Outcomes of Ethics Consultations in Adult ICUs: A Systematic Review and Meta-Analysis

What Factors Contribute to Ethical Problems in Patient Care? A Scoping Review and Case Series of Clinical Ethics Consultations

AbstractBackground: Healthcare professionals (HCPs) are frequently exposed to ethical problems in patient care that can affect the quality of care. Understanding risk factors for ethical problems may help practitioners to address these problems at an early stage. This study aims to provide an overview of ethical risk factors in patient care. Risk factors known from the literature and those found in clinical ethics consultation (CEC) cases are reviewed.

METHODS

A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland.

RESULTS

Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty.

CONCLUSIONS

There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.

Ethical Issues Referred to Clinical Ethics Support at a University Hospital in Korea: Three-Year Experience After Enforcement of Life-Sustaining Treatment Decisions Act

BACKGROUND

Clinical ethics support is a form of preventive ethics aimed at mediating ethics-related conflicts and managing ethical issues arising in the healthcare setting. However, limited evidence exists regarding the specific ethical issues in clinical practice. This study aimed to explore the diverse ethical issues of cases referred to clinical ethics support after the new legislation on hospice palliative care and end-of-life decision-making was implemented in Korea in 2018.

METHODS

A retrospective study of cases referred to clinical ethics support at a university hospital in Korea from February 2018 to February 2021 was conducted. The ethical issues at the time of referral were analyzed via qualitative content analysis of the ethics consultation-related documents.

RESULTS

A total of 60 cases of 57 patients were included in the study, of whom 52.6% were men and 56.1% were older than 60 years of age. The majority of cases (80%) comprised patients from the intensive care unit. One-third of the patients were judged as being at the end-of-life stage. The most frequent ethical categories were identified as goals of care/treatment (78.3%), decision-making (75%), relationship (41.7%), and end-of-life issues (31.7%). More specifically, best interests (71.7%), benefits and burdens/harms (61.7%), refusal (53.3%), and surrogate decision-making (33.3%), followed by withholding or withdrawal (28.3%) were the most frequent ethical issues reported, which became diversified by year. In addition, the ethical issues appeared to differ by age group and judgment of the end-of-life stage.

CONCLUSION

The findings of this study expand the current understanding of the diverse ethical issues including decision-making and goals of care/treatment that have been referred to clinical ethics support since the enforcement of the new legislation in Korea. This study suggests a need for further research on the longitudinal exploration of ethical issues and implementation of clinical ethics support in multiple healthcare centers.

Clinical ethics consultations: a scoping review of reported outcomes

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.

The need for clinical ethics consultation: a monocentric observational survey study in the intensive care unit (Consul.E.T.I. study)

Background

The current organizational structure of the Italian healthcare system does not include the institutionalization of clinical ethics services.

To describe the need for structured clinical ethics consultation services for ICU staff members in the intensive care unit (ICU), a monocentric observational survey study was performed utilizing a paper-based questionnaire.

Results

A total of 73 healthcare professionals (HCPs) responded out of a team of 84 people (87%). The results showed that the need for ethics consultation in the ICU is urgent, the institutionalization of the clinical ethics service is perceived as useful and should be a priority, and the issues on which the HCPs would like ethics consultation to focus are various and belong to “end of life” topics.

Conclusions

HCPs believe that the clinical ethicist should become an integral part of ICU healthcare teams, offering consultations similar to the other specialistic consultations carried out in hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44158-022-00069-0.

Clinical ethics support services in paediatric practice: protocol for a mixed studies systematic review on structures, interventions and outcomes

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.

Making Family-Centered Care for Adults in the ICU a Reality

Despite the value of family-centered care (FCC) in intensive care units (ICUs), this approach is rarely a reality in this context. This article aims to increase the likelihood that ICU-based care incorporates best practices for FCC. Consistent with this goal, this article begins by overviewing FCC and its merits and challenges in ICUs. It then offers a systemic framework for conceptualizing FCC in this challenging environment, as such a model can help guide the implementation of this invaluable approach. This systemic framework combined with previous guidelines for FCC in the ICU are used to inform the series of recommended best practices for FCC in the ICU that balance the needs and realities of patients, families, and the interprofessional healthcare team. These best practices reflect an integration of the existing literature and previously published guidelines as well as our experiences as healthcare providers, family members, and patients. We encourage healthcare leaders and interprofessional ICU healthcare teams to adopt these best practices and modify them for the specific healthcare needs of the patients they serve and their families.

