Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence- and autonomy-based eligibility criteria?

According to the "discrimination argument," it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread "joint" approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy-based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence- and autonomy-based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS.

Research ethics in practice: An analysis of ethical issues encountered in qualitative health research with mental health service users and relatives

The ethics review of qualitative health research poses various challenges that are due to a mismatch between the current practice of ethics review and the nature of qualitative methodology. The process of obtaining ethics approval for a study by a research ethics committee before the start of a research study has been described as "procedural ethics" and the identification and handling of ethical issues by researchers during the research process as "ethics in practice." While some authors dispute and other authors defend the use of procedural ethics in relation to qualitative health research, there is general agreement that it needs to be supplemented with ethics in practice. This article aims to provide an illustration of research ethics in practice by reflecting on the ways in which we identified and addressed ethical and methodological issues that arose in the context of an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the increase of participant access and the heterogeneity of the sample, the protection of privacy and internal confidentiality, and the consideration of personal and contextual factors.

Increasing efficiency and well-being? a systematic review of the empirical claims of the double-benefit argument in socially assistive devices

BACKGROUND

Socially assistive devices (care robots, companions, smart screen assistants) have been advocated as a promising tool in elderly care in Western healthcare systems. Ethical debates indicate various challenges. One of the most prevalent arguments in the debate is the double-benefit argument claiming that socially assistive devices may not only provide benefits for autonomy and well-being of their users but might also be more efficient than other caring practices and might help to mitigate scarce resources in healthcare. Against this background, we used a subset of comparative empirical studies from a comprehensive systematic review on effects and perceptions of human-machine interaction with socially assistive devices to gather and appraise all available evidence supporting this argument from the empirical side.

METHODS

Electronic databases and additional sources were queried using a comprehensive search strategy which generated 9851 records. Studies were screened independently by two authors. Methodological quality of studies was assessed. For 39 reports using a comparative study design, a narrative synthesis was performed.

RESULTS

The data shows positive evidential support to claim that some socially assistive devices (Paro) might be able to contribute to the well-being and autonomy of their users. However, results also indicate that these positive findings may be heavily dependent on the context of use and the population. In addition, we found evidence that socially assistive devices can have negative effects on certain populations. Evidence regarding the claim of efficiency is scarce. Existing results indicate that socially assistive devices can be more effective than standard of care but are far less effective than plush toys or placebo devices.

DISCUSSION

We suggest using the double-benefit argument with great caution as it is not supported by the currently available evidence. The occurrence of potentially negative effects of socially assistive devices requires more research and indicates a more complex ethical calculus than suggested by the double-benefit argument.

Smartphone Apps for Containing the COVID-19 Pandemic in Germany: Qualitative Interview Study With Experts Based on Grounded Theory

BACKGROUND

Smartphone apps, including those for digital contact tracing (DCT), played a crucial role in containing infections during the COVID-19 pandemic. Their primary function is to generate and disseminate information to disrupt transmissions based on various events, such as encounters, vaccinations, locations, or infections. Although the functionality of these apps has been extensively studied, there is still a lack of qualitative research addressing critical issues.

OBJECTIVE

We will demonstrate that the use of DCT presents a challenge due to the tension between continuous health monitoring and uncertainties related to transparency and user sovereignty. On one hand, DCT enables the monitoring of various risk factors, including data-based calculations of infection probabilities. On the other hand, continuous risk management is intertwined with several uncertainties, including the unclear storage of personal data, who has access to it, and how it will be used in the future.

METHODS

We focus on the German "Corona-Warn-App" and support our argument with empirical data from 19 expert interviews conducted between 2020 and 2021. The interviews were conducted using a semistructured questionnaire and analyzed according to the principles of grounded theory.

RESULTS

Our data underscores 3 dimensions: transparency, data sovereignty, and the east-west divide. While transparency is considered an essential foundation for establishing trust in the use of DCT by providing a sense of security, data sovereignty is seen as a high value during the pandemic, protecting users from an undesired loss of control. The aspect of the east-west divide highlights the idea of incorporating sociocultural values and standards into technology, emphasizing that algorithms and data-driven elements, such as distance indicators, encounters, and isolations, are also influenced by sociocultural factors.

CONCLUSIONS

The effective use of DCT for pandemic containment relies on achieving a balance between individual control and technological prevention. Maximizing the technological benefits of these tools is crucial. However, users must also be mindful of the information they share and maintain control over their shared data.

Opportunities and challenges of self-binding directives: A comparison of empirical research with stakeholders in three European countries

BACKGROUND

Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.

AIMS

This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders' views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.

METHOD

Comparisons between the empirical findings were drawn using a structured expert consensus process.

RESULTS

Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals' confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.

CONCLUSIONS

Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.

