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Omondi Aduda DS, Agot K, Ohaga S, Aoko A, Onyango J, Toroitich-Ruto C, Kambona C, Odoyo-June E. Facility characteristics preferred by older men seeking medical male circumcision services in Kenya: qualitative findings from the 'Tasco' study (May 2014-June 2016). BMC Public Health 2024; 24:1718. [PMID: 38937707 PMCID: PMC11210051 DOI: 10.1186/s12889-024-19234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/21/2024] [Indexed: 06/29/2024] Open
Abstract
Primary healthcare facilities are central to the implementation of voluntary medical male circumcision (VMMC) as points of access to integrated health services in line with the Kenya AIDS Strategic Framework II (2020/21-2024/25). Knowledge of factors that explain men's uptake of VMMC and sexual health services at these facilities and preferences of where to get the services remain poorly understood. Using qualitative methodologies, we examined factors that determined facility choice for VMMC services and reasons for preferring the facility among men aged 25-39 years who previously underwent VMMC. The current study draws from focus group discussion interviews with circumcised men and their partners conducted as part of a randomized controlled trial to assess impact of two demand creation interventions in western Kenya. This involved 12 focus group discussions (FGD) with 6-10 participants each. Six FGDs were conducted with circumcised men, and 6 with their sex partners. Thematic issues relevant to a predetermined framework were identified. The themes were organized as follows: service availability, accessibility, affordability, appropriateness and, acceptability. Facility location, physical layout, organization of patient flow, infrastructure, and service provider skills were the outstanding factors affecting the choice of VMMC service outlets by men aged 25-39 years. Additionally, preferences were influenced by individual's disposition, attitudes, knowledge of VMMC services and tacit balance between their own recognized health needs versus desire to conform to social-cultural norms. Facility choice and individual preference are intricate issues, simultaneously involving multiple but largely intra-personal and facility-level factors. The intrapersonal dimensions elicited may also reflect differential responses to strategic communications and demand creation messages with promotion and prevention frames.
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Affiliation(s)
- Dickens S Omondi Aduda
- Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya.
- Impact Research and Development Organization, Kisumu, Kenya.
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Spala Ohaga
- Impact Research and Development Organization, Kisumu, Kenya
| | - Appolonia Aoko
- Division of Global HIV & TB, Division of Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Jacob Onyango
- Impact Research and Development Organization, Kisumu, Kenya
| | - Cathy Toroitich-Ruto
- Division of Global HIV & TB, Division of Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Caroline Kambona
- Division of Global HIV & TB, Division of Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Elijah Odoyo-June
- Division of Global HIV & TB, Division of Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
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Albertsen A. Unjust organ markets and why it is irrelevant that selling a kidney is the best option. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109593. [PMID: 38806229 DOI: 10.1136/jme-2023-109593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/17/2024] [Indexed: 05/30/2024]
Abstract
An important argument against prohibiting organ sales is that it removes the best option available to individuals in dire circumstances. However, this line of reasoning fails to recognise that selling a kidney on a regulated market is only the best option in a very narrow comparison, where a regulated organ market is compared with banning organ sales. Once we acknowledge this narrowness, selling a kidney is not the best option. This paves the way for a distributive justice-based critique of the 'best option' argument for organ markets, which illuminates that organ markets should be compared with a broader set of alternatives. If providing the option of selling a kidney is not the best option, but rather the best option we are willing to provide, and one which means that many people will remain in poverty and unjust circumstances, then this reflects poorly on those societies willing to offer only this option and not a better one.
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Affiliation(s)
- Andreas Albertsen
- Department of Political Science, School of Business and Social Sciences, Aarhus Universitet, Aarhus, Denmark
- The Centre for the Experimental-Philosophical Study of Discrimination-CEPDISC, Department of Political Science, Aarhus University, Aarhus, Denmark
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Mahadevan A, Azizi A, Dastur C, Stern-Nezer S, Nahmias J, Dayyani F. Characterization of patients requiring inpatient hospital ethics consults- A single center study. PLoS One 2024; 19:e0296763. [PMID: 38564582 PMCID: PMC10986956 DOI: 10.1371/journal.pone.0296763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 12/18/2023] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Ethics consultations are often needed at difficult junctures of medical care. However, data on the nature of how patient characteristics, including race/ethnicity, language, and diagnosis, affect ethics consult outcomes are lacking. METHODS We performed a retrospective cohort study of all patients who were seen by the Ethics Consult Service between 2017 and 2021 at a large tertiary academic center with the aim of determining whether patient demographic and clinical factors were associated with the timing of ethics consult requests and recommendations of the ethics team. RESULTS We found that patients admitted for COVID-19 had significantly longer median times to consult from admission compared with other primary diagnoses (19 vs 8 days respectively, p = 0.015). Spanish-speaking patients had longer median times to consult from admission compared to English speaking patients (20 vs 7 days respectively, p = 0.008), indicating that language barriers may play a role in the timing of ethics consultation. CONCLUSIONS This study demonstrates the need to consider clinical and demographic features when planning and prioritizing ethics consultations at large institutions to enhance consult efficiency, resource utilization, and patient experience and autonomy.
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Affiliation(s)
- Aditya Mahadevan
- University of California Irvine School of Medicine, Irvine, Irvine, CA, United States of America
| | - Armon Azizi
- University of California Irvine School of Medicine, Irvine, Irvine, CA, United States of America
| | - Cyrus Dastur
- Department of Neurology, Division of Neurocritical Care, University of California, Irvine, Irvine, CA, United States of America
| | - Sara Stern-Nezer
- Department of Neurology, Division of Neurocritical Care, University of California, Irvine, Irvine, CA, United States of America
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns, Critical Care & Acute Care Surgery, University of California, Irvine, Irvine, CA, United States of America
| | - Farshid Dayyani
- Department of Medicine, Division of Hematology and Oncology, University of California, Irvine, Irvine, CA, United States of America
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Nanyonga MM, Kutyabami P, Kituuka O, Sewankambo NK. Exploration of Clinical Ethics Consultation in Uganda: A case study of Uganda Cancer Institute. RESEARCH SQUARE 2024:rs.3.rs-3853569. [PMID: 38343843 PMCID: PMC10854307 DOI: 10.21203/rs.3.rs-3853569/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Introduction Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESS) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence of mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda. Methodology This qualitative study utilized in-depth-interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers, who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook. Results There was no formal committee nor mechanism utilized to resolve ethical dilemmas at the UCI. The study uncovered six fora where ethical dilemmas were addressed: individual consultations, tumor board meetings, morbidity and mortality meetings, core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas. Conclusion The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.
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Schultz B, Agamah FE, Ewuoso C, Madden EB, Troyer J, Skelton M, Mwaka E. Webinar report: stakeholder perspectives on informed consent for the use of genomic data by commercial entities. JOURNAL OF MEDICAL ETHICS 2023; 50:57-61. [PMID: 36941048 PMCID: PMC10804035 DOI: 10.1136/jme-2022-108650] [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: 09/19/2022] [Accepted: 02/27/2023] [Indexed: 06/18/2023]
Abstract
In July 2020, the H3Africa Ethics and Community Engagement (E&CE) Working Group organised a webinar with ethics committee members and biomedical researchers from various African institutions throughout the Continent to discuss the issue of whether and how biological samples for scientific research may be accessed by commercial entities when broad consents obtained for the samples are silent. 128 people including Research Ethics Committee members (10), H3Africa researchers (46) including members of the E&CE working group, biomedical researchers not associated with H3Africa (27), representatives from the National Institutes of Health (16) and 10 other participants attended the webinar and shared their views. Several major themes emerged during the webinar, with the topics of broad versus explicit informed consent, defining commercial use, legacy samples and benefit sharing prevailing in the discussion. This report describes the consensus concerns and recommendations raised during the meeting and will be informative for future research on ethical considerations for genomic research in the African research context.