La relación entre Bioética y Salud Pública

El proceso de toma de decisiones desde la Salud Pública (SP) se basa en el ser y el deber ser. En Colombia los comités de bioética, ética de la investigación y ética clínica han funcionado con sus propios estatutos para garantizar el derecho a la salud, a pesar de las reformas a la seguridad social. Los antecedentes los llevaron a una fragmentación del sistema de salud caracterizada por la axiología neoliberal (economía de mercado según capacidad de pago) y normativa del Estado Social de Derecho. El sistema pretende resolver esta fragmentación, pero existen problemas estructurales del mercado que solo se solucionarían si funcionaran los mecanismos de regulación y el papel del Estado. Es decir, el sistema es insuficiente para lograr satisfacer las necesidades de la salud debido a las interacciones entre actores sociopolíticos. Este proceso conduce a opciones utilitaristas que sustentan la tendencia en temas de investigación. Los valores en SP junto con la ética de la SP son variables. Para la ética de la SP los valores de la práctica son de importancia pública, relacionados con los objetivos de la SP y los profesionales.

Clinical Ethics Consultation in Neurology - a case series

Background

The concept of clinical ethics consultation (CECs) was implemented to provide support in ethical controversies in clinical settings and are offered in at least every second hospital in Germany. Neurological disorders often require complex decision-making. The aims of this study were to determine which situations lead to CEC in neurology and to investigate the influence of the individual patient’s wishes on the recommendation.

Methods

Standardised CEC protocols in the years 2011 to 2017 at the University Hospitals of Goettingen and Jena were retrospectively surveyed. The contents were categorised along existing protocol templates of CEC scenarios and subsequently paraphrased and reduced to significant meanings.

Results

27 CEC scenarios which were facilitated by various professional disciplines were reviewed. Stroke was the most frequent underlying condition. Nearly all patients were not able to consent. Mostly, the relatives acted as representatives or health advocates. In 67 % of cases, a sense of conflict triggered a CEC; in 33 % a sense of uncertainty was the reason for the CEC request. In 21 CEC scenarios, a recommendation was reached in consensus with all parties involved. In 59 % of cases, a decision was made to continue medical therapy. In seven cases, the patient’s wishes led to a limitation of therapy, while in just two cases this decision was made primarily relying on the patient’s best interest. In only 13 % of cases, a valid advance directive led to respective therapeutic consequences.

Conclusions

CEC is feasible for consensus-finding not only in conflicts, but also in situations of therapeutic uncertainty in neurology. There is a special importance of the patient’s wishes in decision-making in neurology. However, only in a few cases were advance directives precise and specific enough to have sufficient and decisive weight in therapeutic decision-making.

Identifying disincentives to ethics consultation requests among physicians, advance practice providers, and nurses: a quality improvement all staff survey at a tertiary academic medical center

Background

Ethics consult services are well established, but often remain underutilized. Our aim was to identify the barriers and perceptions of the Ethics consult service for physicians, advance practice providers (APPs), and nurses at our urban academic medical center which might contribute to underutilization.

Methods

This was a cross-sectional single-health system, anonymous written online survey, which was developed by the UCSD Health Clinical Ethics Committee and distributed by Survey Monkey. We compare responses between physicians, APPs, and nurses using standard parametric and non-parametric statistical methods. Satisfaction with ethics consult and likelihood of calling Ethics service again were assessed using a 0–100 scale using a 5-likert response structured (0 being “not helpful at all” to 100 being “extremely helpful”) and results presented using box plots and interquartile ranges (IQR).

Results

From January to July 2019, approximately 3800 surveys were sent to all physicians, APPs and nurses with a return rate of 5.5—10%. Although the majority of respondents had encountered an ethical dilemma (85–92.1%) only approximately half had ever requested an Ethics consult. The primary reason for physicians never having requested a consult was that they never felt the need for help (41%). For APPs the primary reasons were not knowing an Ethics consult service was available (33.3%) or not knowing how to contact Ethics (27.8%). For nurses, it was not knowing how to contact the Ethics consult service (30.8%) or not feeling the need for help (26.2%). The median satisfaction score (IQR) for Ethics consult services rated on a 0–100 scale, from physicians was 76 (29), for AAPs 89 (49), and nurses 70 (40) (p = 0.62). The median (IQR) of likelihood of consulting Ethics in the future also on a 0–100 scale was 71 (47) for physicians, 69 (45) for APPs, and 61 (45) for nurses (p = 0.79). APP’s and nurses were significantly more likely than physicians to believe that the team did not act on the Ethics consult’s recommendations.

