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Bruun H, Milling L, Wittrock D, Mikkelsen S, Huniche L. How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety. BMC Med Ethics 2024; 25:58. [PMID: 38762457 PMCID: PMC11102201 DOI: 10.1186/s12910-024-01061-9] [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: 08/09/2023] [Accepted: 05/08/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
- Department of Regional Health Research, Faculty of Health Science, Forensic Mental Health Research Unit Middelfart (RFM), University of Southern Denmark & Psychiatric dept, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Daniel Wittrock
- Department of Quality and Education, Ambulance Syd, the Region of Southern Denmark, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Grönlund CF, Brännström M. Postgraduate nursing students' experiences of practicing ethical communication. Nurs Ethics 2022; 29:1709-1720. [PMID: 35773019 DOI: 10.1177/09697330221109943] [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: 11/17/2022]
Abstract
BACKGROUND Ethics communication has been described as a pedagogical form, promoting development of ethical competence among nursing students. The 'one to five method' was developed by this research group as a tool for facilitating ethical communication in groups among healthcare professionals but has not yet been evaluated. AIM To explore post-graduate nursing students' experiences of practicing ethical communication in groups. RESEARCH DESIGN The study design is qualitative. PARTICIPANTS AND RESEARCH CONTEXT The study comprised 12 nursing students on a post-graduate course for Registered Nurses focusing on palliative care. After education the students engaged as participants and facilitators in ethics communication in groups, with support from the 'one to five method'. Data were derived from the students written reflections and subjected to thematic analysis. ETHICAL CONSIDERATIONS The study was performed in accordance with the ethical standards in the 2013 Helsinki Declaration and approved by the Ethics Committee of the Medical Faculty at Umeå University. RESULTS An overall theme was identified, 'being supported to achieve a democratic dialogue concerning ethical problems' and five themes, related to each step of the 'one to five method'. The themes concerned: putting the experience of an ethical dilemma into words; being confirmed by shared emotions; defining the value conflict using ethical principles; expressing virtues of empathy and raised awareness; jointly finding various action approaches. DISCUSSION Regular ethics communication in groups encourages nursing students to actively seek understanding and clarification of ethically difficult situations. CONCLUSIONS The results indicate that ethics communication in groups could be a way of developing virtues during education. Interventions using the 'one to five method' need to be further studied among student groups from other healthcare contexts.
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Knox JBL. The Ethics Laboratory: A Dialogical Practice for Interdisciplinary Moral Deliberation. HEC Forum 2021; 35:185-199. [PMID: 34559330 DOI: 10.1007/s10730-021-09460-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/29/2022]
Abstract
Recent advancements in therapeutic and diagnostic medicine, along with the creation of large biobanks and methods for monitoring health technologies, have improved the prospects for preventing, treating, and curing illness. These same advancements, however, give rise to a plethora of ethical questions concerning good decision-making and best action. These ethical questions engage policymakers, practitioners, scientists, and researchers from a variety of fields in different ways. Collaborations between professionals in the medical and health sciences and the social sciences and humanities often take an asymmetrical form, as when social scientists use ethnographic approaches to study the moral issues and practices of physicians. The ethics laboratory described in this article is a cross-sectoral and inter-disciplinary forum for collaborative investigation on important moral topics. It offers an experimental way of unpacking implied assumptions, underlying values, and comparable notions from different professional healthcare fields. The aim of this article is to present the ethics laboratory's methodology. The article offers a model and a hermeneutical framework that rests on a dialogical approach to ethical questions. The model and the framework derive from a Danish research project, Personalized Medicine in the Welfare State. This article uses personalized medicine as a point of reference, though it offers an argument for the applicability of the model more broadly.
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Czarkowski M, Różyńska J, Maćkiewicz B, Zawiła-Niedźwiecki J. Clinical Ethics Consultations in the Opinion of Polish Physicians. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:499-509. [PMID: 34398387 PMCID: PMC8566376 DOI: 10.1007/s11673-021-10116-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 04/08/2021] [Indexed: 06/13/2023]
Abstract
Clinical Ethics Consultations (CEC) are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs' perceived availability, use of CECs, and perceived usefulness of such support. Physicians in our study generally encounter hard ethics cases, even-surprisingly-those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful-even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system.
