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Freigeh GE, Fagen H, Firn J. Review of Outpatient Pediatric Ethics Consults at an Academic Medical Center. HEC Forum 2024:10.1007/s10730-024-09536-3. [PMID: 39172214 DOI: 10.1007/s10730-024-09536-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 08/23/2024]
Abstract
Limited data exist in the specific content of pediatric outpatient ethics consults as compared to inpatient ethics consults. Given the fundamental differences in outpatient and inpatient clinical care, we aimed to describe the distinctive nature of ethics consultation in the ambulatory setting. This is a retrospective review at a large, quaternary academic center of all outpatient ethics consults in a 6-year period. Encounter-level demographic data was recorded, and primary ethical issue and contextual features were identified using qualitative conceptual content analysis. A total of 48 consults were identified representing 44 unique patients. The most common primary ethical issue was beneficence and best interest concern comprising 20 (42%) consults, followed by refusal of recommended treatment comprising 11 (23%) consults and patient preference/assent comprising 5 (10%) consults. The most common contextual features were staff-family communication dispute/conflict comprising 28 (58%) consults, followed by legal involvement comprising 25 (52%) consults and quality of life comprising 19 (40%) consults. The most common consulting specialty was hematology/oncology. Ethical issues encountered in the provision of outpatient pediatric care are distinct and differ from those in inpatient consults. Further research is necessary to identify strategies and educational gaps in outpatient ethics consultation to increase its effectiveness and utilization.
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Affiliation(s)
- George E Freigeh
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Suite 2100, Ann Arbor, MI, 48105, USA.
| | - Hannah Fagen
- Department of Family Medicine and Community Health, University of Minnesota Medical School, 516 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Janice Firn
- Department of Learning Health Sciences, University of Michigan Medical School, 1111 E. Catherine St., Ann Arbor, MI, 48109, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, Bldg. 14, Ann Arbor, MI, 48109, USA
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Lyons S, Freigeh GE, Matula KA, Firn JI. Liminal Space: A Retrospective Content Analysis of Ethics Consultation for Patients Aged 18-26. J Adolesc Health 2024:S1054-139X(24)00241-6. [PMID: 39007790 DOI: 10.1016/j.jadohealth.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/17/2024] [Accepted: 05/03/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE To characterize the primary ethical issue and contextual features of ethics consultation for patients aged 18-26 years based on setting (adult vs. pediatric). METHODS A retrospective review of 965 ethics consultation notes to identify patients aged 18-26 years cared for in the pediatric or adult setting between January 1, 2016-December 31, 2020. We collected demographic information and used conceptual content analysis to identify the primary ethical issue and contextual features for each consult and analyzed these using descriptive statistics. RESULTS We identified 46 consults (30 adult and 16 pediatric) for 40 unique patients (28 adult and 12 pediatric). The median age was 19 years in the pediatric setting and 24 in the adult setting. Fifty-three percent were female, 95% non-Hispanic, 68% White, and 76% were inpatient. The primary ethical issue in the adult setting was Refusal of Recommended Treatment (20%), while the dominant contextual issue was Communication Disputes/Conflicts Between the Staff and Patient (23%). The primary ethical issue for the pediatric setting was Goals of Care (31%) and the dominant contextual feature was concerns for Quality of Life (31%). DISCUSSION The primary ethical issues and related contextual features this population experiences differ based on setting. Improved understanding of adolescent and young adult development, especially related to values formation, decision-making, and communication skills training may ameliorate some of these challenges. Referral patterns for this age group overall and particularly for patients on the ends of the spectrum and inpatients raise concerns for ethics consultation use. Further education about ethics services is recommended.
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Affiliation(s)
- Samantha Lyons
- Department of Family Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - George E Freigeh
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kelly A Matula
- University Libraries, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janice I Firn
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan.
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Foxwell AM, Ulrich CM, Walter JK, Weaver MS. Everyday Ethics or Deference to Expertise: Experiences of Pediatric Palliative Care Teams with Ethics Consultancy. J Palliat Med 2024. [PMID: 38973557 DOI: 10.1089/jpm.2023.0568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background: Little is known about the extent to which pediatric palliative care (PPC) clinicians are engaged in ethics consults or how they perceive interactions with ethics consultants. Objective: Describe the extent to which PPC team members serve in pediatric health care ethics (PHCE) consultancy roles and to describe their experiences interacting with pediatric ethic consultant services. Design: Online survey distributed to members of the American Academy of Pediatrics and American Academy of Hospice and Palliative Care pediatric and ethics section and special interest groups in the United States. Results: Eighty-six responses were obtained (response rate 45%) from PPC teams in 70 different children's hospitals located in 34 states. Almost all (97%) reported a functional ethics consult service such that PPC is not expected to meet the ethics need of the institution. A person involved on the PPC team also performed ethics consults in half (49%) of the settings, predominantly the PPC physician. Most respondents who perceive PPC teams engage in ethics-relevant work as part of their everyday PPC work. Formal ethics training was lacking among PPC members involved in ethics consults with few ethics degrees (15%), certifications (6%), or fellowships (2%). Discord (67%), conflict (49%), limitations to treatment (48%), and distress (41%) were cited as the most frequent reasons for which PPC teams consult ethics. PPC respondents identified role clarity, coordinated engagement, timely presence, and open communication as strong PHCE consultant practices. Conclusions: PPC team members performing ethics consults may benefit from additional ethics education and training. Further research is warranted to delineate scope of ethics consultancy relevant to PPC and role clarity.
