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Haltaufderheide J, Nadolny S, Vollmann J, Schildmann J. Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants. JOURNAL OF MEDICAL ETHICS 2022; 48:401-406. [PMID: 34006601 PMCID: PMC9132864 DOI: 10.1136/medethics-2020-107129] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/09/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints-and for what reasons-should be considered when evaluating the quality of a service. In this paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research.
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Affiliation(s)
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
- Nursing Science Staff Unit, Franziskus Hospital Harderberg, Niels-Stensen-Kliniken, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
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Metselaar S, van Schaik M, Widdershoven G. CURA: A clinical ethics support instrument for caregivers in palliative care. Nurs Ethics 2022; 29:1562-1577. [PMID: 35622018 PMCID: PMC9667086 DOI: 10.1177/09697330221074014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article presents an ethics support instrument for healthcare professionals
called CURA. It is designed with a focus on and together with nurses and nurse
assistants in palliative care. First, we shortly go into the background and the
development study of the instrument. Next, we describe the four steps CURA
prescribes for ethical reflection: (1) Concentrate, (2) Unrush, (3) Reflect, and
(4) Act. In order to demonstrate how CURA can structure a moral reflection among
caregivers, we discuss how a case was discussed with CURA at a psychogeriatric
ward of an elderly care home. Furthermore, we go into some considerations
regarding the use of the instrument in clinical practice. Finally, we focus on
the need for further research on the effectiveness and implementation of
CURA.
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Affiliation(s)
- Suzanne Metselaar
- Suzanne Metselaar, Department of Ethics,
Law & Humanities, Amsterdam University Medical Centers, De Boelelaan 1089a,
Amsterdam 1081 HV, The Netherlands.
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van Schaik MV, Pasman HR, Widdershoven G, Molewijk B, Metselaar S. CURA-An Ethics Support Instrument for Nurses in Palliative Care. Feasibility and First Perceived Outcomes. HEC Forum 2021; 35:139-159. [PMID: 34888756 PMCID: PMC10167118 DOI: 10.1007/s10730-021-09456-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
Evaluating the feasibility and first perceived outcomes of a newly developed clinical ethics support instrument called CURA. This instrument is tailored to the needs of nurses that provide palliative care and is intended to foster both moral competences and moral resilience. This study is a descriptive cross-sectional evaluation study. Respondents consisted of nurses and nurse assistants (n = 97) following a continuing education program (course participants) and colleagues of these course participants (n = 124). Two questionnaires with five-point Likert scales were used. The feasibility questionnaire was given to all respondents, the perceived outcomes questionnaire only to the course participants. Data collection took place over a period of six months. Respondents were predominantly positive on most items of the feasibility questionnaire. The steps of CURA are clearly described (84% of course participants agreed or strongly agreed, 94% of colleagues) and easy to apply (78-87%). The perceived outcomes showed that CURA helped respondents to reflect on moral challenges (71% (strongly) agreed), in perspective taking (67%), with being aware of moral challenges (63%) and in dealing with moral distress (54%). Respondents did experience organizational barriers: only half of the respondents (strongly) agreed that they could easily find time for using CURA. CURA is a feasible instrument for nurses and nurse assistants providing palliative care. However, reported difficulties in organizing and making time for reflections with CURA indicate organizational preconditions ought to be met in order to implement CURA in daily practice. Furthermore, these results indicate that CURA helps to build moral competences and fosters moral resilience.
