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Hoon E, Edwards J, Harvey G, Eliott J, Merlin T, Carter D, Moodie S, O'Callaghan G. Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service - a case study. BMC Med Ethics 2023; 24:62. [PMID: 37568138 PMCID: PMC10422737 DOI: 10.1186/s12910-023-00942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Although the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established service, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting. METHODS HOW THE STUDY WAS PERFORMED AND STATISTICAL TESTS USED: A qualitative case study approach was utilised. The study gathered and analysed data using observations of service committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies. RESULTS THE MAIN FINDINGS: An overarching theme identified in the data was a strong commitment to supporting clinicians facing difficult patient care decisions and navigating difficult discussions with patients and families. Another key theme was the role of the new clinical ethics support service in providing clinicians with a pathway to raise system-wide issues with the organisation Executive. While there was strong clinical engagement, consumer and community participation remained a challenge, as did unresolved governance issues and a need for clearer policy relationship between the service and the organisation. Considering these themes in relation to the national capacity building resources, the study identifies three areas likely to require ongoing development and negotiation. These are: the role of the clinical ethics support service as a link between the workforce and the Executive; the incorporation of consumers and patients; and ethical reasoning. To improve the effectiveness of the service, it is necessary to increase clarity on the service's role at the governance and policy level, as well as develop strategies for engaging consumers, patients and families. Finally, the capacity of the service to reflect on complex cases may be enhanced through explicit discussions of various different ethical frameworks and ways of deliberating.
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Affiliation(s)
- Elizabeth Hoon
- School of Public Health, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia.
- Adelaide Medical School, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia.
| | - Jessie Edwards
- Adelaide Medical School, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia
| | - Gill Harvey
- College of Nursing and Health Sciences, Flinders University, PO Box 2100, Adelaide, SA, 5001, Australia
| | - Jaklin Eliott
- School of Public Health, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia
| | - Tracy Merlin
- School of Public Health, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia
| | - Drew Carter
- School of Public Health, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia
| | - Stewart Moodie
- Central Adelaide Local Health Network, Adelaide, SA, 5000, Australia
| | - Gerry O'Callaghan
- School of Public Health, The University of Adelaide, PO Box 5005, Adelaide, SA, 5005, Australia
- Central Adelaide Local Health Network, Adelaide, SA, 5000, Australia
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Blackler L, Scharf AE, Matsoukas K, Colletti M, Voigt LP. Call to action: empowering patients and families to initiate clinical ethics consultations. JOURNAL OF MEDICAL ETHICS 2023; 49:240-243. [PMID: 34732393 DOI: 10.1136/medethics-2021-107426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
Clinical ethics consultations exist to support patients, families and clinicians who are facing ethical or moral challenges related to patient care. They provide a forum for open communication, where all stakeholders are encouraged to express their concerns and articulate their viewpoints. Ethics consultations can be requested by patients, caregivers or members of a patient's clinical or supportive team. Although patients and by extension their families (especially in cases of decisional incapacity) are the common denominators in most ethics consultations, these constituents are the least likely to request them. At many healthcare organisations in the USA, ethics consultations are overwhelmingly requested by physicians and other clinicians. We believe it is vital that healthcare institutions bridge the knowledge gaps and power imbalances over access to ethics consultation services through augmented policies, procedures and infrastructure. With enhanced education and support, patients and families may use ethics consultation to elevate their voices and prioritise their unique characteristics and preferences in the delivery of their healthcare. Empowering patients and families to request ethics consultation can only strengthen the patient/family-clinician relationship, enhance the shared decision-making model of care and ultimately lead to improved patient-centred care.
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Affiliation(s)
- Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy E Scharf
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Konstantina Matsoukas
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Technology Division, Library Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michelle Colletti
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis P Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Wikstøl D, Horn MA, Pedersen R, Magelssen M. Citizen attitudes to non-treatment decision making: a Norwegian survey. BMC Med Ethics 2023; 24:20. [PMID: 36890542 PMCID: PMC9993678 DOI: 10.1186/s12910-023-00900-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Decisions about appropriate treatment at the end of life are common in modern healthcare. Non-treatment decisions (NTDs), comprising both withdrawal and withholding of (potentially) life-prolonging treatment are in principle accepted in Norway. However, in practice they may give rise to significant moral problems for health professionals, patients and next of kin. Here, patient values must be considered. It is relevant to study the moral views and intuitions of the general population on NTDs and special areas of contention such as the role of next of kin in decision-making. METHODS Electronic survey to members of a nationally representative panel of Norwegian adults. Respondents were presented with vignettes describing patients with disorders of consciousness, dementia, and cancer where patient preferences varied. Respondents answered ten questions about the acceptability of non-treatment decision making and the role of next of kin. RESULTS We received 1035 complete responses (response rate 40.7%). A large majority, 88%, supported the right of competent patients to refuse treatment in general. When an NTD was in line with the patient's previously expressed preferences, more respondents tended to find NTDs acceptable. More respondents would accept NTDs for themselves than for the vignette patients. In a scenario with an incompetent patient, clear majorities wanted the views of next of kin to be given some but not decisive weight, and more weight if concordant with the patient's wishes. There were, however, large variations in the respondents' views. CONCLUSION This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. However, the high variance among the respondents and relatively large weight given to next of kin's views, indicate a need for appropriate dialogue among all stakeholders to prevent conflicts and extra burdens. Furthermore, the emphasis given to previously expressed opinions indicates that advance care planning may increase the legitimacy of NTDs and prevent challenging decision-making processes.