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Affiliation(s)
- Anessa M Foxwell
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Connie M Ulrich
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Department of Medical Ethics and Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meaghann S Weaver
- Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Weiner C, Pergert P, Castor A, Molewijk B, Bartholdson C. Children's voices on their values and moral dilemmas when being cared and treated for cancer- a qualitative interview study. BMC Med Ethics 2024; 25:75. [PMID: 38926715 PMCID: PMC11202330 DOI: 10.1186/s12910-024-01075-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Childhood cancers affect about 350 children every year in Sweden and are life-threatening diseases. During the treatment period, situations arise that can become morally challenging for the child. When knowing children's values and morally challenging situations in childhood cancer care, targeted ethics support could be developed and used in care. AIM To explore children's values and moral dilemmas when undergoing cancer treatment. METHODS This is a qualitative study based on empirical data. The data collection was conducted through three focus group interviews and six individual interviews with children between 10 and 18 years (n = 16). A content analysis methodology was used to generate themes. Children who were/have been treated for cancer at three childhood cancer centres in Sweden were invited to participate. The study was approved by the Swedish Ethical Review Authority. The children's participation was based on voluntariness and consent/assent. FINDINGS During the analysis, five themes of values emerged: Personal relationships, Bodily ease and identity, Feeling in control and being involved, Positive distractions and Right care that is needed. Their moral dilemmas were thematized into: Should I consider others or not? Should I rest or not? and Should I refuse treatment or not? CONCLUSION Children undergoing cancer treatment want to have personal relationships with healthcare professionals. Their moral dilemmas were about questioning their own physical and psychological well-being against their expectations, the values of others and the treatment required. Further research is needed to understand how to deal with moral dilemmas in children undergoing cancer treatment.
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Affiliation(s)
- Charlotte Weiner
- Childhood Cancer Research Unit, Department of Women's & Children's Health, Karolinska Institutet, Stockholm, Sweden.
- Children's Regional Health Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
| | - Pernilla Pergert
- Childhood Cancer Research Unit, Department of Women's & Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Caring Sciences, Centre for Research Ethics & Bioethics (CRB), Uppsala University, Uppsala, Sweden
| | - Anders Castor
- Department of Paediatrics, Lund University, Lund, Sweden
| | - Bert Molewijk
- Department of Ethics, Law and Medical Humanities, Amsterdam University Medical Center, Amsterdam, Netherlands
- Center for Medical Ethics, University of Oslo, Oslo, Norway
| | - Cecilia Bartholdson
- Childhood Cancer Research Unit, Department of Women's & Children's Health, Karolinska Institutet, Stockholm, Sweden
- Paediatric Neurology and Musculoskeletal Disorders and Homecare, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Kang Y, Chao S, Battles A, Firn J. Clinical Ethics Consultation for Patients Impacted by Incarceration: A Single Center Retrospective Review. JOURNAL OF CORRECTIONAL HEALTH CARE 2024; 30:198-205. [PMID: 38597931 DOI: 10.1089/jchc.23.10.0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Yena Kang
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Samantha Chao
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Emergency Medicine, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Alethia Battles
- Office of the Vice President and General Counsel, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Janice Firn
- University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Siegel B, Taylor LS, Alizadeh F, Barreto JA, Daniel D, Alexander PMA, Lipsitz S, Moynihan K. Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital. Pediatr Crit Care Med 2024; 25:301-311. [PMID: 38193777 DOI: 10.1097/pcc.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN Retrospective cohort study using mixed methods. SETTING Single-center quaternary pediatric hospital. PATIENTS Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.
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Affiliation(s)
- Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Dennis Daniel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Peta M A Alexander
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Katie Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Geurtzen R, Wilkinson DJC. Incorporating parental values in complex paediatric and perinatal decisions. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:225-235. [PMID: 38219752 DOI: 10.1016/s2352-4642(23)00267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024]
Abstract
Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud Institute of Healthcare Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; Oxford Newborn Care Unit, John Radcliffe Hospital, Oxford University, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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Bosompim Y, Aultman J, Pope J. Specific Trends in Pediatric Ethical Decision-Making: An 18-Year Review of Ethics Consultation Cases in a Pediatric Hospital. HEC Forum 2024:10.1007/s10730-024-09524-7. [PMID: 38416336 DOI: 10.1007/s10730-024-09524-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
This is a qualitative examination of ethics consultation requests, outcomes, and ethics committee recommendations at a tertiary/quaternary pediatric hospital in the U.S. The purpose of this review of consults over an 18-year period is to identify specific trends in the types of ethical dilemmas presented in our pediatric setting, the impact of consultation and committee development on the number and type of consults provided, and any clinical features and/or challenges that emerged and contributed to the nature of ethical situations and dilemmas. Furthermore, in reviewing clinical ethics consultation trends for nearly two decades, we can identify topic areas for further ethics education and training for ethics consultants, ethics committee members, and pediatric healthcare teams and professionals based on our experiences. Our study with nearly two decades of data prior to the COVID-19 pandemic can serve as groundwork for future comparisons of consultation requests and ethics support for pediatric hospitals prior to, during, and following a pandemic.
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Affiliation(s)
- Yaa Bosompim
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Julie Aultman
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Children's Hospital, Akron, OH, USA.
| | - John Pope
- Akron Children's Hospital, Akron, OH, USA
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James R, Carroll RS, Miller JM. Analysis of 20 Years of Ethics Consultations at a U.S. Children's Hospital. THE JOURNAL OF CLINICAL ETHICS 2024; 35:107-118. [PMID: 38728694 DOI: 10.1086/729417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
AbstractEmpirical studies of pediatric clinical ethics cases are scant in the biomedical and bioethics literature. In this study, more than 100 detailed records of clinical ethics consultations spanning from 2000 to 2020 at a moderately sized U.S. Mid-Atlantic children's hospital were abstracted and analyzed. Findings of the analysis were generally consistent with other studies in pediatric clinical ethics, with additional insight into aspects of moral distress associated with cases, family engagement with consultations, and other characteristics of interest also documented. Over the 20-year time frame, ethics consults were completed on average twice a year, with a detectable upward trend. Consultations were requested across the spectrum of services and units within the hospital, with critical care environments represented most frequently and genetic and neurological conditions being the most common primary diagnoses. Ethical analysis most commonly related to questions around the principles of autonomy and beneficence.
