Effect of moral case deliberation on midwives' knowledge and practice regarding respectful maternity care

INTRODUCTION

Although there have been reports of misbehavior and disrespectful maternal care by healthcare providers worldwide, there are few intervention studies aimed at promoting respectful care, particularly among midwives.

RESEARCH OBJECTIVES

The aim of this study was to examine the effect of Moral Case Deliberation (MCD) on the of midwives' knowledge and practice in the field of respectful maternity care.

RESEARCH DESIGN AND METHODS

This semi-experimental study involved 46 midwives working in the maternity departments of two hospitals affiliated with Bushehr University of Medical Sciences in 2023. The two hospitals were randomly divided into control and intervention groups. All midwives from both hospitals were included in the study. The Dilemma Method of MCD was implemented for midwives of intervention hospital. The Midwives' Knowledge and Practice of Respectful Maternity Care scale was used for data collection. It was administered both before and two weeks after the intervention. Data were analyzed using SPSS (version 20).

ETHICAL CONSIDERATIONS

The study was approved by ethics committee of Bushehr University of Medical Sciences in Bushehr, Iran (ethics code: IR.BPUMS.REC.1402.017). All participants provided written informed consent.

FINDINGS

The intervention group showed a significantly greater increase in knowledge scores from pre-test to post-test compared to the control group (p < .001). The intervention group had a significantly higher mean change score in practice self-assessment and practice peer evaluation, from pre-test to post-test, than in the control group (p < .001).

DISCUSSION

MCD based on the dilemma method can improve practice in the field of respect-oriented midwifery care by increasing knowledge and potentially changing attitudes.

CONCLUSION

The Dilemma Method of MCD improved midwives' knowledge and practice regarding respectful maternity care. This method can be included in the midwifery care quality improvement program to promote respectful maternity care. It is necessary to develop methods for wider dissemination of MCD in the cultural context of Iran.

Clinical Ethics Consultation for Patients Impacted by Incarceration: A Single Center Retrospective Review

Health care professionals and patients impacted by incarceration face unique medical, legal, and ethical issues. The frequency and nature of ethics consultations for these patients are underexplored. This study aimed to characterize the primary ethical issue and contextual features of ethics consultations involving patients impacted by incarceration. We conducted a qualitative concept content analysis of ethics consultations involving patients impacted by incarceration and calculated descriptive statistics of demographics to compare these patients with the broader population of patients impacted by incarceration at a single institution from January 1, 2015, through June 30, 2022. We identified 37,184 patients impacted by incarceration (people currently or formerly incarcerated or whose surrogate decision-maker is incarcerated) at our institution. Most were White (70%) and non-Hispanic (88%); 51% were male, 49% female. Individuals impacted by incarceration comprised 3% (n = 38) of ethics consults. Most were White (58%), male (79%), and hospitalized (92%). The primary ethical issues were surrogate decision-making (34%) and fiduciary duties (beneficence/nonmaleficence/best interest; 16%). The primary contextual feature was intra-family communication challenges (37%). Incarceration status impacts access to decision-makers and the provision of medically necessary care. Ethics consultation for women and individuals in outpatient and emergency settings could be underutilized. More education about ethics consultation services and coordination with correctional officials is recommended.

'Sit down and thrash it out': opportunities for expanding ethics consultation during conflict resolution in long-term care

OBJECTIVE

To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution.

DESIGN

An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA).

RESULTS

Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a formal dispute mediation policy. Only five respondents have called an ethics consult for assistance.

CONCLUSION

Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff.

Chaplains as mediators in conflicts concerning method of patients' medical care-study of the situation in Poland

BACKGROUND AND AIMS

Health Care Chaplains, whose primary role is to provide spiritual care to patients, their families, and medical staff, are sometimes asked for help in making difficult decisions and resolving conflicts. Their help is justified especially when religious beliefs and values constitute the root of the problem. The study aims to analyze the phenomenon of asking hospital and hospice chaplains in Poland to take on the role of mediators in conflicts concerning methods of patients' medical care.

METHODS

A survey was conducted among 108 Catholic chaplains, i.e. at least 10% of all chaplains currently working in Polish hospitals and hospices. The survey was conducted using the electronic questionnaire through an intermediary with no follow-up and so self-selecting. The findings obtained were subjected to statistical analysis.

RESULTS

Of all the respondents, 31% admitted having received requests to mediate in a conflict over patient care. Such requests were not conditional upon the type of medical facility, its location, or the chaplain's years of experience. 30% of chaplains receive requests to mediate between patients and doctors. Solving disputes between family members and members of the medical teams are less frequent (25 and 19%, respectively). The majority of the respondents (73%) accept the role of the mediator, although 46% reserve the right to refuse in certain situations.

CONCLUSIONS

Asking health care chaplains to become mediators in conflicts over patients' medical care confirms the need to include mediation skills in the course of their education and gaining professional experience.

