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Araujo LG, Shaw M, Hernández E. The Structure of Clinical Ethical Decision-Making: A Hospital System Needs Assessment. HEC Forum 2024:10.1007/s10730-024-09534-5. [PMID: 38850508 DOI: 10.1007/s10730-024-09534-5] [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: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Bioethical dilemmas can emerge in research and clinical settings, from end-of-life decision-making to experimental therapies. The COVID-19 pandemic raised serious ethical challenges for healthcare organizations, highlighting the need to conduct needs assessments of the bioethics infrastructures of healthcare organizations. Clinical ethics committees (CECs) also create equitable policies, train staff on ethics issues, and play a consultative role in resolving the difficulty of complex individual cases. The main objective of this project was to conduct a needs assessment of the bioethics infrastructure within a comprehensive hospital system. A cross-sectional anonymous online survey, including quantitative and qualitative formatted questions. The survey was sent to five key leaders from the organization's hospitals. Survey questions focused on the composition, structure, function, and effectiveness of their facilities' bioethics infrastructure and ethics-related training and resources. Positive findings included that most facilities have active CECs with multidisciplinary membership; CECs address critical issues and encourage team members to express clinical ethics concerns. Areas of concern included uncertainty about how CECs function and the process for resolving clinical ethics dilemmas. Most reported no formal orientation process for CEC members, and many said there was no ongoing ethics education process. The authors conclude that if CECs are a critical institutional resource where the practice of medicine and mission intersect, having well-functioning ethics committees with trained and oriented members demonstrates an essential commitment to the mission. The survey revealed that more needs to be done to bolster the bioethics infrastructure of this institution.
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Affiliation(s)
- Leana G Araujo
- Administration Department, AdventHealth University, Orlando, FL, USA
| | - Martin Shaw
- Center for Ministry Education and Research, AdventHealth University, Orlando, FL, USA.
| | - Edwin Hernández
- Administration Department, AdventHealth University, Orlando, FL, USA
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Finder SG, Bartlett VL. Clinical Ethics Consultations and the Necessity of NOT Meeting Expectations: I Never Promised You a Rose Garden. HEC Forum 2024; 36:147-165. [PMID: 36125648 PMCID: PMC9486785 DOI: 10.1007/s10730-022-09496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
Clinical ethics consultants (CECs) work in complex environments ripe with multiple types of expectations. Significantly, some are due to the perspectives of professional colleagues and the patients and families with whom CECs consult and concern how CECs can, do, or should function, thus adding to the moral complexity faced by CECs in those particular circumstances. We outline six such common expectations: Ethics Police, Ethics Equalizer, Ethics Superhero, Ethics Expediter, Ethics Healer or Ameliorator, and, finally, Ethics Expert. Framed by examples of requests for ethics consultation that illustrate each kind, along with brief descriptions, we argue that while these expectations ought to be resisted for clear and practical reasons, they also create opportunities for CECs to articulate, educate, and ultimately be responsible to the professional demands of clinical ethics work. Recognizing, acknowledging, and at times resisting those expectations thus become key activities and responsibilities in the performance of ethics consultation.
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Affiliation(s)
- Stuart G Finder
- Director, Center for Healthcare Ethics, Professor of Surgery and of Biomedical Sciences, Cedars-Sinai Medical Center, 116 North Robertson Blvd, Suite 900D, Los Angeles, CA, 90048, USA.
