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Durmaz N, Ulukol B, Şahinoğlu S. Perceptions of pediatric residents and pediatricians about ethical dilemmas: The case of Turkey. Arch Pediatr 2023; 30:537-543. [PMID: 37714736 DOI: 10.1016/j.arcped.2023.06.012] [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] [Received: 01/20/2022] [Revised: 11/30/2022] [Accepted: 06/21/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND This study determined the knowledge, attitudes, and behaviors of pediatricians and pediatric residents regarding issues of ethics, professional education, clinical ethical principles, and consent they encounter in health service delivery. METHODS Participants in the study were 134 pediatricians and pediatric residents from three hospitals in Ankara, Turkey. Participants were asked questions regarding their sociodemographic characteristics, their knowledge and views of ethics and ethical education, whether they had ever encountered an ethical problem, their beliefs about obtaining consent from pediatric patients and their families, and case-based questions. All data were collected and evaluated. RESULTS Of the participants in the study, 82 (61.2%) were residents, 41 (30.6%) were pediatricians, and 11 (8.2%) were faculty lecturers. The data revealed that 10% of the pediatricians and pediatric residents received ethical education, apart from medical ethics/deontology education at medical school, and 90.3% required further education on children and ethical problems. It was determined that 89% of residents and 78% of pediatricians needed help with the ethical problems they encountered during the diagnostic and treatment processes. Overall, 65.7% of the participants stated that the ethical problems they encountered affected the efficiency of health service delivery. It was observed that residents were more affected by ethical issues than pediatricians were. The present study revealed that pediatric residents and pediatricians need ethics education and there is a need to establish ethics counseling centers in hospitals. There is also a need for further studies in pediatrics and ethics.
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Affiliation(s)
- Nihal Durmaz
- Gulhane Training and Research Hospital, Ankara, Turkey.
| | - Betül Ulukol
- Ankara University Faculty of Medicine, Ankara, Turkey
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Friedrich AB, Kohlberg EM, R Malone J. Perceived Benefits of Ethics Consultation Differ by Profession: A Qualitative Survey Study. AJOB Empir Bioeth 2023; 14:50-54. [PMID: 35856904 DOI: 10.1080/23294515.2022.2093423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There are numerous benefits to ethics consultation services, but little is known about the reasons different professionals may or may not request an ethics consultation. Inter-professional differences in the perceived utility of ethics consultation have not previously been studied.Methods: To understand profession-specific perceived benefits of ethics consultation, we surveyed all employees at an urban tertiary children's hospital about their use of ethics committee services (n = 842).Results: Our findings suggest that nurses and physicians find ethics consultations useful for different reasons; physicians were more likely to report normative benefits, while nurses were more likely to report communicative and relational benefits.Conclusions: These findings support an open model of ethics consultation and may also help ethics committees to better understand consultation requests and remain attuned to the needs of various professional groups.
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Affiliation(s)
- Annie B Friedrich
- Bioethics Research Center, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | | | - Jay R Malone
- Department of Pediatrics, Critical Care Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Nowak A, Schildmann J, Nadolny S, Heirich N, Linoh KP, Rosenau H, Dutzmann J, Sedding D, Noutsias M. Clinical ethics case consultation in a university department of cardiology and intensive care: a descriptive evaluation of consultation protocols. BMC Med Ethics 2021; 22:99. [PMID: 34301238 PMCID: PMC8305900 DOI: 10.1186/s12910-021-00668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital. METHODS Semi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. All documents were analysed by two researchers independently. RESULTS Twenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43-96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1-65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases. CONCLUSIONS To the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes.
