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Hughes MT. How to "Do Ethics" in Pediatrics Practice: A Framework for Addressing Everyday Ethics Issues. Pediatr Clin North Am 2024; 71:9-26. [PMID: 37973310 DOI: 10.1016/j.pcl.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pediatricians have a fiduciary responsibility to advocate for the best interests of their patients. They accomplish this through the therapeutic alliance with the patient and their parent. In everyday clinical medicine, the pediatrician may be faced with challenging situations. When a case raises concerns, the pediatrician needs to determine if the issues relate to ethical obligations and whether they are in conflict. To resolve the concerns, a systematic process for gathering, organizing, and analyzing the facts of a case is needed to discern morally permissible options. This article presents a framework for performing an ethics case analysis.
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Affiliation(s)
- Mark T Hughes
- Department of Medicine, Johns Hopkins University School of Medicine; Berman Institute of Bioethics.
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2
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Kalevor S, Uveges MK, Meyer EC. Using Everyday Ethics to Address Bias and Racism in Clinical Care. AACN Adv Crit Care 2022; 33:111-118. [PMID: 35259217 DOI: 10.4037/aacnacc2022566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Shika Kalevor
- Shika Kalevor is a Fellow at the Bioethics Center at Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108
| | - Melissa Kurtz Uveges
- Melissa Kurtz Uveges is Assistant Professor, Boston College William F. Connell School of Nursing, Boston, Massachusetts
| | - Elaine C Meyer
- Elaine C. Meyer is Senior Attending Psychologist, Boston Children's Hospital, and Associate Professor of Psychology, Harvard Medical School Center for Bioethics, Boston, Massachusetts
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3
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Zahedi F, Kadivar M, Khanali Mojen L, Asadabadi M, Tajalli S, Ilkhani M, Barasteh S, Elahikhah M, Larijani B. The ethical challenges of palliative care from the perspectives of pediatricians: A qualitative study in Iran. Front Pediatr 2022; 10:928476. [PMID: 36105856 PMCID: PMC9464941 DOI: 10.3389/fped.2022.928476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Adherence to ethical principles is a requirement for palliative care delivery to children and a main concern of healthcare providers. Physicians usually face ethical challenges during their daily practice in hospitals and need adequate skills and the ability to identify and manage them. This study sought to explore the ethical challenges of palliative care from the perspectives of pediatricians. METHODS This qualitative study was conducted between April and July 2019 using the content analysis approach. Participants were fifteen pediatric medical residents, specialists, and subspecialists purposively recruited from pediatric hospitals in Tehran, Iran. Data were collected using in-depth semi-structured interviews and were analyzed using Graneheim and Lundman's approach to conventional content analysis. Trustworthiness was ensured through the four criteria proposed by Guba and Lincoln. RESULTS Participants' experiences of the ethical challenges of palliative care for children were grouped into two main categories, namely "bewilderment in dealing with children and their families" (with two subcategories) and "conflicts in decision making" (with three subcategories). The final five subcategories were: (a) inability to effectively communicate with children and their families, (b) inability to tell the truth about the disease, (c) physician-parent conflicts, (d) parent-child conflicts, and (e) physician-physician conflicts. CONCLUSION The main ethical challenges of palliative care from the perspectives of Iranian pediatricians are the inability to effectively communicate with children and their families, the inability to tell them the truth, and the inability to manage physician-parent, parent-child, and physician-physician conflicts. Identification and management of these challenges may help improve the quality of pediatric palliative care in Iran. Further studies are needed to confirm these findings in other settings.
