Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review

'Sit down and thrash it out': opportunities for expanding ethics consultation during conflict resolution in long-term care

OBJECTIVE

To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution.

DESIGN

An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA).

RESULTS

Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance.

CONCLUSION

Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

Assisted living (AL) communities are long-term care settings where people live, work, and visit, and where social relationships and care, including end-of-life care, are negotiated. Assisted living is fraught with uncertainty and conflict about values, especially given residents' cognitive and physical frailty. These value-laden issues have implications for both resident and care partners' experiences. Yet, almost no research has examined ethics in this complex care environment. In this article, we draw on and synthesize existing theory, research, and practice knowledge to offer a conceptual model and discuss case examples that highlight everyday ethical issues in AL. We conceptualize the moral decision-making process and hence the moral landscape of AL, as influenced by a myriad of multi-level factors that shape interpersonal encounters and decision-making involving residents and their care partners, which ultimately shape individuals' actions and experiences in the setting. We conclude by discussing implications for research, policy, and practice.

Establishing Clinical Ethics Committees in Primary Care: A Study from Norwegian Municipal Care

Would primary care services benefit from the aid of a clinical ethics committee (CEC)? The implementation of CECs in primary care in four Norwegian municipalities was supported and their activities followed for 2.5 years. In this study, the CECs’ structure and activities are described, with special emphasis on what characterizes the cases they have discussed. In total, the four CECs discussed 54 cases from primary care services, with the four most common topics being patient autonomy, competence and coercion; professionalism; cooperation and disagreement with next of kin; and priority setting, resource use and quality. Nursing homes and home care were the primary care services most often involved. Next of kin were present in 10 case deliberations, whereas patients were never present. The investigation indicates that it might be feasible for new CECs to attain a high level of activity including case deliberations within the time frame. It also confirms that significant, characteristic and complex moral problems arise in primary care services.

Clinical ethics committees in nursing homes: what good can they do? Analysis of a single case consultation

Background:

Ought nursing homes to establish clinical ethics committees (CECs)? An answer to this question must begin with an understanding of how a clinical ethics committee might be beneficial in a nursing home context – to patients, next of kin, professionals, managers, and the institution. With the present article, we aim to contribute to such an understanding.

Aim:

We ask, in which ways can clinical ethics committees be helpful to stakeholders in a nursing home context? We describe in depth a clinical ethics committee case consultation deemed successful by stakeholders, then reflect on how it was helpful.

Research design:

Case study using the clinical ethics committee’s written case report and self-evaluation form, and two research interviews, as data.

Participants and research context:

The nursing home’s ward manager and the patient’s son participated in research interviews.

Ethical considerations:

Data were collected as part of an implementation study. Clinical ethics committee members and interviewed stakeholders consented to study participation, and also gave specific approval for the publication of the present article.

Findings/results:

Six different roles played by the clinical ethics committee in the case consultation are described: analyst, advisor, support, moderator, builder of consensus and trust, and disseminator.

Discussion:

The case study indicates that clinical ethics committees might sometimes be of help to stakeholders in moral challenges in nursing homes.

Conclusions:

Demanding moral challenges arise in the nursing home setting. More research is needed to examine whether clinical ethics committees might be suitable as ethics support structures in nursing homes and community care.