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Affiliation(s)
- Andre Nowak
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,Nursing Science Staff Unit, Franziskus-Hospital Harderberg, Niels-Stensen-Klinken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Nicolas Heirich
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Kim P Linoh
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Henning Rosenau
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Jochen Dutzmann
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Daniel Sedding
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.,Department of Internal Medicine A, Division of Cardiology, Angiology, Nephrology and Intensive Medical Care , Ruppiner Kliniken, Medical School of Brandenburg Theodor Fontane (MHB) , Fehrbelliner Strasse 38 , 16816 , Neuruppin , Germany
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Jenseits der Klinik: Konzeptionelle Überlegungen zum Ethiktransfer in dezentralen Einrichtungen des Gesundheitswesens am Beispiel der BruderhausDiakonie Reutlingen. Ethik Med 2021. [DOI: 10.1007/s00481-021-00634-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungUnser Beitrag stellt ein interaktives Ethik-Konzept vor, das in Zusammenarbeit der BruderhausDiakonie Reutlingen und der Universität Tübingen entwickelt wurde, um den Eigenheiten und Bedarfen einer komplexen Organisationsstruktur gerecht zu werden, die mehrere Geschäftsfelder und Standorte unter sich vereint. Wir skizzieren die Grundzüge des interaktiven Nijmegener Modells, in dem die Kooperation eines auf Leitungsebene angesiedelten Komitees und situationsbezogener Fallbesprechungen ein fruchtbares Zusammenspiel zweier unverzichtbarer Reflexionsweisen bewirken soll („Top-Down“/„Bottom-Up“). Wir zeigen auf, welche Herausforderungen sich bei der Implementierung dieses Modells in die konkrete Aufbauorganisation der BruderhausDiakonie ergaben, und mit welchen konzeptionellen oder „implementationstechnischen“ Mitteln ihnen begegnet wurde. Im Zentrum steht dabei die Erweiterung des Nijmegener Modells um ein Verbindungselement, welches die Zusammenarbeit zwischen zentralem Ausschuss und dezentralen Fallbesprechungen koordiniert und das interaktive Moment des Modells erst ermöglicht.
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Schmitz D, Groß D, Pauli R. Is there a need for a clear advice? A retrospective comparative analysis of ethics consultations with and without recommendations in a maximum-care university hospital. BMC Med Ethics 2021; 22:20. [PMID: 33653322 PMCID: PMC7927398 DOI: 10.1186/s12910-021-00590-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background The theory and practice of ethics consultations (ECs) in health care are still characterized by many controversies, including, for example, the practice of giving recommendations. These controversies are complicated by an astonishing lack of evidence in the whole field. It is not clear how often a recommendation is issued in ethics consultations and when and why this step is taken. Especially in a facilitation model in which giving recommendations is optional, more data would be helpful to evaluate daily practice, ensure that this practice is in line with the overarching goals of this approach and support the development of standards. Methods We analyzed all consultations requested from an EC service working under a facilitation approach at a maximum-care university hospital in Germany over a period of more than 10 years. Our aim was to better understand why—and under what circumstances—some consultation requests result in a recommendation, whereas others can be sufficiently addressed solely by facilitated meetings. We especially wanted to know when and why clients felt the need for clear advice from the EC service while in other cases they did not. We compared ethics consultations in terms of the differences between cases with and without recommendations issued by the ethics consultants using χ2 difference tests and Welch’s t-test. Results A total of 243 ECs were carried out between September 2008 and December 2019. In approximately half of the cases, a recommendation was given. All recommendations were issued upon the request of clients. When physicians asked for an EC, the consultation was significantly more likely to result in a recommendation than when the EC was requested by any other party. ECs in cases on wards with ethics rounds resulted in comparably fewer recommendations than those in wards without ethics rounds. When interpersonal conflicts were part of the problem or relatives were present in the meeting, clients less frequently asked for a recommendation. Conclusion From the client’s point of view, there does not seem to be only one “right” way to provide ethics consultations, but rather several. While facilitated meetings are obviously appreciated by clients, there also seem to be situations in which a recommendation is desired (especially by physicians). Further empirical and theoretical research is needed to validate our single-center results and re-evaluate the role of recommendations in ethics consultations. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00590-x.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Dominik Groß
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
| | - Roman Pauli
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