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Affiliation(s)
- David Wikstøl
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | | | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway. .,MF Norwegian School of Theology, Religion and Society, Oslo, Norway.
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De Panfilis L, Magelssen M, Costantini M, Ghirotto L, Artioli G, Turola E, Perin M. Research, education, ethics consultation: evaluating a Bioethics Unit in an Oncological Research Hospital. BMC Med Ethics 2022; 23:133. [PMID: 36494709 PMCID: PMC9733101 DOI: 10.1186/s12910-022-00863-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study aims to quantitatively and qualitatively evaluate the activities of a Bioethics Unit (BU) 5 years since its implementation (2016-2020). The BU is a research unit providing empirical research on ethical issues related to clinical practice, clinical ethics consultation, and ethical education for health care professionals (HPS). METHODS We performed an explanatory, sequential, mixed-method, observational study, using the subsequent qualitative data to explain the initial quantitative findings. Quantitative data were collected from an internal database and analyzed by descriptive analysis. Qualitative evaluation was performed by semi-structured interviews with 18 HPs who were differently involved in the BU's activities and analyzed by framework analysis. RESULTS Quantitative results showed an extensive increment of the number of BU research projects over the years and the number of work collaborations with other units and wards. Qualitative findings revealed four main themes, concerning: 1. the reasons for contacting the BU and the type of collaboration; 2. the role of the bioethicist; 3. the impact of BU activities on HPs, in terms of developing deeper and more mature thinking; 4. the need to extend ethics support to other settings. Overall, our results showed that performing both empirical bioethics research and more traditional clinical ethics activities at the same unit would produce an impetus to increase collaboration and spread an 'ethical culture' among local HPs. CONCLUSIONS Our findings contribute to a growing body of literature on the models of clinical ethics support services and the role of empirical research in bioethics internationally. They also prepare the ground for the implementation of a multidisciplinary Clinical Ethics Committee (CEC) that aims to support the BU's ethics consultation service within the local context.
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Affiliation(s)
| | - Morten Magelssen
- grid.5510.10000 0004 1936 8921Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Massimo Costantini
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giovanna Artioli
- grid.10383.390000 0004 1758 0937Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Turola
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy ,grid.7548.e0000000121697570PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
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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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Eijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations-a national survey. BMC Med Ethics 2022; 23:62. [PMID: 35733137 PMCID: PMC9219170 DOI: 10.1186/s12910-022-00801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background Patient participation in clinical ethics support services (CESS) has been marked as an important issue. There seems to be a wide variety of practices globally, but extensive theoretical or empirical studies on the matter are missing. Scarce publications indicate that, in Europe, patient participation in CESS (fused and abbreviated hereafter as: PP) varies from region to region, and per type of support. Practices vary from being non-existent, to patients being a full conversation partner. This contrasts with North America, where PP seems more or less standard. While PP seems to be on the rise in Europe, there is no data to confirm this. This study sought a deep understanding of both habits and the attitudes towards PP in the Netherlands, including respondents’ practical and normative perspectives on the matter. Methods and Results We developed a national survey on PP for Dutch CESS staff. Our survey comprised a total of 25 open and close-ended questions, focused on four topics related to PP (1) goals of CESS, (2) status quo of PP, (3) ideas and ideals concerning PP, and (4) obstacles for PP. Discussion The four most important findings were that: (1) Patient participation in Dutch CESS is far from standard. (2) Views on patient participation are very much intertwined with the goals of ethics support. (3) Hesitations, fears and perceived obstacles for PP were not on principle and (4) Most respondents see PP as a positive opportunity, yet requiring additional training, practical guidance and experience. Conclusions Various normative reasons require PP. However, PP seems far from standard and somewhat rare in Dutch CESS settings. Our respondents did not raise many principled objections to PP. Instead, reasons for the lack of PP are intertwined with viewpoints on the goals of CESS, which seemingly focus on supporting health care professionals (HCPs). Training and practical guidance was thought to be helpful for gaining experience for both CESS staff and HCPs.
