitioners and was really focused on the individual needs of patients, who were folks who often felt very marginalized.

I decided I was going to go back to school. I thought I would go straight through and become a nurse practitioner. Like so many people, I really didn't have a clear idea of what clinical nurses do. I sort of thought of them in this sort of stereotypical way of little lady helpers with little paper hats, and I was obviously quite wrong.

During nursing school, I really fell in love with clinical nursing and being in a hospital, just how dynamic it is. You have this group of people who are all focused on doing the right thing for patients; it really was that same theme of thinking about individual rights, making sure that people are not getting marginalized.

During orientation, [I] met our clinical ethicist, and was like, Yep, that's it. That's the thing I really do. She mentored me. I was able to have her shadow me for years, read my notes, and educate me. I got additional ethics training…and learned the mediation approach to ethics consultation, which is the model that we use here, and it all felt very consistent with that initial inspiration, even in college, of really trying to think about, how are we making sure that individuals who may not have access to the things they need have the best chance of getting what they need.

Sisti: What do you do when you get an ethics consultation request? Do you have a standard process, and what's the result?

Narva: A lot of what we do in our model is very traditional in terms of ethics consultation. We typically have one person who's covering the service we offer consultation, 24/7, just with the caveat of like, if it's not an emergency, consider not calling at 3 in the morning. There's always someone who is going to call you back if you have a question.

Whoever's covering will spend a little bit of time talking to the person, [asking] what's going on? What do you think is the ethical issue?

What we will typically do is spend some time in the patient's chart. What is this person's history? Why are they here? What has their experience been? Who are the key players in their health journey?

We really like to make sure we're talking to the clinical team, so not just the person who called, but also the other members. If the resident called, I want to talk to the attending. I want to talk to the nurse. I want to talk to [a] social [worker]. Maybe respiratory therapy is really involved. I'm going to want to talk to that person. And then, really, the standard of practice is also to talk to patients and families.

Sisti: If you had to summarize your top 3 kinds of issues, what are the general ethical conflicts that you see that often come up?

Narva: We have a ton of stuff that comes up at [the] end of life. The patient may no longer be able to advocate for themselves, and there's disagreement about what the next step should be in treatment. Are we going to withhold life-sustaining therapies? Are we going to escalate care for this person to the ICU? Is dialysis appropriate?

Another thing that comes up a lot is moral distress. Clinicians…often [feel] morally constrained from doing the thing that they think is the right thing to do or… uncertain about what the right thing is to do. That is definitely a completely appropriate time to call an ethics consult because the ethics consultant is there to help you think through, what are my ethical obligations? Who is the surrogate decision maker?

Sisti: Is there a particular case that stands out from your career that's been either haunting you or you feel proud of?

Narva: There was a case a couple of years ago, now maybe 7 years ago. Nothing about this is especially unique, except for her length of stay. There was a woman who suffered from an arrest [and] was in a persistent vegetative. She was in the neuro ICU for a year and a half, and I was new in this role and… thinking about a lot of the literature out [at] the time. [I] was thinking about policies related to how…you respond to potentially inappropriate requests for care from families. What do we do when families are asking for things that just aren't medically indicated? It may not be that they're actually physiologically futile, but they probably aren't going to do the thing that families want them to do. I think I was less generous then. I was very into this policy.

This patient…was 65 years old. She had two adult sons, she had a husband, she was really a matriarch in her community. She had another very rare disease, a neurological disease that had taken like 15 years to diagnose, which predated this terrible arrest. And so, this husband had this traumatic experience, and he really wanted to keep going.

There were meetings and meetings and meetings…with him, and he felt like even just having her heart beating would be all that she would want. It was tricky because I really saw the impact on the patient and her body. She was in the ICU for a long time, so her body just started to really fall apart. I saw the impact on the team and on the staff and how distressed folks felt, continuing to provide these aggressive treatments, keeping her intubated, giving her feeds through the pig tube. She was on dialysis at times. It was a lot.

I wasn't at the point where I could appreciate or understand that the history that they'd had as a family was really explaining the story of where they were now and why he didn't want to let go. Her very long time to get this diagnosis of this rare disease was really informing his goals and wishes.

Questions and answers are edited for clarity.