The functioning of hospital ethics committees: a multiple-case study of four Canadian committees

Team members perspectives on conflicts in clinical ethics committees

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.

Models of Ethics Consultation Used by Canadian Ethics Consultants: A Qualitative Study

This article describes a qualitative study of models of ethics consultation used by ethics consultants in Canada. We found four different models used by Canadian ethics consultants whom we interviewed, and one sub-variant. We describe (1) the lone ethics consultant model, (1a) the hub-and-spokes sub-variant of this model; (2) the ethics committee model; (3) the capacity-building model; and (4) the facilitated model. Previous empirical studies of ethics consultation describe only two or three of these models.

The impact of an ethics training programme on the success of clinical ethics services

The interdisciplinary Hannover Qualification Programme on ethics consultation has trained hospital staff to operate clinical ethics services in their respective hospitals since 2003. To evaluate Hannover Qualification Programme, all former participants were contacted using an online questionnaire including four domains: status quo before attending Hannover Qualification Programme, present status, impact of Hannover Qualification Programme, future challenges. Research objectives were the long-term satisfaction with Hannover Qualification Programme and its impact on clinical ethics services. The response rate was 45% (167/369). Hannover Qualification Programme was evaluated as helpful and the responders were capable of applying their acquired skills. Most participants could contribute to the implementation of clinical ethics services. They were satisfied with Hannover Qualification Programme and with the degree of changes in their hospitals. In conclusion, clinical ethics education had long-term effects on trainees and on their respective hospitals. Problems were mentioned rather in the field of utilisation than with implementation or quality of clinical ethics services.

Physicians’ and nurses’ expectations and objections toward a clinical ethics committee

The study aimed to explore the subjective need of healthcare professionals for ethics consultation, their experience with ethical conflicts, and expectations and objections toward a Clinical Ethics Committee. Staff at a university hospital took part in a survey (January to June 2010) using a questionnaire with open and closed questions. Descriptive data for physicians and nurses (response rate = 13.5%, n = 101) are presented. Physicians and nurses reported similar high frequencies of ethical conflicts but rated the relevance of ethical issues differently. Nurses stated ethical issues as less important to physicians than to themselves. Ethical conflicts were mostly discussed with staff from one’s own profession. Respondents predominantly expected the Clinical Ethics Committee to provide competent support. Mostly, nurses feared it might have no influence on clinical practice. Findings suggest that experiences of ethical conflicts might reflect interprofessional communication patterns. Expectations and objections against Clinical Ethics Committees were multifaceted, and should be overcome by providing sufficient information. The Clinical Ethics Committee needs to take different perspectives of professions into account.