Conclusions

Based on the results presented, we were able to identify actionable steps to better engage healthcare providers—and in particular APPs and nurses—and scale up institutional educational efforts to increase awareness of the role of the Ethics consult service at our institution. Actionable steps included implementing a system of ongoing feedback that is critical for the sustainability of the Ethics service role. We hope this project can serve as a blueprint for other hospital-based Ethics consult services to improve the quality of their programs.

Supplementary information

The online version contains supplementary material available at 10.1186/s12910-021-00613-7.

Comparison Is Not a Zero-Sum Game: Exploring Advanced Measures of Healthcare Ethics Consultation

Studies across the healthcare spectrum consistently show that sharing and comparing data across institutions improves the quality of patient care. Whether comparing data about healthcare ethics consultation (HCEC) would similarly improve quality is unknown due to the lack of research on HCEC data sharing and comparison. Methods: To explore this possibility, we analyzed data from two academic medical centers in the Central-Southern United States that both employ a shared, robust coding system for ethics consultations (N = 703 cases total over 2.5 years) using descriptive and chi-square statistics, correlation coefficients and logistic regressions. Results: Our findings relate to patient age, care location, requestor role, and ethical themes, which together contribute to an improved evidence base for explanatory analyses and quality improvement initiatives. Conclusions: We conclude it is possible to analyze and compare HCEC activities across separate institutions using a standardized approach to data gathering, that this approach is consistent with concurrent narrative case review and assessment, and that cross-institutional comparisons are meaningful. Our results suggest future comparative analyses will require additional standardization of advanced measures for describing and analyzing HCEC activities.

Weekly Internal Ethical Case Discussions in an ICU-Results Based on 9 Years of Experience With a Highly Structured Approach

Objectives

Various ethical challenges are prevalent in ICUs. In order to handle these problems, a highly structured internal ethical case discussion within the multiprofessional team was implemented in 2011 in a Swiss ICU and has been regularly practiced almost weekly until present. To explore the results of all ethical case discussions taking place in a general ICU and to discuss the outcomes of the patients. To identify the conditions facilitating the implementation of regular ethical case discussions.

Design

Retrospective case series analysis.

Setting

Mixed academic ICU.

Patients AND INTERVENTION

All patients who had an ethical case discussion between January 2011 and December 2019 following the approach called Modular, Ethical, Treatment decisions, Allocation of resources at the micro-level, and Process.

MEASUREMENTS AND Main Results

Weekly ethical case discussions held regularly on a fixed date were found to be practical for the observed ICU. A total of 314 ethical case discussions were realized in 281 patients. Median patient age was 70 years (interquartile range, 62-77 yr); two thirds were men. The results were categorized into the following groups: established therapy continues, complications to be treated (n = 53; 16.9%); therapy continues, patient's will to be explored further (n = 77; 24.5%); therapy continues, complications to be treated only after evaluation (n = 62; 19.7%); therapy continues with limitations (e.g., do-not-resuscitate order) (n = 98; 31.2%); and change of treatment plan to end-of-life care (n = 17; 5.4%). Of the discussed patients, 115 (40.9%) died in the ICU and 29 (10.3%) after transfer to the normal ward. Seven patients (2.5%) were transferred to a hospice and 55 (19.6%) to another hospital. Sixty-nine (24.6%) were discharged to a rehabilitative facility and six returned home.

Conclusions

Regular ethical case discussions can be successfully implemented, enabling careful review of the patient's will and balancing it with the prognosis of the disease. This facilitates a necessary change of the therapeutic goal whenever appropriate.

Ethics Consultation in Surgical Specialties

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.

[Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]

Ungeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.

Muslim perspectives on advance care planning: a model for community engagement

Background:

Advance care planning is the process of communicating and documenting a person’s future health care preferences. Despite its importance, knowledge of advance care planning is limited, especially among the Islamic community. In addition, little is known about how the Islamic community views advance care planning in the context of their religious and cultural beliefs.

Objectives:

We aimed to increase knowledge of the importance of advance care planning, to improve health care provider and public knowledge, and to encourage dialogue between the community and health care providers.

Methods:

We organized a community event and assembled a multi-disciplinary panel. Through a moderated discussion, the panel members offered their perspectives of advance care planning within a Muslim context.

Results:

Approximately 100 individuals attended the event including community members, health care providers, medical students, and faith leaders. More than 90% of respondents rated the event as very good or excellent, found the session useful and were encouraged to reflect further on advance care planning.