| | - Virginia L Bartlett
- Assistant Director, Center for Healthcare Ethics, Assistant Professor of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, USA
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Racine E, Ji S, Badro V, Bogossian A, Bourque CJ, Bouthillier MÈ, Chenel V, Dallaire C, Doucet H, Favron-Godbout C, Fortin MC, Ganache I, Guernon AS, Montreuil M, Olivier C, Quintal A, Senghor AS, Stanton-Jean M, Martineau JT, Talbot A, Tremblay N. Living ethics: a stance and its implications in health ethics. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:137-154. [PMID: 38478251 PMCID: PMC11076378 DOI: 10.1007/s11019-024-10197-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 05/08/2024]
Abstract
Moral or ethical questions are vital because they affect our daily lives: what is the best choice we can make, the best action to take in a given situation, and ultimately, the best way to live our lives? Health ethics has contributed to moving ethics toward a more experience-based and user-oriented theoretical and methodological stance but remains in our practice an incomplete lever for human development and flourishing. This context led us to envision and develop the stance of a "living ethics", described in this inaugural collective and programmatic paper as an effort to consolidate creative collaboration between a wide array of stakeholders. We engaged in a participatory discussion and collective writing process known as instrumentalist concept analysis. This process included initial local consultations, an exploratory literature review, the constitution of a working group of 21 co-authors, and 8 workshops supporting a collaborative thinking and writing process. First, a living ethics designates a stance attentive to human experience and the role played by morality in human existence. Second, a living ethics represents an ongoing effort to interrogate and scrutinize our moral experiences to facilitate adaptation of people and contexts. It promotes the active and inclusive engagement of both individuals and communities in envisioning and enacting scenarios which correspond to their flourishing as authentic ethical agents. Living ethics encourages meaningful participation of stakeholders because moral questions touch deeply upon who we are and who we want to be. We explain various aspects of a living ethics stance, including its theoretical, methodological, and practical implications as well as some barriers to its enactment based on the reflections resulting from the collaborative thinking and writing process.
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Affiliation(s)
- Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), Université de Montréal, McGill University, 110 avenue des Pins Ouest, Montréal, QC, H2W 1R7, Canada.
| | - Sophie Ji
- Pragmatic Health Ethics Research Unit, IRCM, Montréal, QC, Canada
| | | | - Aline Bogossian
- School of Social Work, Université de Montréal, Montréal, QC, Canada
| | | | | | | | - Clara Dallaire
- Center of Excellence on Partnership with Patients and the Public, Université de Montréal, Research Centre of the Sainte-Justine University Hospital, Québec, Canada
| | | | | | | | | | - Anne-Sophie Guernon
- Pragmatic Health Ethics Research Unit, IRCM, University of Oxford, Montréal, QC, Canada
| | - Marjorie Montreuil
- Ingram School of Nursing, Centre de recherche de l'Institut universitaire en santé mentale de Montréal, McGill University, Québec, Canada
| | | | - Ariane Quintal
- Pragmatic Health Ethics Research Unit, IRCM, Université de Montréal, Québec, Canada
| | - Abdou Simon Senghor
- Pragmatic Health Ethics Research Unit, IRCM, McGill University, Québec, Canada
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Bruun H, Milling L, Wittrock D, Mikkelsen S, Huniche L. How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety. BMC Med Ethics 2024; 25:58. [PMID: 38762457 PMCID: PMC11102201 DOI: 10.1186/s12910-024-01061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/08/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, Faculty of Health Science, Forensic Mental Health Research Unit Middelfart (RFM), University of Southern Denmark & Psychiatric dept, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Daniel Wittrock
- Department of Quality and Education, Ambulance Syd, the Region of Southern Denmark, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Schaufel MA, Schanche E, Onarheim KH, Forthun I, Hufthammer KO, Engelund IE, Miljeteig I. Stretching oneself too thin and facing ethical challenges: Healthcare professionals' experiences during the COVID-19 pandemic. Nurs Ethics 2024:9697330241230683. [PMID: 38317594 DOI: 10.1177/09697330241230683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUNDS Most countries are facing increased pressure on healthcare resources. A better understanding of how healthcare providers respond to new demands is relevant for future pandemics and other crises. OBJECTIVES This study aimed to explore what nurses and doctors in Norway reported as their main ethical challenges during two periods of the COVID-19 pandemic: February 2021 and February 2022. RESEARCH DESIGN A longitudinal repeated cross-sectional study was conducted in the Western health region of Norway. The survey included an open-ended question about ethical challenges among doctors and nurses in hospital departments. Free-text comments were analysed using Systematic Text Condensation and also presented in a frequency table. ETHICAL CONSIDERATIONS Ethical approval was granted by the Regional Research Ethics Committee in Western Norway (131,421). All participants provided consent when participating in the study. RESULTS In 2021, 249 and in 2022, 163 healthcare professionals responded to the open-ended question. Nurses and doctors reported three main categories of ethical challenges related to the COVID-19 pandemic: (1) barriers that hindered them in acting as they ethically would have wanted to do; (2) priority-setting dilemmas linked to overtreatment, transfer of resources and ranking patient needs; and (3) workload expansion threatening work-life balance and employees' health. Category one comprised of resource barriers, regulatory barriers, system barriers, and personal barriers. Regulatory barriers, especially visitor restrictions for next-of-kin, were the most frequently reported in 2021. Resource barriers, related to the increased scarcity of qualified staff, were most frequently reported in 2022. Clinicians stretched themselves thin to avoid compromising on care, diagnostics, or treatment. CONCLUSIONS Developing clinicians' ability to handle and cope with limited healthcare resources is necessary. To foster resilience and sustainability, healthcare leaders, in collaboration with their staff, should ensure fair priority-setting and initiate reflections among doctors and nurses on what it implies to provide 'good enough' care.
