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Affiliation(s)
- Roxanne E Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, The University of Toronto, Toronto, ON, Canada
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2
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Siegel B, Taylor LS, Alizadeh F, Barreto JA, Daniel D, Alexander PMA, Lipsitz S, Moynihan K. Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital. Pediatr Crit Care Med 2024; 25:301-311. [PMID: 38193777 DOI: 10.1097/pcc.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN Retrospective cohort study using mixed methods. SETTING Single-center quaternary pediatric hospital. PATIENTS Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.
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Affiliation(s)
- Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Dennis Daniel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Peta M A Alexander
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Katie Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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3
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James R, Carroll RS, Miller JM. Analysis of 20 Years of Ethics Consultations at a U.S. Children's Hospital. THE JOURNAL OF CLINICAL ETHICS 2024; 35:107-118. [PMID: 38728694 DOI: 10.1086/729417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
AbstractEmpirical studies of pediatric clinical ethics cases are scant in the biomedical and bioethics literature. In this study, more than 100 detailed records of clinical ethics consultations spanning from 2000 to 2020 at a moderately sized U.S. Mid-Atlantic children's hospital were abstracted and analyzed. Findings of the analysis were generally consistent with other studies in pediatric clinical ethics, with additional insight into aspects of moral distress associated with cases, family engagement with consultations, and other characteristics of interest also documented. Over the 20-year time frame, ethics consults were completed on average twice a year, with a detectable upward trend. Consultations were requested across the spectrum of services and units within the hospital, with critical care environments represented most frequently and genetic and neurological conditions being the most common primary diagnoses. Ethical analysis most commonly related to questions around the principles of autonomy and beneficence.
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4
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Siegel BD, Taylor LS, Moynihan KM. Towards organisational quality in ethics through patterns and process. JOURNAL OF MEDICAL ETHICS 2022; 48:989-990. [PMID: 36396423 DOI: 10.1136/jme-2022-108752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Children's Hospital of Westmead, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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5
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Bell JAH, Salis M, Tong E, Nekolaichuk E, Barned C, Bianchi A, Buchman DZ, Rodrigues K, Shanker RR, Heesters AM. Clinical ethics consultations: a scoping review of reported outcomes. BMC Med Ethics 2022; 23:99. [PMID: 36167536 PMCID: PMC9513991 DOI: 10.1186/s12910-022-00832-6] [Citation(s) in RCA: 6] [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: 04/06/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. OBJECTIVE The primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization. METHODS We searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. RESULTS Forty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes. CONCLUSIONS This scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC.
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Affiliation(s)
- Jennifer A H Bell
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
- The Institute for Education Research, University Health Network, Toronto, ON, Canada.
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Marina Salis
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Department of Philosophy, University of Toronto, Toronto, ON, Canada
- William Osler Health System, Brampton, ON, Canada
| | - Eryn Tong
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Erica Nekolaichuk
- Gerstein Science Information Centre, University of Toronto Libraries, University of Toronto, Toronto, ON, Canada
| | - Claudia Barned
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montreal, Montreal, QC, Canada
| | - Andria Bianchi
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation, Toronto, ON, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kevin Rodrigues
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ruby R Shanker
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ann M Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
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6
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Trang J, Herbert A, Sansom-Daly UM. How can advance care planning tools help young people's voices be heard? J Paediatr Child Health 2022; 58:1317-1322. [PMID: 35758055 DOI: 10.1111/jpc.16095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
The integration of the child or young person (CYP) in conversations around advance care planning (ACP) is an important area of paediatric practice. These discussions provide CYP with the opportunity to voice their values, goals and preferences, enabling health-care professionals to ensure they are aligned with their planned course of treatment. This process, often undertaken within the context of the child's family, empowers children to participate in decisions and experience the dignity of self-determination. It also facilitates an increased understanding between the CYP and those involved in their care. The objectives of this paper are to highlight the importance of these conversations for paediatricians and identify barriers, both real and perceived, that may prevent them from engaging with a CYP about their preferences for future care including focusing more on discussion with the parents, and concern about or not having the skills to engage the child in such sensitive conversations. Triggers that can prompt clinicians to undertake ACP are also discussed. A further complexity is that after seeking their perspective, it may become apparent that the CYP may hold different views and perspectives to their parents and/or clinician. This review article will especially examine elements of end-of-life conversations that are critical to support the important goal of listening to the voice of the CYP. This includes considerations around timing, legal aspects, ethical tensions that arise when amplifying a child's voice, clinician/team-member roles, clinical process considerations, and the use of specific interventions and ACP tools to facilitate these conversations with CYP.
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Affiliation(s)
- Jacinta Trang
- Children's Health Queensland Hospital and Health Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Anthony Herbert
- Children's Health Queensland Hospital and Health Service, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Centre for Children's Health Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ursula M Sansom-Daly
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Sydney Youth Cancer Service, Prince of Wales/Sydney Children's Hospital, Sydney, New South Wales, Australia
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7
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Kok N, Zegers M, van der Hoeven H, Hoedemaekers C, van Gurp J. Morisprudence: a theoretical framework for studying the relationship linking moral case deliberation, organisational learning and quality improvement. JOURNAL OF MEDICAL ETHICS 2022; 48:medethics-2021-107943. [PMID: 35584897 DOI: 10.1136/medethics-2021-107943] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims.