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Affiliation(s)
- Baergen Schultz
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Francis E Agamah
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cornelius Ewuoso
- Medicine, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Ebony B Madden
- Training, Diversity and Health Equity Office, Office of the Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Troyer
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Michelle Skelton
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Erisa Mwaka
- College of Health Sciences, Makerere University, Kampala, Uganda
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Khirikoekkong N, Asarath SA, Munruchaitrakun M, Blay N, Waithira N, Cheah PY, Nosten F, Lubell Y, Landier J, Althaus T. Fever and health-seeking behaviour among migrants living along the Thai-Myanmar border: a mixed-methods study. BMC Infect Dis 2023; 23:501. [PMID: 37525093 PMCID: PMC10388507 DOI: 10.1186/s12879-023-08482-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 07/21/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Fever is a common reason to seek healthcare in Southeast Asia, and the decline of malaria has complexified how is perceived, and what actions are taken towards it. We investigated the concept of fever and the determinants influencing health-seeking behaviours among migrants on the Thai-Myanmar border, where rapid economic development collides with precarious political and socio-economic conditions. METHODS We implemented a mixed-methods study between August to December 2019. Phase I used a qualitative approach, with in-depth interviews and focus group discussions. Phase II used a quantitative approach with a close-ended questionnaire based on Phase I findings. A conditional inference tree (CIT) model first identified geographic and socio-demographic determinants, which were then tested using a logistic regression model. RESULTS Fever corresponded to a high diversity of conceptions, symptoms and believed causes. Self-medication was the commonest behaviour at fever onset. If fever persisted, migrants primarily sought care in humanitarian cost-free clinics (45.5%, 92/202), followed by private clinics (43.1%, 87/202), health posts (36.1%, 73/202), public hospitals (33.7%, 68/202) and primary care units (30, 14.9%). The qualitative analysis identified distance and legal status as key barriers for accessing health care. The quantitative analysis further investigated determinants influencing health-seeking behaviour: living near a town where a cost-free clinic operated was inversely associated with seeking care at health posts (adjusted odds ratio [aOR], 0.40, 95% confidence interval [95% CI] [0.19-0.86]), and public hospital attendance (aOR 0.31, 95% CI [0.14-0.67]). Living further away from the nearest town was associated with health posts attendance (aOR 1.05, 95% CI [1.00-1.10] per 1 km). Having legal status was inversely associated with cost-free clinics attendance (aOR 0.27, 95% CI [0.10-0.71]), and positively associated with private clinic and public hospital attendance (aOR 2.56, 95% CI [1.00-6.54] and 5.15, 95% CI [1.80-14.71], respectively). CONCLUSIONS Fever conception and believed causes are context-specific and should be investigated prior to any intervention. Distance to care and legal status were key determinants influencing health-seeking behaviour. Current economic upheavals are accelerating the unregulated flow of undocumented migrants from Myanmar to Thailand, warranting further inclusiveness and investments in the public health system.
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Affiliation(s)
- Napat Khirikoekkong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Supa-At Asarath
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Mayreerat Munruchaitrakun
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Naw Blay
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Naomi Waithira
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - François Nosten
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jordi Landier
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
- Institut de Recherche pour le Développement (IRD), Aix Marseille Univ, INSERM, SESSTIM, Aix Marseille Institute of Public Health, ISSPAM, Marseille, France
| | - Thomas Althaus
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Molewijk B, Pedersen R, Kok A, Førde R, Aasland O. Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees' normative attitudes, user involvement and the handling of disagreement. BMC Med Ethics 2023; 24:29. [PMID: 37173770 PMCID: PMC10182617 DOI: 10.1186/s12910-023-00909-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees' attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. METHODS We used panel data in a longitudinal design study to measure variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0-T1-T2). Mixed models were used to account for dependence of data in persons who participated more than once. RESULTS In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. CONCLUSIONS This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since-despite the intrinsic value of participating in ERG or MCD-CES inherently aims, and should aim, at improving clinical practices.
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Affiliation(s)
- Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of Ethics, Law and Humanities, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Almar Kok
- Department of Epidemiology and Data Science and Department of Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Olaf Aasland
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Regulation of community advisory boards during conduct of clinical trials in Uganda: a qualitative study involving stakeholders. BMC Health Serv Res 2023; 23:119. [PMID: 36740683 PMCID: PMC9899660 DOI: 10.1186/s12913-023-09136-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/31/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Community advisory structures such as Community Advisory Boards (CABs) play an important role of helping researchers to better understand the community at each phase of the clinical trial. CABs can be a source of accurate information on the community, its perception of proposed research and may identify factors that make community members vulnerable to the problem under investigation. Although CABs help to build mutually beneficial relationships between the researcher(s) and the communities in which the clinical trial is being implemented, effective engagement would require ethical guidance and regulatory oversight. The study assessed the stakeholders' perspectives regarding the regulatory oversight of CABs in Uganda. METHODS This was an exploratory study employing qualitative methods of data collection and analysis. Key informant interviews (KIIs) with the trial investigators, CAB chairpersons, community liaison officers, regulators and Research Ethics Committee (REC) chairpersons were conducted. A KII guide was designed and utilized during key informant interviews. The guide included questions on role of investigators and CAB members in clinical trials; challenges of community engagement; facilitation of CABs; regulatory oversight of CABs; work relationships between investigators and CABs; and opinions on how community trials should be conducted among others. All interviews were conducted in English. Qualitative data were transcribed verbatim. A code book was generated based on the transcripts and study objectives. Thematic analysis was used to analyze data and identify themes. Atlas ti was used to support data analysis. RESULTS Of the 34 respondents, 35.3% were investigators, 32.3% CAB chairpersons, 23.5% research regulators/REC Chairs and 8.8% community liaison officers. The findings of the study revealed that CABs are appointed by the research institution/researcher, operate under the guidance of the researcher with limited independence. Additionally, the CABs provide voluntary service and lack guidelines or regulatory oversight. Four themes emerged. CONCLUSION The operations and activities of CABs are not regulated by the national regulators or RECs. The regulatory oversight of CABs should be based on contextualized ethical guidelines. Need for additional training in research ethics, community engagement and sensitization on available ethics guidelines for research.
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Weaver MS, Wichman C, Sharma S, Walter JK. Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work. AJOB Empir Bioeth 2022; 14:135-142. [PMID: 36574230 DOI: 10.1080/23294515.2022.2160512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged. METHODS Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children's hospitals and five programmatic domains. RESULTS 104 children's hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of consultants. Academically-affiliated children's hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5. CONCLUSIONS While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults.
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Affiliation(s)
- Meaghann S Weaver
- Department of Pediatrics, Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Health Affairs, National Center for Ethics in Healthcare, Washington, DC, USA
| | - Christopher Wichman
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shiven Sharma
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer K Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Bain LE, Akondeng C, Njamnshi WY, Mandi HE, Amu H, Njamnshi AK. Community engagement in research in sub-Saharan Africa: current practices, barriers, facilitators, ethical considerations and the role of gender - a systematic review. Pan Afr Med J 2022; 43:152. [PMID: 36785694 PMCID: PMC9922083 DOI: 10.11604/pamj.2022.43.152.36861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/20/2022] [Indexed: 02/15/2023] Open
Abstract
Introduction meaningful community engagement is increasingly being considered the major determinant of successful research, innovation and intervention uptake. Even though there is available literature recommending community engagement in health research, there are still knowledge gaps in how communities might be best engaged in Sub-Saharan Africa. We, therefore, synthesized the existing literature on the current practices, barriers and facilitators, ethical considerations, and gender mainstreaming in the engagement of communities in research in sub-Saharan Africa. Methods this synthesis was developed following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). A combination of keywords and medical subject headings was used to search MEDLINE, EMBASE, Global Health Library through OVID SP, the Cochrane Library, PsychINFO, CINAHL, WHO Afro Library, WHO Global Index Medicus and the National Institute for Health Research, for all literature published between 1 January 2000 to 31 July 2021. Results thirty articles met our inclusion criteria. The key reported facilitators of effective community engagement in research included appropriate community entry and engagement of stakeholders. Barriers to effective community engagement in research included the availability of prohibitive cultural, historical and religious practices; geographical/spatial limitations, difficulties in planning and executing community engagement activities and communication barriers. Awareness creation and sensitization on the research through drama, social media, documentaries, and community durbars are some of the existing practices adopted in engaging communities in research. Gender mainstreaming was not considered appropriately in the engagement of communities in research, as only a few studies made provisions for gender considerations, and most of the time, interchanging gender for sex. Respect for autonomy, privacy and informed consent were the main ethical issues reported. Conclusion gender mainstreaming and ethical standards were reported as important, but not explored in depth. Gender as a social construct needs to be carefully integrated in the entire research cycle. Clear ethical concerns within a research project have to be co-discussed by the research team, community members and potential research participants.