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Affiliation(s)
- Marek Czarkowski
- Collegium Medicum, Cardinal Stefan Wyszyński University, Kazimierza Wóycickiego 1/3, 01-938 Warszawa, Poland
| | - Joanna Różyńska
- University of Warsaw, Krakowskie Przedmieście 3, 00-927 Warszawa, Poland
| | - Bartosz Maćkiewicz
- University of Warsaw, Krakowskie Przedmieście 3, 00-927 Warszawa, Poland
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Ranisch R, Riedel A, Bresch F, Mayer H, Pape KD, Weise G, Renz P. [The Tübingen Model "Ethics Consultants on the Ward": a pilot project to establish decentralized structures of clinical ethics consultation at a university hospital]. Ethik Med 2021; 33:257-274. [PMID: 34155423 PMCID: PMC8210507 DOI: 10.1007/s00481-021-00635-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/28/2021] [Indexed: 01/20/2023]
Abstract
DEFINITION OF THE PROBLEM Clinical ethics committees form an integral part of ethics management and organizational ethics in clinical healthcare facilities. However, working mostly reactive and not being anchored in the corresponding organizational levels, such instruments are limited in terms of effectiveness. ARGUMENTS Based on these shortcomings of clinical ethics consultation the multiprofessional working group "Ethics" at the University Hospital Tübingen, Germany has endeavored to design and implement new structures for sustainable ethical decision-making processes on its hospital wards. The Tübingen Model "Ethics Consultants on the Ward" is a pilot project intended to appoint specifically trained nursing staff on all wards as contact partners for ethical issues. Thus, the Tübingen Model represents an extension to established structures of clinical ethics consultation and complements existing top-down strategies. CONCLUSIONS This article presents the objectives of the Tübingen Model and describes initial experiences in its implementation. After explaining their role within the existing structures of ethics consultation at the hospital, the tasks of the ethics consultants within and across the hospital's wards are presented. Furthermore, the qualification program for ethics consultants (basic and advanced training) as well as a train-the-trainer concept are presented, which support an in-depth development of competencies in nursing as well as medical ethics and provide confidence in the reflection and decision-making processes on the ward.
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Affiliation(s)
- Robert Ranisch
- Klinisches Ethik-Komitee, Universitätsklinikum Tübingen, Gartenstraße 47, 72074 Tübingen, Deutschland
- Professur für Medizinische Ethik mit Schwerpunkt auf Digitalisierung, Fakultät für Gesundheitswissenschaften Brandenburg, Universität Potsdam, Potsdam, Deutschland
- Institut für Ethik und Geschichte der Medizin, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
| | - Annette Riedel
- Fakultät Soziale Arbeit, Bildung und Pflege, Hochschule Esslingen, Esslingen, Deutschland
| | - Friedemann Bresch
- Klinisches Ethik-Komitee, Universitätsklinikum Tübingen, Gartenstraße 47, 72074 Tübingen, Deutschland
| | - Hiltrud Mayer
- Klinisches Ethik-Komitee, Universitätsklinikum Tübingen, Gartenstraße 47, 72074 Tübingen, Deutschland
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Klaus-Dieter Pape
- Klinisches Ethik-Komitee, Universitätsklinikum Tübingen, Gartenstraße 47, 72074 Tübingen, Deutschland
- Katholische Klinikseelsorge in der Psychiatrie und Neurologie, Universitätsklinik Tübingen, Tübingen, Deutschland
| | - Gerda Weise
- Klinisches Ethik-Komitee, Universitätsklinikum Tübingen, Gartenstraße 47, 72074 Tübingen, Deutschland
- Stroke Unit und neurologische Intensivüberwachung, Neurologische Klinik, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Petra Renz
- Stabsstelle Vorstand KV 4 – Pflegeorganisation Qualitätsentwicklung und Pflegeberatung, Universitätsklinikum Tübingen, Tübingen, Deutschland
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Cederquist L, LaBuzetta JN, Cachay E, Friedman L, Yi C, Dibsie L, Zhang Y. Identifying disincentives to ethics consultation requests among physicians, advance practice providers, and nurses: a quality improvement all staff survey at a tertiary academic medical center. BMC Med Ethics 2021; 22:44. [PMID: 33849509 PMCID: PMC8045298 DOI: 10.1186/s12910-021-00613-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background Ethics consult services are well established, but often remain underutilized. Our aim was to identify the barriers and perceptions of the Ethics consult service for physicians, advance practice providers (APPs), and nurses at our urban academic medical center which might contribute to underutilization. Methods This was a cross-sectional single-health system, anonymous written online survey, which was developed by the UCSD Health Clinical Ethics Committee and distributed by Survey Monkey. We compare responses between physicians, APPs, and nurses using standard parametric and non-parametric statistical methods. Satisfaction with ethics consult and likelihood of calling Ethics service again were assessed using a 0–100 scale using a 5-likert response structured (0 being “not helpful at all” to 100 being “extremely helpful”) and results presented using box plots and interquartile ranges (IQR). Results From January to July 2019, approximately 3800 surveys were sent to all physicians, APPs and nurses with a return rate of 5.5—10%. Although the majority of respondents had encountered an ethical dilemma (85–92.1%) only approximately half had ever requested an Ethics consult. The primary reason for physicians never having requested a consult was that they never felt the need for help (41%). For APPs the primary reasons were not knowing an Ethics consult service was available (33.3%) or not knowing how to contact Ethics (27.8%). For nurses, it was not knowing how to contact the Ethics consult service (30.8%) or not feeling the need for help (26.2%). The median satisfaction score (IQR) for Ethics consult services rated on a 0–100 scale, from physicians was 76 (29), for AAPs 89 (49), and nurses 70 (40) (p = 0.62). The median (IQR) of likelihood of consulting Ethics in the future also on a 0–100 scale was 71 (47) for physicians, 69 (45) for APPs, and 61 (45) for nurses (p = 0.79). APP’s and nurses were significantly more likely than physicians to believe that the team did not act on the Ethics consult’s recommendations. Conclusions Based on the results presented, we were able to identify actionable steps to better engage healthcare providers—and in particular APPs and nurses—and scale up institutional educational efforts to increase awareness of the role of the Ethics consult service at our institution. Actionable steps included implementing a system of ongoing feedback that is critical for the sustainability of the Ethics service role. We hope this project can serve as a blueprint for other hospital-based Ethics consult services to improve the quality of their programs. Supplementary information The online version contains supplementary material available at 10.1186/s12910-021-00613-7.