Nurse ethicists: Innovative resource or ideological aspiration?

In recent years, there have been growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts. Initially proposed in the cultural context of the USA where nurse ethicists have long been recognised, the idea is being advocated in other judications outside of the USA such as the UK, Australia and elsewhere. Such calls are not without controversy, however. Underpinning this controversy are ongoing debates about the theoretical, methodological and political dimensions of clinical ethics support services generally, and more recently where nurses might 'fit' within such a service. In considering whether nurse ethicists ought to have a place in clinical ethics support services, a number of questions arise such as: Is such a role warranted? If so, what credentials should nurses assuming the title of 'nurse ethicist' be required to have? What standards of practice ought nurse ethicists be required to uphold? What is the ultimate role and function of nurse ethicists in hospital contexts? And in what contexts might a nurse ethicist be most useful? In this essay, brief attention will be given to addressing these questions. It will be concluded that, as a minimum, nurses wishing to assume an advanced nursing practice role as a nurse ethicist must have substantive grounding in the foundational knowledge of the disciplines of both moral philosophy and nursing ethics. They must also not lose sight of the ultimate goal of nursing ethics, notably, to promote and advance ethical nursing practice and the provision of 'good' nursing care.

Legal Liability of Clinical Ethics Services in Australia: "Should I Be More Worried Than I Am?"

A key function of clinical ethics services (CESs) is to provide decision-making support to health care providers in ethically challenging cases. Cases referred for ethics consultation are likely to involve diverging views or conflict, or to confront the boundaries of appropriate medical practice. Such cases might also attract legal action due to their contentious nature. As CESs become more prevalent in Australia, this article considers the potential legal liability of a CES and its members. With no reported litigation against a CES in Australia, we look to international experience and first principles. We consider the prospects of a claim in negligence, the most likely legal action against a CES, through application of legal principles to a hypothetical case scenario. We conclude that, although unlikely to be successful at this time, a CES could face answerable claims in negligence brought by patients (and families) who are the subject of ethics case consultation.

Perceived Benefits of Ethics Consultation Differ by Profession: A Qualitative Survey Study

BACKGROUND

There are numerous benefits to ethics consultation services, but little is known about the reasons different professionals may or may not request an ethics consultation. Inter-professional differences in the perceived utility of ethics consultation have not previously been studied.Methods: To understand profession-specific perceived benefits of ethics consultation, we surveyed all employees at an urban tertiary children's hospital about their use of ethics committee services (n = 842).Results: Our findings suggest that nurses and physicians find ethics consultations useful for different reasons; physicians were more likely to report normative benefits, while nurses were more likely to report communicative and relational benefits.Conclusions: These findings support an open model of ethics consultation and may also help ethics committees to better understand consultation requests and remain attuned to the needs of various professional groups.

Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work

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.

If Not Now, Then When? Taking Disability Seriously in Bioethics

The impression of bioethicists as "dangerous," as articulated in Mouth Magazine in 1994, has continued to be a theme in the disability movement. We respond to three common responses by bioethicists to this impression-namely, this is from the past, and bioethicists are different now; this is an angry and extremist position; and the Americans with Disabilities Act and other disability rights and justice efforts have solved historical inequities. We draw on the historical record and on our collective experiences as bioethicists engaged in clinical consultation and education and as the founding, former, and current directors of a program focused on disability and rehabilitation ethics to argue that ableism and unexamined assumptions about people with disabilities have persisted in bioethics despite decades of counternarratives, research, and divergent perspectives. Ableism and such assumptions can lead to health care decisions that are prone to bias, mistreatment, and a lack of consideration of viable options for living with disability. As the field of bioethics moves toward certification examinations and as new generations join the field's ranks, these problems need to be rectified with solutions at the individual, interpersonal, and structural levels. It is past time to take disability seriously.

Moral expertise without moral elitism

Skepticism about ethical expertise has grown common, raising concerns that bioethicists' roles are inappropriate or depend on something other than expertise in ethics. While these roles may depend on skills other than those of expertise, overlooking the role of expertise in ethics distorts our conception of moral advising. This paper argues that motivations to reject ethical expertise often stem from concerns about elitism: either an intellectualist elitism, where some privileged elite have supposedly special access in virtue of expertise in moral theory; or an authoritarian elitism, where our reliance on experts in ethics risks violation of autonomy and democracy. The paper sketches an anti-elitist conception of ethics expertise in bioethics as continuous with an anti-elitist conception of ethics expertise in common moral practice, undercutting the intellectualism, and then uses this anti-elitist conception to reject arguments that ethical expertise violates autonomy or democracy. An anti-elitist picture of ethical expertise both renders it consistent with our general moral practice and allows us to resist skeptical concerns.