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Affiliation(s)
- Luchuo Engelbert Bain
- Triangle Research Foundation (TRIFT), Limbe, Cameroon,,Department of Psychology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa,,Global South Health Services and Research (GSHS), Amsterdam, The Netherlands,,Corresponding author: Luchuo Engelbert Bain, Triangle Research Foundation (TRIFT), Limbe, Cameroon.
| | - Claudine Akondeng
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Cameroon National Association of Family Welfare (CAMNAFAW), Yaoundé, Cameroun
| | - Wepnyu Yembe Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Education and Learning for All (ELFA) Cameroon, Yaoundé, Cameroon,,Division of Operational Research in Health, DROS, Ministry of Public Health, Yaoundé, Cameroon
| | - Henshaw Eyambe Mandi
- Triangle Research Foundation (TRIFT), Limbe, Cameroon,,Coalition for Epidemic Preparedness Innovations, Oslo, Norway
| | - Hubert Amu
- Department of Population and Behavioral Sciences, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Alfred Kongnyu Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon,,Education and Learning for All (ELFA) Cameroon, Yaoundé, Cameroon,,Faculty of Medicine and Biomedical Sciences (FMBS), The University of Yaoundé I, Yaoundé, Cameroon
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Biyazin T, Taye A, Belay Y. Patient satisfaction with surgical informed consent at Jimma Medical Center, Ethiopia. BMC Med Ethics 2022; 23:103. [PMID: 36284338 PMCID: PMC9594918 DOI: 10.1186/s12910-022-00841-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 10/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Informed consent is a process in which a healthcare provider obtains permission from an individual prior to surgery. Patient satisfaction with the informed consent process is one of the main indicators of healthcare service quality. This study aimed to assess patient satisfaction with surgical informed consent at Jimma Medical Center, Ethiopia, in 2020. Methods A facility-based cross-sectional study was conducted from April 1 to June 30, 2020, at Jimma Medical Center. Face-to-face interviews were conducted using structured questionnaires. A systematic sampling technique was used to select the study participants. The collected data were coded, entered into Epi data version 3.1, and analyzed using SPSS version 25. Bivariate and multivariate regression analyses were performed to determine the association between patient satisfaction and socio-demographic and facility-related factors. In multivariate regression, predictors with a P-value of < 0.05 were considered statistically significant. Results Totally 372 study participants were interviewed with a response rate of 97.8%. Nearly two-fifths (43%) of patients were satisfied with surgical informed consent. Living in an urban area (AOR: 2.279, 95% CI 1.257–4.131), having current referred history (AOR: 1.856, 95% CI 1.033–3.337), consent form version (AOR: 2.076, 95% CI 1.143–3.773), time spent on the provision of informed consent (AOR: 5.227, 95% CI 2.499–10.936) and having better patient-health providers relationship (AOR: 5.419, 95% CI 3.103–9.464) predictors were positively associated with patient satisfaction. Conclusion Patient satisfaction with the surgical informed consent process was relatively low. Therefore, Health care professionals need to emphasize a way of delivering informed consent, patients' needs and obey a standard informed consent to improve patient satisfaction.
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Affiliation(s)
- Tsegaw Biyazin
- grid.411903.e0000 0001 2034 9160School of Midwifery, Faculty of Health Science, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Ayanos Taye
- grid.411903.e0000 0001 2034 9160School of Nursing, Faculty of Health Science, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Yeshitila Belay
- grid.411903.e0000 0001 2034 9160School of Nursing, Faculty of Health Science, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia
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12
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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: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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13
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Haltaufderheide J, Nadolny S, Vollmann J, Schildmann J. Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants. JOURNAL OF MEDICAL ETHICS 2022; 48:401-406. [PMID: 34006601 PMCID: PMC9132864 DOI: 10.1136/medethics-2020-107129] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/09/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints-and for what reasons-should be considered when evaluating the quality of a service. In this paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research.
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Affiliation(s)
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
- Nursing Science Staff Unit, Franziskus Hospital Harderberg, Niels-Stensen-Kliniken, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
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14
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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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15
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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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16
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Mugenyi L, Mijumbi A, Nanfuka M, Agaba C, Kaliba F, Semakula IS, Nazziwa WB, Ochieng J. Capacity of community advisory boards for effective engagement in clinical research: a mixed methods study. BMC Med Ethics 2021; 22:165. [PMID: 34911524 PMCID: PMC8672338 DOI: 10.1186/s12910-021-00733-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/30/2021] [Indexed: 12/04/2022] Open
Abstract
Background Community engagement is a key component in health research. One of the ways health researchers ensure community engagement is through Community Advisory Boards (CABs). The capacity of CABs to properly perform their role in clinical research has not been well described in many resource limited settings. In this study, we assessed the capacity of CABs for effective community engagement in Uganda. Methods We conducted a cross sectional study with mixed methods. We used structured questionnaires and key informant interviews (KII) to collect data from CAB members, trial investigators, and community liaison officers. For quantitative data, we used descriptive statistics while for qualitative data we used content analysis. Results Seventy three CAB members were interviewed using structured questionnaires; 58.9% males, median age 49 years (IQR 24–70), 71.2% had attained tertiary education, 42.5% never attended any research ethics training, only 26% had a training in human subject protection, 30.1% had training in health research, 50.7% never attended any training about the role of CABs, and 72.6% had no guidelines for their operation. On the qualitative aspect, 24 KIIs cited CAB members to have some skills and ability to understand and review study documents, offer guidance on community norms and expectations and give valuable feedback to the investigators. However, challenges like limited resources, lack of independence and guidelines, and knowledge gaps about research ethics were cited as hindrances of CABs capacity. Conclusion Though CABs have some capacity to perform their role in the Ugandan setting, their functionality is limited by lack of resources to facilitate their work, lack of independence, lack of guidelines for their operations and limited knowledge regarding issues of research ethics and protection of the rights of trial participants. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00733-0.
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Affiliation(s)
| | | | - Mastula Nanfuka
- Makerere University-John Hopkins University Collaboration, Kampala, Uganda
| | | | | | | | | | - Joseph Ochieng
- College of Health Sciences, Makerere University, Kampala, Uganda
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17
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Kang J, Lee M, Cho YS, Jeong JH, Choi SA, Hong J. The relationship between person-centred care and the intensive care unit experience of critically ill patients: A multicentre cross-sectional survey. Aust Crit Care 2021; 35:623-629. [PMID: 34844837 DOI: 10.1016/j.aucc.2021.10.010] [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] [Received: 04/18/2021] [Revised: 09/30/2021] [Accepted: 10/16/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Person-centred care has the potential to improve the patient experience in the intensive care unit (ICU). However, the relationship between person-centred care perceived by critically ill patients and their ICU experience has yet to be determined. OBJECTIVES The aim of this study was to investigate the relationship between person-centred care and the ICU experience of critically ill patients. METHODS This study was a multicentre, cross-sectional survey involving 19 ICUs of four university hospitals in Busan, Korea. The survey was conducted from June 2019 to July 2020, and 787 patients who had been admitted to the ICU for more than 24 hours participated. We measured person-centred care using the Person-Centered Critical Care Nursing perceived by Patient Questionnaire. Participants' ICU experience was measured by the Korean version of the Intensive Care Experience Questionnaire that consists of four subscales. We analysed the relationship between person-centred care and each area of the ICU experience using multivariate linear regression. RESULTS Person-centred care was associated with 'awareness of surroundings' (β = 0.29, p < .001), 'frightening experiences' (β = -0.31, p < .001), and 'satisfaction with care' (β = 0.54, p < .001). However, there was no significant association between person-centred care and 'recall of experience'. CONCLUSIONS We observed that person-centred care was positively related to most of the ICU experiences of critically ill patients except for recall of experience. Further studies on developing person-centred nursing interventions are needed.
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Affiliation(s)
- Jiyeon Kang
- College of Nursing, Dong-A University, 32, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Minju Lee
- Department of Nursing, Youngsan University, 288, Junam-ro, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Young Shin Cho
- Department of Nursing, Youngsan University, 288, Junam-ro, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Jin-Heon Jeong
- Department of Intensive Care Medicine & Neurology, Dong-A University Hospital, Dong-A University College of Medicine, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Sol A Choi
- Medical Intensive Care Unit, Inje University Busan Paik Hospital, 75, Bokji-ro, Busanjin-gu, Busan, Republic of Korea
| | - Jiwon Hong
- College of Nursing, Dong-A University, 32, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea.