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Affiliation(s)
- Farzaneh Zahedi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Kadivar
- Division of Neonatology, Department of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Khanali Mojen
- School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Asadabadi
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saleheh Tajalli
- Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Science, Tehran, Iran
| | - Mahnaz Ilkhani
- School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Maryam Elahikhah
- Students Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Medical Ethics and History of Medicine Research Centre, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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4
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Montreuil M, Séguin M, P. Gros C, Racine E. Everyday ethics of suicide care: Survey of mental health care providers' perspectives and support needs. PLoS One 2021; 16:e0249048. [PMID: 33886553 PMCID: PMC8061990 DOI: 10.1371/journal.pone.0249048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
Suicide occurs in people of all ages and backgrounds, which negatively affects families, communities, and the health care providers (HCPs) who care for them. The objective of this study was to better understand HCPs' perspectives of everyday ethical issues related to caring for suicidal patients, and their perceived needs for training and/or support to address these issues. We conducted a mixed methods survey among HCPs working in mental health in Québec, Canada. Survey questions addressed their perspectives and experiences of everyday ethical challenges they encounter in their practice with people who are suicidal, and their perceived needs for training and/or support therein. 477 HCPs completed the survey. Most participants mentioned encountering ethical issues when caring for people who are suicidal. The challenges HCPs encounter in their practice with people who are suicidal are numerous, including issues related to maintaining privacy, confidentiality, freedom and the therapeutic relationship. The lack of time, resources and professional support to address these issues was emphasized. Most HCPs reported that the training or education they have received does not allow them to address everyday ethical issues related to suicide care. In sum, there is a clear reported need for better training and support for HCPs who are offering care to people who are suicidal in relation to everyday ethical issues they encounter. Implications for practice include providing greater access to training, including access to specialists in ethics to address specific issues. This additional support could alleviate morally distressing situations for HCPs.
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Affiliation(s)
- Marjorie Montreuil
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Quebec, Canada
- Institut de recherches cliniques de Montréal, Montreal, Quebec, Canada
| | - Monique Séguin
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Quebec, Canada
- Department of Psychology, Université du Québec en Outaouais, Gatineau, Quebec, Canada
| | - Catherine P. Gros
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Quebec, Canada
| | - Eric Racine
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Quebec, Canada
- Institut de recherches cliniques de Montréal, Montreal, Quebec, Canada
- Départements de Médecine et Médecine sociale et préventive, Université de Montréal, Montreal, Quebec, Canada
- Departments of Neurology and Neurosurgery, Medicine, and Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
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Kana LA, Feder KJ, Matusko N, Firn JI. Pediatric Interprofessional ICU Ethics Rounds: A Single-Center Study. Hosp Pediatr 2021; 11:411-416. [PMID: 33722824 DOI: 10.1542/hpeds.2020-001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We sought to examine whether sociodemographic differences, such as race and socioeconomic status, existed between patients in the PICU, pediatric cardiothoracic ICU (PCTU), and NICU who were identified as having ethical issues during interprofessional ethics rounds and all other patients admitted to these units and to characterize the primary ethical issues identified in this context. METHODS We compared sociodemographic factors among patients admitted to a quaternary academic children's hospital between January 2017 and December 2018 who were identified as having ethical issues during PICU, PCTU, and NICU interprofessional ethics rounds (n = 122) with those of all other patients admitted to these units (n = 4971). χ2 tests or Fisher's exact tests, Mann-Whitney U tests, and a multivariable logistic regression analysis were performed. RESULTS With bivariate analyses, we detected significant differences by race, insurance type, and ventilator dependence, but no significant differences between the 2 groups existed on the basis of sex, ethnicity, religion, primary language, age, or a socioeconomic status metric. After we adjusted for confounders using a multivariable logistic regression analysis, only patients who were ventilator dependent were at significantly higher odds (odds ratio = 5.78; confidence interval = 3.69-9.04; P < .001) of being identified as having ethical issues. Goals of care was the most frequent ethical issue (44%). CONCLUSIONS Except for ventilator dependence, patients with ethical issues during PICU, PCTU, and NICU interprofessional ethics rounds are demographically similar to overall patients admitted in these units. Future research should be used to assess whether proactive rounds impact the timing of ethics consultation requests as well as to determine if interprofessional ethics rounds influence volume and acuity in formal ethics consultation practices.
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Affiliation(s)
- Lulia A Kana
- Medical School, University of Michigan, Ann Arbor, Michigan
| | - Katherine J Feder
- Medical School, University of Michigan, Ann Arbor, Michigan.,Center for Bioethics and Social Sciences in Medicine and
| | | | - Janice I Firn
- Center for Bioethics and Social Sciences in Medicine and .,Learning Health Sciences
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6
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Montreuil M, Séguin M, Gros CP, Racine E. Survey of Mental Health Care Providers’ Perspectives on the Everyday Ethics of Medical-Aid-in-Dying for People with a Mental Illness. CANADIAN JOURNAL OF BIOETHICS 2020. [DOI: 10.7202/1070236ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: In most jurisdictions where medical-aid-in-dying (MAiD) is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec (Canada) completed the questionnaire. One third of the sample (34.4%) were nurses, one quarter psychologists (24.3%) and one quarter psycho-educators (24%). Nearly half of the respondents (48.4%) considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most (86.2%) reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care.