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Weaver MS, Shostrom VK, Sharma S, Keegan A, Walter JK. Pediatric Ethics Consultation Services. Pediatrics 2023; 151:e2022058947. [PMID: 36720707 PMCID: PMC9979273 DOI: 10.1542/peds.2022-058947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Although guidelines call for the presence of pediatric ethics consultation services (PECS), their existence in children's hospitals remains unquantified. This study determined the prevalence of PECS in children's hospitals and compared the practice environments of those with versus without PECS. METHOD The Children's Hospital Association Annual Benchmark Report survey from 2020 and PECS data were analyzed for the association of PECS with domains of care. RESULTS Two hundred thirty-one hospitals received survey requests, with 148 submitted and 144 reachable to determine PECS (62% response rate), inclusive of 50 states. Ninety-nine (69%) reported having ethics consultation services. Freestanding children's hospitals (28% of all hospitals) were more likely to report the presence of PECS (P <.001), making up 41% of hospitals with a PECS. The median number of staffed beds was 203 (25th quartile 119, 75th quartile 326) for those with PECS compared with 80 for those without (25th quartile 40, 75th quartile 121). Facilities with palliative care, higher trauma ratio, intensive care, and comprehensive programs were more likely to have PECS. Academic affiliation was associated with PECS presence (P <.001). Settings associated with skilled nursing facilities or long-term care programs were not more likely to have PECS. Hospitals designated as federally qualified health centers (P = .04) and accountable care organizations (P = .001) were more likely to have PECS. CONCLUSION Although PECS function as formal means to clarify values and mitigate conflict, one-third of children's hospitals lack PECS. Future research is needed to understand barriers to PECS and improve its presence.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Valerie K. Shostrom
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Keegan
- Children’s Hospital Association, Lenexa, Kansas
| | - Jennifer K. Walter
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics and Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Weaver MS, Sharma S, Walter JK. Pediatric Ethics Consultation Services, Scope, and Staffing. Pediatrics 2023; 151:e2022058999. [PMID: 36720710 PMCID: PMC9979255 DOI: 10.1542/peds.2022-058999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES National standards and guidelines call for a mechanism to address ethical concerns and conflicts in children's hospitals. The roles, responsibilities, and reach of pediatric ethics consultation services (PECS) remain unmeasured. The purpose of this study is to quantify staffing, structure, function, scope, training, and funding of PECS. METHODS Cross-sectional online survey was shared with an ethics informant at 181 children's hospitals in the United States from March to June 2022. Data were summarized descriptively and with semantic content analyses. RESULTS One hundred seventeen surveys were received from individual children's hospitals in 45 states and Washington DC (response rate 65%), with 104 qualifying for survey completion. Almost one-quarter of settings received 50 or more pediatric ethics consults in the past 12 months. On average, 7.4 people at each institution have responsibility for completing ethics consults. Estimated full-time equivalent salary support for ethics is on average 0.5 (range 0-3, median 0.25). One-third (33%) of facilities do not offer any salary support for ethics and three-quarters do not have an institutional budget for the ethics program. Clinical staff primarily initiate consults. End-of-life, benefits versus burdens of treatments, and staff moral distress were the most frequently consulted themes. Almost one-quarter (21%) of children's hospitals do not receive any consults from patients or families. CONLUSIONS The findings from this study reveal wide variation in PECS practices and raise concern about the lack of financial support provided for PECS despite substantial workloads.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, Nebraska
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jennifer K. Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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12
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Friedrich AB, Kohlberg EM, R Malone J. Perceived Benefits of Ethics Consultation Differ by Profession: A Qualitative Survey Study. AJOB Empir Bioeth 2023; 14:50-54. [PMID: 35856904 DOI: 10.1080/23294515.2022.2093423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Annie B Friedrich
- Bioethics Research Center, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | | | - Jay R Malone
- Department of Pediatrics, Critical Care Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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13
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Weaver MS, Wichman C, Sharma S, Walter JK. Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work. AJOB Empir Bioeth 2022; 14:135-142. [PMID: 36574230 DOI: 10.1080/23294515.2022.2160512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Meaghann S Weaver
- Department of Pediatrics, Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Health Affairs, National Center for Ethics in Healthcare, Washington, DC, USA
| | - Christopher Wichman
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shiven Sharma
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer K Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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14
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Teti SL, Armstrong K. Telling Stories with Data. THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022334277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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15
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Sharma S, Weaver MS, Walter JK. The Accessibility of Inpatient Pediatric Ethics Consultation Services to Patient Caregivers. Hosp Pediatr 2022; 12:e291-e294. [PMID: 35934755 PMCID: PMC9486872 DOI: 10.1542/hpeds.2022-006662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ethics consultation services (ECS) support clinical decision-making when there are values conflicts. Accessibility to ECS by patients and families is required to benefit from the service. Multiple national guidelines encourage ready availability of ECS to all stakeholders including patients and families. METHODS All facilities registered with the Children's Hospital Association (n = 190) were contacted using a protocol modeled after an adult ethics consultation practice study. After an online search to identify an ethics contact, calls were made to hospital operators, and each transfer was documented as well as time to ECS contact. If no contact was identified on progression through the call protocol or on completion of the call pathway on 3 occasions each spaced by 1 week, the ECS was labeled "unreached." RESULTS Only 36 (19%) ECS contacts were identified via online search with the remainder 154 (81%) requiring phone calls. Fewer than one-quarter of operators (n = 34/154, 22%) could identify a contact name or number for ECS. Thirty ECS (16%) remained unreachable after completion of the call pathway or 3 separate attempts. Successful ECS contact required an average of 2.9 attempts. Maximum call hold duration was 25 minutes. Callback times averaged 5.8 business days after voicemail. CONCLUSIONS This study revealed limited reachability of ECS. ECS should make their contact information available online and improve information available to operators.