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Nanyonga MM, Kutyabami P, Kituuka O, Sewankambo NK. Exploration of Clinical Ethics Consultation in Uganda: A case study of Uganda Cancer Institute. RESEARCH SQUARE 2024:rs.3.rs-3853569. [PMID: 38343843 PMCID: PMC10854307 DOI: 10.21203/rs.3.rs-3853569/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Introduction Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESS) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence of mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda. Methodology This qualitative study utilized in-depth-interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers, who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook. Results There was no formal committee nor mechanism utilized to resolve ethical dilemmas at the UCI. The study uncovered six fora where ethical dilemmas were addressed: individual consultations, tumor board meetings, morbidity and mortality meetings, core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas. Conclusion The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.
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Perin M, De Panfilis L. Clinical Ethics Committee in an Oncological Research Hospital: two-years Report. Nurs Ethics 2023; 30:1217-1231. [PMID: 37326119 PMCID: PMC10710006 DOI: 10.1177/09697330231174529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
RESEARCH QUESTION AND AIM Clinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020, a CEC was established in an Oncology Research Hospital in the North of Italy. This paper describes the development process and the activities performed 20 months from the CEC's implementation, to increase knowledge about CEC's implementation strategy. RESEARCH DESIGN We collected quantitative data related to number and characteristics of CEC activities carried out from October 2020 to June 2022 using the CEC internal database. Data were reported descriptively and compared with data from the literature to provide a complete overview of the CEC's development and implementation process. PARTICIPANTS AND RESEARCH CONTEXT The study has been conducted at the local health authority (LHA) of Reggio Emilia. It is a report of the activities provided by the CEC, where no HPs or patients were involved. ETHICAL CONSIDERATIONS The report is part of a larger study named EVAluating a Clinical Ethics Committee implementation process (EvaCEC), which has been approved by the Local Ethics Committee (AUSLRE Protocollo n° 2022/0026554 of 24/02/2022). EvaCEC is also the first author's PhD project. FINDINGS In total, the CEC performed 7 ethics consultations (EC), published three policies related to particular ethical questions of clinical and organizational practice, provided one educational online course on ethics consultation targeting employed HPs, and promoted a specific dissemination process among the different departments of the LHA. According to our results, the CEC widely fulfilled the standard threefold set of clinical ethics support services tasks (namely, ethics consultation, ethics education, and policy development), but further investigations are needed to evaluate the CEC's impact on clinical practice. CONCLUSION Our findings may increase knowledge regarding the composition, role, and tasks of a CEC in an Italian setting, informing future strategies and efforts to regulate these institutions officially.