Socially Assistive Devices in Healthcare-a Systematic Review of Empirical Evidence from an Ethical Perspective

Socially assistive devices such as care robots or companions have been advocated as a promising tool in elderly care in Western healthcare systems. Ethical debates indicate various challenges. An important part of the ethical evaluation is to understand how users interact with these devices and how interaction influences users' perceptions and their ability to express themselves. In this review, we report and critically appraise findings of non-comparative empirical studies with regard to these effects from an ethical perspective.Electronic databases and other sources were queried using a comprehensive search strategy generating 9851 records. Studies were screened independently by two authors. Methodological quality of studies was assessed. For 22 reports on 21 datasets using a non-comparative design a narrative synthesis was performed.Data shows positive findings in regard to attitudes and emotional reactions of users. Varying perception of a social relation and social presence are the most commonly observed traits of interaction. Users struggle with understanding technical complexities while functionality of the devices is limited. This leads to a behavioral alignment of users towards the requirements of the devices to be able to make use of them.This evidence adds to three important ethical debates on the use of socially assistive devices in healthcare in regard to (1) reliability of existing empirical evidence to inform normative judgements, (2) ethical significance of the social presence of devices and (3) user autonomy in regard to behavioral alignment.

The Content of Psychiatric Advance Directives: A Systematic Review

OBJECTIVE

Psychiatric advance directives (PADs) enable users of mental health services to express their treatment preferences for future mental health crises. PAD completion rates remain low despite high rates of interest among service users and empirically confirmed benefits of their use. A systematic review of service users' preferences regarding the content of PADs could be a valuable resource for clinicians and policy makers and might help reduce barriers to PAD implementation.

METHODS

A systematic review concordant with PRISMA guidelines was conducted. CINAHL, Cochrane, EMBASE, PsycINFO, MEDLINE, PubMed, SCOPUS, and Web of Science databases were searched up to July 2, 2021. Included articles contained original empirical data on service users' preferences regarding the content of PADs or a document analysis of existing PADs. Studies were analyzed thematically, and a narrative synthesis was conducted. The Mixed Methods Appraisal Tool was used to assess the methodological quality and risk of bias of the included studies.

RESULTS

The search yielded 4,047 articles, 42 of which were eligible for inclusion. Six themes emerged (most of which included subthemes): signs of crisis, general treatment approach, preferences regarding the treatment setting, treatment preferences, coercion, and social instructions.

CONCLUSIONS

The concern that PADs may be unclear or incompatible with practice standards was not confirmed. Service users generally included clear, comprehensible, and clinically relevant information in their PADs, often providing underlying reasons for their preferences. These reasons were related to previous adverse effects of medication and personal experiences with hospital admissions.

Mental Health Service Users' Perspectives on Psychiatric Advance Directives: A Systematic Review

OBJECTIVE

Psychiatric advance directives (PADs) are documents that allow users of mental health services to express their preferences for treatment in future mental health crises. To increase the use of PADs in psychiatric practice, it is helpful to consider how service users view PADs and the factors that facilitate or hinder PAD creation and implementation. A systematic review of the empirical literature on this topic may help inform evidence-based policy making.

METHODS

A systematic review concordant with PRISMA guidelines was conducted. Relevant electronic databases were searched up to July 2, 2021. Articles containing original empirical data on service users' perspectives on PADs were included. Data were analyzed thematically, tabulated, and narratively synthesized.

RESULTS

Fifty-three articles were identified and included. The following categories were identified: general preferences regarding factors such as legal force and revocability; benefits of PADs at the personal, treatment-related, and social levels; challenges and barriers concerning PAD creation and application; and possible and experienced facilitators of PAD creation.

CONCLUSIONS

Users of mental health services are highly interested in PADs and regard them as tools to improve their involvement in care. They generally prefer legally binding PADs that can be revoked only when users are competent to consent. Barriers reported by service users were mainly related to the creation and application of PADs, and support in PAD creation was the most important facilitator identified. The involvement of mental health professionals in creating PADs appears essential to realize the benefits of PADs and to reduce barriers to their use.

Das kombinierte Modell der Entscheidungsassistenz

Hintergrund

Die Auslegung von Artikel 12 der Behindertenrechtskonvention der Vereinten Nationen (Art. 12 UN-BRK) durch den Ausschuss für die Rechte von Menschen mit Behinderungen hat zu einer Kontroverse über die Umsetzung des Artikels in der Psychiatrie geführt.

Fragestellung

Wie kann Art. 12 UN-BRK auf ethisch vertretbare Weise in der Psychiatrie umgesetzt werden?

Material und Methode

Es wurde eine empirisch und rechtlich informierte konzeptionelle und ethische Analyse durchgeführt.

Ergebnisse

Das vorgeschlagene kombinierte Modell der Entscheidungsassistenz gewährleistet die Anerkennung von Menschen mit psychischen Erkrankungen als Rechtssubjekt, deren Gleichbehandlung im Hinblick auf die Erteilung einer Einwilligung sowie die Bereitstellung von Entscheidungsassistenz. Nach diesem Modell dürfen Zwangsbehandlungen nur unter Achtung des Willens und der Präferenzen der Person und weiteren Voraussetzungen der Verhältnismäßigkeit und unabhängiger Überprüfung durchgeführt werden.