Comparison Is Not a Zero-Sum Game: Exploring Advanced Measures of Healthcare Ethics Consultation

Studies across the healthcare spectrum consistently show that sharing and comparing data across institutions improves the quality of patient care. Whether comparing data about healthcare ethics consultation (HCEC) would similarly improve quality is unknown due to the lack of research on HCEC data sharing and comparison. Methods: To explore this possibility, we analyzed data from two academic medical centers in the Central-Southern United States that both employ a shared, robust coding system for ethics consultations (N = 703 cases total over 2.5 years) using descriptive and chi-square statistics, correlation coefficients and logistic regressions. Results: Our findings relate to patient age, care location, requestor role, and ethical themes, which together contribute to an improved evidence base for explanatory analyses and quality improvement initiatives. Conclusions: We conclude it is possible to analyze and compare HCEC activities across separate institutions using a standardized approach to data gathering, that this approach is consistent with concurrent narrative case review and assessment, and that cross-institutional comparisons are meaningful. Our results suggest future comparative analyses will require additional standardization of advanced measures for describing and analyzing HCEC activities.

Between Crisis and Convention: How Should We Address Contingency?

The Covid-19 pandemic has brought about renewed conversation about equality and equity in the distribution of medical resources. Much of the recent conversation has focused on creating and implementing policies in times of crisis when resources are exhausted. Depending on how the pandemic develops, some communities may implement crisis measures, but many health care facilities are currently experiencing shortages of staff and materials even if the facilities have not implemented crisis standards. There is a need for shared conversation about equality and equity in these times of contingency between conventional and crisis medicine. To respond well to these challenges, I recommend that institutions rely on policy, professional education, and ethics consultation. As is the case with crisis policies, creating contingency policies requires that health care professionals decide on how, specifically, to achieve equity. A policy is only as effective as its implementation; therefore, institutions should invest in context-specific education on contingency policies. Finally, ethics consultation should be available for questions that contingency policies cannot address.

The role of hospital ethics committees in emergency medicine practice

Emergency physicians face real-time ethical dilemmas that may occur at any hour of the day or night. Hospital ethics committees and ethics consultation services are not always able to provide immediate responses to emergency physicians' consultation requests. When faced with an emergent dilemma, emergency physicians sometimes rely on risk management or hospital counsel to answer legal questions, but may be better served by real-time ethics consultation. When other resources are not immediately available, emergency physicians should feel confident in making timely decisions, guided by basic principles of medical ethics. We make the following recommendations: (1) availability of a member of the hospital ethics committee to provide in-person or telephonic consultation concurrent with patient care; (2) appointment to the hospital ethics committee of an emergency physician who is familiar with bioethical principles and is available for consultation when other ethics consultants are not; and (3) development of educational tools by professional societies or similar organizations to assist emergency physicians in making reasoned and defensible clinical ethics decisions.

The Hang Up

Over the past year, our ethics service has had numerous consultations involving patients who use the emergency department for regular dialysis. Sometimes, they have access to outpatient hemodialysis that they forgo; other times, they've been "fired" from this kind of outpatient facility, and so the ED is their last option. In most of these cases, we're called because the patient is disruptive once admitted to the ICU and behavior plans haven't helped. But the call from a resident this March 2020 morning was different, the patient had end-stage renal disease and often missed hemodialysis, but he wasn't disruptive. "It's just that he comes in after using cocaine, and given scarcity with the coronavirus and ICU beds…." I have come to think that this is one of the more insidious effects of the pandemic: that there will be a resurgence of the view that some patients deserve health care by virtue of their compliant behavior and that those who are nonadherent don't.

Academic Teaching Hospitals: A Multisite Survey Study

OBJECTIVES

To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated.

DESIGN

Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017.

SETTING

We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included.

SUBJECTS

The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing.

CONCLUSIONS

Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.

The role of online ethics consultation on mental health

BACKGROUND

Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice.

RESEARCH OBJECTIVE

To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness.

ETHICAL CONSIDERATIONS

The research was conducted in accordance with the Declaration of Helsinki.

RESEARCH DESIGN

This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan.

PARTICIPANTS

The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users.

FINDINGS

The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive.

DISCUSSION

The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants.

CONCLUSION

This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses' moral distress, building ethics into decision-making.

When Do Pediatricians Call the Ethics Consultation Service? Impact of Clinical Experience and Formal Ethics Training

Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked to reflect on their ethics training and utilization of ECS via an anonymous, electronic survey distributed in 2017 and 2018, and analyzed in 2018. Participants reported their clinical experience, exposure to formal and informal ethics training, use of formal and informal ethics consultations, and potential barriers to formal consultation. Results: Less experienced pediatricians were more likely to utilize formal ethics consultation and more likely to have formal ethics training. The most commonly reported reasons not to pursue formal ECS consultation were inconvenience and self-reported expertise in pediatric ethics. Conclusions: These results inform ongoing discussions about ethics consultation among pediatricians and the role of formal ethics training in both undergraduate and graduate medical education.