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Affiliation(s)
- Malene Vera van Schaik
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands. .,Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Bert Molewijk
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands.,Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Suzanne Metselaar
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
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Weekly Internal Ethical Case Discussions in an ICU-Results Based on 9 Years of Experience With a Highly Structured Approach. Crit Care Explor 2021; 3:e0352. [PMID: 33786431 PMCID: PMC7994040 DOI: 10.1097/cce.0000000000000352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives Various ethical challenges are prevalent in ICUs. In order to handle these problems, a highly structured internal ethical case discussion within the multiprofessional team was implemented in 2011 in a Swiss ICU and has been regularly practiced almost weekly until present. To explore the results of all ethical case discussions taking place in a general ICU and to discuss the outcomes of the patients. To identify the conditions facilitating the implementation of regular ethical case discussions. Design Retrospective case series analysis. Setting Mixed academic ICU. Patients AND INTERVENTION All patients who had an ethical case discussion between January 2011 and December 2019 following the approach called Modular, Ethical, Treatment decisions, Allocation of resources at the micro-level, and Process. MEASUREMENTS AND Main Results Weekly ethical case discussions held regularly on a fixed date were found to be practical for the observed ICU. A total of 314 ethical case discussions were realized in 281 patients. Median patient age was 70 years (interquartile range, 62-77 yr); two thirds were men. The results were categorized into the following groups: established therapy continues, complications to be treated (n = 53; 16.9%); therapy continues, patient's will to be explored further (n = 77; 24.5%); therapy continues, complications to be treated only after evaluation (n = 62; 19.7%); therapy continues with limitations (e.g., do-not-resuscitate order) (n = 98; 31.2%); and change of treatment plan to end-of-life care (n = 17; 5.4%). Of the discussed patients, 115 (40.9%) died in the ICU and 29 (10.3%) after transfer to the normal ward. Seven patients (2.5%) were transferred to a hospice and 55 (19.6%) to another hospital. Sixty-nine (24.6%) were discharged to a rehabilitative facility and six returned home. Conclusions Regular ethical case discussions can be successfully implemented, enabling careful review of the patient's will and balancing it with the prognosis of the disease. This facilitates a necessary change of the therapeutic goal whenever appropriate.
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Ethikkompetenzen vertiefen und verdichten – Welche Rolle kann die Ethik-Leitlinienentwicklung als exemplarische Methode der Ethikdidaktik in der hochschulischen Pflegeausbildung spielen? Ethik Med 2019. [DOI: 10.1007/s00481-019-00544-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Schildmann J, Nadolny S, Haltaufderheide J, Gysels M, Vollmann J, Bausewein C. Ethical case interventions for adult patients. Cochrane Database Syst Rev 2019; 7:CD012636. [PMID: 31424106 PMCID: PMC6698942 DOI: 10.1002/14651858.cd012636.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions. OBJECTIVES To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies. SEARCH METHODS We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation. AUTHORS' CONCLUSIONS It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.
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Affiliation(s)
- Jan Schildmann
- Martin Luther University Halle‐WittenbergInstitute for History and Ethics of MedicineMagdeburger Str. 8Halle (Saale)Germany06112
| | - Stephan Nadolny
- Martin Luther University Halle‐WittenbergInstitute for History and Ethics of MedicineMagdeburger Str. 8Halle (Saale)Germany06112
- Bielefeld University of Applied SciencesInstitute for Educational and Health‐care Research in the Health SectorInteraktion 1BielefeldNorthrine‐WestphaliaGermany33619
- University of Applied Sciences for DiakoniaBethelweg 8BielefeldNorthrine‐WestphaliaGermany33617
| | - Joschka Haltaufderheide
- Ruhr‐University BochumInstitute for Medical Ethics and History of MedicineMalakowturm – Markstr. 258aBochumGermany44799
| | - Marjolein Gysels
- University of AmsterdamAmsterdam Institute of Social Science ResearchAmsterdamNetherlands
| | - Jochen Vollmann
- Ruhr‐University BochumInstitute for Medical Ethics and History of MedicineMalakowturm – Markstr. 258aBochumGermany44799
| | - Claudia Bausewein
- LMU MunichDepartment of Palliative Medicine, Munich University HospitalMarchioninistr. 15MunichGermany81377
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Abstract
Background: Clinical ethics committees have been broadly implemented in university
hospitals, general hospitals and nursing homes. To ensure the quality of
ethics consultations, evaluation should be mandatory. Research question/aim: The aim of this article is to evaluate the perspectives of all people
involved and the process of implementation on the wards. Research design and participants: The data were collected in two steps: by means of non-participating
observation of four ethics case consultations and by open-guided interviews
with 28 participants. Data analysis was performed according to grounded
theory. Ethical considerations: The study received approval from the local Ethics Commission (registration
no.: 32/11/10). Findings: ‘Communication problems’ and ‘hierarchical team conflicts’ proved to be the
main aspects that led to ethics consultation, involving two factors:
unresolvable differences arise in the context of team conflicts on the ward
and unresolvable differences prevent a solution being found. Hierarchical
asymmetries, which are common in the medical field, support this vicious
circle. Based on this, minor or major disagreements regarding clinical
decisions might be seen as ethical conflicts. The expectation on the
clinical ethics committee is to solve this (communication) problem, but the
participants experienced that hierarchy is maintained by the clinical ethics
committee members. Discussion: The asymmetrical structures of the clinical ethics committee reflect the
institutional hierarchical nature. They endure, despite the fact that the
clinical ethics committee should be able to detect and overcome them.