Schlussfolgerungen

Art. 12 UN-BRK kann nach dem kombinierten Modell der Entscheidungsassistenz auf ethisch vertretbare Weise in der Psychiatrie umgesetzt werden.

Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants

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.

Das Verständnis von Wohl im Betreuungsrecht – eine Analyse anlässlich der Streichung des Wohlbegriffs aus dem reformierten Gesetz

Mit der 2023 in Kraft tretenden Reform des Betreuungsrechts wird der Begriff „Wohl“ aus dem Gesetz gestrichen. Hierdurch soll stärker hervorgehoben werden, dass sich der Betreuer an den subjektiven Wünschen des Betreuten statt an einem objektiven Wohlverständnis orientieren soll. In diesem Beitrag wird ermittelt, welches Verständnis von Wohl das reformierte Betreuungsrecht in Abgleich zu gängigen medizinethisch-philosophischen Auffassungen des Wohls implizit enthält. Indem untersucht wird, in welchem Verhältnis das betreuungsrechtliche und das medizinethische bzw. philosophische Verständnis von Wohl zueinanderstehen, soll die interdisziplinäre Verständigung zwischen Recht und Ethik gefördert werden.

In der Begründung zur Reform wird betont, dass dem Betreuungsrecht weiterhin ein subjektives Verständnis von Wohl zugrunde liege. Dieses Verständnis deckt sich jedoch nicht mit philosophischen subjektiven Theorien des Wohlergehens, nach denen nur das zum Wohl einer Person beiträgt, was diese sich wünscht. Das Betreuungsrecht nimmt hingegen an, dass die Befolgung bestimmter Wünsche zu objektiven Schädigungen der Person führen und damit ihr Wohl beeinträchtigen kann. Negative Konsequenzen für das objektive Wohl eines Betreuten sind betreuungsrechtlich insofern relevant, als dass sie eine Grenze für die Befolgung aktueller Wünsche aufzeigen, die auf einem natürlichen Willen basieren und nicht Ausdruck von Selbstbestimmung sind. Dies ähnelt einer hybriden Konzeption des Wohls aus medizinethisch-philosophischer Sicht, nach der grundsätzlich angenommen wird, dass die Befolgung der Wünsche einer Person zu ihrem Wohl beiträgt, während aber auch gewisse objektive Kriterien als relevant für ihr Wohl angesehen werden.

Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany

PURPOSE

Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law.

METHODS

Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis.

RESULTS

Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice.

CONCLUSIONS

The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.

Equality in the Informed Consent Process: Competence to Consent, Substitute Decision-Making, and Discrimination of Persons with Mental Disorders

According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on a status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory.

Types of Ethical Problems and Expertise in Clinical Ethics Consultation in Psychiatry - Insights From a Qualitative Empirical Ethics Study

Background: Ethics consultation has been advocated as a valuable tool in ethically challenging clinical situations in healthcare. It is paramount for the development and implementation of clinical ethics support services (CESS) in psychiatry that interventions can address the moral needs of mental health professionals adequately and communicate the nature of the services clearly. This study explores types of ethical problems and concepts of ethical expertise as core elements of CESS in mental healthcare with the aim of contributing to the further development of ethical support in psychiatry. Methods: We conducted 13 semi-structured interviews with mental health professionals and CESS members and triangulated them with four non-participant observations of ethical case consultations in psychiatry. Data were analyzed according to principles of grounded theory and are discussed from a normative perspective. Results: The analysis of the empirical data reveals a typology of three different ethical problems professionals want to refer to CESS: (1) Dyadic problems based on the relationship between patients and professionals, (2) triangular problems, where a third party is involved and affected as a side effect, and (3) problems on a systemic level. However, CESS members focus largely on types (1) and (2), while the third remains unrecognized or members do not feel responsible for these problems. Furthermore, they reflect a strong inner tension connected to their role as ethical experts which can be depicted as a dilemma. On the one hand, as ethically trained people, they reject the idea that their judgments have expert status. On the other hand, they feel that mental health professionals reach out for them to obtain guidance and that it is their responsibility to offer it. Conclusion: CESS members and professionals in mental healthcare have different ideas of the scope of responsibility of CESS. This contains the risk of misunderstandings and misconceptions and may affect the quality of consultations. It is necessary to adapt concepts of problem solving to practitioners' needs to overcome these problems. Secondly, CESS members struggle with their role as ethical experts. CESS members in psychiatry need to develop a stable professional identity. Theoretical clarification and practical training are needed.