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Affiliation(s)
- Marta Perin
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ludovica De Panfilis
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Perin M, Magelssen M, Ghirotto L, De Panfilis L. Evaluating a clinical ethics committee (CEC) implementation process in an oncological research hospital: protocol for a process evaluation study using normalisation process theory (EvaCEC). BMJ Open 2023; 13:e067335. [PMID: 36894200 PMCID: PMC10008162 DOI: 10.1136/bmjopen-2022-067335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION A Clinical Ethics Committee (CEC) is a multi-professional service whose aim is to support healthcare professionals (HPs) and healthcare organisations to deal with the ethical issues of clinical practice.Although CEC are quite common worldwide, their successful implementation in a hospital setting presents many challenges.EVAluating a Clinical Ethics Committee implementation process (EvaCEC) will evaluate the implementation of a CEC in a comprehensive cancer centre in Northern Italy 16 months after its establishment. METHODS AND ANALYSIS EvaCEC is a mixed-method study with a retrospective quantitative analysis and a prospective qualitative evaluation by a range of data collection tools to enable the triangulation of data sources and analysis. Quantitative data related to the amount of CEC activities will be collected using the CEC's internal databases. Data on the level of knowledge, use and perception of the CEC will be collected through a survey with closed-ended questions disseminated among all the HPs employed at the healthcare centre. Data will be analysed with descriptive statistics.The Normalisation Process Theory (NPT) will be used for the qualitative evaluation to determine whether and how the CEC can be successfully integrated into clinical practice. We will perform one-to-one semistructured interviews and a second online survey with different groups of stakeholders who had different roles in the implementation process of the CEC. Based on NPT concepts, the interviews and the survey will assess the acceptability of the CEC within the local context and needs and expectations to further develop the service. ETHICS AND DISSEMINATION The protocol has been approved by the local ethics committee. The project is co-chaired by a PhD candidate and by a healthcare researcher with a doctorate in bioethics and expertise in research. Findings will be disseminated widely through peer-reviewed publications, conferences and workshops. TRIAL REGISTRATION NUMBER NCT05466292.
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Affiliation(s)
- Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Ethik-Fortbildungen als Element der Klinischen Ethikarbeit: Ein Überblick über Formate und weitere strukturierende Elemente. Ethik Med 2023. [DOI: 10.1007/s00481-023-00755-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
ZusammenfassungAusgehend von den Erfahrungswerten sechs Klinischer Ethiker*innen an Universitätsklinika in Deutschland wurde eine strukturierte Auseinandersetzung mit dem Arbeitsfeld der Fortbildungen im Rahmen der Klinischen Ethikarbeit vorgenommen. Die Zusammenarbeit wurde von der Fragestellung geleitet, was bei der Konzeption einer Ethik-Fortbildung innerhalb einer Einrichtung zu berücksichtigen ist. Der methodische Zugang zur Beantwortung der explorativen Fragestellung bestand in einem mehrstufigen, deskriptiven Verfahren, das alternierend in gemeinsamen Arbeitssitzungen und individueller Arbeit zwischen den Sitzungen umgesetzt wurde.Als Resultat zeigt der Aufsatz eine Übersicht über die Bandbreite möglicher Fortbildungsformate auf, die denjenigen Hilfestellung bieten kann, die in ihrer Einrichtung Fortbildungen zu ethischen Themen konzipieren und durchführen wollen. Darüber hinaus bietet er einen Überblick über die bei der Umsetzung jeweils zu berücksichtigenden direkt strukturierenden sowie indirekt strukturierenden Merkmale. Es wird an Beispielen aufgezeigt, welche Formatvarianten sich in Kombination mit welchen direkt strukturierenden Merkmalen in den ausgewählten Universitätsklinika bewährt haben.Der Beitrag liefert eine Diskussionsgrundlage, um die strukturierte Auseinandersetzung mit konzeptionellen Fragen ethischer Fortbildung in der Klinik zu befördern.
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Weaver MS, Shostrom VK, Sharma S, Keegan A, Walter JK. Pediatric Ethics Consultation Services. Pediatrics 2023; 151:e2022058947. [PMID: 36720707 PMCID: PMC9979273 DOI: 10.1542/peds.2022-058947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Although guidelines call for the presence of pediatric ethics consultation services (PECS), their existence in children's hospitals remains unquantified. This study determined the prevalence of PECS in children's hospitals and compared the practice environments of those with versus without PECS. METHOD The Children's Hospital Association Annual Benchmark Report survey from 2020 and PECS data were analyzed for the association of PECS with domains of care. RESULTS Two hundred thirty-one hospitals received survey requests, with 148 submitted and 144 reachable to determine PECS (62% response rate), inclusive of 50 states. Ninety-nine (69%) reported having ethics consultation