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Affiliation(s)
- Marleen Eijkholt
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.
| | | | - Wieke Ligtenberg
- Department of Ethics, Law and Humanities, Amsterdam UMC, Amsterdam, Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, Amsterdam, Netherlands
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Clinical ethical practice and associated factors in healthcare facilities in Ethiopia: a cross-sectional study. BMC Med Ethics 2022; 23:61. [PMID: 35717181 PMCID: PMC9206399 DOI: 10.1186/s12910-022-00800-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 06/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Clinical ethical practice (CEP) is required for healthcare workers (HCWs) to improve health-care delivery. However, there are gaps between accepted ethical standards and CEP in Ethiopia. There have been limited studies conducted on CEP in the country. Therefore, this study aimed to determine the magnitude and associated factors of CEP among healthcare workers in healthcare facilities in Ethiopia. Method From February to April 2021, a mixed-method study was conducted in 24 health facilities, combining quantitative and qualitative methods. Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. For quantitative and qualitative data analysis, Stata version 14 and Atlas.ti version 7 were utilized. Multiple logistic regression and thematic analysis for quantative and qualitative respectively used. Results From a total of 432 study participants, 407 HCWs were involved in the quantitative analysis, 36 participants were involved in five focus group discussions (FGDs), and eleven key informant interviews (KIIs) were involved in the qualitative analysis. The score of good CEP was 32.68%. Similarly, the scores of good knowledge and attitude were 33.50% and 25.31%, respectively. In the multiple logistic regression models, satisfaction with the current profession, availability of functional CECs, compassionate leaders, previously thought clinical ethics in pre-service education and good attitude were significant factors associated with CEP. Among these significant factors, knowledge, compassionate leaders, poor infrastructure, a conducive environment and positive attitudes were also determinants of CEP according to qualitative findings. Conclusions The CEP in health care services in Ethiopia is low. Satisfaction with the current profession, functional CECs, positive attitude, compassionate leaders and previously thought clinical ethics were significant factors associated with CEP. The Ministry of Health (MoH) should integrate interventions by considering CECs, compassionate leadership, and positive attitudes and enhance the knowledge of health professionals. Additionally, digitalization, intersectoral collaboration and institutionalization are important for promoting CEP. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00800-0.
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Dittborn M, Cave E, Archard D. Clinical ethics support services during the COVID-19 pandemic in the UK: a cross-sectional survey. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107818. [PMID: 34753795 PMCID: PMC8593272 DOI: 10.1136/medethics-2021-107818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The COVID-19 pandemic highlighted the need for clinical ethics support provision to ensure as far as possible fair decision making and to address healthcare workers' moral distress. PURPOSE To describe the availability, characteristics and role of clinical ethics support services (CESSs) in the UK during the COVID-19 pandemic. METHOD A descriptive cross-sectional online survey was developed by the research team. The survey included questions on CESSs characteristics (model, types of support, guidance development, membership, parent and patient involvement) and changes in response to the pandemic. Invitations to participate were widely circulated via National Health Service institutional emails and relevant clinical ethics groups known to the research team. RESULTS Between October 2020 and June 2021, a total of 53 responses were received. In response to the pandemic, new CESSs were established, and existing provision changed. Most took the form of clinical ethics committees, groups and advisory boards, which varied in size and membership and the body of clinicians and patient populations they served. Some services provided moral distress support and educational provision for clinical staff. During the pandemic, services became more responsive to clinicians' requests for ethics support and advice. More than half of respondents developed local guidance and around three quarters formed links with regional or other local services. Patient and/or family members' involvement in ethics discussions is infrequent. CONCLUSIONS The pandemic has resulted in an expansion in the number of CESSs. Though some may disband as the pandemic eases, the reliance on CESSs during the pandemic demonstrates the need for additional research to better understand the effectiveness of their various forms, connections, guidance, services and modes of working and for better support to enhance consistency, transparency, communication with patients and availability to clinical staff.