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Yoon NYS, Ong YT, Yap HW, Tay KT, Lim EG, Cheong CWS, Lim WQ, Chin AMC, Toh YP, Chiam M, Mason S, Krishna LKR. Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019. BMC Med Ethics 2020; 21:51. [PMID: 32611436 PMCID: PMC7329412 DOI: 10.1186/s12910-020-00492-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Amidst expanding roles in education and policy making, questions have been raised about the ability of Clinical Ethics Committees (CEC) s to carry out effective ethics consultations (CECons). However recent reviews of CECs suggest that there is no uniformity to CECons and no effective means of assessing the quality of CECons. To address this gap a systematic scoping review of prevailing tools used to assess CECons was performed to foreground and guide the design of a tool to evaluate the quality of CECons. METHODS Guided by Levac et al's (2010) methodological framework for conducting scoping reviews, the research team performed independent literature reviews of accounts of assessments of CECons published in six databases. The included articles were independently analyzed using content and thematic analysis to enhance the validity of the findings. RESULTS Nine thousand sixty-six abstracts were identified, 617 full-text articles were reviewed, 104 articles were analyzed and four themes were identified - the purpose of the CECons evaluation, the various domains assessed, the methods of assessment used and the long-term impact of these evaluations. CONCLUSION This review found prevailing assessments of CECons to be piecemeal due to variable goals, contextual factors and practical limitations. The diversity in domains assessed and tools used foregrounds the lack of minimum standards upheld to ensure baseline efficacy. To advance a contextually appropriate, culturally sensitive, program specific assessment tool to assess CECons, clear structural and competency guidelines must be established in the curation of CECons programs, to evaluate their true efficacy and maintain clinical, legal and ethical standards.
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Affiliation(s)
- Nicholas Yue Shuen Yoon
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Yun Ting Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Hong Wei Yap
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Dr, Experimental Medicine Building, Singapore, 636921, Singapore
| | - Kuang Teck Tay
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Elijah Gin Lim
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Clarissa Wei Shuen Cheong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Wei Qiang Lim
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, 117599, Singapore
| | - Ying Pin Toh
- Department of Family Medicine, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK.
- Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
- Centre of Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Winter MC, Friedman DN, McCabe MS, Voigt L. Content review of pediatric ethics consultations at a cancer center. Pediatr Blood Cancer 2019; 66:e27617. [PMID: 30666797 PMCID: PMC6777958 DOI: 10.1002/pbc.27617] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/01/2018] [Accepted: 12/27/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND/OBJECTIVES Ethical challenges in pediatric oncology arise at every stage of illness. However, there are sparse data on the content of and reason for ethics consultations in the field. We sought to evaluate the content and characteristics of ethics consultations in pediatric patients at a cancer center. DESIGN/METHODS We retrospectively identified ethics consultations performed for patients diagnosed with cancer at ≤21 years of age who were treated in the Department of Pediatrics from 2007 to 2017. Using an established coding schema, two independent reviewers analyzed the content of ethics consultation notes and identified core ethical issues and relevant contextual issues. Demographic, clinical, and consultation-specific data were also collected. RESULTS Thirty-five consultations were performed for 32 unique patients. The most commonly identified ethical issues were obligation to provide nonbeneficial treatment (29%) and resuscitation preferences (26%). Communication conflicts were the most commonly identified contextual issue (40%). There were two themes that emerged repeatedly but were not a part of the original coding schema-four consultations (11%) that involved physicians questioning their obligation to provide potentially toxic treatment in the setting of poor patient/parent compliance, and two consultations (6%) related to complex risk-benefit analysis in the setting of an invasive procedure with uncertain benefit. CONCLUSIONS Pediatric ethics consultations are infrequent at this specialty cancer hospital. Ethical issues focused on treatment and end-of-life care and included a diversity of communication conflicts.
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Affiliation(s)
- Meredith C. Winter
- Supportive Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary S. McCabe
- Consultant Advisor, National Coalition for Cancer Survivorship, Silver Spring, MD
| | - Louis Voigt
- Department of Anesthesiology, Pain and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
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Schmitz D, Groß D, Frierson C, Schubert GA, Schulze-Steinen H, Kersten A. Ethics rounds: affecting ethics quality at all organisational levels. JOURNAL OF MEDICAL ETHICS 2018; 44:805-809. [PMID: 30154217 DOI: 10.1136/medethics-2018-104831] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/31/2018] [Accepted: 08/04/2018] [Indexed: 06/08/2023]
Abstract
Clinical ethics support (CES) services are experiencing a phase of flourishing and of growing recognition. At the same time, however, the expectations regarding the acceptance and the integration of traditional CES services into clinical processes are not met. Ethics rounds as an additional instrument or as an alternative to traditional clinical ethics support strategies might have the potential to address both deficits. By implementing ethics rounds, we were able to better address the needs of the clinical sections and to develop a more comprehensive account of ethics quality in our hospital, which covers the level of decisions and actions, and also the level of systems and processes and aspects of ethical leadership.