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Affiliation(s)
- Lynette Cederquist
- Department of Medicine, Division of General Internal Medicine, University of California San Diego, 9500 Gilman Drive #0945, La Jolla, CA, 92093-0945, USA.
| | - Jamie Nicole LaBuzetta
- Department of Neurosciences, University of California San Diego, 9300 Campus Point Drive #7740, La Jolla, CA, 92037-7740, USA
| | - Edward Cachay
- Department of Medicine, Division of Infectious Diseases, University of California San Diego, 200 W. Arbor Drive #8681, San Diego, CA, 92103-8681, USA
| | - Lawrence Friedman
- Department of Medicine, Division of General Internal Medicine, University of California San Diego, 200 W. Arbor Drive #8985, San Diego, CA, 92103-8985, USA
| | - Cassia Yi
- Department of Nursing, University of California San Diego, 200 W. Arbor Drive #8929, San Diego, CA, 92103-8929, USA
| | - Laura Dibsie
- Department of Nursing, University of California San Diego, 200 W. Arbor Drive #8929, San Diego, CA, 92103-8929, USA
| | - Yiran Zhang
- Department of Family Medicine and Public Health, Division of Biostatistics and Bioinformatics, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
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Fischer-Grönlund C, Brännström M, Zingmark K. The 'one to five' method - A tool for ethical communication in groups among healthcare professionals. Nurse Educ Pract 2021; 51:102998. [PMID: 33639607 DOI: 10.1016/j.nepr.2021.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/24/2022]
Abstract
Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.
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Affiliation(s)
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology, Sweden.
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Conceptualizing and Fostering the Quality of CES Through a Dutch National Network on CES (NEON). HEC Forum 2021; 34:169-186. [PMID: 33449233 PMCID: PMC9142414 DOI: 10.1007/s10730-020-09432-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 12/03/2022]
Abstract
The prevalence of Clinical ethics support (CES) services is increasing. Yet, questions about what quality of CES entails and how to foster the quality of CES remain. This paper describes the development of a national network (NEON), which aimed to conceptualize and foster the quality of CES in the Netherlands simultaneously. Our methodology was inspired by a responsive evaluation approach which shares some of our key theoretical presuppositions of CES. A responsive evaluation methodology engages stakeholders in developing quality standards of a certain practice, instead of evaluating a practice by predefined standards. In this paper, we describe the relationship between our theoretical viewpoint on CES and a responsive evaluation methodology. Then we describe the development of the network (NEON) and focus on three activities that exemplify our approach. In the discussion, we reflect on the similarities and differences between our approach and other international initiatives focusing on the quality of CES.
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Magelssen M, Karlsen H, Pedersen R, Thoresen L. Implementing clinical ethics committees as a complex intervention: presentation of a feasibility study in community care. BMC Med Ethics 2020; 21:82. [PMID: 32873310 PMCID: PMC7466831 DOI: 10.1186/s12910-020-00522-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
Background How should clinical ethics support services such as clinical ethics committees (CECs) be implemented and evaluated? We argue that both the CEC itself and the implementation of the CEC should be considered as ‘complex interventions’. Main text We present a research project involving the implementation of CECs in community care in four Norwegian municipalities. We show that when both the CEC and its implementation are considered as complex interventions, important consequences follow – both for implementation and the study thereof. Emphasizing four such sets of consequences, we argue, first, that the complexity of the intervention necessitates small-scale testing before larger-scale implementation and testing is attempted; second, that it is necessary to theorize the intervention in sufficient depth; third, that the identification of casual connections charted in so-called logic models allows the identification of factors that are vital for the intervention to succeed and which must therefore be studied; fourth, that an important part of a feasibility study must be to identify and chart as many as possible of the causally important contextual factors. Conclusion The conceptualization of the implementation of a CEC as a complex intervention shapes the intervention and the way evaluation research should be performed, in several significant ways. We recommend that researchers consider whether a complex intervention approach is called for when studying CESS implementation and impact.
