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Schallenburger M, Schwartz J, Icks A, In der Schmitten J, Batzler YN, Meier S, Mendez-Delgado M, Tenge T, Neukirchen M. Triggers of intensive care patients with palliative care needs from nurses' perspective: a mixed methods study. Crit Care 2024; 28:181. [PMID: 38807236 PMCID: PMC11134896 DOI: 10.1186/s13054-024-04969-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/24/2024] [Indexed: 05/30/2024] Open
Abstract
PURPOSE Triggers have been developed internationally to identify intensive care patients with palliative care needs. Due to their work, nurses are close to the patient and their perspective should therefore be included. In this study, potential triggers were first identified and then a questionnaire was developed to analyse their acceptance among German intensive care nurses. METHODS For the qualitative part of this mixed methods study, focus groups were conducted with intensive care nurses from different disciplines (surgery, neurosurgery, internal medicine), which were selected by convenience. Data were analysed using the "content-structuring content analysis" according to Kuckartz. For the quantitative study part, the thus identified triggers formed the basis for questionnaire items. The questionnaire was tested for comprehensibility in cognitive pretests and for feasibility in a pilot survey. RESULTS In the qualitative part six focus groups were conducted at four university hospitals. From the data four main categories (prognosis, interprofessional cooperation, relatives, patients) with three to 15 subcategories each could be identified. The nurses described situations requiring palliative care consults that related to the severity of the disease, the therapeutic course, communication within the team and between team and patient/relatives, and typical characteristics of patients and relatives. In addition, a professional conflict between nurses and physicians emerged. The questionnaire, which was developed after six cognitive interviews, consists of 32 items plus one open question. The pilot had a response rate of 76.7% (23/30), whereby 30 triggers were accepted with an agreement of ≥ 50%. CONCLUSION Intensive care nurses see various triggers, with interprofessional collaboration and the patient's prognosis playing a major role. The questionnaire can be used for further surveys, e.g. interprofessional triggers could be developed.
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Affiliation(s)
- Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jacqueline Schwartz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany.
| | - Andrea Icks
- Institute of Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany
| | - Jürgen In der Schmitten
- Institute of Family Medicine/General Practice, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Yann-Nicolas Batzler
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Meier
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Miguel Mendez-Delgado
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Theresa Tenge
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Center of Integrated Oncology Aachen, Bonn, Cologne (CIO ABCD), Heinrich-Heine-University, Düsseldorf, Germany
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Bruun H, Milling L, Wittrock D, Mikkelsen S, Huniche L. How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety. BMC Med Ethics 2024; 25:58. [PMID: 38762457 PMCID: PMC11102201 DOI: 10.1186/s12910-024-01061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/08/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, Faculty of Health Science, Forensic Mental Health Research Unit Middelfart (RFM), University of Southern Denmark & Psychiatric dept, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Daniel Wittrock
- Department of Quality and Education, Ambulance Syd, the Region of Southern Denmark, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Siegel B, Taylor LS, Alizadeh F, Barreto JA, Daniel D, Alexander PMA, Lipsitz S, Moynihan K. Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital. Pediatr Crit Care Med 2024; 25:301-311. [PMID: 38193777 DOI: 10.1097/pcc.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN Retrospective cohort study using mixed methods. SETTING Single-center quaternary pediatric hospital. PATIENTS Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.
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Affiliation(s)
- Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Dennis Daniel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Peta M A Alexander
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Katie Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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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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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Vries ALC, Molewijk BC. GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care. PATIENT EDUCATION AND COUNSELING 2023; 114:107854. [PMID: 37356115 DOI: 10.1016/j.pec.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC). METHODS Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders' needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool. RESULTS The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges. CONCLUSION The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM. PRACTICE IMPLICATIONS GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.
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Affiliation(s)
- Karl Gerritse
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Casper Martens
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Medical Psychology, Amsterdam UMC location VUmc, location Vrije Universiteit Amsterdam, the Netherlands.
| | - Annelou L C de Vries
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Child and Adolescent Psychiatry, Amsterdam UMC location University of Amsterdam, the Netherlands.
| | - Bert C Molewijk
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
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