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18
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Kouatly I, Nizam M, Arawi T, Kurdahi Badr L. Moral and Professional Values of Nurses in Lebanon. J Contin Educ Nurs 2021; 52:429-437. [PMID: 34432577 DOI: 10.3928/00220124-20210804-09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Moral and professional values vary among cultures. The purpose of this study was to explore the moral and professional values of registered nurses at a university medical center in a Middle Eastern country and determine the relationship among formal ethics education, background variables (age, gender, nursing degree, regular daily prayer), and nurses' professional and moral values. METHOD A cross-sectional survey method with 123 nurses was used. Data on background variables, moral and professional values, and confidence in ethical decision-making were assessed. RESULTS Professional values were significantly higher among older nurses and nurses with master's degrees compared with younger nurses and nurses with bachelor's degrees. Daily prayer was related to higher mean scores for moral values. Nurses were confident in their ethical decision-making; however, formal education in ethics did not influence professional or moral values. CONCLUSION Although formal education in ethics did not influence the professional or moral values of nurses in Lebanon, this finding does not negate the need for future studies to investigate the content and duration of ethics education that is likely to affect professional or moral values. [J Contin Educ Nurs. 2021;52(9):429-437.].
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19
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Duarte D, El-Hagrassy MM, Couto T, Gurgel W, Minuzzi L, Saperson K, Corrêa H. Challenges and potential solutions for physician suicide risk factors in the COVID-19 era: psychiatric comorbidities, judicialization of medicine, and burnout. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2021; 45:e20210293. [PMID: 34788525 PMCID: PMC10226769 DOI: 10.47626/2237-6089-2021-0293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Suicide among physicians constitutes a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in general, despite an overall contraction in physician mortality rates in both genders. METHODS This narrative review was conducted by searching and analyzing articles/databases that were relevant to addressing questions raised by a prior meta-analysis and how they might be affected by COVID-19. This process included unstructured searches on Pubmed for physician suicide, burnout, judicialization of medicine, healthcare organizations, and COVID-19, and Google searches for relevant databases and medical society, expert, and media commentaries on these topics. We focus on three factors critical to addressing physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. RESULTS We found relevant articles on suicide reporting, physician mental health, the effects of healthcare judicialization, and organizational involvement on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physician suicide rates, inadequate diagnosis and management of psychiatric comorbidities and the chronic effects on physicians' work capacity, and, finally, judicialization of medicine and organizational failures increasing physician burnout. We discuss these factors in general and in relation to the COVID-19 pandemic. CONCLUSIONS We present an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors.
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Affiliation(s)
- Dante Duarte
- Spaulding HospitalHarvard Medical SchoolBostonMAUSA Spaulding Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
| | - Mirret M. El-Hagrassy
- Spaulding HospitalHarvard Medical SchoolBostonMAUSA Spaulding Hospital, Harvard Medical School, Boston, MA, USA.
- Neurology DepartmentUniversity of Massachusetts Medical SchoolWorcesterMAUSA Neurology Department, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Tiago Couto
- Universidade Federal de UberlândiaUberlândiaMGBrazil Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.
| | - Wagner Gurgel
- Universidade de São PauloSão PauloSPBrazil Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Luciano Minuzzi
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
- Mood Disorders Program and Women’s Health Concerns Clinic, St. Joseph’s Healthcare HamiltonONCanada Mood Disorders Program and Women’s Health Concerns Clinic, St. Joseph’s Healthcare Hamilton, ON, Canada.
| | - Karen Saperson
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
| | - Humberto Corrêa
- Faculdade de MedicinaUniversidade Federal de Minas GeraisBelo HorizonteMGBrazil Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
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20
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Nowak A, Schildmann J, Nadolny S, Heirich N, Linoh KP, Rosenau H, Dutzmann J, Sedding D, Noutsias M. Clinical ethics case consultation in a university department of cardiology and intensive care: a descriptive evaluation of consultation protocols. BMC Med Ethics 2021; 22:99. [PMID: 34301238 PMCID: PMC8305900 DOI: 10.1186/s12910-021-00668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital. METHODS Semi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. All documents were analysed by two researchers independently. RESULTS Twenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43-96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1-65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases. CONCLUSIONS To the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes.
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Affiliation(s)
- Andre Nowak
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,Nursing Science Staff Unit, Franziskus-Hospital Harderberg, Niels-Stensen-Klinken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Nicolas Heirich
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Kim P Linoh
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Henning Rosenau
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Jochen Dutzmann
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Daniel Sedding
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.,Department of Internal Medicine A, Division of Cardiology, Angiology, Nephrology and Intensive Medical Care , Ruppiner Kliniken, Medical School of Brandenburg Theodor Fontane (MHB) , Fehrbelliner Strasse 38 , 16816 , Neuruppin , Germany
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21
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Critical Care Nurses' Qualitative Reports of Experiences With Physician Behaviors, Nursing Issues, and Other Obstacles in End-of-Life Care. Dimens Crit Care Nurs 2021; 40:237-247. [PMID: 34033445 DOI: 10.1097/dcc.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Critical care nurses (CCNs) frequently provide end of life (EOL) care in intensive care units (ICUs). Obstacles to EOL care in ICUs exist and have been previously published along with reports from CCNs. Further data exploring obstacles faced during ICU EOL care may increase awareness of common EOL obstacles. Research focusing on obstacles related to physician behaviors and nursing issues (and others) may provide improvement of care. OBJECTIVE The aim of this study was to gather first-hand data from CCNs regarding obstacles related to EOL care. METHODS A random, geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from an item asking CCNs to tell us of the obstacles they experience providing EOL care to dying patients were analyzed. RESULTS There were 104 participants who provided 146 responses to this item reflecting EOL obstacles. These obstacles were divided into 11 themes; 6 physician-related obstacles and 5 nursing- and other related obstacles. Major EOL ICU barrier themes were inadequate physician communication, physicians giving false hope, poor nurse staffing, and inadequate EOL care education for nurses. DISCUSSION AND CONCLUSION Poor physician communication was the main obstacle noted by CCNs during ICU EOL care, followed by physicians giving false hope. Heavy patient workloads with inadequate staffing were also a major barrier in CCNs providing EOL care.
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22
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Abstract
OBJECTIVES To provide a concise review of data and literature pertaining to the etiologies of conflict in the ICU, as well as current approaches to conflict management. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing conflict in the ICU as well as prevention and management strategies. STUDY SELECTION Descriptive and interventional studies addressing conflict, bioethics, clinical ethics consultation, palliative care medicine, conflict management, and conflict mediation in critical care. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for critical care practice and training. DATA SYNTHESIS Conflict frequently erupts in the ICU between patients and families and care teams, as well as within and between care teams. Conflict engenders a host of untoward consequences for patients, families, clinicians, and facilities rendering abrogating conflict a key priority for all. Conflict etiologies are diverse but understood in terms of a framework of triggers. Identifying and de-escalating conflict before it become intractable is a preferred approach. Approaches to conflict management include utilizing clinical ethics consultation, and palliative care medicine clinicians. Conflict Management is a new technique that all ICU clinicians may use to identify and manage conflict. Entrenched conflict appears to benefit from Bioethics Mediation, an approach that uses a neutral, unaligned mediator to guide parties to a mutually acceptable resolution. CONCLUSIONS Conflict commonly occurs in the ICU around difficult and complex decision-making. Patients, families, clinicians, and institutions suffer undesirable consequences resulting from conflict, establishing conflict prevention and resolution as key priorities. A variety of approaches may successfully identify, manage, and prevent conflict including techniques that are utilizable by all team members in support of clinical excellence.
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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: 21] [Impact Index Per Article: 7.0] [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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Earp BD. Male or female genital cutting: why 'health benefits' are morally irrelevant. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106782. [PMID: 33462078 DOI: 10.1136/medethics-2020-106782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 06/12/2023]
Abstract
The WHO, American Academy of Pediatrics and other Western medical bodies currently maintain that all medically unnecessary female genital cutting of minors is categorically a human rights violation, while either tolerating or actively endorsing medically unnecessary male genital cutting of minors, especially in the form of penile circumcision. Given that some forms of female genital cutting, such as ritual pricking or nicking of the clitoral hood, are less severe than penile circumcision, yet are often performed within the same families for similar (eg, religious) reasons, it may seem that there is an unjust double standard. Against this view, it is sometimes claimed that while female genital cutting has 'no health benefits', male genital cutting has at least some. Is that really the case? And if it is the case, can it justify the disparate treatment of children with different sex characteristics when it comes to protecting their genital integrity? I argue that, even if one accepts the health claims that are sometimes raised in this context, they cannot justify such disparate treatment. Rather, children of all sexes and genders have an equal right to (future) bodily autonomy. This includes the right to decide whether their own 'private' anatomy should be exposed to surgical risk, much less permanently altered, for reasons they themselves endorse when they are sufficiently mature.