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Affiliation(s)
- Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway.
| | - Heidi Karlsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Lisbeth Thoresen
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hartman L, Inguaggiato G, Widdershoven G, Wensing-Kruger A, Molewijk B. Theory and practice of integrative clinical ethics support: a joint experience within gender affirmative care. BMC Med Ethics 2020; 21:79. [PMID: 32847572 PMCID: PMC7448443 DOI: 10.1186/s12910-020-00520-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/13/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinical ethics support (CES) aims to support health care professionals in dealing with ethical issues in clinical practice. Although the prevalence of CES is increasing, it does meet challenges and pressing questions regarding implementation and organization. In this paper we present a specific way of organizing CES, which we have called integrative CES, and argue that this approach meets some of the challenges regarding implementation and organization. METHODS This integrative approach was developed in an iterative process, combining actual experiences in a case study in which we offered CES to a team that provides transgender health care and reflecting on the theoretical underpinnings of our work stemming from pragmatism, hermeneutics and organizational and educational sciences. RESULTS In this paper we describe five key characteristics of an integrative approach to CES; 1. Positioning CES more within care practices, 2. Involving new perspectives, 3. Creating co-ownership of CES, 4. Paying attention to follow up, and 5. Developing innovative CES activities through an emerging design. CONCLUSIONS In the discussion we compare this approach to the integrated approach to CES developed in the US and the hub and spokes strategy developed in Canada. Furthermore, we reflect on how an integrative approach to CES can help to handle some of the challenges of current CES.
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Affiliation(s)
- Laura Hartman
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands.
| | - Giulia Inguaggiato
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
| | - Annelijn Wensing-Kruger
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Heggestad AKT, Førde R, Magelssen M, Arnekleiv B. Ethics reflection groups for school nurses. Nurs Ethics 2020; 28:210-220. [PMID: 32729357 DOI: 10.1177/0969733020940373] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND School nurses have great responsibilities as the connecting link between school, children/adolescents, parents, and other healthcare services. Being in this middle position, and handling complex situations and problems related to children in school, may be demanding and also lead to ethical challenges. Clinical ethics support, such as ethics reflection groups, may be of help when dealing with ethical challenges. However, there is little research on experiences with ethics reflection groups among school nurses. AIM The aim of this research was to explore how nurses in school healthcare experience their role, and how they experience participation in ethics reflection groups, using a model for systematic ethics reflection, the Centre for Medical Ethics model. RESEARCH DESIGN The project had a qualitative design, using focus group interviews and thematic analysis. ETHICAL CONSIDERATIONS The study was evaluated by the Data Protection Official at the Norwegian Centre for Research Data (project no. 57373). The participants were given oral and written information about the study and signed a written consent. PARTICIPANTS AND CONTEXT Twelve participants from school healthcare were recruited to the interviews. FINDINGS School nurses described their role as extremely challenging. How the school nurses experienced their role also influenced how they experienced participating in ethics reflection groups. The Centre for Medical Ethics model was experienced as both challenging and comprehensive. However, they also experienced that the model helped them to clarify their role and could also help them to find better solutions. CONCLUSION The role as school nurse is complex and demanding, with several ethical challenges. Ethics reflection groups may be of great help when dealing with these challenges. However, it is of great importance that the methods used are adjusted to the professionals' needs and context.
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Abstract
This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals.
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Yoon NYS, Ong YT, Yap HW, Tay KT, Lim EG, Cheong CWS, Lim WQ, Chin AMC, Toh YP, Chiam M, Mason S, Krishna LKR. Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019. BMC Med Ethics 2020; 21:51. [PMID: 32611436 PMCID: PMC7329412 DOI: 10.1186/s12910-020-00492-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Amidst expanding roles in education and policy making, questions have been raised about the ability of Clinical Ethics Committees (CEC) s to carry out effective ethics consultations (CECons). However recent reviews of CECs suggest that there is no uniformity to CECons and no effective means of assessing the quality of CECons. To address this gap a systematic scoping review of prevailing tools used to assess CECons was performed to foreground and guide the design of a tool to evaluate the quality of CECons. METHODS Guided by Levac et al's (2010) methodological framework for conducting scoping reviews, the research team performed independent literature reviews of accounts of assessments of CECons published in six databases. The included articles were independently analyzed using content and thematic analysis to enhance the validity of the findings. RESULTS Nine thousand sixty-six abstracts were identified, 617 full-text articles were reviewed, 104 articles were analyzed and four themes were identified - the purpose of the CECons evaluation, the various domains assessed, the methods of assessment used and the long-term impact of these evaluations. CONCLUSION This review found prevailing assessments of CECons to be piecemeal due to variable goals, contextual factors and practical limitations. The diversity in domains assessed and tools used foregrounds the lack of minimum standards upheld to ensure baseline efficacy. To advance a contextually appropriate, culturally sensitive, program specific assessment tool to assess CECons, clear structural and competency guidelines must be established in the curation of CECons programs, to evaluate their true efficacy and maintain clinical, legal and ethical standards.