Conclusion:

This event was successful in raising awareness about advance care planning within the Islamic community as well as educating health care providers on Islamic views. This model of community and health care provider engagement may also be beneficial for other faith groups wishing to discuss advance care planning within their respective religious and cultural contexts.

Functions, Operations and Policy of a Volunteer Ethics Committee: A Quantitative and Qualitative Analysis of Ethics Consultations from 2013 to 2018

Few institutions have published reviews concerning the case consultation history of their ethics committees, and policies used by ethics committees to address inappropriate treatment are infrequently reviewed. We sought to characterize the operation of our institution's ethics committee as a representative example of a volunteer ethics committee, and outline its use of a policy to address inappropriate treatment, the Conscientious Practice Policy (CPP). Patients were identified for retrospective review from the ethics consultation database. Patient demographics, medical admission information, and consultation information were obtained from the medical record. Consultation notes were analyzed with directed content analysis. The use of the CPP was documented in each case. Groups of interest were compared via two-sample t-tests. There were 178 consultations between 2013 and 2018. The majority originated from medicine services (N = 145, 82.4%). The most common consultation reasons were end-of-life balances of acute and palliative care (N = 85, 47.2%), best interest standard (N = 82, 46.1%), medical futility (N = 68, 38.2%), and code status and intubation status (N = 67, 37.6%). Average age was 65.5 years and average hospitalization before consultation was 51.4 days. 92 patients (53.3%) had a code status change that occurred after consultation. A policy to address inappropriate treatment (CPP) was used in 42 (23.9%) of the consultations. Bivariate analysis demonstrated a reduction in policy use over time, with use in 32.1% of consultations from 2013 to 2016 and 11.4% of consultations 2017-2018, p = 0.002. End-of-life issues were the most common reason for consultation. Our consultation volume was lower than previously-published reports. A policy used to address inappropriate treatment was frequently used, although use decreased over time.

Giving nurses a voice during ethical conflict in the ICU

BACKGROUND

Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit. There is a gap in our understanding of nurses' perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit.

RESEARCH QUESTION/OBJECTIVES/METHODS

The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice.

PARTICIPANTS AND RESEARCH CONTEXT

Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States.

ETHICAL CONSIDERATIONS

This study was approved by the Institutional Review Board at the organization where the study took place.

FINDINGS

Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict.

DISCUSSION

Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict.

CONCLUSION

These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.

Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019

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.

Importance of systematic deliberation and stakeholder presence: a national study of clinical ethics committees

BACKGROUND

Case consultation performed by clinical ethics committees (CECs) is a complex activity which should be evaluated. Several evaluation studies have reported stakeholder satisfaction in single institutions. The present study was conducted nationwide and compares clinicians' evaluations on a range of aspects with the CEC's own evaluation.

METHODS

Prospective questionnaire study involving case consultations at 19 Norwegian CECs for 1 year, where consultations were evaluated by CECs and clinicians who had participated.

RESULTS

Evaluations of 64 case consultations were received. Cases were complex with multiple ethical problems intertwined. Clinicians rated the average CEC consult highly, being both satisfied with the process and perceiving it to be useful across a number of aspects. CEC evaluations corresponded well with those of clinicians in a large majority of cases. Having next of kin/patients present was experienced as predominantly positive, though practised by only half of the CECs. The educational function of the consult was evaluated more positively when the CEC used a systematic deliberation method.

CONCLUSIONS

CEC case consultation was found to be a useful service. The study is also a favourable evaluation of the Norwegian CEC system, implying that it is feasible to implement well-functioning CECs on a large scale. There are good reasons to involve the stakeholders in the consultations as a main rule.

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit

BACKGROUND

Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety.

OBJECTIVE

To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families.

METHODS

In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables.

RESULTS

The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change.

CONCLUSIONS

When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Objectives and outcomes of clinical ethics services: a Delphi study

OBJECTIVES

To explore the objectives and outcomes most appropriate for evaluating clinical ethics support services (CESs) in the USA.

METHODS

A three-round e-Delphi was sent to two professional medical ethics listservs (Medical College of Wisconsin-Bioethics and American Society for Bioethics and Humanities) as well as 19 individual experts. The survey originally contained 15 objectives and 9 outcomes. In round 1, participants were asked to validate the content of these lists. In round 2, we had 17 objectives and 10 outcomes, and participants were asked to rank them for appropriateness in a top 10 list of objectives and a top 5 list of outcomes.