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Affiliation(s)
- Brian D Earp
- Yale-Hastings Program in Ethics and Health Policy, Yale University and The Hastings Center, New Haven, CT 06511, USA
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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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Giannini A. Clinical ethics at bedside in Intensive Care Unit: what difference does ethics consultation make? Minerva Anestesiol 2020; 86:598-600. [DOI: 10.23736/s0375-9393.20.14546-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Haltaufderheide J, Nadolny S, Gysels M, Bausewein C, Vollmann J, Schildmann J. Outcomes of clinical ethics support near the end of life: A systematic review. Nurs Ethics 2019; 27:838-854. [PMID: 31742473 DOI: 10.1177/0969733019878840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clinical ethics support services have been advocated in recent decades. In clinical practice, clinical ethics support services are often requested for difficult decisions near the end of life. However, their contribution to improving healthcare has been questioned and demands for evaluation have been put forward. Research indicates that there are considerable challenges associated with defining adequate outcomes for clinical ethics support services. In this systematic review, we report findings of qualitative studies and surveys, which have been conducted to evaluate clinical ethics support services near the end of life. METHODS Electronic databases and other sources were queried from 1970 to May 2018. Two authors screened studies independently. Methodological quality of studies was assessed. For each arm of the review, an individual synthesis was performed. Prospero ID: CRD42016036241. ETHICAL CONSIDERATIONS Ethical approval is not needed as it is a systematic review of published literature. RESULTS In all, 2088 hits on surveys and 2786 on qualitative studies were found. After screening, nine surveys and four qualitative studies were included. Survey studies report overall positive findings using a very wide and heterogeneous range of outcomes. Negative results were reported only occasionally. However, methodological quality and conceptual justification of used outcomes was often weak and limits generalizability of results. CONCLUSION Evidence points to positive outcomes of clinical ethics support services. However, methodological quality needs to be improved. Further qualitative or mixed-method research on evaluating clinical ethics support services may contribute to the development of evaluating outcomes of clinical ethics support services by means of broaden the range of appropriate (process-oriented) outcomes of (different types of) clinical ethics support services.
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Affiliation(s)
| | - Stephan Nadolny
- Bielefeld University of Applied Sciences, Germany; Martin Luther University Halle-Wittenberg, Germany; University of Applied Sciences for Diakonia, Germany
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Kuperberg E. Clinical Ethics Needs Assessment: Adapting Clinical Ethics to a Population Health Program. HEC Forum 2019; 32:21-32. [PMID: 31650339 DOI: 10.1007/s10730-019-09386-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The clinical encounter between providers and patients is insufficient: most factors influencing health outcomes occur outside the clinic. Community Health Needs Assessments address this insufficiency via collaboration between hospitals and the communities they serve to address systemic sociological-economic variables impacting health outcomes. Considering this, why are Health Care Ethics Consultation (HCEC) services limited to the clinical setting? We can cultivate better ethics outcomes by addressing systemic sociological-economic factors that cause recurring ethics issues in the hospital. In this article, I argue for the need for a Community Ethics Needs Assessment (CENA). CENA is a novel concept; thus, this article is exploratory. I argue for the necessity of a CENA and, more importantly, outline what methodology a CENA would use to both identify and address an ethics need.
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Abstract
OBJECTIVES Clinical ethics consultation as a mechanism for supporting patients, family, and staff during ethically challenging situations has become standard of care. Despite this, there is a lack of consensus about the effectiveness of clinical ethics consultation consultation in the ICU. We performed a systematic review of outcomes associated with clinical ethics consultation within adult ICUs. DATA SOURCES We searched MEDLINE, PubMed, Cochrane CENTRAL, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature from 1984 to May 2017. STUDY SELECTION Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias using the Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa Scale. Pooled estimates of effect were calculated where possible. We screened 3,970 abstracts and reviewed 325 full-text articles of which 16 met all eligibility criteria. DATA EXTRACTION We examined changes in processes and outcomes as a result of clinical ethics consultation in the ICU. Categories of outcomes included user perception, clinical decision, or conflict resolution and resource utilization. DATA SYNTHESIS The use of clinical ethics consultation in the ICU was associated with positive user experience (383/435 found clinical ethics consultation helpful), although stress and disagreement with clinical ethics consultation recommendations was greater in a subset (113/431 surrogates and providers). Consensus for a clinical decision was more frequently achieved with clinical ethics consultation (odds ratio, 4.09; 95% CI, 1.01-16.55; p = 0.05). Clinical ethics consultation was associated with lower resource utilization including significantly decreased ICU length of stay (mean difference, -4.65 d; 95% CI, -8.86 to -0.44; p = 0.03). CONCLUSIONS Our review identified outcome-based assessment as the predominant measure used to report effectiveness of clinical ethics consultation consultations. In particular, clinical ethics consultation decreased ICU length of stay and increased family and healthcare provider satisfaction. However, using outcome measures as the primary endpoint may not reflect the original intent of the clinical ethics consultation service. Based on our review, we propose a list of process measures that may better capture the key domains of a quality clinical ethics consultation.
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Everhart JL, Haskell H, Khan A. Patient- and Family-Centered Care: Leveraging Best Practices to Improve the Care of Hospitalized Children. Pediatr Clin North Am 2019; 66:775-789. [PMID: 31230622 DOI: 10.1016/j.pcl.2019.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article aims to broaden pediatric hospital medicine providers' understanding of patient- and family-centered care (PFCC) and equip them to both implement and advance PFCC. The article discusses the origins and history of PFCC and reviews selected relevant literature. The article shares an overview of several existing frameworks for patient-centeredness, emphasizing an emerging concept called coproduction. The article reviews several attitudes, skills, and infrastructure components that are considered essential prerequisites for effective coproduction. The article then highlights several strategies for promoting coproduction in Hospital Medicine, organized around 4 key tenets of coproduction (cocommissioning, codesign, codelivery, and coassessment).
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Affiliation(s)
- Jennifer L Everhart
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, 300 Pasteur Drive MC 5776, Stanford, CA 94305-5776, USA.
| | - Helen Haskell
- Mothers Against Medical Error, 155 South Bull Street, Columbia, SC 29205, USA
| | - Alisa Khan
- Division of General Pediatrics, Boston Children's Hospital, 21 Autumn Street, Room 200.2, Boston, MA 02215, USA
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Mertz M, Fischer T, Salloch S. The value of bioethical research: A qualitative literature analysis of researchers' statements. PLoS One 2019; 14:e0220438. [PMID: 31356629 PMCID: PMC6663028 DOI: 10.1371/journal.pone.0220438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 07/16/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Value and waste in preclinical and clinical research projects are intensively debated in biomedicine at present. Such different aspects as the need for setting objectives and priorities, improving study design, quality of reporting, and problematic incentives of the academic reward system are addressed. While this debate is also fueled by ethical considerations and thus informed by bioethical research, up to now, the field of bioethics lacks a similar extensive debate. Nonetheless, bioethical research should not go unquestioned regarding its scientific or social value. What exactly constitutes the value of bioethical research, however, remains widely unclear so far. METHODS This explorative study investigated possible value dimensions for bioethical research by conducting a qualitative literature analysis of researchers' statements about the value of their studies. 40 bioethics articles published 2015 in four relevant journals (The American Journal of Bioethics, Bioethics, BMC Medical Ethics and Journal of Medical Ethics) were analyzed. The value dimensions of "advancing knowledge" (e.g. research results that are relevant for science itself and for further research) and "application" (e.g. increasing applicability of research results in practice) were used as main deductive categories for the analysis. Further subcategories were inductively generated. RESULTS The analysis resulted in 62 subcategories representing a wide range of value dimensions for bioethical research. Of these, 45 were subcategories of "advancing knowledge" and 17 of "application". In 21 articles, no value dimensions related to "application" was found; the remaining 19 articles mentioned "advancing knowledge" as well as "application". The value dimensions related to "advancing knowledge" were, in general, more fine-grained. CONCLUSIONS Even though limitations arise regarding the sample, the study revealed a plethora of value dimensions that can inform further debates about what makes bioethical research valuable for science and society. Besides theoretical reflections on the value of bioethics more meta-research in bioethics is needed.