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Affiliation(s)
- Nicholas Yue Shuen Yoon
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Yun Ting Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Hong Wei Yap
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Dr, Experimental Medicine Building, Singapore, 636921, Singapore
| | - Kuang Teck Tay
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Elijah Gin Lim
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Clarissa Wei Shuen Cheong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Wei Qiang Lim
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, 117599, Singapore
| | - Ying Pin Toh
- Department of Family Medicine, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Level 4, 11 Hospital Drive, Singapore, 169610, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK.
- Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
- Centre of Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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Magelssen M, Pedersen R, Miljeteig I, Ervik H, Førde R. Importance of systematic deliberation and stakeholder presence: a national study of clinical ethics committees. JOURNAL OF MEDICAL ETHICS 2020; 46:66-70. [PMID: 31488518 DOI: 10.1136/medethics-2018-105190] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/29/2019] [Accepted: 08/25/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Case consultation performed by clinical ethics committees (CECs) is a complex activity which should be evaluated. Several evaluation studies have reported stakeholder satisfaction in single institutions. The present study was conducted nationwide and compares clinicians' evaluations on a range of aspects with the CEC's own evaluation. METHODS Prospective questionnaire study involving case consultations at 19 Norwegian CECs for 1 year, where consultations were evaluated by CECs and clinicians who had participated. RESULTS Evaluations of 64 case consultations were received. Cases were complex with multiple ethical problems intertwined. Clinicians rated the average CEC consult highly, being both satisfied with the process and perceiving it to be useful across a number of aspects. CEC evaluations corresponded well with those of clinicians in a large majority of cases. Having next of kin/patients present was experienced as predominantly positive, though practised by only half of the CECs. The educational function of the consult was evaluated more positively when the CEC used a systematic deliberation method. CONCLUSIONS CEC case consultation was found to be a useful service. The study is also a favourable evaluation of the Norwegian CEC system, implying that it is feasible to implement well-functioning CECs on a large scale. There are good reasons to involve the stakeholders in the consultations as a main rule.
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Affiliation(s)
| | | | - Ingrid Miljeteig
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Håvard Ervik
- Clinical Ethics Committee, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
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Dekeuwer C, Bogaert B, Eggert N, Harpet C, Romero M. Falling on deaf ears: a qualitative study on clinical ethical committees in France. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:515-529. [PMID: 31147810 DOI: 10.1007/s11019-019-09907-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The French medical context is characterized by institutionalization of the ethical reflection in health care facilities and an important disparity between spaces of ethical reflection. In theory, the healthcare professional may mobilise an arsenal of resources to help him in his ethical reflection. But what happens in practice? We conducted semi-structured interviews with 22 health-care professionals who did and did not have recourse to clinical ethical committees. We also implemented two focus groups with 18 professionals involved in various spaces of ethical reflection in order to let them debate about a better way to organize ethical reflection in their institutional contexts. The qualitative analysis allows to us to underline the coexistence of different conceptions of ethics among health care professionals. We also observed that the participants in our study shared the experience of ethically problematic situations as roadblocks in the process of communication and decision-making. We therefore report the factors which favour or inhibit the ethical course leading to the resolution or at the very least soothing of the situation at hand. Finally, we discuss methodological issues and underline the fact that while the patient is at the heart of the professional's ethical preoccupations, this does not imply that they are actors in decisions that concern them.
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Affiliation(s)
- Catherine Dekeuwer
- Faculté de Philosophie, Institut de Recherches Philosophiques de Lyon, Université Jean Moulin, 18 rue Chevreul, 69007, Lyon, France.
| | - Brenda Bogaert
- Chaire Valeurs du Soin Centré Patient, Institut de Recherches Philosophiques de Lyon, Université Jean Moulin, 18 rue Chevreul, 69007, Lyon, France
| | - Nadja Eggert
- Plateforme Interdisciplinaire d'Éthique (Ethos), Université de Lausanne. Bâtiment Amphipôle, Quartier UNIL-Sorge, 1015, Lausanne, Switzerland
| | - Claire Harpet
- Faculté de Philosophie, Institut de Recherches Philosophiques de Lyon, Université Jean Moulin, 18 rue Chevreul, 69007, Lyon, France
- UMR 7206 Laboratoire d'Éco-anthropologie et d'Ethnobiologie MNHN/MdH, Paris, France
| | - Morgane Romero
- Espace Ethique Auvergne Rhône-Alpes, 7-11 rue Guillaume Paradin, 69008, Lyon, France
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Bruun H, Huniche L, Stenager E, Mogensen CB, Pedersen R. Hospital ethics reflection groups: a learning and development resource for clinical practice. BMC Med Ethics 2019; 20:75. [PMID: 31651308 PMCID: PMC6813973 DOI: 10.1186/s12910-019-0415-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. Methods This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. Results A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. Conclusion This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.