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Affiliation(s)
- Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meaghann S Weaver
- Department of Pediatrics, University of Nebraska, Omaha, Nebraska
- National Center for Ethics in Healthcare, Washington, DC
| | - Jennifer K Walter
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Marron JM, Hantel A, Abel GA, Peppercorn JM. Ethics Consultation in Oncology: The Search for Quality in Quantity. JCO Oncol Pract 2022; 18:610-613. [PMID: 35947815 PMCID: PMC9509056 DOI: 10.1200/op.22.00440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 09/03/2023] Open
Affiliation(s)
- Jonathan M. Marron
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jeffrey M. Peppercorn
- Center for Bioethics, Harvard Medical School, Boston, MA
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
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17
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Madrigal VN, Curry K. Pediatric Ethics Consults for Caregivers: Anybody Home? Hosp Pediatr 2022; 12:e306-e308. [PMID: 35934746 DOI: 10.1542/hpeds.2022-006734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Vanessa N Madrigal
- Pediatric Ethics Program, Children's National Hospital, Washington, DC.,Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University, Washington, DC
| | - Kara Curry
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University, Washington, DC
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18
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Weiner C, Pergert P, Castor A, Molewijk B, Bartholdson C. Difficult situations and moral questions raised during moral case deliberations in Swedish childhood cancer care – A qualitative nationwide overview. Eur J Oncol Nurs 2022; 60:102189. [DOI: 10.1016/j.ejon.2022.102189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/18/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022]
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19
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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence. BMC Palliat Care 2022; 21:113. [PMID: 35751075 PMCID: PMC9229823 DOI: 10.1186/s12904-022-01003-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background With paediatric patients, deciding whether to withhold/withdraw life-sustaining treatments (LST) at the end of life is difficult and ethically sensitive. Little is understood about how and why physicians decide on withholding/withdrawing LST at the end of life in paediatric patients. In this study, we aimed to synthesise results from the literature on physicians’ perceptions about decision-making when dealing with withholding/withdrawing life-sustaining treatments in paediatric patients. Methods We conducted a systematic review of empirical qualitative studies. Five electronic databases (Pubmed, Cinahl®, Embase®, Scopus®, Web of Science™) were exhaustively searched in order to identify articles published in English from inception through March 17, 2021. Analysis and synthesis were guided by the Qualitative Analysis Guide of Leuven. Results Thirty publications met our criteria and were included for analysis. Overall, we found that physicians agreed to involve parents, and to a lesser extent, children in the decision-making process about withholding/withdrawing LST. Our analysis to identify conceptual schemes revealed that physicians divided their decision-making into three stages: (1) early preparation via advance care planning, (2) information giving and receiving, and (3) arriving at the final decision. Physicians considered advocating for the best interests of the child and of the parents as their major focus. We also identified moderating factors of decision-making, such as facilitators and barriers, specifically those related to physicians and parents that influenced physicians’ decision-making. Conclusions By focusing on stakeholders, structure of the decision-making process, ethical values, and influencing factors, our analysis showed that physicians generally agreed to share the decision-making with parents and the child, especially for adolescents. Further research is required to better understand how to minimise the negative impact of barriers on the decision-making process (e.g., difficult involvement of children, lack of paediatric palliative care expertise, conflict with parents). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01003-5.
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Affiliation(s)
- Yajing Zhong
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
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20
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Alexander D, Quirke MB, Doyle C, Hill K, Masterson K, Brenner M. The Meaning Given to Bioethics as a Source of Support by Physicians Who Care for Children Who Require Long-Term Ventilation. QUALITATIVE HEALTH RESEARCH 2022; 32:916-928. [PMID: 35348409 PMCID: PMC9189592 DOI: 10.1177/10497323221083744] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The role and potential of bioethics input when a child requires the initiation of technology dependence to sustain life is relatively unknown. In particular, little is understood about the meaning physicians give to bioethics as a source of support during the care of children in pediatric intensive care who require long-term ventilation (LTV). We used a hermeneutic phenomenological approach to underpin the collection and analysis of data. Unstructured interviews of 40 physicians in four countries took place during 2020. We found that elements of trust, communication and acceptance informed the physicians' perceptions of the relationship with bioethics. These ranged from satisfaction to disappointment with their input into critical decisions. Bioethics services have potential to help physicians gain clarity over distressing and complex care decisions, yet physicians perceive the service inconsistently as a means of support. This research provides a sound basis to guide more beneficial interactions between clinicians and bioethics services.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Mary B. Quirke
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Carmel Doyle
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Katie Hill
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Kate Masterson
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
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21
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Fox E, Danis M, Tarzian AJ, Duke CC. Ethics Consultation in U.S. Hospitals: A National Follow-Up Study. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:5-18. [PMID: 33769216 DOI: 10.1080/15265161.2021.1893547] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
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Affiliation(s)
- Ellen Fox
- Altarum Institute
- Fox Ethics Consulting
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22
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Development and Retrospective Review of a Pediatric Ethics Consultation Service at a Large Academic Center. HEC Forum 2021; 32:269-281. [PMID: 32180057 DOI: 10.1007/s10730-020-09397-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The primary objective was to review pediatric ethics consultations (PECs) at a large academic health center over a nine year period, assessing demographics, ethical issues, and consultant intervention. The secondary objective was to describe the evolution of PECs at our institution. This was a retrospective review of Consultation Summary Sheets compiled for PECs at our Academic Health Center between January 2008 and April 2017. There were 165 PECs reviewed during the study period. Most consult requests came from the inpatient setting, with the Pediatric and Neonatal Intensive Care Units being the highest utilizers. Consultation utilization increased over the study period. The most common patient age was less than one year. Physicians were most likely to request consultation. Patient Best Interest, Withholding/Withdrawing of Life Sustaining Therapy, and Provider Moral Distress were ethical issues most commonly identified by the consultants. Making recommendations was the most common consultant intervention. The ethics consultation process evolved over time from informal provider discussions, to a hospital infant care review committee, to a pediatric only consultation service, to a combined adult/pediatric consultation service, with variable levels of salary support for consultants. Ethics consultation requests are growing at our institution. Similarities in identified ethical issues exist between our findings and existing literature, however meaningful comparisons remains elusive secondary to variability in approaches to investigation and reporting. A combined paid/volunteer/trainee ethics consultation service model appears sustainable and real time ethics consultation is feasible using this approach.