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Affiliation(s)
- Marjorie Montreuil
- Ingram School of Nursing, McGill University, Montreal; Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun; Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Monique Séguin
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun; Department of Psychology, Université du Québec en Outaouais, Gatineau, Québec, Canada
| | - Catherine P. Gros
- Ingram School of Nursing, McGill University, Montreal; Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Québec, Canada
| | - Eric Racine
- Institut de recherches cliniques de Montréal, Montréal; Université de Montréal, Montréal; McGill University, Montreal, Québec, Canada
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Moon M, Macauley RC, Geis GM, Laventhal NT, Opel DJ, Sexson WR, Statter MB. Institutional Ethics Committees. Pediatrics 2019; 143:peds.2019-0659. [PMID: 31036674 DOI: 10.1542/peds.2019-0659] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In hospitals throughout the United States, institutional ethics committees (IECs) have become a standard vehicle for the education of health professionals about biomedical ethics, for the drafting and review of hospital policy, and for clinical ethics case consultation. In addition, there is increasing interest in a role for the IEC in organizational ethics. Recommendations are made about the membership and structure of an IEC, and guidance is provided for those serving on an IEC.
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Affiliation(s)
| | | | - Gina Marie Geis
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Douglas J. Opel
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Mindy B. Statter
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
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8
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An Ethical Conflict Between Parents and Clinician in a Child with a Language Delay. J Dev Behav Pediatr 2017; 38 Suppl 1:S66-S68. [PMID: 28141726 DOI: 10.1097/dbp.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A developmental-behavioral pediatrician evaluated a 2-year-old child for developmental delays. He determined that the child had mild expressive language delays; the child had an intelligible vocabulary of 20 words and at least 20 other words that he said unclearly. He said a few contracted 2-word phrases, such as "gimme" and "its ok." He was shy and generally clung to his parents who spoke softly and very little. His development in all other domains was normal. Hearing evaluation and the neurological examination were normal.The pediatrician provided suggestions to the parents in order to stimulate language and scheduled a follow-up appointment in 3 months. The parents asked him to refer the child for early intervention and write a letter to the US Immigration and Naturalization Service. They asked that the letter state that the child had a disabling condition and returning the child and his family to their country of origin would cause permanent harm to the child. The parents then gave the pediatrician a draft of a letter that had been prepared by an immigration lawyer.The physician explained to the parents that the child had a mild expressive language delay and that he would like to see the child again in 3 months before deciding on early intervention. He advised them to obtain a copy of his medical note from the medical records department. The parents insisted that he write the letter and got upset and called him "heartless" when the physician refused to write the letter.
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9
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Zizzo N, Bell E, Racine E. What are the focal points in bioethics literature? Examining the discussions about everyday ethics in Parkinson’s disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/1477750916672400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Natalie Zizzo
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Quebec, Canada
- Division of Experimental Medicine and Biomedical Ethics Unit, McGill University, Quebec, Canada
| | - Emily Bell
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Quebec, Canada
- Department of Neurology and Neurosurgery, McGill University, Quebec, Canada
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Quebec, Canada
- Division of Experimental Medicine and Biomedical Ethics Unit, McGill University, Quebec, Canada
- Department of Neurology and Neurosurgery, McGill University, Quebec, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Quebec, Canada
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10
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Morain SR, Iezzoni LI, Mello MM, Park ER, Metlay JP, Horner G, Campbell EG. When are primary care physicians untruthful with patients? A qualitative study. AJOB Empir Bioeth 2016; 8:32-39. [PMID: 28949868 DOI: 10.1080/23294515.2016.1226987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Notwithstanding near-universal agreement on the theoretical importance of truthfulness, empirical research has documented gaps between ethical norms and physician behaviors. Although prior research has explored situations in which physicians may not be truthful with patients, it has focused on contexts within specialty practice. In this article, we report on a qualitative study of truthfulness in primary care. METHODS We conducted a qualitative study during December 2014-March 2015 involving both focus groups and in-depth, semistructured interviews with 32 primary care physicians from the Boston, MA, and Baltimore, MD, metro areas in three specialties: internal medicine, family practice, and pediatrics. Interviews and focus groups were led using a semistructured guide, which explored situations in which primary care physicians find it difficult to be honest with patients; factors shaping truthfulness; and rationales for truthful and untruthful communication. RESULTS While physicians described outright lying to patients as rare, other deviations from truthfulness were not uncommon, including slanting and deliberately withholding information. Physicians described a range of factors as influencing truthfulness, from patient-level characteristics such as educational background to societal considerations including avoiding unnecessary tests and procedures. Physicians described truthfulness as an ethical requirement, deviations from which required further justification. Perceived justifications included promoting patient well-being and avoiding harm. CONCLUSIONS Our results suggest a potential need to augment opportunities for training in "everyday ethics" challenges, such as the appropriateness of deception in response to patient requests for inappropriate tests or pain medications. Furthermore, they indicate that, in various circumstances encountered in primary care, physicians perceive other moral duties as potentially in conflict with the duty of truthfulness. Further ethical analysis should focus on identifying when deviations from complete truthfulness do and do not serve patients' interests, to guide physicians in striking a reasonable balance among principles of medical ethics that may conflict with one another.