RESULTS

Participants came to a high(at least 70%) level of agreement on seven objectives: mediate, educate, develop policy, improve the moral quality of a decision or action, counsel, create a moral space and manage moral distress. Participants came to a moderate (at least 51%) level of agreement on three objectives: empower, awareness of ethics and preventative ethics. Participants also came to a moderate (at least 51%) level of agreement on five outcomes: ethical justification, transformation of institution, improvement of quality of life, principled consensus and satisfaction with the expertise of a CES.

CONCLUSION

This e-Delphi identified 10 objectives and 5 outcomes that are a good starting point for developing outcome measures to evaluate CESs in the USA, while reminding us of the diversity of perspectives still evident in the field.

Ethical case interventions for adult patients

BACKGROUND

Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions.

OBJECTIVES

To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies.

SEARCH METHODS

We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation.

AUTHORS' CONCLUSIONS

It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.

Continuing competency in ethical decision making: An interpretive description of occupational therapists' perspectives

BACKGROUND.

Competency in ethical decision making is a criterion for ethical practice, and it is expected to advance with ongoing professional development. However, research exploring continuing competency needs of occupational therapists regarding ethical decision making is limited.

PURPOSE.

The purpose of this study was to explore potential gaps and directions for development related to continuing competency in ethical decision making from the perspective of practicing occupational therapists.

METHOD.

Interpretive description informed secondary data analysis of professional narratives from a grounded theory study regarding ethical decision making. In-depth interviews were conducted with a purposive sample of 18 occupational therapists. Data analyses focused on identifying gaps and future directions regarding continuing competency.

FINDINGS.

Two main themes regarding gaps were identified: "I didn't have the knowledge" and "I don't have anybody." Education, tool development, and ethics mentorship were identified directions for development.

IMPLICATIONS.

Findings advance understanding of continuing competency needs of occupational therapists regarding ethical decision making.

Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation

Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Ethical considerations

Out-of-hospital cardiac arrest (OHCA) continues to be a leading cause of mortality worldwide. In Canada over 40,000 cardiac arrests that occur each year, a majority occur unexpectedly outside of the hospital setting. However, the reality is that without rapid and appropriate treatment within minutes, most victims will die before reaching the hospital. In the late 1980s case reports identifying favorable outcomes with the use of extracorporeal cardiopulmonary resuscitation (eCPR) in out-of-hospital cardiac arrest (OHCA) began to be reported. Since then case reports, observational studies, propensity analysis, and a systematic review of international practices continues to suggest eCPR as a feasible intervention for refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in select adult patients. However, in spite of this mounting base of evidence, clinicians continue to report concerns over a paucity of robust data showing definitive eCPR effectiveness compared with conventional resuscitation. This review will explore the ethical issues related to the impact eCPR might have on the orthodoxy pertaining to current resuscitation strategies, the impact of shifting decision-making on families particularly in dealing with a "bridge to nowhere" scenario, a call to accounting for greater data integrity and improved outcome reporting to assess eCPR effectiveness, and addressing the "Should we just do it" question. A recommendation is proposed for the creation of an ethics consultation service to assist families and staff in dealing with the invariable value conflicts and stresses likely to arise.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

CONTEXT

Palliative care continues to be a rapidly growing field aimed at improving quality of life for patients and their caregivers.

OBJECTIVES

The purpose of this review was to provide a synthesis of the evidence in palliative care to inform the fourth edition of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

METHODS

Ten key review questions addressing eight content domains guided a systematic review focused on palliative care interventions. We searched eight databases in February 2018 for systematic reviews published in English from 2013, after the last edition of National Consensus Project guidelines was published, to present. Experienced literature reviewers screened, abstracted, and appraised data per a detailed protocol registered in PROSPERO. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations criteria. The review was supported by a technical expert panel.

RESULTS

We identified 139 systematic reviews meeting inclusion criteria. Reviews addressed the structure and process of care (interdisciplinary team care, 13 reviews; care coordination, 18 reviews); physical aspects (48 reviews); psychological aspects (26 reviews); social aspects (two reviews); spiritual, religious, and existential aspects (11 reviews); cultural aspects (three reviews); care of the patient nearing the end of life (grief/bereavement programs, six reviews; final days of life, two reviews); ethical and legal aspects (36 reviews).

CONCLUSION

A substantial body of evidence exists to support clinical practice guidelines for quality palliative care, but the quality of evidence is limited.