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23
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Nathanson PG, Walter JK, McKlindon DD, Feudtner C. Relational, Emotional, and Pragmatic Attributes of Ethics Consultations at a Children's Hospital. Pediatrics 2021; 147:peds.2020-1087. [PMID: 33674461 PMCID: PMC8015157 DOI: 10.1542/peds.2020-1087] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric ethics consultations are important but understudied, with little known about consultations' contextual attributes, which may influence how ethically problematic situations are perceived and addressed. METHODS We analyzed data regarding 245 pediatric clinical ethics consultations performed between 2013 and 2018 at a large children's hospital. Prespecified data elements included 17 core problematic issues that initiate consultations, 9 ethical considerations identified by the consultation service, and 7 relational, emotional, and pragmatic contextual attributes of the consultation. The main process measure was the cumulative consultation process, ranging from one-on-one discussions with the requestor, to meeting with the clinical team, separate meetings with the patient or family and the clinical team, or combined meeting with the patient or family and the clinical team. RESULTS The most-prevalent core problematic issues were intensity or limitation of treatment (38.8%) and treatment adherence and refusal (31%). Common pertinent ethical considerations were best interest (79.2%), benefits versus harms of treatment (51%), and autonomy and decision-making (46.5%). A total of 39.2% of consults culminated with a meeting with the clinical team, 9.4% with separate meetings, and 8.2% with a meeting with all parties. Common contextual attributes were discord (43.3%), acknowledged dilemma (33.5%), and articulate disagreement (29.8%). In exploratory analyses, specific contextual attributes were associated with the core problematic issue that initiated the consultation and with how the consultative process culminated. CONCLUSIONS Pediatric ethics consultations have contextual attributes that in exploratory analyses are associated with specific types of problems and, to a lesser degree, with the cumulative ethics consultation process.
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Affiliation(s)
- Pamela G. Nathanson
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Jennifer K. Walter
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Pediatrics, Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna D. McKlindon
- Department of Medical Ethics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Chris Feudtner
- Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and .,Department of Pediatrics, Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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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 PMCID: PMC8006201 DOI: 10.1542/hpeds.2020-001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [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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25
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Weiner C, Pergert P, Molewijk B, Castor A, Bartholdson C. Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care. BMC Med Ethics 2021; 22:27. [PMID: 33731101 PMCID: PMC7970765 DOI: 10.1186/s12910-021-00597-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 03/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden.
Methods This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation. Results Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level. Conclusions Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.
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Affiliation(s)
- Charlotte Weiner
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Paediatric Regional Health Care, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Pernilla Pergert
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Paediatric Haematology and Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Bert Molewijk
- Department of Medical Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.,Center for Medical Ethics, University of Oslo, Oslo, Norway
| | - Anders Castor
- Paediatrics, Lund University, Lund, Sweden.,Pediatric Oncology, Hematology, Immunology and Nephrology, Skåne University Hospital, Lund, Sweden
| | - Cecilia Bartholdson
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden. .,Paediatric Neurology and Musculoskeletal Disorders and Homecare, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
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26
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Glover AC, Cunningham TV, Sterling EW, Lesandrini J. How Much Volume Should Healthcare Ethics Consult Services Have? THE JOURNAL OF CLINICAL ETHICS 2020. [DOI: 10.1086/jce2020312158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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27
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Navin MC, Wasserman JA, Jain S, Baughman KR, Laventhal NT. When Do Pediatricians Call the Ethics Consultation Service? Impact of Clinical Experience and Formal Ethics Training. AJOB Empir Bioeth 2020; 11:83-90. [PMID: 32207383 DOI: 10.1080/23294515.2020.1737983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Rochester, Michigan, USA
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Susanna Jain
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Katie R Baughman
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Naomi T Laventhal
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
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28
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Teti SL. A Listening Tour: Pediatric Clinical Ethics Rounds. THE JOURNAL OF CLINICAL ETHICS 2020. [DOI: 10.1086/jce2020311027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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29
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Lion AH, Skiles JL, Watson BN, Young JD, Torke AM. Chaplain care in pediatric oncology: Insight for interprofessional collaboration. Pediatr Blood Cancer 2019; 66:e27971. [PMID: 31429523 DOI: 10.1002/pbc.27971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although attending to spiritual and religious needs is part of high quality care of pediatric cancer patients, oncology clinicians may not understand the role of the chaplain, resulting in underutilization of resources and failure to fully integrate the chaplain into the clinical team. We provide a description of what the chaplain does in the care of pediatric oncology patients. METHODS We conducted a qualitative content analysis of chaplain chart notes over a one-year period on the pediatric oncology service at a freestanding children's hospital. Using criteria designed to capture multiple potential factors in chaplain referral, we selected 30 patients for thematic analysis. RESULTS In 2016, 166 pediatric patients were diagnosed with cancer and received ongoing care at our institution. From the 30 patients selected, 230 chaplain encounters were documented in the medical chart. Three major themes emerged. (1) The chaplains provided a rich description of spiritual and psychosocial aspects of the patient and family's experience; (2) chaplains provided diverse interventions, both religious and secular in nature; and (3) chaplains provided care within a longitudinal relationship. All three themes depend on the empathic listening by a chaplain. CONCLUSIONS The chaplains' observations about patient and family beliefs, experiences, and emotional/spiritual states have the potential to inform the interdisciplinary care of the patient. Chaplain documentation provides insight into how spiritual care interventions and close relationships may promote patient and family well-being. In future work, we will explore how to give voice to their insights in caring for pediatric oncology patients.
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Affiliation(s)
- Alex H Lion
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis, Indiana.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indianapolis, Indiana
| | - Jodi L Skiles
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis, Indiana
| | | | - J Daniel Young
- Mississippi United Methodist Conference, Jackson, Mississippi
| | - Alexia M Torke
- Indiana University School of Medicine, Indianapolis, Indiana.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indianapolis, Indiana.,Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
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30
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Romo RD, Carpenter JG, Buck H, Lindley LC, Xu J, Owen JA, Sullivan SS, Bakitas M, Dionne-Odom JN, Zubkoff L, Matzo M. HPNA 2019-2022 Research Agenda: Development and Rationale. J Hosp Palliat Nurs 2019; 21:E17-E23. [PMID: 31166302 PMCID: PMC6776462 DOI: 10.1097/njh.0000000000000580] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.