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Affiliation(s)
- H Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - L Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - E Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C B Mogensen
- Focused Research Unit in Emergency Medicine, Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Kohlen H. Ethische Fragen der Pflegepraxis im Krankenhaus und Möglichkeiten der Thematisierung. Ethik Med 2019. [DOI: 10.1007/s00481-019-00547-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bruun H, Pedersen R, Stenager E, Mogensen CB, Huniche L. Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors. BMC Med Ethics 2019; 20:49. [PMID: 31311525 PMCID: PMC6636139 DOI: 10.1186/s12910-019-0387-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. Methods The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Results The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. Conclusion The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.
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Affiliation(s)
- Henriette Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark.
| | - Reidar Pedersen
- Center for medical Ethics, Institute of Health and Society, University of Oslo, Kirkevejen 166, 0450, Oslo, Norway
| | - Elsebeth Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Christian Backer Mogensen
- Focused Research Unit in Emergency Medicine Institute for Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Lotte Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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Lantos JD, Saleem S, Raza F, Syltern J, Khoo EJ, Iyengar A, Pais P, Chinnappa J, Lezama-Del Valle P, Kidszun A. Clinical Ethics in Pediatrics: An International Perspective. THE JOURNAL OF CLINICAL ETHICS 2019. [DOI: 10.1086/jce2019301035] [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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Famuyide M, Compretta C, Ellis M. Neonatal nurse practitioner ethics knowledge and attitudes. Nurs Ethics 2018; 26:2247-2258. [PMID: 30319013 DOI: 10.1177/0969733018800772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neonatal nurse practitioners have become the frontline staff exposed to a myriad of ethical issues that arise in the day-to-day environment of the neonatal intensive care unit. However, ethics competency at the time of graduation and after years of practice has not been described. RESEARCH AIM To examine the ethics knowledge base of neonatal nurse practitioners as this knowledge relates to decision making in the neonatal intensive care unit and to determine whether this knowledge is reflected in attitudes toward ethical dilemmas in the neonatal intensive care unit. RESEARCH DESIGN This was a prospective cohort study that examined decision making at the threshold of viability, life-sustaining therapies for sick neonates, and a ranking of the five most impactful ethical issues. PARTICIPANTS AND RESEARCH CONTEXT All 47 neonatal nurse practitioners who had an active license in the State of Mississippi were contacted via e-mail. Surveys were completed online using Survey Monkey software. ETHICAL CONSIDERATIONS The study was approved by the University of Mississippi Medical Center Institutional Review Board (IRB; #2015-0189). FINDINGS Of the neonatal nurse practitioners who completed the survey, 87.5% stated that their religious practices affected their ethical decision making and 76% felt that decisions regarding life-sustaining treatment for a neonate should not involve consultation with the hospital's legal team or risk management. Only 11% indicated that the consent process involved patient understanding of possible procedures. Participating in the continuation or escalation of care for infants at the threshold of viability was the top ethical issue encountered by neonatal nurse practitioners. DISCUSSION Our findings reflect deficiencies in the neonatal nurse practitioner knowledge base concerning ethical decision making, informed consent/permission, and the continuation/escalation of care. CONCLUSION In addition to continuing education highlighting ethics concepts, exploring the influence of religion in making decisions and knowing the most prominent dilemmas faced by neonatal nurse practitioners in the neonatal intensive care unit may lead to insights into potential solutions.
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Bruun H, Lystbaek SG, Stenager E, Huniche L, Pedersen R. Ethical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010-2015: a qualitative content analyses. BMC Med Ethics 2018; 19:62. [PMID: 29914461 PMCID: PMC6006832 DOI: 10.1186/s12910-018-0308-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/04/2018] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this article is to give more insight into what ethical challenges clinicians in mental healthcare experience and discuss with a Clinical Ethics Committee in psychiatry in the Region of Southern Denmark. Ethical considerations are an important part of the daily decision-making processes and thereby for the quality of care in mental healthcare. However, such ethical challenges have been given little systematic attention – both in research and in practices. Methods A qualitative content analysis of 55 written case-reports from the Clinical Ethics Committee. The Committee offers clinicians in mental healthcare structured ethical analyses of ethical challenges and makes a thorough written case-report. Results The ethical challenges are grouped into three overarching topics: 1. Clinicians and their relation to patients and relatives. 2. Clinicians and institutional aspects of mental healthcare 3. Clinicians and mental healthcare in a wider social context. Through presentation of illustrative examples the complexity of daily clinical life in mental healthcare becomes evident, as well as typical interests, values and arguments. Conclusions This qualitative study indicates that difficult ethical challenges are an inherent part of mental healthcare that requires time, space and competence to be dealt with adequately.