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Affiliation(s)
- Dagmar Schmitz
- Department of History, Theory and Ethics in Medicine, RWTH Aachen University, Aachen, Germany
| | - Dominik Groß
- Department of History, Theory and Ethics in Medicine, RWTH Aachen University, Aachen, Germany
| | - Charlotte Frierson
- Department of History, Theory and Ethics in Medicine, RWTH Aachen University, Aachen, Germany
| | | | - Henna Schulze-Steinen
- Department of Surgical Intensive Medicine and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Alexander Kersten
- Department of Cardiology, Angiology and Internal Intensive Medicine, RWTH Aachen University, Aachen, Germany
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Abstract
In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.
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Bahus MK, Førde R. Discussing End-of-Life Decisions in a Clinical Ethics Committee: An Interview Study of Norwegian Doctors' Experience. HEC Forum 2017; 28:261-72. [PMID: 26922945 DOI: 10.1007/s10730-015-9296-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
With disagreement, doubts, or ambiguous grounds in end-of-life decisions, doctors are advised to involve a clinical ethics committee (CEC). However, little has been published on doctors' experiences with discussing an end-of-life decision in a CEC. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from discussing end-of-life decisions in CECs and why. We will disseminate some Norwegian doctors' experiences when discussing end-of-life decisions in CECs, based on semi-structured interviews with fifteen Norwegian physicians who had brought an end-of-life decision case to a CEC. Almost half of the cases involved conflicts with the patients' relatives. In a majority of the cases, there was uncertainty about what would be the ethically preferable solution. Reasons for referring the case to the CEC were to get broader illumination of the case, to get perspective from people outside the team, to get advice, or to get moral backing on a decision already made. A great majority of the clinicians reported an overall positive experience with the CECs' discussions. In cases where there was conflict, the clinicians reported less satisfaction with the CECs' discussions. The study shows that most doctors who have used a CEC in an end-of-life decision find it useful to have ethical and/or legal aspects illuminated, and to have the dilemma scrutinized from a new perspective. A systematic discussion seems to be significant to the clinicians.
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Affiliation(s)
- Marianne K Bahus
- School of Business and Law, Department of Law, University of Agder, Kristiansand, Norway.
| | - Reidun Førde
- Faculty of Medicine, Centre for Medical Ethics, Institute of General Practice and Community Medicine, University of Oslo, Oslo, Norway
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Bliss SE, Oppenlander JE, Dahlke JM, Meyer GJ, Williford EM, Macauley RC. Measuring Quality in Ethics Consultation. THE JOURNAL OF CLINICAL ETHICS 2016. [DOI: 10.1086/jce2016272163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Morrison W, Womer J, Nathanson P, Kersun L, Hester DM, Walsh C, Feudtner C. Pediatricians' Experience with Clinical Ethics Consultation: A National Survey. J Pediatr 2015. [PMID: 26210945 DOI: 10.1016/j.jpeds.2015.06.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation. STUDY DESIGN We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable. RESULTS Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic. CONCLUSION There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.