Training clinical ethics committee members between 1992 and 2017: systematic scoping review

INTRODUCTION

Clinical ethics committees (CECs) support and enhance communication and complex decision making, educate healthcare professionals and the public on ethical matters and maintain standards of care. However, a consistent approach to training members of CECs is lacking. A systematic scoping review was conducted to evaluate prevailing CEC training curricula to guide the design of an evidence-based approach.

METHODS

Arksey and O'Malley's methodological framework for conducting scoping reviews was used to evaluate prevailing accounts of CEC training published in six databases. Braun and Clarke's thematic analysis approach was adopted to thematically analyse data across different healthcare and educational settings.

RESULTS

7370 abstracts were identified, 92 full-text articles were reviewed and 55 articles were thematically analysed to reveal four themes: the design, pedagogy, content and assessment of CEC curricula.

CONCLUSION

Few curricula employ consistent approaches to training. Many programmes fail to provide CEC trainees with sufficient knowledge, skills and experience to meet required competencies. Most programmes do not inculcate prevailing sociocultural, research, clinical and educational considerations into training processes nor provide longitudinal support for CEC trainees. Most CEC training programmes are not supported by host institutions threatening the sustainability of the programme and compromising effective assessment and longitudinal support of CEC trainees. While further reviews are required, this review underlines the need for host organisations to support and oversee a socioculturally appropriate ethically sensitive, clinically relevant longitudinal training, assessment and support process for CEC trainees if CECs are to meet their roles effectively.

Clinical Ethics Support Services Are Not as Well-Established in Forensic Psychiatry as in General Psychiatry

Background: Mental health care professionals deal with complex ethical dilemmas that involve the principles of autonomy, justice, beneficence, and non-maleficence. Such dilemmas are even more prominent in forensic mental health care, where the restriction of personal rights is legitimated not only by patient well-being but also by public safety interests. Little is known about either the use of formal ethics support services or specific ethical needs in forensic mental health care. Knowledge about the current structures and how they compare with those in general psychiatry would help to identify the most important ethical issues and to analyze whether there are unmet needs that might require specific ethics support. Methods: We performed a survey study in all general psychiatric and forensic psychiatric inpatient departments in Germany. The aims were to compare the availability and functioning of clinical ethics structures and to identify specific ethical needs in inpatient forensic and general mental health care. Results: Clinical ethics support was available in 74% of general psychiatric hospitals but in only 43% of all forensic psychiatric hospitals and 25% of those offering treatment for offenders with substance use disorders. Most ethics support services were interdisciplinary. The most frequently requested retrospective and prospective ethics consultations were on issues of omission and termination of treatment, coercive measures, and advance directives. Among the hospitals without access to ethics support, 71% indicated a need for training in ethics. Discussion: Our results show that ethics consultation is well established in general psychiatry, but less so in forensic psychiatry. Mental health care professionals in forensic psychiatry seem to have a need for ethics support and training in clinical ethics. We also found a difference in access to ethics structures between hospitals that treat mentally disordered offenders and those that treat offenders with substance use disorders. Further research should focus on how ethics support can be comprehensively implemented in forensic mental health care and how this might improve treatment quality and patient and staff well-being.

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.

Ethics Consultations Related to Opioid Use Disorder

BACKGROUND

The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention.

OBJECTIVE

The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital.

METHODS

We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital.

RESULTS

Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital.

CONCLUSION

The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults.

Team members perspectives on conflicts in clinical ethics committees

Background:

Clinical ethics committees have been broadly implemented in university hospitals, general hospitals and nursing homes. To ensure the quality of ethics consultations, evaluation should be mandatory.

Research question/aim:

The aim of this article is to evaluate the perspectives of all people involved and the process of implementation on the wards.

Research design and participants:

The data were collected in two steps: by means of non-participating observation of four ethics case consultations and by open-guided interviews with 28 participants. Data analysis was performed according to grounded theory.

Ethical considerations:

The study received approval from the local Ethics Commission (registration no.: 32/11/10).

Findings:

‘Communication problems’ and ‘hierarchical team conflicts’ proved to be the main aspects that led to ethics consultation, involving two factors: unresolvable differences arise in the context of team conflicts on the ward and unresolvable differences prevent a solution being found. Hierarchical asymmetries, which are common in the medical field, support this vicious circle. Based on this, minor or major disagreements regarding clinical decisions might be seen as ethical conflicts. The expectation on the clinical ethics committee is to solve this (communication) problem, but the participants experienced that hierarchy is maintained by the clinical ethics committee members.