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Affiliation(s)
- H Bruun
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark. .,Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark.
| | - S G Lystbaek
- Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark
| | - E Stenager
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark
| | - L Huniche
- User Perspectives, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Ethics of End of Life Decisions in Pediatrics: A Narrative Review of the Roles of Caregivers, Shared Decision-Making, and Patient Centered Values. Behav Sci (Basel) 2018; 8:bs8050042. [PMID: 29701637 PMCID: PMC5981236 DOI: 10.3390/bs8050042] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/18/2022] Open
Abstract
Background: This manuscript reviews unique aspects of end of life decision-making in pediatrics. Methods: A narrative literature review of pediatric end of life issues was performed in the English language. Results: While a paternalistic approach is typically applied to children with life-limiting medical prognoses, the cognitive, language, and physical variability in this patient population is wide and worthy of review. In end of life discussions in pediatrics, the consideration of a child’s input is often not reviewed in depth, although a shared decision-making model is ideal for use, even for children with presumed limitations due to age. This narrative review of end of life decision-making in pediatric care explores nomenclature, the introduction of the concept of death, relevant historical studies, limitations to the shared decision-making model, the current state of end of life autonomy in pediatrics, and future directions and needs. Although progress is being made toward a more uniform and standardized approach to care, few non-institutional protocols exist. Complicating factors in the lack of guidelines include the unique facets of pediatric end of life care, including physical age, paternalism, the cognitive and language capacity of patients, subconscious influencers of parents, and normative values of death in pediatrics. Conclusions: Although there have been strides in end of life decision-making in pediatrics, further investigation and research is needed in this field.
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Rasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum 2017; 29:313-346. [PMID: 28600658 PMCID: PMC5688194 DOI: 10.1007/s10730-017-9325-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a "bottom-up" perspective might give healthcare personnel opportunities to think and reflect more than a "top-down" perspective. A "bottom-up" approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a "top-down" approach risks removing such moral responsibility.
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Affiliation(s)
- Dara Rasoal
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden.
| | - Kirsti Skovdahl
- Department of Nursing and Health Sciences, University College in Southeast Norway, Drammen, Norway
| | - Mervyn Gifford
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden
| | - Annica Kihlgren
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden
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Real de Asúa D, Herreros B. Why dedicate yourself to bioethics? Seven reasons to get you started. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Real de Asúa D, Herreros B. Why dedicate yourself to bioethics? Seven reasons to get you started. Rev Clin Esp 2016; 216:271-5. [PMID: 26823202 DOI: 10.1016/j.rce.2015.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/22/2015] [Accepted: 12/13/2015] [Indexed: 11/25/2022]
Abstract
The aim of clinical bioethics is to promote rational clinical decisions that take into account the clinical facts and the preferences and values of individuals involved in a situation that entails a moral problem. The objective of the present study is to list the reasons why we consider bioethics knowledge and skills to be essential in daily practice and to promote a proactive mindset in clinical bioethics research. The arguments set forth include the need to adapt to changes in the clinical relationship in recent decades, the importance of an ethical approach both for the physician and the patient, the role of bioethics in preventing professional burnout, the ability of ethics to promote a more equitable distribution of resources and the possibility of conducting clinical research in bioethics, a field that has scarcely been explored in Spain.
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Affiliation(s)
- D Real de Asúa
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España; Grupo de Trabajo de Bioética y Profesionalismo, Sociedad Española de Medicina Interna, España; Instituto de Ética Clínica «Francisco Vallés», Universidad Europea de Madrid, Madrid, España.
| | - B Herreros
- Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España; Grupo de Trabajo de Bioética y Profesionalismo, Sociedad Española de Medicina Interna, España; Instituto de Ética Clínica «Francisco Vallés», Universidad Europea de Madrid, Madrid, España
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Czarkowski M, Kaczmarczyk K, Szymańska B. Hospital Ethics Committees in Poland. SCIENCE AND ENGINEERING ETHICS 2015; 21:1525-1535. [PMID: 25388547 DOI: 10.1007/s11948-014-9609-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/10/2014] [Indexed: 06/04/2023]
Abstract
According to UNESCO guidelines, one of the four forms of bioethics committees in medicine are the Hospital Ethics Committees (HECs). The purpose of this study was to evaluate how the above guidelines are implemented in real practice. There were 111 hospitals selected out of 176 Polish clinical hospitals and hospitals accredited by Center of Monitoring Quality in Health System. The study was conducted by the survey method. There were 56 (50%) hospitals that responded to the survey. The number of HECs members fluctuated between 3 and 16 members, where usually 5 (22% of HECs) members were part of the board committee. The composition of the HECs for professions other than physicians was diverse and non-standardized (nurses-in 86% of HECs, clergy-42%, lawyers-38%, psychologists-28%, hospital management-23%, rehab staff-7 %, patient representatives-3%, ethicists-2%). Only 55% of HECs had a professional set of standards. 98% of HECs had specific tasks. 62% of HECs were asked for their expertise, and 55% prepared <6.88% of the opinions were related to interpersonal relations between hospital personnel, patients and their families with emphasis on the interactions between superiors and their inferiors or hospital staff and patients and their families. Only 12% of the opinions were reported by the respondents as related to ethical dilemmas. In conclusion, few Polish hospitals have HECs, and the structure, services and workload are not always adequate. To ensure a reliable operation of HECs requires the development of relevant legislation, standard operating procedures and well trained members.