Disagreements among care givers are described as one of the most difficult
ethically relevant situations and should be recognised by the clinical
ethics committee. On the contrary, discussion of team conflicts and clinical
ethical issues should not be combined, since the first is a mandate for team
supervision. Conclusion: To avoid dominance by physicians and an excessively factual character of the
presentation, the case or conflict could be presented by both physicians and
nurses, a strategy that strengthens the interpersonal and emotional aspects
and also integrates both professional perspectives.
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Affiliation(s)
| | | | | | - Gabriella Marx
- Gabriella Marx, Department of General
Practice/Primary Care, University Medical Center Hamburg-Eppendorf,
Martinistraße 52, W37, 20246 Hamburg, Germany.
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Riedel A, Giese C. Ethikkompetenzentwicklung in der (zukünftigen) pflegeberuflichen Qualifizierung – Konkretion und Stufung als Grundlegung für curriculare Entwicklungen. Ethik Med 2019. [DOI: 10.1007/s00481-018-00515-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Haan MM, van Gurp JLP, Naber SM, Groenewoud AS. Impact of moral case deliberation in healthcare settings: a literature review. BMC Med Ethics 2018; 19:85. [PMID: 30400913 PMCID: PMC6219174 DOI: 10.1186/s12910-018-0325-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/23/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND An important and supposedly impactful form of clinical ethics support is moral case deliberation (MCD). Empirical evidence, however, is limited with regard to its actual impact. With this literature review, we aim to investigate the empirical evidence of MCD, thereby a) informing the practice, and b) providing a focus for further research on and development of MCD in healthcare settings. METHODS A systematic literature search was conducted in the electronic databases PubMed, CINAHL and Web of Science (June 2016). Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of our decisions. The qualitative analysis was supported by ATLAS.ti. RESULTS Based on a qualitative analysis of 25 empirical papers, we identified four clusters of themes: 1) facilitators and barriers in the preparation and context of MCD, i.e., a safe and open atmosphere created by a facilitator, a concrete case, commitment of participants, a focus on the moral dimension, and a supportive organization; 2) changes that are brought about on a personal and inter-professional level, with regard to professional's feelings of relief, relatedness and confidence; understanding of the perspectives of colleagues, one's own perspective and the moral issue at stake; and awareness of the moral dimension of one's work and awareness of the importance of reflection; 3) changes that are brought about in caring for patients and families; and 4) changes that are brought about on an organizational level. CONCLUSIONS This review shows that MCD brings about changes in practice, mostly for the professional in inter-professional interactions. Most reported changes are considered positive, although challenges, frustrations and absence of change were also reported. Empirical evidence of a concrete impact on the quality of patient care is limited and is mostly based on self-reports. With patient-focused and methodologically sound qualitative research, the practice and the value of MCD in healthcare settings can be better understood, thus making a stronger case for this kind of ethics support.
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Affiliation(s)
- Maaike M. Haan
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, P.O. Box 9101 (114), 6500 HB, Nijmegen, The Netherlands
| | - Jelle L. P. van Gurp
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, P.O. Box 9101 (114), 6500 HB, Nijmegen, The Netherlands
| | - Simone M. Naber
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, P.O. Box 9101 (114), 6500 HB, Nijmegen, The Netherlands
| | - A. Stef Groenewoud
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, P.O. Box 9101 (114), 6500 HB, Nijmegen, The Netherlands
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Schildmann J, Nadolny S, Haltaufderheide J, Gysels M, Vollmann J, Bausewein C. Ethical case interventions for adult patients. Hippokratia 2017. [DOI: 10.1002/14651858.cd012636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jan Schildmann
- Wilhelm Löhe University of Applied Sciences; Institute for Ethics; Merkurstr. 41 Fürth Germany 90763
| | - Stephan Nadolny
- Diaconia University of Applied Sciences Bielefeld; Bethelweg 8 Bielefeld Northrine-Westphalia Germany 33617
| | - Joschka Haltaufderheide
- Ruhr-University Bochum; Institute for Medical Ethics and History of Medicine; Malakowturm Markstr. 258a Bochum Germany 44799
| | - Marjolein Gysels
- University of Amsterdam; Amsterdam Institute of Social Science Research; Amsterdam Netherlands
| | - Jochen Vollmann
- Ruhr-University Bochum; Institute for Medical Ethics and History of Medicine; Malakowturm Markstr. 258a Bochum Germany 44799
| | - Claudia Bausewein
- LMU Munich; Department of Palliative Medicine, Munich University Hospital; Marchioninistr. 15 Munich Germany 81377
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Rushton CH. Moral Resilience: A Capacity for Navigating Moral Distress in Critical Care. AACN Adv Crit Care 2017; 27:111-9. [PMID: 26909461 DOI: 10.4037/aacnacc2016275] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics and Professor of Nursing and Pediatrics, Berman Institute of Bioethics, Johns Hopkins University School of Nursing, and Johns Hopkins University School of Medicine, 1809 Ashland Avenue, Baltimore, MD 21205