Discussion:

The asymmetrical structures of the clinical ethics committee reflect the institutional hierarchical nature. They endure, despite the fact that the clinical ethics committee should be able to detect and overcome them. Disagreements among care givers are described as one of the most difficult ethically relevant situations and should be recognised by the clinical ethics committee. On the contrary, discussion of team conflicts and clinical ethical issues should not be combined, since the first is a mandate for team supervision.

Conclusion:

To avoid dominance by physicians and an excessively factual character of the presentation, the case or conflict could be presented by both physicians and nurses, a strategy that strengthens the interpersonal and emotional aspects and also integrates both professional perspectives.

A Pilot Study

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to "diagnose" and "solve" the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue-ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Neonatal nurse practitioner ethics knowledge and attitudes

BACKGROUND

Neonatal nurse practitioners have become the frontline staff exposed to a myriad of ethical issues that arise in the day-to-day environment of the neonatal intensive care unit. However, ethics competency at the time of graduation and after years of practice has not been described.

RESEARCH AIM

To examine the ethics knowledge base of neonatal nurse practitioners as this knowledge relates to decision making in the neonatal intensive care unit and to determine whether this knowledge is reflected in attitudes toward ethical dilemmas in the neonatal intensive care unit.

RESEARCH DESIGN

This was a prospective cohort study that examined decision making at the threshold of viability, life-sustaining therapies for sick neonates, and a ranking of the five most impactful ethical issues.

PARTICIPANTS AND RESEARCH CONTEXT

All 47 neonatal nurse practitioners who had an active license in the State of Mississippi were contacted via e-mail. Surveys were completed online using Survey Monkey software.

ETHICAL CONSIDERATIONS

The study was approved by the University of Mississippi Medical Center Institutional Review Board (IRB; #2015-0189).

FINDINGS

Of the neonatal nurse practitioners who completed the survey, 87.5% stated that their religious practices affected their ethical decision making and 76% felt that decisions regarding life-sustaining treatment for a neonate should not involve consultation with the hospital's legal team or risk management. Only 11% indicated that the consent process involved patient understanding of possible procedures. Participating in the continuation or escalation of care for infants at the threshold of viability was the top ethical issue encountered by neonatal nurse practitioners.

DISCUSSION

Our findings reflect deficiencies in the neonatal nurse practitioner knowledge base concerning ethical decision making, informed consent/permission, and the continuation/escalation of care.

CONCLUSION

In addition to continuing education highlighting ethics concepts, exploring the influence of religion in making decisions and knowing the most prominent dilemmas faced by neonatal nurse practitioners in the neonatal intensive care unit may lead to insights into potential solutions.

The Emergence of Clinical Research Ethics Consultation: Insights From a National Collaborative

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards (IRBs), to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation (REC) services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying ethical commentaries to highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research.

A Lifesaving View of Vascularized Composite Allotransplantation: Patient Experience of Social Death Before and After Face, Hand, and Larynx Transplant

Introduction:

Most solid organ transplantation is viewed as lifesaving, whereas vascularized composite allotransplantation (VCA) has been viewed as life enhancing. This article challenges the latter and argues that “social death” evident in severe face, hand, and larynx disfigurement can be potentially treated via VCA. Social death (from a social science perspective) consists of a combination of 7 components: social isolation, loneliness, ostracism, loss of personhood, change of role and identity, harm, and disfigurement.

Methods:

In February 2016, PubMed and Google were searched for case reports of human face, hand, and larynx transplantation. Patient and team narratives were then coded for components of social death using social science and medical model criteria.

Results:

Eleven narratives were identified among 9 articles. The social science model (but not the medical model) described pretransplant social death and the resolution of social death by receiving VCA. Notably, the medical model of social death was deemed unsuitable for application to VCA. This is because case narratives consistently contradict elements of the medical model.

Conclusions:

By including social death as a patient inclusion criterion for face, hand, and larynx VCA, these transplants can be considered lifesaving. Additionally, because VCA requires lifelong immunosuppressant medication, considering VCA as a lifesaving intervention improves the technology’s risk–benefit analysis. Guidance for assessing social death is provided.

The interactions of Canadian ethics consultants with health care managers and governing boards during times of crisis

BACKGROUND

Health care organizations can be very complex, and are often the setting for crisis situations. In recent years, Canadian health care organizations have faced large-scale systemic medical errors, a nation-wide generic injectable drug shortage, iatrogenic infectious disease outbreaks, and myriad other crises. These situations often have an ethical component that ethics consultants may be able to address. Organizational leaders such as health care managers and governing boards have responsibilities to oversee and direct the response to crisis situations. This study investigates the nature and degree of involvement of Canadian ethics consultants in such situations.

METHODS

This qualitative study used semi-structured interviews with Canadian ethics consultants to investigate the nature of their interactions with upper-level managers and governing board members in health care organizations, particularly in times of organizational crisis. We used a purposive sampling technique to identify and recruit ethics consultants throughout Canada.