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Affiliation(s)
- Niek Kok
- IQ healthcare, Radboudumc, Nijmegen, The Netherlands
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8
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Alexander D, Quirke MB, Doyle C, Hill K, Masterson K, Brenner M. The Meaning Given to Bioethics as a Source of Support by Physicians Who Care for Children Who Require Long-Term Ventilation. QUALITATIVE HEALTH RESEARCH 2022; 32:916-928. [PMID: 35348409 PMCID: PMC9189592 DOI: 10.1177/10497323221083744] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The role and potential of bioethics input when a child requires the initiation of technology dependence to sustain life is relatively unknown. In particular, little is understood about the meaning physicians give to bioethics as a source of support during the care of children in pediatric intensive care who require long-term ventilation (LTV). We used a hermeneutic phenomenological approach to underpin the collection and analysis of data. Unstructured interviews of 40 physicians in four countries took place during 2020. We found that elements of trust, communication and acceptance informed the physicians' perceptions of the relationship with bioethics. These ranged from satisfaction to disappointment with their input into critical decisions. Bioethics services have potential to help physicians gain clarity over distressing and complex care decisions, yet physicians perceive the service inconsistently as a means of support. This research provides a sound basis to guide more beneficial interactions between clinicians and bioethics services.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Mary B. Quirke
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Carmel Doyle
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Katie Hill
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Kate Masterson
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
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9
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Fox E, Danis M, Tarzian AJ, Duke CC. Ethics Consultation in U.S. Hospitals: A National Follow-Up Study. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:5-18. [PMID: 33769216 DOI: 10.1080/15265161.2021.1893547] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
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Affiliation(s)
- Ellen Fox
- Altarum Institute
- Fox Ethics Consulting
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10
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Tarzian A, Fox E, Danis M, Duke CC. Ethics Consultation in U.S. Hospitals: Adherence to National Practice Standards. AJOB Empir Bioeth 2021; 13:10-21. [PMID: 34793287 DOI: 10.1080/23294515.2021.1996118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adherence to widely accepted practice standards is a frequently used measure of healthcare quality. In the U.S., the most widely recognized authoritative source of practice standards for ethics consultation (EC) is the second edition of the American Society for Bioethics and Humanities' Core Competencies for Healthcare Ethics Consultation report. METHODS To determine the extent to which EC practices in U.S. hospitals adhere to these practice standards, we developed and analyzed 12 evaluative measures from a national survey. RESULTS Only three of the 12 standards achieved over 75% adherence with reported EC practices: allowing anyone involved in a case to request an EC (100%), not requiring an attending physician's permission to conduct an EC (97.6%), and having at least one person on the ethics consultation service (ECS) with advanced level EC proficiency (79.3%). CONCLUSIONS Implications are discussed for achieving consensus on EC standards as they continue to evolve.
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Affiliation(s)
- Anita Tarzian
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, District of Columbia, USA.,University of Maryland, Baltimore, Maryland, USA
| | - Ellen Fox
- Altarum, Washington, District of Columbia, USA.,Fox Ethics Consulting, Arlington, Virginia, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland, USA
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11
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Crico C, Sanchini V, Casali PG, Pravettoni G. Evaluating the effectiveness of clinical ethics committees: a systematic review. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:135-151. [PMID: 33219898 PMCID: PMC7910230 DOI: 10.1007/s11019-020-09986-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 06/11/2023]
Abstract
Clinical Ethics Committees (CECs), as distinct from Research Ethics Committees, were originally established with the aim of supporting healthcare professionals in managing controversial clinical ethical issues. However, it is still unclear whether they manage to accomplish this task and what is their impact on clinical practice. This systematic review aims to collect available assessments of CECs' performance as reported in literature, in order to evaluate CECs' effectiveness. We retrieved all literature published up to November 2019 in six databases (PubMed, Ovid MEDLINE, Scopus, Philosopher's Index, Embase and Web of Science), following PRISMA guidelines. We included only articles specifically addressing CECs and providing any form of CECs performance assessment. Twenty-nine articles were included. Ethics consultation was the most evaluated of CECs' functions. We did not find standardized tools for measuring CECs' efficacy, but 33% of studies considered "user satisfaction" as an indicator, with 94% of them reporting an average positive perception of CECs' impact. Changes in patient treatment and a decrease of moral distress in health personnel were reported as additional outcomes of ethics consultation. The highly diverse ways by which CECs carry out their activities make CECs' evaluation difficult. The adoption of shared criteria would be desirable to provide a reliable answer to the question about their effectiveness. Nonetheless, in general both users and providers consider CECs as helpful, relevant to their work, able to improve the quality of care. Their main function is ethics consultation, while less attention seems to be devoted to bioethics education and policy formation.
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Affiliation(s)
- Chiara Crico
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Virginia Sanchini
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy.