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Affiliation(s)
- Rafael D Romo
- Rafael D. Romo, PhD, RN, PHN, is assistant professor of Nursing, University of Virginia School of Nursing, Charlottesville. Joan G. Carpenter, PhD, CRNP, ACHPN, FPCN, is research associate, University of Pennsylvania School of Nursing, and health science specialist, Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia, Pennsylvania. Harleah Buck, PhD, RN, FPCN, FAHA, FAAN, is associate professor and coordinator of Chronic Illness Initiatives, University of Southern Florida, Tampa. Lisa C. Lindley, PhD, RN, FPCN, is associate professor, College of Nursing, University of Tennessee, Knoxville. Jiayun Xu, PhD, RN, is assistant professor, College of Health and Human Sciences, Purdue University School of Nursing, West Lafayette, Indiana. John A. Owen, EdD, MSc, is associate director, Center for Academic Strategic Partnerships for Interprofessional Research and Education (ASPIRE), University of Virginia School of Nursing, Charlottesville. Suzanne S. Sullivan, PhD, MBA, RN, CHPN, is assistant professor, University at Buffalo State University of New York School of Nursing. Marie Bakitas, DNSc, CRNP, NP-C, AOCN, ACHPN, FAAN, is professor and Marie L. O'Koren Endowed Chair in Nursing, University of Alabama at Birmingham School of Nursing. J. Nicholas Dionne-Odom, PhD, MSN, MA, RN, FPCN, is assistant professor of nursing, University of Alabama at Birmingham School of Nursing. Lisa Zubkoff, PhD, is assistant professor of psychiatry, Dartmouth University Geisel School of Medicine and the Dartmouth Institute, Hanover, New Hampshire. Marianne Matzo, PhD, RN, APRN-CNP, AOCNP, AHPCN, FPCN, FAAN, is director of research, Hospice and Palliative Nurses Association, Pittsburgh, PA
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Mertz M, Fischer T, Salloch S. The value of bioethical research: A qualitative literature analysis of researchers' statements. PLoS One 2019; 14:e0220438. [PMID: 31356629 PMCID: PMC6663028 DOI: 10.1371/journal.pone.0220438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 07/16/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Value and waste in preclinical and clinical research projects are intensively debated in biomedicine at present. Such different aspects as the need for setting objectives and priorities, improving study design, quality of reporting, and problematic incentives of the academic reward system are addressed. While this debate is also fueled by ethical considerations and thus informed by bioethical research, up to now, the field of bioethics lacks a similar extensive debate. Nonetheless, bioethical research should not go unquestioned regarding its scientific or social value. What exactly constitutes the value of bioethical research, however, remains widely unclear so far. METHODS This explorative study investigated possible value dimensions for bioethical research by conducting a qualitative literature analysis of researchers' statements about the value of their studies. 40 bioethics articles published 2015 in four relevant journals (The American Journal of Bioethics, Bioethics, BMC Medical Ethics and Journal of Medical Ethics) were analyzed. The value dimensions of "advancing knowledge" (e.g. research results that are relevant for science itself and for further research) and "application" (e.g. increasing applicability of research results in practice) were used as main deductive categories for the analysis. Further subcategories were inductively generated. RESULTS The analysis resulted in 62 subcategories representing a wide range of value dimensions for bioethical research. Of these, 45 were subcategories of "advancing knowledge" and 17 of "application". In 21 articles, no value dimensions related to "application" was found; the remaining 19 articles mentioned "advancing knowledge" as well as "application". The value dimensions related to "advancing knowledge" were, in general, more fine-grained. CONCLUSIONS Even though limitations arise regarding the sample, the study revealed a plethora of value dimensions that can inform further debates about what makes bioethical research valuable for science and society. Besides theoretical reflections on the value of bioethics more meta-research in bioethics is needed.
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Affiliation(s)
- Marcel Mertz
- Institute of History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Fischer
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
- Clinic for Dermatology and Venereology, University Medical Center Rostock, Rostock, Germany
| | - Sabine Salloch
- Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany
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Winter MC, Friedman DN, McCabe MS, Voigt L. Content review of pediatric ethics consultations at a cancer center. Pediatr Blood Cancer 2019; 66:e27617. [PMID: 30666797 PMCID: PMC6777958 DOI: 10.1002/pbc.27617] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/01/2018] [Accepted: 12/27/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND/OBJECTIVES Ethical challenges in pediatric oncology arise at every stage of illness. However, there are sparse data on the content of and reason for ethics consultations in the field. We sought to evaluate the content and characteristics of ethics consultations in pediatric patients at a cancer center. DESIGN/METHODS We retrospectively identified ethics consultations performed for patients diagnosed with cancer at ≤21 years of age who were treated in the Department of Pediatrics from 2007 to 2017. Using an established coding schema, two independent reviewers analyzed the content of ethics consultation notes and identified core ethical issues and relevant contextual issues. Demographic, clinical, and consultation-specific data were also collected. RESULTS Thirty-five consultations were performed for 32 unique patients. The most commonly identified ethical issues were obligation to provide nonbeneficial treatment (29%) and resuscitation preferences (26%). Communication conflicts were the most commonly identified contextual issue (40%). There were two themes that emerged repeatedly but were not a part of the original coding schema-four consultations (11%) that involved physicians questioning their obligation to provide potentially toxic treatment in the setting of poor patient/parent compliance, and two consultations (6%) related to complex risk-benefit analysis in the setting of an invasive procedure with uncertain benefit. CONCLUSIONS Pediatric ethics consultations are infrequent at this specialty cancer hospital. Ethical issues focused on treatment and end-of-life care and included a diversity of communication conflicts.
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Affiliation(s)
- Meredith C. Winter
- Supportive Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mary S. McCabe
- Consultant Advisor, National Coalition for Cancer Survivorship, Silver Spring, MD
| | - Louis Voigt
- Department of Anesthesiology, Pain and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
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Hopia H, Heino-Tolonen T. Families in Paediatric Oncology Nursing: Critical Incidents From the Nurses' Perspective. J Pediatr Nurs 2019; 44:e28-e35. [PMID: 30528181 DOI: 10.1016/j.pedn.2018.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Paediatric oncology nurses encounter challenges with families on a daily basis. This study explores how nurses describe significant incidents when encountering families and family members during the child's hospitalisation in the paediatric oncology unit. DESIGN AND METHODS A qualitative study with a phenomenological approach in which 17 paediatric oncology nurses from three different hospitals described critical incidents related to families. The participants' written descriptions were analysed using inductive content analysis. RESULTS The results indicate three domains where critical incidents occur: 1) Families' capability and resources, 2) parents' behaviour and 3) emotional labour in paediatric oncology nursing. CONCLUSION The results indicate that paediatric oncology nurses face situations with patients' parents that can cause them stress and uncertainty, as well as burden them emotionally. Some of the incidents dealt with difficult ethical questions. Because of the challenges that families are facing, as described in the study, nurses need to focus more on helping families identify their resources and empower themselves in order to adapt to a new situation in their lives. IMPLICATIONS The results provide important information not only for paediatric nursing but also for education and management. Since the quality of family nursing does not only depend on the competence of nurses or available resources, support from management concerning the work with families of severely sick children would be beneficial to the nurses. In addition, educational interventions need to be developed in order to strengthen the capability of nurses to successfully respond to challenging situations with families.