Supported Decision-Making in Persons With Dementia: Development of an Enhanced Consent Procedure for Lumbar Puncture

The right to make autonomous decisions is enshrined in law. However, the question how persons with cognitive deficits can be enabled to make autonomous decisions has not been satisfactorily addressed. In particular, the concept of supported decision-making and its implementation into practice has been poorly explored for persons with dementia (PwD).This article describes the empirical development and implementation of support tools to enhance informed consent processes (so called enhanced consent procedures/ECP) for PwD on whether to undergo lumbar puncture. In the end of the process of pilot testing and further development of the tools, the following tools were defined: (1) Standardized Interview Structure, (2) Elaborated Plain Language, (3) Ambience and Room Design, (4) Keyword Lists, (5) Priority Cards, (6) Visualization, and (7) Simplified Written Informed Consent (Patient Information), as well as the general attitude (8) Person-Centered Attitude of the facilitator. As the development, implementation and evaluation of ECP tools is one objective of the transnational ENSURE project, we also include an overview of future empirical procedures. So far, our findings can serve as a selection of possibilities to support PwD in decision-making and help practitioners achieve an appropriate balance between the autonomy and protection of PwD in complex decision-making situation. Future studies should address the question if the proposed set of tools is effective to enhance informed consent processes in PwD.

Under which conditions are changes in the treatment of people under involuntary commitment justified during the COVID-19 pandemic? An ethical evaluation of current developments in Germany

The COVID-19 pandemic poses significant challenges in psychiatric hospitals, particularly in the context of the treatment of people under involuntary commitment. The question arises at various points in the procedure for and process of involuntary commitment whether procedural modifications or further restrictive measures are necessary to minimise the spread of COVID-19 and protect all people involved from infection. In the light of current developments in Germany, this article examines under which conditions changes in the treatment of people under involuntary commitment are ethically justified in view of the COVID-19 pandemic. Among others, we discuss ethical arguments for and against involuntary commitments with reference to COVID-19, the use of different coercive interventions, the introduction of video hearings, an increased use of video surveillance and interventions based on the German Infection Protection Act. We argue that strict hygiene concepts, the provision of sufficient personal protective equipment and frequent testing for COVID-19 should be the central strategies to ensure the best possible protection against infection. Any further restrictions of the liberty of people under involuntary commitment require a sound ethical justification based on the criteria of suitability, necessity and proportionality. A strict compliance with these criteria and the continued oversight by external and independent control mechanisms are important to prevent ethically unjustified restrictions and discrimination against people with the diagnosis of a mental disorder during the COVID-19 pandemic.

Commentary 1: Research with Persons Under Involuntary Commitment-Ethical Issues Surrounding Competence and Voluntariness

In this case commentary, we analyze ethical concerns that were raised in response to an interview with a woman with bipolar disorder who was under involuntary commitment. We focus on competence and voluntariness as two prerequisites for valid informed consent. We recommend that judgments of competence be based on whether prospective research participants sufficiently possess certain decision-making abilities. Based on this functional approach, we argue that manic symptoms need not undermine competence and that, even if we were to assume that the research participant became incompetent during the interview, this would not invalidate her consent retroactively. It would, however, compromise her ability to revoke her consent. We furthermore show that obtaining additional proxy consent for research participation may compromise the autonomy of service users who are competent to consent. Then we turn to the issue of voluntariness. Arguing that neither the great strength nor the external etiology of a desire compromises voluntariness, we propose that the voluntariness of a decision instead depends on whether the decision-maker endorses it on reflection. The researchers disclosed that prospective research participants' decision about study participation would have no influence on the duration of the commitment or the quality of care. We contend that because of this neither coercion nor undue influence was exerted in the informed consent process. Nevertheless, there is an increased likelihood of perceived coercion and undue influence under conditions of involuntary commitment, and we close by suggesting some safeguards to prevent this.

Challenges faced by peer support workers during the integration into hospital-based mental health-care teams: Results from a qualitative interview study

BACKGROUND

Being aware of the challenges that may occur during the implementation of peer support work in psychiatry is important to facilitate the integration of peer support workers (PSWs) into multidisciplinary mental health-care teams.

AIM

The purpose of this study is to explore the challenges faced by PSWs during their integration into hospital-based mental health-care teams.

METHODS

Qualitative content analysis of nine open-ended, semi-structured interviews with PSWs is undertaken in five adult psychiatric hospitals in North Rhine-Westphalia, Germany.

RESULTS

The analysis of the data revealed three themes: (1) 'Pioneers and the pressure to succeed'; (2) 'a colleague, a rival or yet another patient?' and (3) 'sharing of information, boundaries and professionalism'. All three themes relate to several concrete challenges on different systemic levels and have the potential to impede the PSWs' integration process.

CONCLUSION

Specific implementation strategies which address potential barriers on the different systemic levels should be developed and applied prior to the start of the integration of PSWs into multidisciplinary mental health-care teams.

Outcomes of clinical ethics support near the end of life: A systematic review

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.

Ethical case interventions for adult patients

BACKGROUND

Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions.

OBJECTIVES

To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies.

SEARCH METHODS

We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation.

AUTHORS' CONCLUSIONS

It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.

Do we understand the intervention? What complex intervention research can teach us for the evaluation of clinical ethics support services (CESS)

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.