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Meyer-Zehnder B, Albisser Schleger H, Tanner S, Schnurrer V, Vogt DR, Reiter-Theil S, Pargger H. How to introduce medical ethics at the bedside - Factors influencing the implementation of an ethical decision-making model. BMC Med Ethics 2017; 18:16. [PMID: 28231781 PMCID: PMC5324224 DOI: 10.1186/s12910-017-0174-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/08/2017] [Indexed: 11/11/2022] Open
Abstract
Background As the implementation of new approaches and procedures of medical ethics is as complex and resource-consuming as in other fields, strategies and activities must be carefully planned to use the available means and funds responsibly. Which facilitators and barriers influence the implementation of a medical ethics decision-making model in daily routine? Up to now, there has been little examination of these factors in this field. Methods A medical ethics decision-making model called METAP was introduced on three intensive care units and two geriatric wards. An evaluation study was performed from 7 months after deployment of the project until two and a half years. Quantitative and qualitative methods including a questionnaire, semi-structured face-to-face and group-interviews were used. Results Sixty-three participants from different professional groups took part in 33 face-to-face and 9 group interviews, and 122 questionnaires could be analysed. The facilitating factors most frequently mentioned were: acceptance and presence of the model, support given by the medical and nursing management, an existing or developing (explicit) ethics culture, perception of a need for a medical ethics decision-making model, and engaged staff members. Lack of presence and acceptance, insufficient time resources and staff, poor inter-professional collaboration, absence of ethical competence, and not recognizing ethical problems were identified as inhibiting the implementation of the METAP model. However, the results of the questionnaire as well as of explicit inquiry showed that the respondents stated to have had enough time and staff available to use METAP if necessary. Conclusions Facilitators and barriers of the implementation of a medical ethics decision-making model are quite similar to that of medical guidelines. The planning for implementing an ethics model or guideline can, therefore, benefit from the extensive literature and experience concerning the implementation of medical guidelines. Lack of time and staff can be overcome when people are convinced that the benefits justify the effort.
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Affiliation(s)
- Barbara Meyer-Zehnder
- Department of Clinical Ethics, Psychiatric Hospitals and University Hospital Basel, University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland. .,Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Heidi Albisser Schleger
- Department of Clinical Ethics, Psychiatric Hospitals and University Hospital Basel, University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland.,Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Sabine Tanner
- Department of Clinical Ethics, Psychiatric Hospitals and University Hospital Basel, University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland
| | - Valentin Schnurrer
- Department of Clinical Ethics, Psychiatric Hospitals and University Hospital Basel, University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland
| | - Deborah R Vogt
- Clinical Trail Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Stella Reiter-Theil
- Department of Clinical Ethics, Psychiatric Hospitals and University Hospital Basel, University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland
| | - Hans Pargger
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Meyer-Zehnder B, Barandun Schäfer U, Albisser Schleger H, Reiter-Theil S, Pargger H. [Ethical case discussions in the intensive care unit : from testing to routine]. Anaesthesist 2014; 63:477-87. [PMID: 24820357 DOI: 10.1007/s00101-014-2331-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 03/20/2014] [Accepted: 04/07/2014] [Indexed: 01/30/2023]
Abstract
BACKGROUND The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions. MATERIAL AND METHODS In a surgical intensive care unit a fixed date in the schedule is reserved for ethical case discussions (level 3 of the escalation model). At this level a team member who has been specified according to a quarterly plan is responsible for the organization and performance of the discussion. All protocols of the 44 ethical case discussions in 41 patients between January 2011 and July 2012 were collected and summarized. A short questionnaire to all participants recorded their assessment of the benefits for the patient and the team as well as their perception of personal stress reduction. Also queried was the impact of this method on the collaboration between nurses and physicians and the ethical competence. RESULTS Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence. CONCLUSION A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.
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Affiliation(s)
- B Meyer-Zehnder
- Operative Intensivbehandlung, Departement Anästhesie, Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz,
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