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Affiliation(s)
| | - Lisa I Iezzoni
- b Mongan Institute for Health Policy, Massachusetts General Hospital and Harvard Medical School
| | - Michelle M Mello
- c Stanford Law School and Stanford University School of Medicine
| | - Elyse R Park
- b Mongan Institute for Health Policy, Massachusetts General Hospital and Harvard Medical School
| | - Joshua P Metlay
- d Division of General Internal Medicine, Massachusetts General Hospital
| | - Gabrielle Horner
- e Mongan Institute for Health Policy, Massachusetts General Hospital
| | - Eric G Campbell
- b Mongan Institute for Health Policy, Massachusetts General Hospital and Harvard Medical School
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Erdem F, Atalay M. The effect of health transformation policies on the resident physicians' perception of the medical profession in Turkey. Int J Health Plann Manage 2016; 32:189-216. [PMID: 26997337 DOI: 10.1002/hpm.2340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 11/06/2022] Open
Abstract
Although the new changes in the health system in Turkey has resulted in positive implications with respect to the groups that use the healthcare services, it has been singled out for criticism by the professional associations because of its erosive consequences particularly for the medical profession as a whole. The purpose of this study is to explain how the health transformation policies and practices influenced the working conditions and perceptions of the resident physicians in Turkey with regard to the medical profession. A qualitative research design was employed, and the data was collected through document analysis and focus group interview. The common findings highlight that the new practices have had an aggravated effect on the working conditions of the resident physicians, which has resulted in several contentious issues. These include the increased workload, insufficient training and development, economic and social conditions and a heightened number of violent acts against physicians. Negatively, these influence the motivation of the physicians and their perception of the medical profession. This finding suggests that the medical profession is able to be studied as an appropriate case for the phenomenon of deprofessionalization. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ferda Erdem
- Faculty of Economics and Administrative Sciences, Department of Business Administration, Akdeniz University, Antalya, Turkey
| | - Murat Atalay
- Faculty of Economics and Administrative Sciences, Department of Business Administration, Akdeniz University, Antalya, Turkey
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12
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Morrison W, Womer J, Nathanson P, Kersun L, Hester DM, Walsh C, Feudtner C. Pediatricians' Experience with Clinical Ethics Consultation: A National Survey. J Pediatr 2015. [PMID: 26210945 DOI: 10.1016/j.jpeds.2015.06.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation. STUDY DESIGN We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable. RESULTS Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic. CONCLUSION There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.