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium.
| | - Paolo Giovanni Casali
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO, European Institute of Oncology IRCCS, Milan, Italy
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12
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Moynihan KM, Taylor L, Crowe L, Balnaves MC, Irving H, Ozonoff A, Truog RD, Jansen M. Ethical climate in contemporary paediatric intensive care. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106818. [PMID: 33431646 DOI: 10.1136/medethics-2020-106818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Liz Crowe
- Department of Pediatric Intensive Care, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mary-Claire Balnaves
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Irving
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Al Ozonoff
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melanie Jansen
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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13
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Evans AM, Jonas M, Lantos J. Pediatric Palliative Care in a Pandemic: Role Obligations, Moral Distress, and the Care You Can Give. Pediatrics 2020; 146:peds.2020-1163. [PMID: 32461261 DOI: 10.1542/peds.2020-1163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 11/24/2022] Open
Abstract
Many ethical issues arise concerning the care of critically ill and dying patients during the coronavirus disease 2019 (COVID-19) pandemic. In this issue's Ethics Rounds, we present 2 cases that highlight 2 different sorts of ethical issues. One is focused on the decisions that have to be made when the surge of patients with respiratory failure overwhelm ICUs. The other is focused on the psychological issues that arise for parents who are caring for a dying child when infection-control policies limit the number of visitors. Both of these situations raise challenges for caregivers who are trying to be honest, to deal with their own moral distress, and to provide compassionate palliative care.
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Affiliation(s)
- Amanda M Evans
- John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia;
| | - Monique Jonas
- Department of General Practice, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; and
| | - John Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri
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14
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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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Navin MC, Wasserman JA, Jain S, Baughman KR, Laventhal NT. When Do Pediatricians Call the Ethics Consultation Service? Impact of Clinical Experience and Formal Ethics Training. AJOB Empir Bioeth 2020; 11:83-90. [PMID: 32207383 DOI: 10.1080/23294515.2020.1737983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked to reflect on their ethics training and utilization of ECS via an anonymous, electronic survey distributed in 2017 and 2018, and analyzed in 2018. Participants reported their clinical experience, exposure to formal and informal ethics training, use of formal and informal ethics consultations, and potential barriers to formal consultation. Results: Less experienced pediatricians were more likely to utilize formal ethics consultation and more likely to have formal ethics training. The most commonly reported reasons not to pursue formal ECS consultation were inconvenience and self-reported expertise in pediatric ethics. Conclusions: These results inform ongoing discussions about ethics consultation among pediatricians and the role of formal ethics training in both undergraduate and graduate medical education.
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Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Rochester, Michigan, USA
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Susanna Jain
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Katie R Baughman
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Naomi T Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
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16
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Ong YT, Yoon NYS, Yap HW, Lim EG, Tay KT, Toh YP, Chin A, Radha Krishna LK. Training clinical ethics committee members between 1992 and 2017: systematic scoping review. JOURNAL OF MEDICAL ETHICS 2020; 46:36-42. [PMID: 31527139 DOI: 10.1136/medethics-2019-105666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/20/2019] [Accepted: 08/25/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Clinical ethics committees (CECs) support and enhance communication and complex decision making, educate healthcare professionals and the public on ethical matters and maintain standards of care. However, a consistent approach to training members of CECs is lacking. A systematic scoping review was conducted to evaluate prevailing CEC training curricula to guide the design of an evidence-based approach. METHODS Arksey and O'Malley's methodological framework for conducting scoping reviews was used to evaluate prevailing accounts of CEC training published in six databases. Braun and Clarke's thematic analysis approach was adopted to thematically analyse data across different healthcare and educational settings. RESULTS 7370 abstracts were identified, 92 full-text articles were reviewed and 55 articles were thematically analysed to reveal four themes: the design, pedagogy, content and assessment of CEC curricula. CONCLUSION Few curricula employ consistent approaches to training. Many programmes fail to provide CEC trainees with sufficient knowledge, skills and experience to meet required competencies. Most programmes do not inculcate prevailing sociocultural, research, clinical and educational considerations into training processes nor provide longitudinal support for CEC trainees. Most CEC training programmes are not supported by host institutions threatening the sustainability of the programme and compromising effective assessment and longitudinal support of CEC trainees. While further reviews are required, this review underlines the need for host organisations to support and oversee a socioculturally appropriate ethically sensitive, clinically relevant longitudinal training, assessment and support process for CEC trainees if CECs are to meet their roles effectively.
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Affiliation(s)
- Yun Ting Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Yue Shuen Yoon
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hong Wei Yap
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Elijah Gin Lim
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kuang Teck Tay
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ying Pin Toh
- Family Medicine Residency, National University Health System, Singapore, Singapore
| | - Annelissa Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore, Singapore
| | - Lalit Kumar Radha Krishna
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
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Isaacs D. Why do we not ask for more clinical ethics consultations? J Paediatr Child Health 2018; 54:937-938. [PMID: 30178592 DOI: 10.1111/jpc.14136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- David Isaacs
- Children's Hospital at Westmead, Sydney, New South Wales, Australia
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