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Affiliation(s)
- Wynne Morrison
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - James Womer
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Temple University School of Medicine, Philadelphia, PA
| | - Pamela Nathanson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Leslie Kersun
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D Micah Hester
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Corbett Walsh
- New York University School of Medicine, New York, NY
| | - Chris Feudtner
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Crigger N, Fox M, Rosell T, Rojjanasrirat W. Moving It Along: A study of healthcare professionals' experience with ethics consultations. Nurs Ethics 2015; 24:279-291. [PMID: 26338282 DOI: 10.1177/0969733015597571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ethics consultation is the traditional way of resolving challenging ethical questions raised about patient care in the United States. Little research has been published on the resolution process used during ethics consultations and on how this experience affects healthcare professionals who participate in them. OBJECTIVES The purpose of this qualitative research was to uncover the basic process that occurs in consultation services through study of the perceptions of healthcare professionals. DESIGN AND METHOD The researchers in this study used a constructivist grounded theory approach that represents how one group of professionals experienced ethics consultations in their hospital in the United States. RESULTS The results were sufficient to develop an initial theory that has been named after the core concept: Moving It Along. Three process stages emerged from data interpretation: moral questioning, seeing the big picture, and coming together. It is hoped that this initial work stimulates additional research in describing and understanding the complex social process that occurs for healthcare professionals as they address the difficult moral issues that arise in clinical practice.
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Affiliation(s)
| | - Maria Fox
- University of Kansas Medical Center, USA
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Thomas SM, Ford PJ, Weise KL, Worley S, Kodish E. Not just little adults: a review of 102 paediatric ethics consultations. Acta Paediatr 2015; 104:529-34. [PMID: 25611088 DOI: 10.1111/apa.12940] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 11/27/2022]
Abstract
AIM The American Academy of Pediatrics statement on institutional ethics committees highlights the importance of paediatric ethics consultation. However, little has been published on actual experience with ethics consultation in paediatrics. The objective of this study was to review and describe topics covered by a large retrospective sample of clinical ethics consultations in paediatric medicine. METHODS We reviewed ethics consultations involving patients of <18 years of age from January 2005 to July 2013 at one institution. Descriptive statistics of the patient population, the reason for the ethics consultation and the consultant's perceived contribution to the case were generated. Subgroups of patients were compared based on demographic and clinical characteristics using Wilcoxon's rank sum tests, chi-square tests and logistic regression models. RESULTS Most of the 102 eligible consultations originated from intensive care units and were requested by attending physicians. The most frequent topic leading to consultation was end-of-life issues. Both younger age and male sex were associated with consults for end-of-life issues (p < 0.001 and p = 0.010). CONCLUSION This analysis provides important information describing the type of consults requested in paediatric medicine, which is necessary given the movement towards professionalising clinical ethics consultation. Further empirical research is needed on ethics consultation in paediatrics.
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Affiliation(s)
- Stefanie M. Thomas
- Department of Pediatric Hematology/Oncology and Blood and Marrow Transplantation; Cleveland Clinic Children's; Cleveland OH USA
| | - Paul J. Ford
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
| | - Kathryn L. Weise
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
| | - Sarah Worley
- Department of Quantitative Health Sciences; Cleveland Clinic Foundation; Cleveland OH USA
| | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care; Cleveland Clinic Foundation; Cleveland OH USA
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'It's time she stopped torturing herself': structural constraints to decision-making about life-sustaining treatment by medical trainees. Soc Sci Med 2015; 132:132-40. [PMID: 25813727 DOI: 10.1016/j.socscimed.2015.03.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article explores how structural factors associated with the profession and organization of medicine can constrain internal medicine residents, leading them to sometimes limit or terminate treatment in end-of-life care in ways that do not always embrace patient autonomy. Specifically, it examines the opportunities and motivations that explain why residents sometimes arrogate decision-making for themselves about life-sustaining treatment. Using ethnographic data drawn from over two years at an American community hospital, I contend that unlike previous studies which aggregate junior and senior physicians' perspectives, medical trainees face unique constraints that can lead them to intentionally or unintentionally overlook patient preferences. This is especially salient in cases where they misunderstand their patients' wishes, disagree about what is in their best interest, and/or lack the standing to pursue alternative ethical approaches to resolving these tensions. The study concludes with recommendations that take into account the structural underpinnings of arrogance in decision-making about life-sustaining treatment.
