Implementation of ethics grand rounds in an otolaryngology department

Implementing a formal curriculum on surgical ethics and palliative care for otolaryngology residents

OBJECTIVE

Residents are faced with ethical issues every day but most residency curriculums do not routinely include formal ethics skills training. In order to address this, a comprehensive curriculum on ethics and surgical palliative care was implemented for otolaryngology residents.

METHODS

An 8-h ethics didactics curriculum was designed in collaboration with our institution's Institute of Ethics. Varied strategies were used to cover basic principles and practical skills. Anonymous assessments were completed by learners at 3 points during the curriculum on a 5-point scale.

RESULTS

Nine residents were surveyed. Prior to the curriculum, a large majority of residents (85 %) expressed little to no familiarity with basic ethical principles. There was statistically significant improvement in understanding of and familiarity with bioethics topics, including the four principles of bioethics (Δ = 2.4, p = 0.004). There was also statistically significant improvement in comfort with the implementation of ethical decision making and palliative care skills, including with difficult conversations with patients (Δ = 1.3, p = 0.03). Participation in sessions was excellent with positive qualitative feedback.

CONCLUSION

An interactive curriculum in ethics and palliative care can be engaging and practical for busy surgical residents, with measurable improvement in comfort with challenging cases and ethical, patient-centered care.

Shedding Light on the Hidden Curriculum: A Systematic Review of Ethics Education during General Surgery and Subspecialty Training

INTRODUCTION

Ethics education in surgical residencies is often delivered in an informal and nonstructured manner as part of a "hidden curriculum", leading to few residencies routinely including it in their core curriculum. This systematic review aimed to summarize the delivery modes, curriculum, structure, and effectiveness of ethics educational interventions for surgical trainees.

METHODS

We performed a comprehensive database search including MEDLINE, Embase, Scopus and CENTRAL to search for articles describing the implementation of ethics educational interventions for general surgery or subspecialty trainees.

RESULTS

A total of 14 studies were included. Only 2 centers performed targeted needs assessment. Curricula covered included informed consent, the doctor-patient relationship, breaking bad news, decision-making, end-of-life care, conflicts of interest, considering patients' personal contexts, and surgical research ethics. Modes of delivery varied across studies, including case-based learning, group discussions, didactic lectures, reading material, role-playing, simulated patients, and ethics morbidity and mortality (M&M) meetings. Evaluations were most commonly via surveys exploring knowledge and self-reported confidence, with only 3 studies measuring actual trainee performance using objective structured clinical examinations. In general, the educational interventions increased trainees' confidence/preparedness in handling ethical dilemmas.

CONCLUSION

We recommend comprehensive local needs assessment to guide curricular development and designing specific learning objectives and measurable milestones to ensure evaluation. Educational interventions are best delivered in a graduated manner with the complexity of the topic mirroring residents' real-life clinical responsibilities and experiences. Teaching modalities should be tailored according to the nature of the curricular content being taught to make the learning experience more interactive and effective.

[Ethical case discussions in the intensive care unit : from testing to routine]

BACKGROUND

The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions.

MATERIAL AND METHODS

In a surgical intensive care unit a fixed date in the schedule is reserved for ethical case discussions (level 3 of the escalation model). At this level a team member who has been specified according to a quarterly plan is responsible for the organization and performance of the discussion. All protocols of the 44 ethical case discussions in 41 patients between January 2011 and July 2012 were collected and summarized. A short questionnaire to all participants recorded their assessment of the benefits for the patient and the team as well as their perception of personal stress reduction. Also queried was the impact of this method on the collaboration between nurses and physicians and the ethical competence.

RESULTS

Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence.

CONCLUSION

A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.

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.