Beneficial effects of peer support in psychiatric hospitals. A critical reflection on the results of a qualitative interview and focus group study

Background: The implementation of peer support work in psychiatric hospitals is a relatively recent development. Consequently, the effects of peer support work on mental health professionals, patients and peer support workers (PSWs) are mostly unknown.Aims: To explore the beneficial effects of peer support work in detail and to reflect critically on potential sources of misunderstanding.Method: (1) Nine open-ended, semi-structured interviews with PSWs and (2) five focus groups with mental health professionals plus one focus group with PSWs. The data were analyzed using qualitative content analysis.Results: Our data show various beneficial effects on patients, such as the themes "less professional distance," "more time for one-on-one attendance" and "a role model for recovery." Themes that emerged for mental health professionals were, amongst others, "adding a new perspective," "improved continuity in treatment offers" and "preserving a respectful tone in meetings."Conclusions: It is necessary to minimize the risk of role confusion to achieve the beneficial potential of peer support work. A thorough education on what peer support work can and cannot deliver is essential and could help to foster its successful implementation.

[Advance research directives in the context of dementia research: Ethical reflections on the disclosure requirement]

In November 2016, the German Federal Diet adopted an amendment to the German Medicinal Products Act (Arzneimittelgesetz), which permits non-therapeutic biomedical research on incompetent adults under a number of strict conditions. One of these conditions is that the potential research participant has declared her wish to participate in biomedical research in a valid research advance directive. Before completing the research advance directive, the potential research participant must be informed about the circumstances of research participation. It has been argued that the legislature should have omitted the disclosure requirement for research advance directives. In this article, we consider reasons for maintaining such a disclosure requirement. In addition, we propose a practically feasible disclosure standard for research advance directives. According to this standard, potential research participants should be informed about types of biomedical studies rather than about particular studies.

Ward Atmosphere and Patient Satisfaction in Psychiatric Hospitals With Different Ward Settings and Door Policies. Results From a Mixed Methods Study

Background: Open-door policies in psychiatry are discussed as a means to improve the treatment of involuntarily committed patients in various aspects. Current research on open-door policies focuses mainly on objective effects, such as the number of coercive interventions or serious incidents. The aim of the present study was to investigate more subjective perceptions of different psychiatric inpatient settings with different door policies by analyzing ward atmosphere and patient satisfaction. Methods: Quantitative data on the ward atmosphere using the Essen Climate Evaluation Scale (EssenCES) and on patient satisfaction (ZUF-8) were obtained from involuntarily committed patients (n = 81) in three psychiatric hospitals with different ward settings and door policies (open, facultative locked, locked). Furthermore, qualitative interviews with each of 15 patients, nurses, and psychiatrists were conducted in one psychiatric hospital with a facultative locked ward comparing treatment in an open vs. a locked setting. Results: Involuntarily committed patients rated the EssenCES' subscale "Experienced Safety" higher in an open setting compared with a facultative locked and a locked setting. The subscale "Therapeutic Hold" was rated higher in an open setting than a locked setting. Regarding the safety experienced from a mental health professionals' perspective, the qualitative interviews further revealed advantages and disadvantages of door locking in specific situations, such as short-term de-escalation vs. increased tension. Patient satisfaction did not differ between the hospitals but correlated weakly with the EssenCES' subscale "Therapeutic Hold." Conclusion: Important aspects of the ward atmosphere seem to be improved in an open vs. a locked setting, whereas patient satisfaction does not seem to be influenced by the door status in the specific population of patients under involuntary commitment. The ward atmosphere turned out to be more sensitive to differences between psychiatric inpatient settings with different door policies. It can contribute to a broader assessment by including subjective perceptions by those who are affected directly by involuntary commitments. Regarding patient satisfaction under involuntary commitment, further research is needed to clarify both the relevance of the concept and its appropriate measurement.

Psychiatric Advance Directives Under the Convention on the Rights of Persons With Disabilities: Why Advance Instructions Should Be Able to Override Current Preferences

Psychiatric advance directives (PADs) are documents by means of which mental health service users can make known their preferences regarding treatment in a future mental health crisis. Many states with explicit legal provisions for PADs have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). While important UN bodies consider PADs a useful tool to promote the autonomy of service users, we show that an authoritative interpretation of the CRPD by the Committee on the Rights of Persons with Disabilities has the adverse consequence of rendering PADs ineffective in situations where they could be of most use to service users. Based on two clinical vignettes, we demonstrate that reasonable clinical recommendations can be derived from a more realistic and flexible CRPD model. Concerns remain about the accountability of support persons who give effect to PADs. A model that combines supported decision making with competence assessment is able to address these concerns.

Psychiatrists' views on different types of advance statements in mental health care in Germany

BACKGROUND

Advance directives enable patients to ensure that treatment decisions will be based on their autonomous will, even if they are incompetent at the time at which the treatment decision is taken. Although psychiatric advance directives are legally binding in Germany and their benefits are widely acknowledged, they are still infrequently used in German psychiatric practice.

AIMS

The aim of this study is to assess psychiatrists' attitudes toward the use of advance statements in mental health care.

METHODS

A postal survey of psychiatrists in Germany was carried out to examine their views on advance statements in psychiatry. The survey addressed psychiatrists' experiences of and attitudes toward different types of advance statements, including psychiatric advance statements written by patients without any specific assistance, and joint crisis plans ( 'Behandlungsvereinbarungen'), where involvement of the clinical team is required. A total of 396 responded.