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Affiliation(s)
- Marcel Mertz
- Institute of History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Fischer
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
- Clinic for Dermatology and Venereology, University Medical Center Rostock, Rostock, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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Schildmann J, Nadolny S, Haltaufderheide J, Gysels M, Vollmann J, Bausewein C. Ethical case interventions for adult patients. Cochrane Database Syst Rev 2019; 7:CD012636. [PMID: 31424106 PMCID: PMC6698942 DOI: 10.1002/14651858.cd012636.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions. OBJECTIVES To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies. SEARCH METHODS We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation. AUTHORS' CONCLUSIONS It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.
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Affiliation(s)
- Jan Schildmann
- Martin Luther University Halle‐WittenbergInstitute for History and Ethics of MedicineMagdeburger Str. 8Halle (Saale)Germany06112
| | - Stephan Nadolny
- Martin Luther University Halle‐WittenbergInstitute for History and Ethics of MedicineMagdeburger Str. 8Halle (Saale)Germany06112
- Bielefeld University of Applied SciencesInstitute for Educational and Health‐care Research in the Health SectorInteraktion 1BielefeldNorthrine‐WestphaliaGermany33619
- University of Applied Sciences for DiakoniaBethelweg 8BielefeldNorthrine‐WestphaliaGermany33617
| | - Joschka Haltaufderheide
- Ruhr‐University BochumInstitute for Medical Ethics and History of MedicineMalakowturm – Markstr. 258aBochumGermany44799
| | - Marjolein Gysels
- University of AmsterdamAmsterdam Institute of Social Science ResearchAmsterdamNetherlands
| | - Jochen Vollmann
- Ruhr‐University BochumInstitute for Medical Ethics and History of MedicineMalakowturm – Markstr. 258aBochumGermany44799
| | - Claudia Bausewein
- LMU MunichDepartment of Palliative Medicine, Munich University HospitalMarchioninistr. 15MunichGermany81377
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Schildmann J, Nadolny S, Haltaufderheide J, Gysels M, Vollmann J, Bausewein C. Do we understand the intervention? What complex intervention research can teach us for the evaluation of clinical ethics support services (CESS). BMC Med Ethics 2019; 20:48. [PMID: 31307458 PMCID: PMC6633613 DOI: 10.1186/s12910-019-0381-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evaluating clinical ethics support services (CESS) has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS. MAIN BODY In this paper, we argue that a first necessary step for progress is to better understand the intervention(s) in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a first step, we introduce principles of "complex intervention research" and show how CESS fulfil the criteria of "complex interventions". In a second step, we develop a generic "conceptual framework" for "ethics consultation on request" as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of "bioethics mediation" to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: "proactive ethics consultation" and "moral case deliberation" and discuss implications for evaluating both types of CESS. CONCLUSION To make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer "good" CESS.
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Affiliation(s)
- Jan Schildmann
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle, Germany.
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle, Germany
- Institute for educational and health-care research in the health sector (InBVG), Bielefeld University of Applied Sciences, Interaktion 1, 33619, Bielefeld, Germany
- University of Applied Sciences for Diakonia, Bethelweg 8, 33617, Bielefeld, Germany
| | - Joschka Haltaufderheide
- Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Markstr. 258a, 44779, Bochum, Germany
| | - Marjolein Gysels
- Centre for Social Science and Global Health, University of Amsterdam, AHTC, Tower C4, Paasheuvelweg 25, 1105, BP Amsterdam, Netherlands
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Markstr. 258a, 44779, Bochum, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Jackson C, Gardy JL, Shadiloo HC, Silva DS. Trust and the ethical challenges in the use of whole genome sequencing for tuberculosis surveillance: a qualitative study of stakeholder perspectives. BMC Med Ethics 2019; 20:43. [PMID: 31272443 PMCID: PMC6610958 DOI: 10.1186/s12910-019-0380-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 06/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Emerging genomic technologies promise more efficient infectious disease control. Whole genome sequencing (WGS) is increasingly being used in tuberculosis (TB) diagnosis, surveillance, and epidemiology. However, while the use of WGS by public health agencies may raise ethical, legal, and socio-political concerns, these challenges are poorly understood. METHOD Between November 2017 and April 2018, we conducted semi-structured interviews with 22 key stakeholders across the fields of governance and policy, public health, and laboratory sciences representing the major jurisdictions currently using WGS in national TB programs. Thematic analysis of the interviews was conducted using NVivo 11. RESULTS Respondents identified several ethical and practical challenges associated with WGS in TB care and surveillance, all related to issues of trust, including: 1) the power of public health; 2) data sharing and profits derived from surveillance efforts; and 3) concerns regarding who has access to, and can benefit from, the technology. Additional challenges included: the potential utility that WGS adds to a public health program, the risks associated with linking necessary epidemiological metadata to the genomic data, and challenges associated with jurisdictional capacity to implement the technology. CONCLUSIONS Successful implementation of WGS is dependent on fostering relationships of trust between those working with genomics technology and those directly impacted by it, including clinicians. Building trust (a) between the public and the public health agencies and (b) within public health agencies themselves is critical due to the inherent complexity of WGS and its implementation for communicable disease control purposes.
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Affiliation(s)
- Carly Jackson
- Faculty of Health Sciences, Simon Fraser University, BLU 11300 - 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Jennifer L Gardy
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, the University of British Columbia, Vancouver, BC, Canada
| | - Hedieh C Shadiloo
- Faculty of Health Sciences, Simon Fraser University, BLU 11300 - 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Diego S Silva
- Faculty of Health Sciences, Simon Fraser University, BLU 11300 - 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. .,Sydney Health Ethics, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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Preisz A. Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making. J Paediatr Child Health 2019; 55:621-624. [PMID: 30932284 DOI: 10.1111/jpc.14447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 12/14/2022]
Abstract
Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision-making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision-making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life-sustaining treatment. Behavioural psychology research suggests there are two systems of thinking - fast and slow - that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health-care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision-making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.
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Affiliation(s)
- Anne Preisz
- Clinical Ethics, Clinical Governance Unit, Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Sydney Health Ethics, University of Sydney, Sydney, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
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Shaw MK, Babovič M, Monrouxe LV. Healthcare professionals', students', patients' and donors' perceptions of stem cell research and therapy: a systematic review protocol. BMJ Open 2019; 9:e025801. [PMID: 30798317 PMCID: PMC6398628 DOI: 10.1136/bmjopen-2018-025801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Stem cell research (SCR) and the biomedical potential of developing therapies are crucial topics in biomedicine. Like other biotechnologies, stem cells are context specific entities understood through local conceptualisations of culture, politics, nationhood, as well as their perceived therapeutic efficacy. There is a need to recognise how these developments are understood within the healthcare community and by those who may use them. This protocol describes a systematic literature review that aims to explore healthcare professionals', healthcare students', patients', and donors' perceptions of SCR and therapy (SCR/T) and the factors that influence their perceptions. METHODS AND ANALYSIS Following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines a systematic review will be undertaken. Web of Science, Scopus, Medline+Journals @Ovid and Ariti Library will be systematically searched for studies on healthcare professionals', healthcare students', patients' and donors' perceptions of SCR and developing therapies. All articles will be screened by a researcher for inclusion and evaluation based on 12 criteria for evaluating qualitative research. At least 20% of articles will also be reviewed by a second researcher and any disagreement will be solved via consensus. Data extracted from the articles will be analysed using thematic synthesis enabling the identification of concepts across studies and the development of new theory. ETHICS AND DISSEMINATION As part of a larger research project, ethical approval has been provided by the Institutional Research Board (IRB) at Chang Gung Memorial Hospital. This review will be able to determine the impact that certain perceptions of SCR/T will have on the development of future medical knowledge and practice. The results of the study will be published in a peer-reviewed journal and disseminated at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42018103627.