services. Freestanding children's hospitals (28% of all hospitals) were more likely to report the presence of PECS (P <.001), making up 41% of hospitals with a PECS. The median number of staffed beds was 203 (25th quartile 119, 75th quartile 326) for those with PECS compared with 80 for those without (25th quartile 40, 75th quartile 121). Facilities with palliative care, higher trauma ratio, intensive care, and comprehensive programs were more likely to have PECS. Academic affiliation was associated with PECS presence (P <.001). Settings associated with skilled nursing facilities or long-term care programs were not more likely to have PECS. Hospitals designated as federally qualified health centers (P = .04) and accountable care organizations (P = .001) were more likely to have PECS. CONCLUSION Although PECS function as formal means to clarify values and mitigate conflict, one-third of children's hospitals lack PECS. Future research is needed to understand barriers to PECS and improve its presence.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Valerie K. Shostrom
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Keegan
- Children’s Hospital Association, Lenexa, Kansas
| | - Jennifer K. Walter
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics and Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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De Panfilis L, Magelssen M, Costantini M, Ghirotto L, Artioli G, Turola E, Perin M. Research, education, ethics consultation: evaluating a Bioethics Unit in an Oncological Research Hospital. BMC Med Ethics 2022; 23:133. [PMID: 36494709 PMCID: PMC9733101 DOI: 10.1186/s12910-022-00863-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study aims to quantitatively and qualitatively evaluate the activities of a Bioethics Unit (BU) 5 years since its implementation (2016-2020). The BU is a research unit providing empirical research on ethical issues related to clinical practice, clinical ethics consultation, and ethical education for health care professionals (HPS). METHODS We performed an explanatory, sequential, mixed-method, observational study, using the subsequent qualitative data to explain the initial quantitative findings. Quantitative data were collected from an internal database and analyzed by descriptive analysis. Qualitative evaluation was performed by semi-structured interviews with 18 HPs who were differently involved in the BU's activities and analyzed by framework analysis. RESULTS Quantitative results showed an extensive increment of the number of BU research projects over the years and the number of work collaborations with other units and wards. Qualitative findings revealed four main themes, concerning: 1. the reasons for contacting the BU and the type of collaboration; 2. the role of the bioethicist; 3. the impact of BU activities on HPs, in terms of developing deeper and more mature thinking; 4. the need to extend ethics support to other settings. Overall, our results showed that performing both empirical bioethics research and more traditional clinical ethics activities at the same unit would produce an impetus to increase collaboration and spread an 'ethical culture' among local HPs. CONCLUSIONS Our findings contribute to a growing body of literature on the models of clinical ethics support services and the role of empirical research in bioethics internationally. They also prepare the ground for the implementation of a multidisciplinary Clinical Ethics Committee (CEC) that aims to support the BU's ethics consultation service within the local context.
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Affiliation(s)
| | - Morten Magelssen
- grid.5510.10000 0004 1936 8921Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Massimo Costantini
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giovanna Artioli
- grid.10383.390000 0004 1758 0937Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Turola
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy ,grid.7548.e0000000121697570PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
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Sanchini V, Crico C, Casali PG, Pravettoni G. Measuring the impact of clinical ethics support services: further points for consideration. JOURNAL OF MEDICAL ETHICS 2022; 48:877-878. [PMID: 36316032 DOI: 10.1136/jme-2022-108671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Virginia Sanchini
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | - Chiara Crico
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Paolo G Casali
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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Bell JAH, Salis M, Tong E, Nekolaichuk E, Barned C, Bianchi A, Buchman DZ, Rodrigues K, Shanker RR, Heesters AM. Clinical ethics consultations: a scoping review of reported outcomes. BMC Med Ethics 2022; 23:99. [PMID: 36167536 PMCID: PMC9513991 DOI: 10.1186/s12910-022-00832-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. OBJECTIVE The primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization. METHODS We searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. RESULTS Forty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes. CONCLUSIONS This scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC.