RESULTS

We found variability in the interactions between ethics consultants and upper-level managers and governing boards. Some ethics consultants we interviewed did not participate in managing organizational crisis situations. Most ethics consultants reported that they had assisted in the management of some crises and that their participation was usually initiated by managers. Some ethics consultants reported the ability to bring issues to the attention of upper-level managers and indirectly to their governing boards. The interactions between managers and ethics consultants were characterized by varying degrees of collegiality. Ethics consultants reported participating in or chairing working groups, participating in incident management teams, and developing decision-making frameworks.

CONCLUSIONS

Canadian ethics consultants tend to believe that they have valuable skills to offer in the management of organizational crisis situations. Most of the ethics consultants we interviewed believed that they play an important role in this regard.

The use of Ethics Decision-Making Frameworks by Canadian Ethics Consultants: A Qualitative Study

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants.

Expertise, Ethics Expertise, and Clinical Ethics Consultation: Achieving Terminological Clarity

The language of ethics expertise has become particularly important in bioethics in light of efforts to establish the value of the clinical ethics consultation (CEC), to specify who is qualified to function as a clinical ethics consultant, and to characterize how one should evaluate whether or not a person is so qualified. Supporters and skeptics about the possibility of ethics expertise use the language of ethics expertise in ways that reflect competing views about what ethics expertise entails. We argue for clarity in understanding the nature of expertise and ethics expertise. To be an ethics expert, we argue, is to be an expert in knowing what ought to be done. Any attempt to articulate expertise with respect to knowing what ought to be done must include an account of ethics that specifies the nature of moral truth and the means by which we access this truth or a theoretical account of ethics such that expertise in another domain is linked to knowing or being better at judging what ought to be done and the standards by which this "knowing" or "being better at judging" is determined. We conclude with a discussion of the implications of our analysis for the literature on ethics expertise in CEC. We do think that there are clear domains in which a clinical ethics consultant might be expert but we are skeptical about the possibility that this includes ethics expertise. Clinical ethics consultants should not be referred to as ethics experts.

Keeping it Ethically Real

Many clinical ethicists have argued that ethics expertise is impossible. Their skeptical argument usually rests on the assumptions that to be an ethics expert is to know the correct moral conclusions, which can only be arrived at by having the correct ethical theories. In this paper, I argue that this skeptical argument is unsound. To wit, ordinary ethical deliberations do not require the appeal to ethical or meta-ethical theories. Instead, by agreeing to resolve moral differences by appealing to reasons, the participants agree to the Default Principle-a substantive rule that tells us how to adjudicate an ethical disagreement. The Default Principle also entails a commitment to arguments by parity, and together these two methodological approaches allow us to make genuine moral progress without assuming any deep ethical principles. Ethical expertise, in one sense, is thus the ability and knowledge to deploy the Default Principle and arguments by parity.

Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order

BACKGROUND

Advance directives guide healthcare providers to listen to and respect patients' wishes regarding their right to die in circumstances when cardiopulmonary resuscitation is required, and hospitals accredited by The Joint Commission are required to have a do-not-resuscitate (DNR) policy in place. However, when surgery and anesthesia are necessary for the care of the patient with a DNR order, this advance directive can create ethical dilemmas specifically involving patient autonomy and the physician's responsibility to do no harm.

METHODS

This paper discusses the ethical considerations regarding perioperative DNR orders and provides guidance on how to handle situations that may arise in the conduct of perioperative care.

RESULTS

Because of the potential conflicts between ethical care and the restrictions of DNR orders, it is critically important to discuss the medical and ethical issues surrounding this clinical scenario with the patient or surrogate prior to any surgical intervention. However, many anesthesiologists do not adequately address this ethical dilemma prior to the procedure.

CONCLUSION

Practitioners are advised to first consider what is best for the patient and, when in doubt, to communicate with patients or surrogates and with colleagues to arrive at the most appropriate care plan. If irreconcilable conflicts arise, consultation with the institution's bioethics committee, if available, is beneficial to help reach a resolution.

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool (ECQAT). ECQAT enables raters to assess the quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation (ethics question, consultation-specific information, ethical analysis, and conclusions and/or recommendations), established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT, the resulting product, and recommended future testing and potential uses for the tool.

Moving It Along: A study of healthcare professionals' experience with ethics consultations

BACKGROUND

Ethics consultation is the traditional way of resolving challenging ethical questions raised about patient care in the United States. Little research has been published on the resolution process used during ethics consultations and on how this experience affects healthcare professionals who participate in them.

OBJECTIVES

The purpose of this qualitative research was to uncover the basic process that occurs in consultation services through study of the perceptions of healthcare professionals.

DESIGN AND METHOD

The researchers in this study used a constructivist grounded theory approach that represents how one group of professionals experienced ethics consultations in their hospital in the United States.