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Affiliation(s)
- Hanna Hopia
- JAMK University of Applied Sciences, School of Health and Social Studies, Jyvaskyla, Finland.
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deSante-Bertkau JE, McGowan ML, Matheny Antommaria AH. Systematic Review of Typologies Used to Characterize Clinical Ethics Consultations. THE JOURNAL OF CLINICAL ETHICS 2018. [DOI: 10.1086/jce2018294291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Giambra BK, Haas SM, Britto MT, Lipstein EA. Exploration of Parent-Provider Communication During Clinic Visits for Children With Chronic Conditions. J Pediatr Health Care 2018; 32:21-28. [PMID: 28866436 PMCID: PMC5726919 DOI: 10.1016/j.pedhc.2017.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The purpose of this study was to explore the communication behaviors demonstrated by parents of children with chronic conditions and provider team members when communicating about the child's care in outpatient clinics using concepts from the Theory of Shared Communication (TSC). METHODS This was a secondary data analysis of 30 previously recorded pediatric clinic visits. Communication among parents and provider team members was analyzed using a researcher-developed coding scheme based on the TSC. RESULTS Provider team members dominated communication during clinic visits, showing more frequent use of asking, explaining, advocating, and negotiating behaviors than parents. Parents were engaged in communication with frequent asking, explaining, and advocating behaviors. DISCUSSION Parents of children with chronic conditions and multidisciplinary providers demonstrated the communication behaviors of the TSC in an outpatient clinic setting. Provider dominance of communication in the clinic setting may disempower parents and impair relationships.
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Colaco KA, Courtright A, Andreychuk S, Frolic A, Cheng J, Kam AJ. Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning and resource needs. JOURNAL OF MEDICAL ETHICS 2018; 44:13-20. [PMID: 28751469 DOI: 10.1136/medethics-2016-103531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 12/24/2016] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments (EDs) in order to build ethics capacity and provide a foundation for the development of an ethics education programme. METHODS This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. RESULTS Of the 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress (16%), conflict management with patients or families (16%) and resource issues (15%). Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams (42%) was the most desired method. CONCLUSIONS Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists.
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Affiliation(s)
- Keith A Colaco
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Alanna Courtright
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Andreychuk
- Office of Clinical and Organizational Ethics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrea Frolic
- Office of Clinical and Organizational Ethics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ji Cheng
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - April Jacqueline Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Brunnquell D. Minimizing the Child's Interests by Focus on Parental Values and Identities. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:21-23. [PMID: 29111937 DOI: 10.1080/15265161.2017.1378765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Wasson K, Anderson E, Hagstrom E, McCarthy M, Parsi K, Kuczewski M. What Ethical Issues Really Arise in Practice at an Academic Medical Center? A Quantitative and Qualitative Analysis of Clinical Ethics Consultations from 2008 to 2013. HEC Forum 2017; 28:217-28. [PMID: 26423767 DOI: 10.1007/s10730-015-9293-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male (55.8 %), white (57.1 %), between 50 and 69 years old (38.5 %), of non-Hispanic origin (85.9 %), and of Roman Catholic faith (43.6 %). Nearly half (47.4 %) were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making (93.6 %), goals of care/treatment (80.8 %), and end-of-life (73.1 %). More specifically, capacity (57.1 %), patient's wishes/autonomy (54.5 %), and surrogate decision maker (51.3 %) were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment (12.8 %), patient wishes/autonomy (12.2 %), and capacity (11.5 %). Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field.
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Affiliation(s)
- Katherine Wasson
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA.
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Ave., Bldg. 120, Rm. 284, Maywood, IL, 60153, USA.
| | - Emily Anderson
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA
| | - Erika Hagstrom
- Loyola University Medical Center, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA
| | - Michael McCarthy
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA
| | - Kayhan Parsi
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA
| | - Mark Kuczewski
- The Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, 2160 S. 1st Avenue, Bldg. 120, Room 280, Maywood, IL, 60153, USA
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Johnson LM, Hamilton KV, Valdez JM, Knapp E, Baker JN, Nichols KE. Ethical considerations surrounding germline next-generation sequencing of children with cancer. Expert Rev Mol Diagn 2017; 17:523-534. [PMID: 28399664 DOI: 10.1080/14737159.2017.1316665] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The advent of next-generation sequencing (NGS) has introduced an exciting new era in biomedical research. NGS forms the foundation of current genetic testing approaches, including targeted gene panel testing, as well as more comprehensive whole-exome and whole-genome sequencing. Together, these approaches promise to provide critical insights into the understanding of health and disease. However, with NGS testing come many ethical questions and concerns, particularly when testing involves children. These concerns are especially relevant for children with cancer, where the testing of tumor and germline tissues is increasingly being incorporated into clinical care. Areas covered: In this manuscript, we explore the key ethical considerations related to conducting germline NGS testing in pediatric oncology, focusing on the four main principles of beneficence, non-maleficence, autonomy and justice. Expert commentary: The ethical issues surrounding germline NGS testing are complex and result in part from our limited understanding of the medical relevance of many of the results obtained and poor knowledge of the impacts of testing, both beneficial and detrimental, on patients and their families. In this article we discuss the risks and benefits of germline NGS testing and the arguments for and against such testing in children with cancer.