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Affiliation(s)
- Jennifer A H Bell
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada. .,Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,The Institute for Education Research, University Health Network, Toronto, ON, Canada. .,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Marina Salis
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Department of Philosophy, University of Toronto, Toronto, ON, Canada.,William Osler Health System, Brampton, ON, Canada
| | - Eryn Tong
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Erica Nekolaichuk
- Gerstein Science Information Centre, University of Toronto Libraries, University of Toronto, Toronto, ON, Canada
| | - Claudia Barned
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montreal, Montreal, QC, Canada
| | - Andria Bianchi
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,KITE Research Institute, Toronto Rehabilitation, Toronto, ON, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kevin Rodrigues
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ruby R Shanker
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ann M Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
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14
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Clinical ethical practice and associated factors in healthcare facilities in Ethiopia: a cross-sectional study. BMC Med Ethics 2022; 23:61. [PMID: 35717181 PMCID: PMC9206399 DOI: 10.1186/s12910-022-00800-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 06/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Clinical ethical practice (CEP) is required for healthcare workers (HCWs) to improve health-care delivery. However, there are gaps between accepted ethical standards and CEP in Ethiopia. There have been limited studies conducted on CEP in the country. Therefore, this study aimed to determine the magnitude and associated factors of CEP among healthcare workers in healthcare facilities in Ethiopia. Method From February to April 2021, a mixed-method study was conducted in 24 health facilities, combining quantitative and qualitative methods. Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. For quantitative and qualitative data analysis, Stata version 14 and Atlas.ti version 7 were utilized. Multiple logistic regression and thematic analysis for quantative and qualitative respectively used. Results From a total of 432 study participants, 407 HCWs were involved in the quantitative analysis, 36 participants were involved in five focus group discussions (FGDs), and eleven key informant interviews (KIIs) were involved in the qualitative analysis. The score of good CEP was 32.68%. Similarly, the scores of good knowledge and attitude were 33.50% and 25.31%, respectively. In the multiple logistic regression models, satisfaction with the current profession, availability of functional CECs, compassionate leaders, previously thought clinical ethics in pre-service education and good attitude were significant factors associated with CEP. Among these significant factors, knowledge, compassionate leaders, poor infrastructure, a conducive environment and positive attitudes were also determinants of CEP according to qualitative findings. Conclusions The CEP in health care services in Ethiopia is low. Satisfaction with the current profession, functional CECs, positive attitude, compassionate leaders and previously thought clinical ethics were significant factors associated with CEP. The Ministry of Health (MoH) should integrate interventions by considering CECs, compassionate leadership, and positive attitudes and enhance the knowledge of health professionals. Additionally, digitalization, intersectoral collaboration and institutionalization are important for promoting CEP. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00800-0.
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15
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Stoll J, Westermair AL, Kübler U, Reisch T, Cattapan K, Bridler R, Maier R, Trachsel M. A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry. BMC Psychiatry 2022; 22:370. [PMID: 35650555 PMCID: PMC9156353 DOI: 10.1186/s12888-022-04024-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far. METHODS Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate. RESULTS After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended. CONCLUSIONS Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.
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Affiliation(s)
- Julia Stoll
- grid.7400.30000 0004 1937 0650Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Anna Lisa Westermair
- grid.7400.30000 0004 1937 0650Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland ,grid.412556.10000 0004 0479 0775Clinical Ethics Unit, University Hospital Basel and University Psychiatric Clinics Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | - Ulrike Kübler
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Thomas Reisch
- grid.483141.b0000 0004 0478 9635Psychiatriezentrum Münsingen, Münsingen, Switzerland
| | - Katja Cattapan
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland ,grid.5734.50000 0001 0726 5157University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - René Bridler
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Robert Maier
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland. .,Clinical Ethics Unit, University Hospital Basel and University Psychiatric Clinics Basel, Basel, Switzerland.
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16
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Żaczek M, Górski A, Weber-Dąbrowska B, Letkiewicz S, Fortuna W, Rogóż P, Pasternak E, Międzybrodzki R. A Thorough Synthesis of Phage Therapy Unit Activity in Poland-Its History, Milestones and International Recognition. Viruses 2022; 14:1170. [PMID: 35746642 PMCID: PMC9227841 DOI: 10.3390/v14061170] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 01/27/2023] Open
Abstract
The year 2020 marked 15 years of the Phage Therapy Unit in Poland, the inception of which took place just one year after Poland's accession to the European Union (2004). At first sight, it is hard to find any connection between these two events, but in fact joining the European Union entailed the need to adapt the regulatory provisions concerning experimental treatment in humans to those that were in force in the European Union. These changes were a solid foundation for the first phage therapy center in the European Union to start its activity. As the number of centers conducting phage therapy in Europe and in the world constantly and rapidly grows, we want to grasp the opportunity to take a closer look at the over 15-year operation of our site by analyzing its origins, legal aspects at the local and international levels and the impressive number and diversity of cases that have been investigated and treated during this time. This article is a continuation of our work published in 2020 summarizing a 100-year history of the development of phage research in Poland.