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17
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Knifed E, Goyal A, Bernstein M. Moral angst for surgical residents: A qualitative study. Am J Surg 2010; 199:571-6. [DOI: 10.1016/j.amjsurg.2009.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 04/03/2009] [Accepted: 04/06/2009] [Indexed: 10/19/2022]
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Pedersen R, Akre V, Førde R. Barriers and challenges in clinical ethics consultations: the experiences of nine clinical ethics committees. BIOETHICS 2009; 23:460-469. [PMID: 18549426 DOI: 10.1111/j.1467-8519.2008.00664.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. One important task for these committees is clinical ethics consultations. This qualitative study explores significant barriers confronting the ethics committees in providing such consultation services. The interviews with the committees indicate that there is a substantial need for clinical ethics support services and, in general, the committee members expressed a great deal of enthusiasm for the committee work. They also reported, however, that tendencies to evade moral disagreement, conflict, and 'outsiders' are common in the hospitals. Sometimes even the committees comply with some of these tendencies. The committees agree that there is a need to improve their routines and procedures, clarify the committees' profile and field of responsibility, to make the committees well-known, to secure adequate operating conditions, and to develop organizational integration and support. Various strategies to meet these challenges on a local, regional or national level are also explored in this paper.
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CQ Sources/Bibliography. Camb Q Healthc Ethics 2009. [DOI: 10.1017/s0963180109090628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
These CQ Sources were compiled by Bette Anton.
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Førde R, Pedersen R, Akre V. Clinicians' evaluation of clinical ethics consultations in Norway: a qualitative study. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2008; 11:17-25. [PMID: 17909984 DOI: 10.1007/s11019-007-9102-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 08/29/2007] [Indexed: 05/17/2023]
Abstract
Clinical ethics committees have existed in Norway since 1996. By now all hospital trusts have one. An evaluation of these committees' work was started in 2004. This paper presents results from an interview study of eight clinicians who evaluated six committees' deliberations on 10 clinical cases. The study indicates that the clinicians found the clinical ethics consultations useful and worth while doing. However, a systematic approach to case consultations is vital. Procedures and mandate of the committees should be known to clinicians in advance to ensure that they know what to expect. Equally important is bringing all relevant facts, medical as well as psychosocial, into the discussion. A written report from the deliberation is also important for the committees to be taken seriously by the clinicians. This study indicates that the clinicians want to be included in the deliberation, and not only in the preparation or follow-up. Obstacles for referring a case to the committee are the medical culture's conflict aversion and its anxiety of being judged by outsiders. The committees were described as a court by some of the clinicians. This is a challenge for the committees in their attempt to balance support and critique in their consultation services.
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Affiliation(s)
- Reidun Førde
- Section for Medical Ethics, University of Oslo, Oslo, Norway.
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Abstract
This article briefly describes the background and status of medical education in the areas of ethics and professionalism. Methods of teaching and assessment are described for medical students, residents, and practitioners within the core competency framework of medical education. Key areas of content for child and adolescent psychiatrists are described.
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Affiliation(s)
- Arden D Dingle
- Child and Adolescent Psychiatry, Emory University School of Medicine, 1256 Briarcliff Road #317 South, Atlanta, GA 30306, USA.
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Abstract
Ethical conflicts are common in hospital medicine. This article reviews core medical ethics principles, describes models for conducting hospital-based ethics case consultations, and highlights the contributions of hospital ethics committees to high quality patient care.
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Gordon EJ. A better way to evaluate clinical ethics consultations? An ecological approach. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2007; 7:26-9. [PMID: 17366185 DOI: 10.1080/15265160601109127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Elisa J Gordon
- Alden March Bioethics Institute, The Albany Medical College, Albany, NY 12208-3478, USA.
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Derenzo EG, Mokwunye N, Lynch JJ. Rounding: How Everyday Ethics can Invigorate a Hospital’s Ethics Committee. HEC Forum 2006; 18:319-31. [PMID: 17717756 DOI: 10.1007/s10730-006-9022-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Evan G Derenzo
- Center for Ethics, Washington Hosptial Center, 110 Irving Street, NW, Washington, DC 20010, USA.
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Gordon EJ, Hamric AB. The Courage to Stand Up: The Cultural Politics of Nurses’ Access to Ethics Consultation. THE JOURNAL OF CLINICAL ETHICS 2006. [DOI: 10.1086/jce200617305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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