RESULTS

The results were sufficient to develop an initial theory that has been named after the core concept: Moving It Along. Three process stages emerged from data interpretation: moral questioning, seeing the big picture, and coming together. It is hoped that this initial work stimulates additional research in describing and understanding the complex social process that occurs for healthcare professionals as they address the difficult moral issues that arise in clinical practice.

Ethical challenges in nursing homes--staff's opinions and experiences with systematic ethics meetings with participation of residents' relatives

BACKGROUND

Many ethical problems exist in nursing homes. These include, for example, decision-making in end-of-life care, use of restraints and a lack of resources.

AIMS

The aim of the present study was to investigate nursing home staffs' opinions and experiences with ethical challenges and to find out which types of ethical challenges and dilemmas occur and are being discussed in nursing homes.

METHODS

The study used a two-tiered approach, using a questionnaire on ethical challenges and systematic ethics work, given to all employees of a Norwegian nursing home including nonmedical personnel, and a registration of systematic ethics discussions from an Austrian model of good clinical practice.

RESULTS

Ninety-one per cent of the nursing home staff described ethical problems as a burden. Ninety per cent experienced ethical problems in their daily work. The top three ethical challenges reported by the nursing home staff were as follows: lack of resources (79%), end-of-life issues (39%) and coercion (33%). To improve systematic ethics work, most employees suggested ethics education (86%) and time for ethics discussion (82%). Of 33 documented ethics meetings from Austria during a 1-year period, 29 were prospective resident ethics meetings where decisions for a resident had to be made. Agreement about a solution was reached in all 29 cases, and this consensus was put into practice in all cases. Residents did not participate in the meetings, while relatives participated in a majority of case discussions. In many cases, the main topic was end-of-life care and life-prolonging treatment.

CONCLUSIONS

Lack of resources, end-of-life issues and coercion were ethical challenges most often reported by nursing home staff. The staff would appreciate systematic ethics work to aid decision-making. Resident ethics meetings can help to reach consensus in decision-making for nursing home patients. In the future, residents' participation should be encouraged whenever possible.

A Pharmaceutical Bioethics Consultation Service: Six-Year Descriptive Characteristics and Results of a Feedback Survey

Background: Bioethics consultations are conducted in varied settings, including hospitals, universities, and other research institutions, but there is sparse information about bioethics consultations conducted in corporate settings such as pharmaceutical companies. The purpose of this article is to describe a bioethics consultation service at a pharmaceutical company, to report characteristics of consultations completed by the service over a 6-year period, and to share results of a consultation feedback survey. Methods: Data on the descriptive characteristics of bioethics consultations were collected from 2008 to 2013 and analyzed in Excel 2007. Categorical data were analyzed via the pivot table function, and time-based variables were analyzed via formulas. The feedback survey was administered to consultation requesters from 2009 to 2012 and also analyzed in Excel 2007. Results: Over the 6-year period, 189 bioethics consultations were conducted. The number of consultations increased from five per year in 2008 to approximately one per week in 2013. During this time, the format of the consultation service was changed from a committee-only approach to a tiered approach (tailored to the needs of the case). The five most frequent topics were informed consent, early termination of a clinical trial, benefits and risks, human biological samples, and patient rights. The feedback survey results suggest the consultation service is well regarded overall and viewed as approachable, helpful, and responsive. Conclusions: Pharmaceutical bioethics consultation is a unique category of bioethics consultation that primarily focuses on pharmaceutical research and development but also touches on aspects of clinical ethics, business ethics, and organizational ethics. Results indicate there is a demand for a tiered bioethics consultation service within this pharmaceutical company and that advice was valued. This company's experience indicates that a bioethics consultation service raises awareness about bioethics, empowers employees to raise bioethical concerns, and helps them reason through challenging issues.

Ethics consultation in pediatrics: long-term experience from a pediatric oncology center

There is little information about the content of ethics consultations (EC) in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records (2000-2011) at St. Jude Children's Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician's fiduciary responsibility to the patient. Nonpatient consultations provided guidance in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates that the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision making among multiple stakeholders, and further prospective research is needed on the role of ethics consultation in pediatrics.