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Affiliation(s)
- Wynne Morrison
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - James Womer
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Temple University School of Medicine, Philadelphia, PA
| | - Pamela Nathanson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Leslie Kersun
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D Micah Hester
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Corbett Walsh
- New York University School of Medicine, New York, NY
| | - Chris Feudtner
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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13
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Behmanesh F, Ahanchian H, Vakili R, Ahanchian N, Bagheri S. Teaching final-year medical students in a paediatric ambulatory care unit. CLINICAL TEACHER 2014; 11:361-4. [DOI: 10.1111/tct.12150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Fatemeh Behmanesh
- School of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
| | - Hamid Ahanchian
- School of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
| | - Rahim Vakili
- School of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
| | - Narges Ahanchian
- School of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
| | - Sepideh Bagheri
- School of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
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14
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Barina R. Ethics Outside of Inpatient Care: The Need for Alliances Between Clinical and Organizational Ethics. HEC Forum 2014; 26:309-23. [DOI: 10.1007/s10730-014-9238-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Hernández González A, Rodríguez Núñez A, Cambra Lasaosa FJ, Quintero Otero S, Ramil Fraga C, García Palacios MV, Hernández Rastrollo R, Ruiz Extremera MA. [Knowledge of health care ethics in paediatric residents]. An Pediatr (Barc) 2013; 80:106-13. [PMID: 24103240 DOI: 10.1016/j.anpedi.2013.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 06/02/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics.
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Affiliation(s)
- A Hernández González
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - A Rodríguez Núñez
- Unidad de Cuidados Intensivos Pediátricos, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - F J Cambra Lasaosa
- Unidad de Cuidados Intensivos Pediátricos, Hospital Sant Joan de Déu, Barcelona, España
| | - S Quintero Otero
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Puerta del Mar, Cádiz, España
| | - C Ramil Fraga
- Unidad de Cuidados Intensivos Pediátricos, Complejo Hospitalario Universitario de A Coruña, A Coruña, España
| | - M V García Palacios
- Servicio de Medicina Preventiva, Hospital Universitario Puerta del Mar, Cádiz, España
| | - R Hernández Rastrollo
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Infanta Cristina, Badajoz, España
| | - M A Ruiz Extremera
- Departamento de Pediatría, Hospital Universitario San Cecilio, Granada, España
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Abstract
Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.
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Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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17
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Dauwerse L, van der Dam S, Abma T. Morality in the mundane: specific needs for ethics support in elderly care. Nurs Ethics 2011; 19:91-103. [PMID: 22140180 DOI: 10.1177/0969733011412102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethics support is called for to improve the quality of care in elderly institutions. Various forms of ethics support are presented, but the needs for ethics support remain unknown. Using a mixed-methods design, this article systematically investigates the specific needs for ethics support in elderly care. The findings of two surveys, two focus groups and 17 interviews demonstrate that the availability of ethics support is limited. There is a need for ethics support, albeit not unconditionally. Advice-based forms of ethics support are less appropriate as they are removed from practice. Ethics support should be tailored to the often mundane and easily overlooked moral issues that arise in long-term care. Attention should also be given to the learning styles of nurses who favour experiential learning. Raising awareness and developing a climate of openness and dialogue are the most suitable ways to deal with the mundane moral issues in elderly care.
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Affiliation(s)
- Linda Dauwerse
- VU Medisch Centrum, Van der Boechorststraat 7, Amsterdam, The Netherlands.
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18
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An ethical conflict between parents and clinician in a child with a language delay. J Dev Behav Pediatr 2011; 32:559-60. [PMID: 21836525 DOI: 10.1097/dbp.0b013e31822bc5fe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A developmental-behavioral pediatrician evaluated a 2-year-old child for developmental delays. He determined that the child had mild expressive language delays; the child had an intelligible vocabulary of 20 words and at least 20 other words that he said unclearly. He said a few contracted 2-word phrases, such as "gimme" and "its ok." He was shy and generally clung to his parents who spoke softly and very little. His development in all other domains was normal. Hearing evaluation and the neurological examination were normal. The pediatrician provided suggestions to the parents in order to stimulate language and scheduled a follow-up appointment in 3 months. The parents asked him to refer the child for early intervention and write a letter to the US Immigration and Naturalization Service. They asked that the letter state that the child had a disabling condition and returning the child and his family to their country of origin would cause permanent harm to the child. The parents then gave the pediatrician a draft of a letter that had been prepared by an immigration lawyer.The physician explained to the parents that the child had a mild expressive language delay and that he would like to see the child again in 3 months before deciding on early intervention. He advised them to obtain a copy of his medical note from the medical records department. The parents insisted that he write the letter and got upset and called him "heartless" when the physician refused to write the letter.