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Affiliation(s)
- Maciej Żaczek
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
| | - Andrzej Górski
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Infant Jesus Teaching Hospital, Medical University of Warsaw, 02-005 Warsaw, Poland
| | - Beata Weber-Dąbrowska
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
| | - Sławomir Letkiewicz
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Health Sciences, Jan Długosz University in Częstochowa, 42-200 Częstochowa, Poland
| | - Wojciech Fortuna
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Neurosurgery, Wrocław Medical University, 50-556 Wrocław, Poland
| | - Paweł Rogóż
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
| | - Edyta Pasternak
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Bioethics Committee, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland
| | - Ryszard Międzybrodzki
- Bacteriophage Laboratory, Department of Phage Therapy, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (A.G.); (B.W.-D.); (E.P.); (R.M.)
- Phage Therapy Unit, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wrocław, Poland; (S.L.); (W.F.); (P.R.)
- Department of Clinical Immunology, Medical University of Warsaw, 02-006 Warsaw, Poland
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17
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Kok N, Zegers M, van der Hoeven H, Hoedemaekers C, van Gurp J. Morisprudence: a theoretical framework for studying the relationship linking moral case deliberation, organisational learning and quality improvement. JOURNAL OF MEDICAL ETHICS 2022; 48:medethics-2021-107943. [PMID: 35584897 DOI: 10.1136/medethics-2021-107943] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims.
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Affiliation(s)
- Niek Kok
- IQ healthcare, Radboudumc, Nijmegen, The Netherlands
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18
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Dittborn M, Portales B, Brierley J. Clinical ethics support services in paediatric practice: protocol for a mixed studies systematic review on structures, interventions and outcomes. BMJ Open 2022; 12:e057867. [PMID: 35396303 PMCID: PMC8996013 DOI: 10.1136/bmjopen-2021-057867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Clinical ethics support services (CESS) have been developing worldwide with growing interest in evaluating their quality. Paediatric-specific CESSs (p-CESS) have received little attention, and evidence from adult services might not be generalisable. Evidence on service models and practices is crucial to inform further research and debate on quality evaluation and minimum standards for p-CESSs. We aim to systematically identify, appraise and synthesise evidence for p-CESS structures, processes and outcomes. METHODS AND ANALYSIS We will conduct a mixed-studies systematic review including peer-reviewed empirical studies published in English or Spanish language providing data on the evaluation and/or impact on any aspect of p-CESS. We will search seven electronic databases: MEDLINE, Philosopher's Index, EMBASE, PsycINFO, LILACS, Web of Science and CINHAL, without filters applied. Search terms will be related to "clinical ethics support" AND "paediatrics" AND "structure/process/outcome". Reference and citation list of included studies will be handsearched. A 10% random sample of retrieved titles/abstracts and all full texts will be independently dual-screened. We will conduct narrative and thematic synthesis for quantitative and qualitative data, respectively, following sequential explanatory synthesis guided by Donabedian's framework of structure, process and outcomes. Quality will be assessed using the Mixed-Methods Appraisal Tool (2018). The review will be reported using the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses for reporting systematic reviews of qualitative and quantitative evidence template. Stakeholders will be involved twice in the review process; prior to data extraction and synthesis and after preliminary results. ETHICS AND DISSEMINATION As a systematic review of published data, no ethical approval is necessary. Results will be published in a relevant academic peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021280978.
