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Hauschildt KE. Whose Good Death? Valuation and Standardization as Mechanisms of Inequality in Hospitals. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2024; 65:221-236. [PMID: 36523154 PMCID: PMC10267289 DOI: 10.1177/00221465221143088] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Although most clinicians have come to perceive invasive life-sustaining treatments as overly aggressive at the end of life, some of the public and greater proportions of some socially disadvantaged groups have not. Drawing on 1,500+ hours of observation in four intensive care units and 69 interviews with physicians and patients' family members, I find inequality occurs through two mechanisms complementary to the cultural health capital and fundamental causes explanations prevalent in existing health disparities literature: in valuation, as the attitudes and values of the socially disadvantaged are challenged and ignored, and in standardization, as the outcomes preferred by less advantaged groups are defined as inappropriate and made harder to obtain by the informal and formal practices and policies of racialized organizations. I argue inequality is produced in part because wealthier and White elites shape institutional preferences and practices and, therefore, institutions and clinical standards to reflect their cultural tastes.
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Functions, Operations and Policy of a Volunteer Ethics Committee: A Quantitative and Qualitative Analysis of Ethics Consultations from 2013 to 2018. HEC Forum 2020; 34:55-71. [PMID: 32979112 DOI: 10.1007/s10730-020-09426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
Few institutions have published reviews concerning the case consultation history of their ethics committees, and policies used by ethics committees to address inappropriate treatment are infrequently reviewed. We sought to characterize the operation of our institution's ethics committee as a representative example of a volunteer ethics committee, and outline its use of a policy to address inappropriate treatment, the Conscientious Practice Policy (CPP). Patients were identified for retrospective review from the ethics consultation database. Patient demographics, medical admission information, and consultation information were obtained from the medical record. Consultation notes were analyzed with directed content analysis. The use of the CPP was documented in each case. Groups of interest were compared via two-sample t-tests. There were 178 consultations between 2013 and 2018. The majority originated from medicine services (N = 145, 82.4%). The most common consultation reasons were end-of-life balances of acute and palliative care (N = 85, 47.2%), best interest standard (N = 82, 46.1%), medical futility (N = 68, 38.2%), and code status and intubation status (N = 67, 37.6%). Average age was 65.5 years and average hospitalization before consultation was 51.4 days. 92 patients (53.3%) had a code status change that occurred after consultation. A policy to address inappropriate treatment (CPP) was used in 42 (23.9%) of the consultations. Bivariate analysis demonstrated a reduction in policy use over time, with use in 32.1% of consultations from 2013 to 2016 and 11.4% of consultations 2017-2018, p = 0.002. End-of-life issues were the most common reason for consultation. Our consultation volume was lower than previously-published reports. A policy used to address inappropriate treatment was frequently used, although use decreased over time.
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Rosoff PM. Healthcare Rationing Cutoffs and Sorites Indeterminacy. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:479-506. [PMID: 31356664 DOI: 10.1093/jmp/jhz012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as "beneficial," "effective," or even "futile," the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient Greek philosophical conundrum known as the "sorites paradox." I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing).
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Affiliation(s)
- Philip M Rosoff
- Duke University School of Medicine, Durham, North Carolina, USA
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Hauschildt K, De Vries R. Reinforcing medical authority: clinical ethics consultation and the resolution of conflicts in treatment decisions. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:307-326. [PMID: 31565808 PMCID: PMC7012693 DOI: 10.1111/1467-9566.13003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Despite substantial efforts in the past 15 years to professionalise the field of clinical ethics consultation, sociologists have not re-examined past hypotheses about the role of such services in medical decision-making and their effect on physician authority. In relation to those hypotheses, we explore two questions: (i) What kinds of issues does ethics consultation resolve? and (ii) what is the nature of the resolution afforded by these consults? We examined ethics consultation records created between 2011 and mid-2015 at a large tertiary care US hospital and found that in most cases, the problems addressed are not novel ethical dilemmas as classically conceived, but are instead disagreements between clinicians and patients or their surrogates about treatment. The resolution offered by a typical ethics consultation involves strategies to improve communication rather than the parsing of ethical obligations. In cases where disagreements persist, the proposed solution is most often based on technical clinical judgements, reinforcing the role of physician authority in patient care and the ethical decisions made about that care.