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19
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Carrese JA, McDonald EL, Moon M, Taylor HA, Khaira K, Catherine Beach M, Hughes MT. Everyday ethics in internal medicine resident clinic: an opportunity to teach. MEDICAL EDUCATION 2011; 45:712-21. [PMID: 21649704 PMCID: PMC3233355 DOI: 10.1111/j.1365-2923.2011.03931.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Being a good doctor requires competency in ethics. Accordingly, ethics education during residency training is important. We studied the everyday ethics-related issues (i.e. ordinary ethics issues commonly faced) that internal medical residents encounter in their out-patient clinic and determined whether teaching about these issues occurred during faculty preceptor-resident interactions. METHODS This study involved a multi-method qualitative research design combining observation of preceptor-resident discussions with preceptor interviews. The study was conducted in two different internal medicine training programme clinics over a 2-week period in June 2007. Fifty-three residents and 19 preceptors were observed, and 10 preceptors were interviewed. Transcripts of observer field notes and faculty interviews were carefully analysed. The analysis identified several themes of everyday ethics issues and determined whether preceptors identified and taught about these issues. RESULTS Everyday ethics content was considered present in 109 (81%) of the 135 observed case presentations. Three major thematic domains and associated sub-themes related to everyday ethics issues were identified, concerning: (i) the Doctor-Patient Interaction (relationships; communication; shared decision making); (ii) the Resident as Learner (developmental issues; challenges and conflicts associated with training; relationships with colleagues and mentors; interactions with the preceptor), and; (iii) the Doctor-System Interaction (financial issues; doctor-system issues; external influences; doctor frustration related to system issues). Everyday ethics issues were explicitly identified by preceptors (without teaching) in 18 of 109 cases (17%); explicit identification and teaching occurred in only 13 cases (12%). CONCLUSIONS In this study a variety of everyday ethics issues were frequently encountered as residents cared for patients. Yet, faculty preceptors infrequently explicitly identified or taught these issues during their interactions with residents. Ethics education is important and residents may regard teaching about the ethics-related issues they actually encounter to be highly relevant. A better understanding of the barriers to teaching is needed in order to promote education about everyday ethics in the out-patient setting.
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Affiliation(s)
- Joseph A Carrese
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA.
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20
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Taylor HA, McDonald EL, Moon M, Hughes MT, Carrese JA. Teaching ethics to paediatrics residents: the centrality of the therapeutic alliance. MEDICAL EDUCATION 2009; 43:952-9. [PMID: 19769644 DOI: 10.1111/j.1365-2923.2009.03449.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
CONTEXT Previous research on ethical issues encountered by medical professionals in training and practice have presented the thematic content of the cases they encounter rather than the activities in which clinicians engage and in which they most often encounter ethical issues. We conducted a direct observation study of paediatrics residents and their preceptors seeing patients in an out-patient general paediatrics clinic. Our objectives were to describe the everyday ethics-related issues paediatrics residents encounter as they interact with patients. Our ultimate goal is to use this knowledge to enhance current efforts to teach ethics to paediatrics residents. METHODS The study team directly observed paediatrics residents discussing patients with their faculty preceptors (19 half-day sessions, 76 hours) in an out-patient general paediatrics clinic located in an urban academic medical centre. Each interaction between resident and preceptor about a single patient was considered a case for further analysis. RESULTS A total of 247 cases were recorded. Forty-one of the cases were coded as having ethics-related content. A constant comparative method of qualitative data analysis revealed that residents were most likely to encounter ethical issues when engaged in the following activities: (i) maintaining a therapeutic alliance with the caregiver (e.g. the parent); (ii) prioritising patient or family needs; (iii) adjusting to the power embodied by the role of doctors, and (iv) distinguishing suboptimal care from abuse or neglect. In addition, our findings indicate that it is through their efforts to maintain the therapeutic alliance with the caregivers of their patients that residents engage in and integrate three processes: developing their medical knowledge; adhering to professional norms, and balancing the power inherent in the doctor's role with their responsibility to serve the patient's interests. CONCLUSIONS Medical faculty tasked with teaching ethics to paediatrics residents can utilise the results of this project to better target and enhance their ethics education efforts directed at residents in the out-patient setting. Future research could further examine and test these findings in other clinical settings (e.g. adult general medicine).
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Affiliation(s)
- Holly A Taylor
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA.
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