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Affiliation(s)
- Malissa Kay Shaw
- Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Memorial Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Mojca Babovič
- Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Memorial Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Lynn Valerie Monrouxe
- Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Memorial Hospital Taoyuan Branch, Taoyuan, Taiwan
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Henry B, Verbeek PR, Cheskes S. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Ethical considerations. Resuscitation 2019; 137:1-6. [PMID: 30731112 DOI: 10.1016/j.resuscitation.2019.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/18/2018] [Accepted: 01/26/2019] [Indexed: 01/05/2023]
Abstract
Out-of-hospital cardiac arrest (OHCA) continues to be a leading cause of mortality worldwide. In Canada over 40,000 cardiac arrests that occur each year, a majority occur unexpectedly outside of the hospital setting. However, the reality is that without rapid and appropriate treatment within minutes, most victims will die before reaching the hospital. In the late 1980s case reports identifying favorable outcomes with the use of extracorporeal cardiopulmonary resuscitation (eCPR) in out-of-hospital cardiac arrest (OHCA) began to be reported. Since then case reports, observational studies, propensity analysis, and a systematic review of international practices continues to suggest eCPR as a feasible intervention for refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in select adult patients. However, in spite of this mounting base of evidence, clinicians continue to report concerns over a paucity of robust data showing definitive eCPR effectiveness compared with conventional resuscitation. This review will explore the ethical issues related to the impact eCPR might have on the orthodoxy pertaining to current resuscitation strategies, the impact of shifting decision-making on families particularly in dealing with a "bridge to nowhere" scenario, a call to accounting for greater data integrity and improved outcome reporting to assess eCPR effectiveness, and addressing the "Should we just do it" question. A recommendation is proposed for the creation of an ethics consultation service to assist families and staff in dealing with the invariable value conflicts and stresses likely to arise.
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Affiliation(s)
- B Henry
- Sunnybrook Health Sciences Centre, Canada; Dept. of Family and Community Medicine, University of Toronto, Canada.
| | - P R Verbeek
- Sunnybrook Center for Prehospital Medicine, Canada
| | - S Cheskes
- Sunnybrook Center for Prehospital Medicine, Canada; Department of Family Community Medicine, Division of Emergency Medicine, University of Toronto, Canada
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Nasir AA, Abdur-Rahman LO, Adesiyun OO, Bamigbola KT, Adegboye MB, Raji HO, Adesiyun OAM, Adeniran JO. Analysis of Presentations and Outcomes of Care of Children with Disorders of Sexual Development in a Nigerian Hospital. J Pediatr Adolesc Gynecol 2019; 32:21-26. [PMID: 30149125 DOI: 10.1016/j.jpag.2018.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/13/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE To describe the presentation, diagnosis, management, and short-term outcome of children with disorders of sexual development (DSD) in the context of multidisciplinary team care. DESIGN Prospective descriptive study. SETTING University Teaching Hospital. PARTICIPANTS All children who presented with genital ambiguity. INTERVENTIONS AND MAIN OUTCOME MEASURES Records of all patients diagnosed and managed for DSD between January 2011 and December 2016 were reviewed. The care pathway included clinical, laboratory, internal genitalia evaluation, and panel (including parents) meeting. RESULTS Fifteen children presented with DSD at a median age of 20 months. Only 5/15 (33.3%) presented in the neonatal period. Ten of fifteen patients (66.7%) presented with genital ambiguity. Ovotesticular DSD was the most common diagnosis (9/15; 60%). Seven of the patients were genetically female (46, XX), 1 was genetically male (46, XY) and 1 without genetic diagnosis. Six patients were assigned male gender and they underwent male genitoplasty. Five of them had excision of Müllerian structures with gonadectomy. Three of fifteen patients (20%) were diagnosed as 46, XX DSD, at a median age of 7 years. All of them were due to congenital adrenal hyperplasia and underwent female genitoplasty. Two patients were diagnosed as XY, DSD. They were both raised as female at presentation and were reassigned male sex. Both had urethroplasty done. Four patients had postoperative urethrocutaneous fistula and 1 had partial wound dehiscence. The median follow-up period was 21 months (interquartile range, 2-26 months). CONCLUSION The frequency of ovotesticular DSD is high in our setting. The decision of sex assignment was finally made at a median age of 7.5 months in most of our patients with satisfactory short-term surgical outcome.
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Affiliation(s)
- Abdulrasheed A Nasir
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria.
| | - Lukman O Abdur-Rahman
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Omotayo O Adesiyun
- Department of Paediatrics, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Kayode T Bamigbola
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Majeed B Adegboye
- Department of Anaesthesia, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Hadijat O Raji
- Department of Obstetrics and Gynaecology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Olusola A M Adesiyun
- Department of Radiology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - James O Adeniran
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
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Muggli M, De Geyter C, Reiter-Theil S. Shall parent / patient wishes be fulfilled in any case? A series of 32 ethics consultations: from reproductive medicine to neonatology. BMC Med Ethics 2019; 20:4. [PMID: 30621671 PMCID: PMC6325683 DOI: 10.1186/s12910-018-0342-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/26/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Questions concerning the parent/ patient's autonomy are seen as one of the most important reasons for requesting Ethics Consultations (ECs). Respecting parent/ patient's autonomy also means respecting the patient's wishes. But those wishes may be controversial and sometimes even go beyond legal requirements. The objective of this case series of 32 ECs was to illustrate ethically challenging parent / patients' wishes during the first stages of life and how the principle of patient's autonomy was handled. METHODS The case series has a qualitative retrospective approach. A documentary sheet was designed de novo and information was gained from EC minutes and medical charts. The cases originate from the following specialties: reproductive medicine, obstetrics and neonatology as well as two interdisciplinary cases. RESULTS Through the structured EC minutes aspects of patient / parents' wishes could be identified explicitly. Overall the patient / parents' wishes were not supported in 61% of the cases. Central reasons for rejection of patient / parent wishes were mainly the protection of the best interest of the unborn / new-born child as well as the rejection of clinical approaches that were regarded as being substandard treatment. CONCLUSION The study shows that treatment decisions in reproductive medicine, obstetrics and neonatology raise substantial ethical questions leading to the request for ethics consultation. The systematic case series presented here gives insight into the ethical reflection carried out to support the clinicians in their decision-making and counselling. It shows that clinicians, after using ethics consultation, make deliberate decisions that do not "automatically" fulfil the treatment requests of the patients and parents (to-be).
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Affiliation(s)
- Mirella Muggli
- Department of Clinical Ethics, Psychiatric Hospitals of the University Basel, University Hospital, University of Basel, Wilhelm Klein-Strasse 27, CH-4002 Basel, Switzerland
- Institute of Reproductive Medicine and Gynaecological Endocrinology (RME), University Hospital, University of Basel, Vogesenstrasse 134, CH-4031 Basel, Switzerland
| | - Christian De Geyter
- Institute of Reproductive Medicine and Gynaecological Endocrinology (RME), University Hospital, University of Basel, Vogesenstrasse 134, CH-4031 Basel, Switzerland
| | - Stella Reiter-Theil
- Department of Clinical Ethics, Psychiatric Hospitals of the University Basel, University Hospital, University of Basel, Wilhelm Klein-Strasse 27, CH-4002 Basel, Switzerland
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Jansen MA, Schlapbach LJ, Irving H. Evaluation of a paediatric clinical ethics service. J Paediatr Child Health 2018; 54:1199-1205. [PMID: 29746009 DOI: 10.1111/jpc.13933] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/22/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Abstract
AIM To evaluate a paediatric clinical ethics service incorporating both normative and empirical analysis. METHODS Section 1: Review of consensus guidelines to identify emerging standards for clinical ethics services (CES) and evaluation of the service in relation to these. Section 2: Description of service activity data. Section 3: Feedback from clinical staff involved in clinical ethics consultations was collected using a web-based survey. RESULTS Four guideline documents were reviewed, and clear emerging consensus standards were identified. Our service fulfils identified knowledge and skill core competencies and at least partially fulfils all of the identified service-level standards. Clinicians report that clinical ethics consultation decreases their moral distress. CONCLUSIONS There is emerging consensus for staff competencies and service-level standards for CES. The role of CES in staff well-being needs to be explored. Collaborative, multi-modal research to develop standards and evaluate CES is needed.
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Affiliation(s)
- Melanie A Jansen
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helen Irving
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Oncology Services Group, Children's Health Queensland, Brisbane, Queensland, Australia
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Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:1751-1761. [PMID: 28749855 DOI: 10.1097/ccm.0000000000002624] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine whether patient- and family-centered care interventions in the ICU improve outcomes. DATA SOURCES We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016. STUDY SELECTION We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs. DATA EXTRACTION We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes. DATA SYNTHESIS There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis. CONCLUSIONS Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.