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Affiliation(s)
- Mariana Dittborn
- Paediatric Bioethics Centre, Great Ormond Street Hospital for Children, London, UK
- Centro de Bioética, Universidad del Desarrollo, Santiago, Chile
| | | | - Joe Brierley
- Paediatric Bioethics Centre, Great Ormond Street Hospital for Children, London, UK
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Dittborn M, Cave E, Archard D. Clinical ethics support services during the COVID-19 pandemic in the UK: a cross-sectional survey. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107818. [PMID: 34753795 PMCID: PMC8593272 DOI: 10.1136/medethics-2021-107818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The COVID-19 pandemic highlighted the need for clinical ethics support provision to ensure as far as possible fair decision making and to address healthcare workers' moral distress. PURPOSE To describe the availability, characteristics and role of clinical ethics support services (CESSs) in the UK during the COVID-19 pandemic. METHOD A descriptive cross-sectional online survey was developed by the research team. The survey included questions on CESSs characteristics (model, types of support, guidance development, membership, parent and patient involvement) and changes in response to the pandemic. Invitations to participate were widely circulated via National Health Service institutional emails and relevant clinical ethics groups known to the research team. RESULTS Between October 2020 and June 2021, a total of 53 responses were received. In response to the pandemic, new CESSs were established, and existing provision changed. Most took the form of clinical ethics committees, groups and advisory boards, which varied in size and membership and the body of clinicians and patient populations they served. Some services provided moral distress support and educational provision for clinical staff. During the pandemic, services became more responsive to clinicians' requests for ethics support and advice. More than half of respondents developed local guidance and around three quarters formed links with regional or other local services. Patient and/or family members' involvement in ethics discussions is infrequent. CONCLUSIONS The pandemic has resulted in an expansion in the number of CESSs. Though some may disband as the pandemic eases, the reliance on CESSs during the pandemic demonstrates the need for additional research to better understand the effectiveness of their various forms, connections, guidance, services and modes of working and for better support to enhance consistency, transparency, communication with patients and availability to clinical staff.
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Affiliation(s)
- Mariana Dittborn
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, UK
| | - Emma Cave
- Durham Law School, Durham University, Durham, UK
| | - David Archard
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
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20
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Shrestha C, Shrestha A, Joshi J, Karki S, Acharya S, Joshi S. Does teaching medical ethics ensure good knowledge, attitude, and reported practice? An ethical vignette-based cross-sectional survey among doctors in a tertiary teaching hospital in Nepal. BMC Med Ethics 2021; 22:109. [PMID: 34353314 PMCID: PMC8340509 DOI: 10.1186/s12910-021-00676-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Importance of awareness of medical ethics and its integration into medical curriculum has been frequently highlighted. Study 1 aimed to assess the knowledge, attitude, and reported practices of medical ethics among clinicians at Patan Academy of Health Sciences, a tertiary care teaching hospital in Nepal. Study 2 was conducted to assess whether there was a difference in knowledge, attitude, and reported practices of medical ethics among doctors who received formal medical ethics education during undergraduate studies and those who did not. METHODS Two cross-sectional surveys using self-administered questionnaires were conducted. Study 1 included 72 participants; interns, medical officers, and consultants working at Patan Academy of Health Sciences. Study 2 was a comparative study conducted among 54 medical officers who had received formal medical ethics education (Group 1) and 60 medical officers who did not (Group 2). RESULTS Participants who had completed post-graduate education had higher knowledge (p = 0.050), practice (p < 0.001), and overall combined scores (p = 0.011). Participants with ethics education had higher knowledge (p < 0.001), attitude (p = 0.001), practice (p < 0.001), and overall score (p < 0.001). Most participants preferred consulting colleagues if an ethical dilemma arose. Fewer participants had heard of the Declaration of Helsinki. Most participants thought doctors to be most capable of judging what is best for the patient (Study 1: 70.42%, Study 2 Group 1: 42.59%, Group 2: 80%). Case scenarios in which participants demonstrated poor practice were ethical issues concerning truth-telling, end-of-life decisions, treating HIV/AIDS patients, treating a minor, and reporting colleague's errors. CONCLUSIONS This study found that participants who have received medical ethics education have higher knowledge, attitude, and practice scores. The results further justify the need for medical ethics education to be a part of the core medical curriculum. A blame-free environment where seniors can be approached for advice should be created. Research ethics should also be given attention. During medical ethics training, ethical issues where doctors perform poorly should be given more priority and should be discussed in a country-specific context.
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Affiliation(s)
| | | | | | | | - Sajan Acharya
- New York Medical College/Metropolitan Hospital Center, New York, USA
| | - Suchita Joshi
- Department of Neonatology, Nepal Mediciti Hospital, Lalitpur, Nepal
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21
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O'Cionnaith C, Wand APF, Peisah C. Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness. Clin Interv Aging 2021; 16:1315-1325. [PMID: 34285476 PMCID: PMC8285123 DOI: 10.2147/cia.s311773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice. Case Presentation Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted. Conclusion There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.
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Affiliation(s)
- Cathal O'Cionnaith
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Anne P F Wand
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia.,Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Carmelle Peisah
- Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Capacity Australia, Crows Nest, NSW, Australia
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