RESULTS

Results suggest that generally speaking, respondents held favorable views on joint crisis plans for mental health care. In all, 80.7% of participants agreed that more frequent use of joint crisis plans in clinical practice would be desirable. However, clinicians' attitudes differ largely depending on the type of advance statement. Implications for the use of advance statements in psychiatry are discussed.

CONCLUSION

The findings suggest that increasing the support structures available to train physicians and inform patients could lead to increased adoption of advance statements.

Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals' and patients' view: a qualitative interview study

BACKGROUND

Treating legally committed patients on open, instead of locked wards is controversially discussed and the affected stakeholders (patients, mental health professionals) have ambiguous views on the benefits and disadvantages. The study aims to assess the opinions and values of relevant stakeholders with regard to the requirements for implementing open wards in psychiatric hospitals.

METHODS

Semi-structured interviews were conducted with 15 psychiatrists, 15 psychiatric nurses and 15 patients, and were analyzed using qualitative content analysis.

RESULTS

The interviewees identified conceptual, personnel and spatial requirements necessary for an open door policy. Observation and door watch concepts are judged to be essential for open wards, and patients appreciate the therapeutic value they hold. However, nurses find the door watch problematic. All groups suggest seclusion or small locked divisions as a possible way of handling agitated patients. All stakeholders agree that such concepts can only succeed if sufficient, qualified staff is available. They also agree that freedom of movement is a key element in the management of acutely ill patients, which can be achieved with an open door policy. Finally, the interviewees suggested removing the door from direct view to prevent absconding.

CONCLUSIONS

For psychiatric institutions seeking to implement (partially) open wards, the present results may have high practical relevance. The stakeholders' suggestions also illustrate that fundamental clinical changes depend on resource investments which - at least at a certain point - might not be feasible for individual psychiatric institutions but presumably require initiatives on the level of mental health care providers or policy makers.

"I need to know what makes somebody tick …": Challenges and Strategies of Implementing Shared Decision-Making in Individualized Oncology

BACKGROUND

Shared decision-making (SDM) has been advocated as an ethical framework for decision-making in cancer care. According to SDM, patients make decisions in light of their values and based on the available evidence. However, SDM is difficult to implement in cancer care. A lack of applicability in practice is often reported. This empirical-ethical study explores factors potentially relevant to current difficulties in translating the concept of SDM into clinical practice.

METHODS

This study was conducted with nonparticipant observation of the decision-making process in patients with gastrointestinal cancers for whom the benefit of adjuvant chemotherapy was uncertain according to clinical guidelines. Triangulation of qualitative data analysis was conducted by means of semistructured interviews subsequent to the observation. Observation notes and interview transcripts were analyzed according to the principles of grounded theory.

RESULTS

Deviating from the concept of SDM, oncologists initiated a process of eliciting values and medical information prior to conveying information. The purpose of this approach was to select and individualize information relevant to the treatment decision. In doing so, the oncologists observed used two strategies: "biographical communication" and a "metacommunicative approach." Both strategies could be shown to be effective or to fail depending on patients' characteristics such as their view of the physicians' role and the relevance of value-related information for medical decision-making.

CONCLUSION

In contrast to the conceptual account of SDM, oncologists are in need of patient-related information prior to conveying information. Both strategies observed to elicit such information are in principle justifiable but need to be adapted in accordance with patient preferences and decision-making styles.

IMPLICATIONS FOR PRACTICE

This study showed that knowledge of patients' values and preferences is very important to properly adapt the giving of medical information and to further the process of shared decision-making. Shared decision-making (SDM) trainings should consider different strategies of talking about values. The right strategy depends largely on the patient's preferences in communication. To be aware of the role of values in SDM and to be able to switch communicative strategies might prove to be of particular value. A more systematic evaluation of the patient's decision-making preferences as part of routine procedures in hospitals might help to reduce value-related barriers in communication.

Risks and errors in medicine. Concept and evaluation of an optional study module with integrated teaching of ethical, legal and communicative competencies

Objective: The presentation and discussion of the content, methodology and evaluation results of a course on "Risks and Errors in Medical Science", adopting an integrated approach for the teaching of ethical, legal and communicative aspects. Method: Written, structured evaluation using the adapted evaluation form "Evasys" as well as open questions on positive and negative aspects of the course and assessment of the effects thereof from the participants' viewpoint. The free text responses are evaluated according to the principles of qualitative content analysis. Results: Thirty-two from thirty-six participants (88.9%) evaluated the course in written form. The value for the global assessment of the course is a 1.7 (1=very good, 6=unsatisfactory). The self-assessed learning success was evaluated with a 1.9. In the qualitative analysis of the free text answers the case orientated teaching, the use of simulated patients as well as the legal content and the ethical models of the doctor-patient relationship were evaluated positively. Negative aspects of the course were, among other things, the weighting of the contents and the limited amount of time allotted. Impacts and changes were identified by the students in terms of knowledge of legal aspects, reflection on their own action and the training and further development of communication aptitudes. The students saw the relevance of the course for their studies especially in the supplement to the compulsory curriculum as well as in the significance of the content of medical law. Conclusions: The experience of the authors and the written evaluation results show that the concept of integrated teaching can be implemented in medical studies and that it is predominantly evaluated positively. The primary challenges are the weighting of the different contents and methods as well as the comparatively high demand for coordination among representatives of various disciplines.