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Bærøe K, Ives J, de Vries M, Schildmann J. On classifying the field of medical ethics. BMC Med Ethics 2017; 18:30. [PMID: 28449689 PMCID: PMC5406875 DOI: 10.1186/s12910-017-0193-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 04/25/2017] [Indexed: 11/21/2022] Open
Abstract
In 2014, the editorial board of BMC Medical Ethics came together to devise sections for the journal that would (a) give structure to the journal (b) help ensure that authors’ research is matched to the most appropriate editors and (c) help readers to find the research most relevant to them. The editorial board decided to take a practical approach to devising sections that dealt with the challenges of content management. After that, we started thinking more theoretically about how one could go about classifying the field of medical ethics. This editorial elaborates and reflects on the practical approach that we took at the journal, then considers an alternative theoretically derived approach, and reflects on the possibilities, challenges and value of classifying the field more broadly.
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Affiliation(s)
- Kristine Bærøe
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Jonathan Ives
- Biomedical Ethics and Law, Centre for Ethics in Medicine, The University of Bristol, Bristol, UK
| | - Martine de Vries
- Biomedical Ethics and Law, Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Schildmann
- Professur für Medizinethik an der Wilhelm Löhe Hochschule, Fürth; Medizinische Klinik und Poliklinik III, Klinikum der Universität München, Campus Großhadern, Munich, Germany
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Haltaufderheide J, Mertz M, Vollmann J, Schildmann J. Do Not Try To Run Before You Can Walk: Empirical and Meta-Ethical Presuppositions of Using Ethical Theory in Clinical Ethics Consultation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:51-53. [PMID: 27471944 DOI: 10.1080/15265161.2016.1196261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Marcel Mertz
- b Hannover Medical School and University Hospital Cologne
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Safo S, Cunningham C, Beckman A, Haughton L, Starrels JL. "A place at the table:" a qualitative analysis of community board members' experiences with academic HIV/AIDS research. BMC Med Res Methodol 2016; 16:80. [PMID: 27401678 PMCID: PMC4940842 DOI: 10.1186/s12874-016-0181-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/25/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Community advisory boards (CAB) are proposed as one mechanism to carry out successful community based participatory research (CBPR), but the presence of CABs may be insufficient to optimize academic-community partnerships. METHODS We conducted semi-structured interviews with minority members of a CAB partnered with a HIV/AIDS research center and identified three themes. RESULTS First, lack of trust in researchers included two subthemes: researchers' lacked respect for community-based organizations' (CBO's) interests and paid inadequate attention to building trust. Second, power imbalance included three subthemes: CAB members felt like inferior "token" members, felt that a lack of communication led to disempowerment, and held preconceived beliefs of researchers that led to perceived power imbalance. Third, CAB members suggested best practices, including using collaborations to build trust, actively allocating power, and sharing tangible research benefits with CBOs. CONCLUSIONS Our findings indicate that CABs must be founded on trust and instilled with power to meet the tenets of CBPR.
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Affiliation(s)
- Stella Safo
- />Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 United States
- />Department of General Internal Medicine, New York, USA
- />Albert Einstein School of Medicine, New York, USA
| | - Chinazo Cunningham
- />Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 United States
- />Department of General Internal Medicine, New York, USA
- />Albert Einstein School of Medicine, New York, USA
| | | | | | - Joanna L. Starrels
- />Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 United States
- />Department of General Internal Medicine, New York, USA
- />Albert Einstein School of Medicine, New York, USA
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Bliss SE, Oppenlander JE, Dahlke JM, Meyer GJ, Williford EM, Macauley RC. Measuring Quality in Ethics Consultation. THE JOURNAL OF CLINICAL ETHICS 2016. [DOI: 10.1086/jce2016272163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Kelley MC, Brazg T, Wilfond BS, Lengua LJ, Rivin BE, Martin-Herz SP, Diekema DS. Ethical challenges in research with orphans and vulnerable children: a qualitative study of researcher experiences. Int Health 2016; 8:187-96. [DOI: 10.1093/inthealth/ihw020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 03/03/2016] [Indexed: 11/12/2022] Open
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Abstract
BACKGROUND The American Society for Bioethics and Humanities has recommended regular evaluation of the quality of Health Care Ethics Consultation. This manuscript discusses the impact of ethics consultation on clinicians' perceptions of a patient's plan of care and on the personal values of clinicians who participated in an ethics consultation. METHODS Following IRB approval, select data points were abstracted from case file report forms for ethics consultations over a 12 month period. Clinicians involved in the care of a patient who was the focus of an ethics consultation were invited to participate in an anonymous online survey. Clinicians who initiated an ethics consultation, were interviewed during the course of an ethics consultation, or were present at a patient care conference attended by an ethics consultant were invited to participate. A purposive sampling approach was used to invite clinicians to participate in an in-person interview. RESULTS The survey response rate was 44.4% (123 respondents from 277 invited). Over 60% of participants felt the consultation helped clarify the values of the patient and/or patient's family and helped them clarify their own values. Only 32% of participants indicated the patient's plan of care changed as a result of the ethics consultation, yet 75% indicated their confidence in the plan of care increased as a result of the ethics consultation. Preliminary findings from the qualitative interviews support the overall positive assessments reported by survey respondents. CONCLUSIONS Ethics consultation can help clinicians clarify their own values and helps them clarify the values of patients and patients' families. Ethics consultation offers meaningful support when clinicians face ethically challenging cases, provides an opportunity to address moral distress, and is viewed favorably by those who experience the resource.
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Affiliation(s)
- Lucia D. Wocial
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, and Indiana University School of Nursing, Indianapolis, IN
| | - Elizabeth Molnar
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, and Indiana University School of Nursing, Indianapolis, IN
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Mary A. Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Monsudi KF, Oladele TO, Nasir AA, Ayanniyi AA. Medical ethics in sub-Sahara Africa: closing the gaps. Afr Health Sci 2015; 15:673-81. [PMID: 26124819 DOI: 10.4314/ahs.v15i2.47] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Health care providers are expected to have the skills and knowledge relevant to their field and should also be familiar with the ethical and legal expectations that arise out of the standard practices. OBJECTIVES To elucidate the practice of the health care providers in relation to healthcare ethics in Nigeria. METHODS A self-administered structured questionnaire was devised and distributed to staff of two tertiary health care facilities in Northern Nigeria. The questionnaire comprised of detailed questions regarding day-to-day aspects of Medical ethical issues. RESULTS A total of 307(76.2%) out of 403 health care providers responded to the questionnaire. The median age of the respondents was 34 years. More than half 168(54.7%) of the respondents disagreed as to whether "Ethical conduct is important only to avoid legal action. Many respondents 135 (44.0%) agreed to adhering to "patient's wishes", on the other hand over two-third of the respondents 211 (68.7%) agreed that "doctor should do what is best" irrespective of the patient's opinion. There were significant differences (p<0.05) between the perception of physicians and non-physicians on many ethical issues. CONCLUSION This study has shown gap in knowledge and practice of healthcare ethics among health care providers. There is a need for periodic education on clinical ethics in our hospitals.
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Affiliation(s)
- Kehinde F Monsudi
- Department of Ophthalmology, Federal Medical Center, Birnin Kebbi, Nigeria
| | - Tajudeen O Oladele
- Department of Psychiatric, Federal Neuropsychiatric Hospital, Kware, Nigeria
| | - Abdulrasheed A Nasir
- Department of Surgery, University of Ilorin / University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Abdulkabir A Ayanniyi
- Department of Ophthalmology, University of Abuja/ University of Abuja Teaching Hospital, Abuja Nigeria
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Park DW, Moon JY, Ku EY, Kim SJ, Koo YM, Kim OJ, Lee SH, Jo MW, Lim CM, Armstrong JD, Koh Y. Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods. J Korean Med Sci 2015; 30:495-501. [PMID: 25829820 PMCID: PMC4366973 DOI: 10.3346/jkms.2015.30.4.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/12/2014] [Indexed: 11/20/2022] Open
Abstract
This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P < 0.001). The highest incidence of cases with identified ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behaviorrelated issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-oflife (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behaviorrelated issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.
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Affiliation(s)
- Dong Won Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jae Young Moon
- Department of Internal Medicine, Chungnam National University College of Medicine. Daejeon, Korea
| | - Eun Yong Ku
- Department of Nursing, College of Medicine, Konkuk University, Seoul, Korea
| | - Sun Jong Kim
- Department of Internal Medicine, College of Medicine, Konkuk University, Seoul, Korea
| | - Young-Mo Koo
- Department of Medical Humanities and Social Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - Ock-Joo Kim
- Department of Medical History and Medical Humanities, Seoul National University College of Medicine, Seoul, Korea
| | - Soon Haeng Lee
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Woo Jo
- Department of Preventive Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Younsuck Koh
- Department of Medical Humanities and Social Sciences, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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