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Affiliation(s)
- Mariana Dittborn
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, UK
| | - Emma Cave
- Durham Law School, Durham University, Durham, UK
| | - David Archard
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
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Magelssen M, Karlsen H, Thoresen L. Establishing Clinical Ethics Committees in Primary Care: A Study from Norwegian Municipal Care. HEC Forum 2021; 35:201-214. [PMID: 34596811 PMCID: PMC8485308 DOI: 10.1007/s10730-021-09461-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 12/03/2022]
Abstract
Would primary care services benefit from the aid of a clinical ethics committee (CEC)? The implementation of CECs in primary care in four Norwegian municipalities was supported and their activities followed for 2.5 years. In this study, the CECs’ structure and activities are described, with special emphasis on what characterizes the cases they have discussed. In total, the four CECs discussed 54 cases from primary care services, with the four most common topics being patient autonomy, competence and coercion; professionalism; cooperation and disagreement with next of kin; and priority setting, resource use and quality. Nursing homes and home care were the primary care services most often involved. Next of kin were present in 10 case deliberations, whereas patients were never present. The investigation indicates that it might be feasible for new CECs to attain a high level of activity including case deliberations within the time frame. It also confirms that significant, characteristic and complex moral problems arise in primary care services.
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Affiliation(s)
- Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Heidi Karlsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Department for Interdisciplinary Health Sciences, Institute of Health and Society , University of Oslo, Oslo, Norway
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Moodley K, Kabanda SM, Kleinsmidt A, Obasa AE. COVID-19 underscores the important role of Clinical Ethics Committees in Africa. BMC Med Ethics 2021; 22:131. [PMID: 34563181 PMCID: PMC8465788 DOI: 10.1186/s12910-021-00696-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 08/13/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has magnified pre-existing challenges in healthcare in Africa. Long-standing health inequities, embedded in the continent over centuries, have been laid bare and have raised complex ethical dilemmas. While there are very few clinical ethics committees (CECs) in Africa, the demand for such services exists and has increased during the COVID-19 pandemic. The views of African healthcare professionals or bioethicists on the role of CECs in Africa have not been explored or documented previously. In this study, we aim to explore such perspectives, as well as the challenges preventing the establishment of CECs in Africa. METHODS Twenty healthcare professionals and bioethicists from Africa participated in this qualitative study that utilized in-depth semi-structured interviews with open-ended questions. Themes were identified through thematic analysis of interviews and open-ended responses. RESULTS Kenya and South Africa are the only countries on the continent with formal established CECs. The following themes emerged from this qualitative study: (1) Lack of formal CECs and resolution of ethical dilemmas; (2) Role of CECs during COVID-19; (3) Ethical dilemmas presented to CECs pre-COVID-19; (4) Lack of awareness of CECs; (5) Lack of qualified bioethicists or clinical ethicists; (6) Limited resources to establish CECs; (7) Creating interest in CECs and networking. CONCLUSIONS This study illustrates the importance of clinical ethics education among African HCPs and bioethicists, more so now when COVID-19 has posed a host of clinical and ethical challenges to public and private healthcare systems. The challenges and barriers identified will inform the establishment of CECs or clinical ethics consultation services (CESs) in the region. The study results have triggered an idea for the creation of a network of African CECs.
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Affiliation(s)
- Keymanthri Moodley
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Siti Mukaumbya Kabanda
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Anita Kleinsmidt
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Adetayo Emmanuel Obasa
- Department of Medicine, Centre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Magelssen M, Karlsen H. Clinical ethics committees in nursing homes: what good can they do? Analysis of a single case consultation. Nurs Ethics 2021; 29:94-103. [PMID: 34254541 PMCID: PMC8866748 DOI: 10.1177/09697330211003269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Ought nursing homes to establish clinical ethics committees (CECs)? An answer
to this question must begin with an understanding of how a clinical ethics
committee might be beneficial in a nursing home context – to patients, next
of kin, professionals, managers, and the institution. With the present
article, we aim to contribute to such an understanding. Aim: We ask, in which ways can clinical ethics committees be helpful to
stakeholders in a nursing home context? We describe in depth a clinical
ethics committee case consultation deemed successful by stakeholders, then
reflect on how it was helpful. Research design: Case study using the clinical ethics committee’s written case report and
self-evaluation form, and two research interviews, as data. Participants and research context: The nursing home’s ward manager and the patient’s son participated in
research interviews. Ethical considerations: Data were collected as part of an implementation study. Clinical ethics
committee members and interviewed stakeholders consented to study
participation, and also gave specific approval for the publication of the
present article. Findings/results: Six different roles played by the clinical ethics committee in the case
consultation are described: analyst, advisor, support, moderator, builder of
consensus and trust, and disseminator. Discussion: The case study indicates that clinical ethics committees might sometimes be
of help to stakeholders in moral challenges in nursing homes. Conclusions: Demanding moral challenges arise in the nursing home setting. More research
is needed to examine whether clinical ethics committees might be suitable as
ethics support structures in nursing homes and community care.
