The role of ethics committees and ethics consultation in allocation decisions: a 4-stage process

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.

Roles and responsibilities of clinical ethics committees in priority setting

BACKGROUND

Fair prioritization of healthcare resources has been on the agenda for decades, but resource allocation dilemmas in clinical practice remain challenging. Can clinical ethics committees (CECs) be of help? The aim of the study was to explore whether and how CECs handle priority setting dilemmas and contribute to raising awareness of fairness concerns.

METHOD

Descriptions of activities involving priority setting in annual reports from Norwegian CECs (2003-2015) were studied and categorized through qualitative content analysis.

RESULTS

Three hundred thirty-nine reports from 38 CECs were studied. We found 78 activities where resource use or priority setting were explicitly highlighted as main topics. Of these, 29 were seminars or other educational activities, 21 were deliberations on individual patient cases, whereas 28 were discussions of principled or general cases. Individual patient cases concerned various distributional dilemmas where values were at stake. Six main topics and seven roles for the CEC were identified. CECs handle issues concerning the introduction of new costly drugs, extraordinarily costly established treatment, the application of priority setting criteria, resource use for vulnerable groups, resource constraints compromising practice, and futility of care. The CEC can act as an analyst, advisor, moderator, disseminator, facilitator, watch dog, and guardian of values and laws.

DISCUSSION

In order to fulfil their responsibilities in handling priority setting cases, CECs need knowledge of both the ethics and the institutionalized systems of priority setting. There is potential for developing this aspect of the CECs' work further.

CONCLUSIONS

The Norwegian CECs are involved in priority setting decisions where they can play multiple constructive roles. In particular, they advise and raise awareness of ethical aspects in resource allocations; bridge clinical practice with higher-level decisions; and promote fair resource allocation and stakeholder rights and interests.

An Exploration of the Role of Hospital Committees to Enhance Productivity

Productivity is the main concern of hospitals as organizations providing health services. As the role of hospital committees is increasing and their productivity and performance improvement is very important, the present study was performed to identify weaknesses and strengths of committee sessions. This analytical-descriptive study was conducted cross- sectional from January to April in 2012. Summary of 405 committee session's agendas related to 11 kinds of committees in 8 hospitals (out of 23 hospitals) of capital cities in 3 provinces of Sistan and Balouchestan, South Khorasan and Khorasan Razavi in Iran were extracted. Data was collected through a form and was analyzed by SPSS16 software using descriptive statistics and variance analysis and content analysis technique. This study showed that the number of hospital committee's sessions holding in 2012 was more than 2011. The differences between public and private hospitals in terms of the following subjects were significant (P-Value < 0.001). In terms of the number of selected policies, participants of the committees, and the duration of the sessions the public hospitals had better conditions. And regarding documentation process, feedback of decisions to personnel and the implementation of the formulated policies in the committees, private hospitals performed better. According to the results of this study, to improve the productivity of hospital committees, it is suggested to motivate senior, tactical and operational managers to appropriately participate in the committees and necessary planning for the committees in advance is mandatory.

[Avoidance of overuse as an integral part of medical professionalism. Conceptual analysis and new perspective]

BACKGROUND

The topics of rationing and priority setting have been increasingly discussed over the past 5 years in Germany by physicians together with other health care stakeholders. The topic of overuse, however, has not been discussed with similar intensity and publicity.

OBJECTIVES

This analysis paper outlines the relationships and differences between efficiency, priority setting, and rationing. Furthermore, it argues why and how German physicians should address the topic of overuse with more transparency and intensity.

DISCUSSION

Efforts of physicians to rationalize health care mainly comprise efforts to decrease overuse. The identification of important areas of overuse includes the prioritization of indications and medical interventions. Rationing health care can be unavoidable, for example, because other strategies such as rationalization, price regulation or disinvestments are not sufficient to avoid scarcity of financial resources. In such a case, rationing health care is unavoidable and, therefore, cannot be unethical per se. However, the debate on rationing becomes more legitimate if physicians demonstrate sufficient efforts to reduce overuse sufficiently. The Choosing Wisely initiative in the USA is outlined as one interesting option of how physicians could demonstrate and prove such efforts. Additional and more effective strategies to decrease overuse might be possible.

CONCLUSION

German physicians demand a more explicit communication within their communities and together with other stakeholders on the appropriateness of existing and potential future activities to decrease overuse. Such initiatives to avoid and decrease overuse should primarily be motivated through the ethical principle of beneficence, while the effect of cost containment should be considered as a welcomed side effect.

How can bedside rationing be justified despite coexisting inefficiency? The need for 'benchmarks of efficiency'

Imperfect efficiency in healthcare delivery is sometimes given as a justification for refusing to ration or even discuss how to pursue fair rationing. This paper aims to clarify the relationship between inefficiency and rationing, and the conditions under which bedside rationing can be justified despite coexisting inefficiency. This paper first clarifies several assumptions that underlie the classification of a clinical practice as being inefficient. We then suggest that rationing is difficult to justify in circumstances where the rationing agent is or should be aware of and contributes to clinical inefficiency. We further explain the different ethical implications of this suggestion for rationing decisions made by clinicians. We argue that rationing is more legitimate when sufficient efforts are undertaken to decrease inefficiency in parallel with efforts to pursue unavoidable but fair rationing. While the qualifier 'sufficient' is crucial here, we explain why 'sufficient efforts' should be translated into 'benchmarks of efficiency' that address specific healthcare activities where clinical inefficiency can be decreased. Referring to recent consensus papers, we consider some examples of specific clinical situations where improving clinical inefficiency has been recommended and consider how benchmarks for efficiency might apply. These benchmarks should state explicitly how much inefficiency shall be reduced in a reasonable time range and why these efforts are 'sufficient'. Possible strategies for adherence to benchmarks are offered to address the possibility of non-compliance.

[Rationalization and rationing at the bedside. A normative and empirical status quo analysis]

BACKGROUND

The topic of bedside rationing is increasingly discussed in Germany. Further need for clarification exists for the question how bedside rationing (e.g., in the area of overcare) can be justified despite coexistent inefficiencies.

DISCUSSION

This paper outlines and analyses the relationship of waste avoidance and rationing from an ethical perspective. Empirical findings regarding the status quo of bedside rationing and rationalization are presented. These normative and empirical explorations will then be further specified regarding opportunities for future physician-driven activities to tackle overuse.

CONCLUSION

The self-government partners in Germany should communicate more explicitly within their communities and to the public how and with which benchmarks they aim to reduce inefficient health care (overuse) in an appropriate manner. Physician-driven activities such as the "Choosing Wisely®" initiative in the USA could provide a first step to raise the awareness for overuse among physicians as well as in the public.