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Affiliation(s)
- Liza-Marie Johnson
- a Section of Bioethics , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Kayla V Hamilton
- b Division of Cancer Predisposition , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Jessica M Valdez
- b Division of Cancer Predisposition , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Esther Knapp
- c Department of Pediatrics , University of Louisville , Louisville , KY , USA
| | - Justin N Baker
- d Division of Quality of Life and Palliative Care , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Kim E Nichols
- b Division of Cancer Predisposition , St. Jude Children's Research Hospital , Memphis , TN , USA
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Bartholdson C, Molewijk B, Lützén K, Blomgren K, Pergert P. Ethics case reflection sessions: Enablers and barriers. Nurs Ethics 2017. [PMID: 29529973 DOI: 10.1177/0969733017693471] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In previous research on ethics case reflection (ECR) sessions about specific cases, healthcare professionals in childhood cancer care were clarifying their perspectives on the ethical issue to resolve their main concern of consolidating care. When perspectives were clarified, consequences in the team included 'increased understanding', 'group strengthening' and 'decision grounding'. Additional analysis of the data was needed on conditions that could contribute to the quality of ECR sessions. OBJECTIVE The aim of this study was to explore conditions for clarifying perspectives during ECR sessions. RESEARCH DESIGN Data were collected from observations and interviews and the results emerged from an inductive analysis using grounded theory. Participants and research context: Six observations during ECR sessions and 10 interviews were performed with healthcare professionals working in childhood cancer care and advanced paediatric homecare. Ethical considerations: The study was approved by a regional ethical review board. Participants were informed about their voluntary involvement and that they could withdraw their participation without explaining why. FINDINGS Two categories emerged: organizational enablers and barriers and team-related enablers and barriers. Organizational enablers and barriers included the following sub-categories: the timing of the ECR session, the structure during the ECR session and the climate during the ECR session. Sub-categories to team-related enablers and barriers were identified as space for inter-professional perspectives, varying levels of ethical skills and space for the patient's and the family's perspectives. DISCUSSION Space for inter-professional perspectives included the dominance of a particular perspective that can result from hierarchical positions. The medical perspective is relevant for understanding the child's situation but should not dominate the ethical reflection. CONCLUSION Conditions for ECR sessions have been explored and the new knowledge can be used when training facilitators as well as for those who organize/implement ECR sessions. Awareness of space for different perspectives, including the possible medical advantage over the nursing perspective, could reduce the somewhat unilateral attention and contribute to an inter-professionally shared reflection.
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Affiliation(s)
- Cecilia Bartholdson
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Bert Molewijk
- VU University Medical Center Amsterdam, The Netherlands; University of Oslo, Norway.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Kim Lützén
- Karolinska Institutet, Sweden.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Klas Blomgren
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Pernilla Pergert
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
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Lotz JD, Jox RJ, Meurer C, Borasio GD, Führer M. Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians. Palliat Med 2016; 30:960-970. [PMID: 26847523 PMCID: PMC5117124 DOI: 10.1177/0269216316628422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. AIM Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. DESIGN We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. SETTING/PARTICIPANTS We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. RESULTS The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. CONCLUSION The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.
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Affiliation(s)
- Julia Desiree Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Christine Meurer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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McDougall RJ, Notini L. What kinds of cases do paediatricians refer to clinical ethics? Insights from 184 case referrals at an Australian paediatric hospital. JOURNAL OF MEDICAL ETHICS 2016; 42:586-591. [PMID: 27317508 DOI: 10.1136/medethics-2015-103025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 04/27/2016] [Indexed: 06/06/2023]
Abstract
Clinical ethics has been developing in paediatric healthcare for several decades. However, information about how paediatricians use clinical ethics case consultation services is extremely limited. In this project, we analysed a large set of case records from the clinical ethics service of one paediatric hospital in Australia. We applied a paediatric-specific typology to the case referrals, based on the triadic doctor-patient-parent relationship. We reviewed the 184 cases referred to the service in the period 2005-2014, noting features including the type of case, the referring department(s) and the patient's age at referral. The two most common types of referral involved clinician uncertainty about the appropriate care pathway for the child (26% of total referrals) and situations where the child's parents disagreed with the doctors' recommendations for the child's care (22% of total referrals). Referrals came from 28 different departments. Cancer, cardiology/cardiac surgery and general medicine referred the highest numbers of cases. The most common patient age groups were children under 1, and 14-15 years old. For three controversial areas of paediatric healthcare, clinicians had initiated processes of routine review of cases by the clinical ethics service. These insights into the way in which one very active paediatric clinical ethics service is used further our understanding of the work of paediatric clinical ethics, particularly the kinds of ethically challenging cases that paediatricians view as appropriate to refer for clinical ethics support.
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Affiliation(s)
- Rosalind J McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Lauren Notini
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
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Antommaria AHM. Characterizing clinical ethics consultations: the need for a standardized typology of cases. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:18-20. [PMID: 25970383 DOI: 10.1080/15265161.2015.1021973] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Gillam L, McDougall R, Delany C. Making meaning from experience: a working typology for pediatrics ethics consultations. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:24-26. [PMID: 25970385 DOI: 10.1080/15265161.2015.1021969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Lynn Gillam
- a Melbourne School of Population and Global Health and Royal Children's Hospital
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Char DS. Ethical concerns raised among pediatric heart failure clinicians. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:36-37. [PMID: 25970391 DOI: 10.1080/15265161.2015.1021971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Swota A, Bradfield S. Eliciting parental values and preferences in the medical decision-making process. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:34-35. [PMID: 25970390 DOI: 10.1080/15265161.2015.1021978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Alissa Swota
- a University of North Florida Wolfson Children's Hospital
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Henriksen Hellyer J, Schiltz B, Moon W, Grafelman M, Yoshimatsu K, Swetz KM. Pediatric clinical ethics consultations at an academic medical center: does one size fit all? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:20-24. [PMID: 25970384 DOI: 10.1080/15265161.2015.1023115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Kon AA. They're Not Just Little Adults: Special Considerations in Pediatric Clinical Ethics Consultation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:30-32. [PMID: 25970388 DOI: 10.1080/15265161.2015.1021967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Alexander A Kon
- a Naval Medical Center San Diego and the University of California , San Diego
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Spriggs M, Gillam L. A cautionary note on anonymous referrals for clinical ethics case consultations. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:32-33. [PMID: 25970389 DOI: 10.1080/15265161.2015.1021968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Merle Spriggs
- a Children's Bioethics Centre, University of Melbourne/Murdoch Childrens Research Institute
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Kilham H, Isaacs D, Kerridge I, Newson A. Rethinking pediatric ethics consultations. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:26-28. [PMID: 25970386 DOI: 10.1080/15265161.2015.1021970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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