Immunological differences between insect venom-allergic patients with and without immunotherapy and asymptomatically sensitized subjects

BACKGROUND

Currently available tests are unable to distinguish between asymptomatic sensitization and clinically relevant Hymenoptera venom allergy. A reliable serological marker to monitor venom immunotherapy (VIT) does also not exist. Our aim was to find reliable serological markers to predict tolerance to bee and vespid stings.

METHODS

We included 77 asymptomatically sensitized subjects, 85 allergic patients with acute systemic sting reactions, and 61 allergic patients currently treated with VIT. Levels of sIgE and sIgG₄ to bee and vespid venom, rApi m 1, and rVes v 5 were measured immediately after allergic sting reactions or before sting challenges and 4 weeks later. All sting challenges were tolerated. The inhibitory activity was determined using BAT inhibition and ELIFAB assay.

RESULTS

Median sIgG₄ levels were 96-fold higher in VIT patients (P < .001) while sIgE/sIgG₄ ratios were consistently lower (P < .001). The ELIFAB assay was paralleled by low sIgE/sIgG₄ ratios in VIT patients, showing markedly higher allergen-blocking capacity (P < .001). An almost complete inhibition of the basophil response was seen in all patients treated with vespid venom, but not in those treated with bee venom. Four weeks after the sting, sIgE and sIgG₄ levels were increased in allergic and asymptomatically sensitized patients, but not in VIT patients.

CONCLUSION

Immunological responses after stings varied in bee and vespid venom-allergic patients. In patients under VIT, sIgE and sIgG₄ remained completely stable after sting challenges. Monitoring VIT efficacy was only possible in vespid venom allergy, and the sIgG₄ threshold for rVes v 5 had the highest sensitivity to confirm tolerance. The BAT inhibition test was the most reliable tool to confirm tolerance on an individual basis.

[Level of Development of Clinical Ethics Consultation in Psychiatry - Results of a Survey Among Psychiatric Acute Clinics and Forensic Psychiatric Hospitals]

OBJECTIVE

The aim of this article is to assess the level of development of clinical ethics consultation in psychiatric institutions in North Rhine-Westphalia.

METHODS

Survey among medical directors, directors of nursing and administrative directors of all psychiatric acute clinics and forensic psychiatric hospitals in North Rhine-Westphalia.

RESULTS

113 persons working in psychiatric acute clinics responded (response rate: 48 %) and 13 persons working in forensic psychiatric hospitals (response rate 62 %). We received at least one response from 89 % of all psychiatric acute clinics and from 100 % of all forensic psychiatric hospitals. 92 % of the responding psychiatric acute clinics and 29 % of the responding forensic psychiatric hospitals have already implemented clinical ethics consultation.

CONCLUSION

Clinical ethics consultation is more widespread in psychiatric institutions than was hitherto assumed. Future medical ethics research should therefore give greater attention to the methodology and the quality of clinical ethics consultation in psychiatric practice.

[Physician perspectives on the impact of patient preferences and the role of next-of-kin of patients in evidence-based decision-making: A qualitative interview study from oncology]

The impact of patient preferences in evidence-based medicine is a complex issue which touches on theoretical questions as well as medical practice in the clinical context. The interaction between evidence-based recommendations and value-related patient preferences in clinical practice is, however, highly complex and requires not only medical knowledge but social, psychological and communicative competencies on the side of the physician. The multi-layered process of oncology physicians' clinical decision-making was explored in 14 semi-structured interviews with respect to a first diagnosis of a pancreatic adenocarcinoma. A case vignette was used and the Q method ("card sorting") was applied to analyze the influence of different factors (such as evidence, patient preferences and the role of relatives) on physicians' deliberations. Content analysis (Mayring) was performed. The results show that the participating oncologists consider patient preferences as an important guidance which, however, is limited on certain occasions where the physicians assume a leadership role in decision-making. From the interviewees' perspectives, the preferences of the patients' relatives are likewise of high importance because debilitating oncologic treatments can only be carried out if patients have both social and psychological support. There is a need for an ongoing reflection of the physicians' own values and due consideration of the patients' social role within the context of shared decision-making.

What does physicians' clinical expertise contribute to oncologic decision-making? A qualitative interview study

BACKGROUND

Physicians' clinical expertise forms an exclusive body of competences, which helps them to find the appropriate diagnostics and treatment for each individual patient. Empirical evidence, however, suggests that there is an inverse relationship between the number of years in practice and the quality of care provided by a physician. Knowledge and adherence to professional standards (such as clinical guidelines) are often used as indicators in previous research.