Education and the improvement of clinical ethics services

The proliferation of clinical ethics in health care institutions around the world has raised the question about the qualifications of those who serve on ethics committees and ethics consultation services. This paper discusses some of weaknesses associated with the most common educational responses to this concern and proposes a complementary approach. Since the majority of those involved in clinical ethics are practicing health professionals, the question of qualification is especially challenging as the role of ethics committees and, increasingly, ethics consultation services are becoming increasingly important to the functioning of health care institutions. Since the challenging nature of health care finances often leads institutions to rely on voluntary participation of committed health professional with only token administrative or clerical support to provide the needed ethics services, significant challenges are created for attaining competence and functional effectiveness. The article suggests that a complementary approach should be adopted for sustaining and building capacity in clinical ethics. Ethics committees and consultation services should systematically adopt quality improvement techniques to effect designed changes in clinical ethics performance and to build ethical capacity within targeted clinical units and services. Demonstrating improvements in functioning can go a long way to build confidence and capacity for clinical ethics and can help in justifying the need for support. To do so, however, requires that ethics committees and consultation services first shift attention to those areas that demonstrate weak or questionable ethical performance, including the established practices of the ethics committee and consultation service, and second seek collaboration with the involved health care providers to pursue demonstrable change. Such an approach has a much better chance of improving the capacity for clinical ethics in health care institutions than relying on educational approaches alone.

Ethics committees and consultants

The increasing complexity of healthcare creates numerous ethical challenges in patient care and in institutional functions and policies. During the past several decades, clinical ethics consultation services and institutional ethics committees have been developed to assist patients, medical professionals, and institutions in addressing ethical challenges. This chapter discusses the nature of clinical ethics consultation and the training of ethics consultants and committees. The authors review the experience at their institution (Mayo Clinic). Finally, the value of ethics consultation, as described in the medical literature, is reviewed.

Clinical ethics consultation in patients with head and neck cancer

BACKGROUND

The purpose of this study was to describe the impact of clinical ethics consultations among patients with head and neck cancer in order to better anticipate and manage clinical challenges.

METHODS

A database was queried to identify patients with head and neck cancer for whom ethics consultation was performed at a comprehensive cancer center (n = 14). Information from the database was verified via data abstraction and analyzed qualitatively and quantitatively.

RESULTS

Common requests for ethics consultation involved code status (6 of 14) and withdrawal/withholding life-sustaining treatments (6 of 14). Common contextual features were interpersonal conflicts (6 of 14) and communication barriers (5 of 14). Airway management concerns were frequent (5 of 14). Whereas 21% of patients had do not resuscitate (DNR) orders before ethics consultation, 79% were DNR subsequently.

CONCLUSION

Ethics consultations among patients with head and neck cancer reflect distinctive complexities inherent to their disease, but are entirely consistent with global clinical ethical themes. Consideration of communication barriers, social isolation/stigma, symptom control, and airway management are critical.

Core competencies for clinical ethics committees

Clinical ethics committees (CECs) are increasing in number in the UK and have mostly developed in response to local interest, as opposed to being mandated as in the USA. However, there is no regulatory framework for UK CECs with no defined educational requirements or specification of core competencies for their members. The UK Clinical Ethics Network has consulted extensively with its members to set out, for the first time in the UK, the core competencies necessary for the provision of clinical ethics support. Recommendations for educational and membership requirements for CECs have also been made. Given the appropriate resources the standards proposed can be appropriately evaluated and are consistent with principles of ethical governance.

Does ethics education influence the moral action of practicing nurses and social workers?

PURPOSE/METHODS

This study investigated the relationship between ethics education and training, and the use and usefulness of ethics resources, confidence in moral decisions, and moral action/activism through a survey of practicing nurses and social workers from four United States (US) census regions.

FINDINGS

The sample (n = 1215) was primarily Caucasian (83%), female (85%), well educated (57% with a master's degree). no ethics education at all was reported by 14% of study participants (8% of social workers had no ethics education, versus 23% of nurses), and only 57% of participants had ethics education in their professional educational program. Those with both professional ethics education and in-service or continuing education were more confident in their moral judgments and more likely to use ethics resources and to take moral action. Social workers had more overall education, more ethics education, and higher confidence and moral action scores, and were more likely to use ethics resources than nurses.

CONCLUSION

Ethics education has a significant positive influence on moral confidence, moral action, and use of ethics resources by nurses and social workers.

Strangers at the benchside: research ethics consultation

Institutional ethics consultation services for biomedical scientists have begun to proliferate, especially for clinical researchers. We discuss several models of ethics consultation and describe a team-based approach used at Stanford University in the context of these models. As research ethics consultation services expand, there are many unresolved questions that need to be addressed, including what the scope, composition, and purpose of such services should be, whether core competencies for consultants can and should be defined, and how conflicts of interest should be mitigated. We make preliminary recommendations for the structure and process of research ethics consultation, based on our initial experiences in a pilot program.

Strangers at the benchside: research ethics consultation

Institutional ethics consultation services for biomedical scientists have begun to proliferate, especially for clinical researchers. We discuss several models of ethics consultation and describe a team-based approach used at Stanford University in the context of these models. As research ethics consultation services expand, there are many unresolved questions that need to be addressed, including what the scope, composition, and purpose of such services should be, whether core competencies for consultants can and should be defined, and how conflicts of interest should be mitigated. We make preliminary recommendations for the structure and process of research ethics consultation, based on our initial experiences in a pilot program.