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Affiliation(s)
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Michigan, USA
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Abstract
Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second (and third) opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution.
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Affiliation(s)
- Philip M Rosoff
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University Medical Center, 108 Seeley G. Mudd Building, Box 3040, 10 Bryan-Searle Drive, Durham, NC, 27710, USA. .,Departments of Pediatrics and Medicine, Duke University Medical Center, Durham, NC, USA.
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Marron JM, Jones E, Wolfe J. Is There Ever a Role for the Unilateral Do Not Attempt Resuscitation Order in Pediatric Care? J Pain Symptom Manage 2018; 55:164-171. [PMID: 28916293 PMCID: PMC5735032 DOI: 10.1016/j.jpainsymman.2017.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Abstract
Care for children as they near the end of life is difficult and very complex. More difficult still are the decisions regarding what interventions are and are not indicated during these trying times. Occasionally, families of children who are nearing the end of life disagree with the assessment of the medical team regarding these interventions. In rare cases, the medical team can be moved to enact a do not attempt resuscitation order against the wishes of the patient's parents. This article presents one such illustrative case and discusses the ethical issues relevant to such challenging clinical scenarios. The authors posit that such a unilateral do not attempt resuscitation order is only appropriate in very limited circumstances in pediatric care. Instead, focus should be placed on open discussion between parents and members of the clinical team, shared decision making, and maintenance of the clinician-parent relationship while simultaneously supporting members of the clinical team who express discomfort with parental decisions. The authors propose an alternative framework for approaching such a conflict based on clinician-parent collaboration and open communication.
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Affiliation(s)
- Jonathan M Marron
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA; Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
| | - Emma Jones
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Rosoff PM, Schneiderman LJ. Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:26-34. [PMID: 28112611 DOI: 10.1080/15265161.2016.1265163] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The Institute of Medicine and the American Heart Association have issued a "call to action" to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the "improved" results when nonprofessional bystanders are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes.
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Courtwright AM, Brackett S, Cadge W, Krakauer EL, Robinson EM. Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. J Crit Care 2014; 30:173-7. [PMID: 25457115 DOI: 10.1016/j.jcrc.2014.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study investigated the impact of age, race, and functional status on decisions not to offer cardiopulmonary resuscitation (CPR) despite patient or surrogate requests that CPR be performed. METHODS This was a retrospective cohort study of all ethics committee consultations between 2007 and 2013 at a large academic hospital with a not offering CPR policy. RESULTS There were 134 cases of disagreement over whether to provide CPR. In 45 cases (33.6%), the patient or surrogate agreed to a do-not-resuscitate (DNR) order after initial ethics consultation. In 67 (75.3%) of the remaining 89 cases, the ethics committee recommended not offering CPR. In the other 22 (24.7%) cases, the ethics committee recommended offering CPR. There was no significant relationship between age, race, or functional status and the recommendation not to offer CPR. Patients who were not offered CPR were more likely to be critically ill (61.2% vs 18.2%, P < .001). The 90-day mortality rate among patients who were not offered CPR was 90.2%. CONCLUSIONS There was no association between age, race, or functional status and the decision not to offer CPR made in consultation with an ethics committee. Orders to withhold CPR were more common among critically ill patients.
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Affiliation(s)
- Andrew M Courtwright
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Sharon Brackett
- Patient Care Services, Ellison 4 Surgical Intensive Care Unit, Massachusetts General Hospital, Boston, MA
| | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, MA
| | - Eric L Krakauer
- Division of Palliative Care, Massachusetts General Hospital, Boston, MA; Departments of Medicine and of Global Health & Social Medicine, Harvard Medical School, Boston, MA
| | - Ellen M Robinson
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA
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