METHODS

Semistructured interviews and the Q method were used for an explorative study on oncologists' views on the interplay between their own clinical expertise, intuition, and the external evidence incorporated in clinical guidelines. The interviews were audio recorded, transcribed ad verbatim, and analysed using qualitative content analysis.

RESULTS

Data analysis shows the complex character of clinical expertise with respect to experience, professional development, and intuition. An irreplaceable role is attributed to personal and bodily experience during the providing of care for a patient. Professional experience becomes important, particularly in those situations that lie out of the focus of "guideline medicine." Intuition is regarded as having a strong emotional component and helps for deciding which therapeutic option the patient can deal with.

CONCLUSIONS

Using measurable knowledge and adherence to standards as indicators does not account for the complexity of clinical expertise. Other factors, such as the importance of bodily experience and physicians' intuitive knowledge, must be considered, also with respect to the occurrence of treatment biases.

Treatment recommendations within the leeway of clinical guidelines: A qualitative interview study on oncologists' clinical deliberation

Background

Recommending the optimal treatment for an individual patient requires a well-balanced consideration of various medical, social and ethical factors. The interplay of these factors, interpretation of the patient’s situation and understanding of the existing clinical guidelines can lead to divergent therapy recommendations, depending on the attending physician. Gaining a better understanding of the individual process of medical decision-making and the differences occurring will support the delivery of optimal individualized care within the clinical setting.

Methods

A case vignette of a 64-year-old patient with locally advanced pancreatic adenocarcinoma was discussed with oncologists in 14 qualitative, semi-structured interviews at two academic institutions. Relevant factors that emerged were ranked by the participants using the Q card sorting method. Qualitative data analysis and descriptive statistics were performed.

Results

Oncologists recommend different therapeutic approaches within the leeway of the relevant clinical guidelines. One group of participants endorses a rather aggressive and potentially curative approach with a combination chemotherapy following the FOLFIRINOX protocol to provide the patient with the best chances of resectability. The second group suggests a milder chemotherapy approach with gemcitabine, highlighting the palliative approach and the patient’s quality of life. Clinical guidelines are generally seen as an important point of reference, but are complicated to apply in highly individual cases.

Conclusion

The physician’s individual assessment of factors, such as biological age, general condition or prognosis, plays a decisive role in treatment recommendations, particularly in those cases which are not fully covered by guidelines. Judgment and discretion remain crucial in clinical decision-making and cannot and should not be fully ruled out by evidence-based guidelines. Therefore, a more comprehensive reflection on the interaction between evidence-based medicine and the physician’s estimation of each individual case is desirable. Knowledge of existing barriers can enhance the implementation of guidelines, for example, through medical education.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3783-6) contains supplementary material, which is available to authorized users.

["Something humane has been lost". Re-evaluation of the attitudes of senior physicians towards the G-DRG System - a qualitative normative analysis]

Only a few years after the implementation of the G-DRG (German Diagnosis Related Group) system physicians already began to complain of its negative effects on the quality of inpatient healthcare. The present study examines the recent experiences senior physicians have made with regard to the impact of the G-DRG system on the quality of healthcare and medical professionalism. Nine qualitative guided expert interviews were conducted focusing on the experiences of physicians in leading positions dealing with the G-DRG system in their everyday work. The interviewees report an intensification of work attributable to an increasing number of inpatient cases, a more lenient definition of medical indications and a reduction in patient retention time. The physicians interviewed have felt increasingly constrained by economic conditions. Additionally, they stated that the G-DRG system's incentive structure encourages the discrimination of older, care-dependent and multimorbid patients. Possible countermeasures include a political revision of incentive regulation as well as a strengthening of up-to-date professional ethical education and teaching.

Cost-effectiveness of methods in personalized medicine. Results of a decision-analytic model in patients with acute myeloid leukemia with normal karyotype

BACKGROUND

During the last years, molecular genetic data are increasingly used as prognostic and predictive factors in acute myeloid leukemia (AML). The molecular genetic profile permits a rapid risk categorization and beyond that a prediction of differential treatment efficacy of post-remission chemotherapy versus an allogeneic hematopoietic cell transplantation (HCT) in specific subgroups.

METHODS

The aim of this study was to evaluate cost-effectiveness of two different strategies of risk categorization (conventional cytogenetic diagnostics (CCD) versus molecular genetic diagnostics (MGD)) in patients with AML, using a decision-analytic state-transition model. The model is run as (Monte Carlo) microsimulation in which individuals pass through in cycles with a cycle length of one month and a time horizon of ten years.

FINDINGS

Results show that on average, individuals within the MGD group generated about US$ 32,000 higher costs but survived about seven months longer than individuals within the CCD group. This leads to an Incremental Cost-Effectiveness Ratio (ICER) of about US$ 4928 per survived month.

INTERPRETATION

With a GDP (Gross Domestic Product) of US$ 26,467 (€ 33,630) per capita in Germany in 2012, the base-case ICER of US$ 4928 per survived month projected to US$ 59,136 per survived year is in between the simple GDP and the three times GDP per capita.