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Affiliation(s)
| | - Heidi Karlsen
- Centre for Medical Ethics, University of Oslo, Norway
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12
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Robertsen A, Helseth E, Førde R. Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see. BMC Med Ethics 2021; 22:43. [PMID: 33849500 PMCID: PMC8043091 DOI: 10.1186/s12910-021-00612-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient's best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians' strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. METHODS Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians' strategies related to treatment-limiting decision-making. RESULTS A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital's strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team-family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The "wait-and-see" physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. CONCLUSIONS Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.
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Affiliation(s)
- Annette Robertsen
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Reidun Førde
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
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13
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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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14
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Moodley K, Kabanda SM, Soldaat L, Kleinsmidt A, Obasa AE, Kling S. Clinical Ethics Committees in Africa: lost in the shadow of RECs/IRBs? BMC Med Ethics 2020; 21:115. [PMID: 33208150 PMCID: PMC7672173 DOI: 10.1186/s12910-020-00559-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background Clinical Ethics Committees (CECs) are well established at healthcare institutions in resource-rich countries. However, there is limited information on established CECs in resource poor countries, especially in Africa. This study aimed to establish baseline data regarding existing formal CECs in Africa to raise awareness of and to encourage the establishment of CECs or Clinical Ethics Consultation Services (CESs) on the continent.
Methods A descriptive study was undertaken using an online questionnaire via SunSurveys to survey healthcare professionals and bioethicists in Africa. Data were subjected to descriptive analysis and Fischer's exact test was applied to determine associations. Texts from the open-ended questions were thematically analysed. Results In total 109 participants from 37 African countries completed the survey in December 2019. A significant association was found between participants’ bioethics qualification or training and involvement in clinical ethics (p = 0.005). All participants were familiar with Research Ethics Committees (RECs), and initially conflated RECs with CECs. When CECs were explained in detail, approximately 85.3% reported that they had no formal CECs in their institutions. The constraints to developing CECs included lack of training, limited resources, and lack of awareness of CECs. However, the majority of participants (81.7%) were interested in establishing CECs. Participants listed assistance required in establishing CECs including funding, resources, capacity building and collaboration with other known CECs. The results do not reflect CECs established since the onset of COVID-19 in Africa. Conclusions This study provides a first look into CECs in Africa and found very few formal CECs on the continent indicating an urgent need for the establishment of CECs or CESs in Africa. While the majority of healthcare professionals and bioethicists are aware of ethical dilemmas in healthcare, the concept of formal CECs is foreign. This study served to raise awareness of CECs. Research ethics and RECs overshadow CECs in Africa because international funders from the global north support capacity development in research ethics and establish RECs to approve the research they fund in Africa. Raising awareness via educational opportunities, research and conferences about CECs and their role in improving the quality of health care in Africa is sorely needed.
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Affiliation(s)
- Keymanthri Moodley
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.
| | - Siti Mukaumbya Kabanda
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Leza Soldaat
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Anita Kleinsmidt
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Adetayo Emmanuel Obasa
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Sharon Kling
- Centre for Medical Ethics and Law, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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15
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Magelssen M, Karlsen H, Pedersen R, Thoresen L. Implementing clinical ethics committees as a complex intervention: presentation of a feasibility study in community care. BMC Med Ethics 2020; 21:82. [PMID: 32873310 PMCID: PMC7466831 DOI: 10.1186/s12910-020-00522-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
Background How should clinical ethics support services such as clinical ethics committees (CECs) be implemented and evaluated? We argue that both the CEC itself and the implementation of the CEC should be considered as ‘complex interventions’. Main text We present a research project involving the implementation of CECs in community care in four Norwegian municipalities. We show that when both the CEC and its implementation are considered as complex interventions, important consequences follow – both for implementation and the study thereof. Emphasizing four such sets of consequences, we argue, first, that the complexity of the intervention necessitates small-scale testing before larger-scale implementation and testing is attempted; second, that it is necessary to theorize the intervention in sufficient depth; third, that the identification of casual connections charted in so-called logic models allows the identification of factors that are vital for the intervention to succeed and which must therefore be studied; fourth, that an important part of a feasibility study must be to identify and chart as many as possible of the causally important contextual factors. Conclusion The conceptualization of the implementation of a CEC as a complex intervention shapes the intervention and the way evaluation research should be performed, in several significant ways. We recommend that researchers consider whether a complex intervention approach is called for when studying CESS implementation and impact.
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Affiliation(s)
- Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway.
| | - Heidi Karlsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Lisbeth Thoresen
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
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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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