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Affiliation(s)
- Marek Czarkowski
- Department of Endocrinology and Internal Medicine, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.
- Center of Bioethics of the Supreme Medical Council, ul. Sobieskiego 110, 00-764, Warsaw, Poland.
| | - Katarzyna Kaczmarczyk
- Department of Endocrinology and Internal Medicine, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Beata Szymańska
- Department of Endocrinology and Internal Medicine, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
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Magelssen M, Pedersen R, Førde R. Novel Paths to Relevance: How Clinical Ethics Committees Promote Ethical Reflection. HEC Forum 2015; 28:205-16. [DOI: 10.1007/s10730-015-9291-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/24/2015] [Indexed: 10/23/2022]
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Lillemoen L, Pedersen R. Ethics reflection groups in community health services: an evaluation study. BMC Med Ethics 2015; 16:25. [PMID: 25889307 PMCID: PMC4413993 DOI: 10.1186/s12910-015-0017-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 04/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic ethics support in community health services in Norway is in the initial phase. There are few evaluation studies about the significance of ethics reflection on care. The aim of this study was to evaluate systematic ethics reflection in groups in community health (including nursing homes and residency), - from the perspectives of employees participating in the groups, the group facilitators and the service managers. The reflection groups were implemented as part of a research and development project. METHODS A mixed-methods design with qualitative focus group interviews, observations and written reports were used to evaluate. The study was conducted at two nursing homes, two home care districts and a residence for people with learning disabilities. Participants were employees, facilitators and service managers. The study was guided by ethical standard principles and was approved by the Norwegian Social Science Data Services. RESULTS We found support for ethics reflection as a valuable measure to strengthen clinical practice. New and improved solutions, more cooperation between employees, and improved collaboration with patients and their families are some of the results. No negative experiences were found. Instead, the ethics reflection based on experiences and challenges in the workplace, was described as a win-win situation. The evaluation also revealed what is needed to succeed and useful tips for further development of ethics support in community health services. CONCLUSIONS Ethics reflection groups focusing on ethical challenges from the participants' daily work were found to be significant for improved practice, collegial support and cooperation, personal and professional development among staff, facilitators and managers. Resources needed to succeed were managerial support, and anchoring ethics sessions in the routine of daily work.
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Affiliation(s)
| | - Reidar Pedersen
- University of Oslo, P.O.Box 1130, Blindern, NO-0318, Oslo, Norway.
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Hem MH, Pedersen R, Norvoll R, Molewijk B. Evaluating clinical ethics support in mental healthcare: a systematic literature review. Nurs Ethics 2014; 22:452-66. [PMID: 25091004 DOI: 10.1177/0969733014539783] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded 'grey zone articles', in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients' and caregivers' views on ethical challenges, is presented.
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Abstract
Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission's Guidance about Compliance: Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the many ethical elements that are highlighted in the Commission's Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK.
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Schlairet MC, Kiser K, Norris S. Clinical ethics support services: an evolving model. Nurs Outlook 2012; 60:309-15. [PMID: 22357314 DOI: 10.1016/j.outlook.2012.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 01/04/2012] [Accepted: 01/15/2012] [Indexed: 10/28/2022]
Abstract
Ethical issues arising in clinical practice are complex and clinicians must be able to manage the needs of ethically vulnerable patients and families. This paper describes a model for providing Clinical Ethics Support Services as a broad spectrum of care for management of conflict and ethically difficult situations in health care and describes how an ethics consultation process was transformed to a Holistic Care Continuum for managing the needs of ethically vulnerable patients. During a 4-year journey at a regional medical center, a Family Support Team played a central role in identification of ethically vulnerable patients/family, interdisciplinary connectivity, and iterative engagement in the clinical milieu. Concepts of professional advocacy and interdisciplinary perspectives resulted in a model for ethically sound patient care promoting communication among patients/family, staff, and professionals; clarification of interdisciplinary roles and responsibilities; establishment of mutually derived goals and shared solutions; and implementation of interventions maximizing institutional resources.
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Affiliation(s)
- Maura C Schlairet
- College of Nursing, Valdosta State University, 1500 N. Patterson St.,Valdosta, GA 31698, USA.
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Clinical ethics committees in Norway: what do they do, and does it make a difference? Camb Q Healthc Ethics 2011; 20:389-95. [PMID: 21676326 DOI: 10.1017/s0963180111000077] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The first clinical ethics committees (CEC) in Norway were established in 1996. This started as an initiative from hospital clinicians, the Norwegian Medical Association, and health authorities and politicians. Norwegian hospitals are, by and large, publicly funded through taxation, and all inpatient treatment is free of charge. Today, all the 23 hospital trusts (providing specialized and hospital-based healthcare services to the Norwegian population of 4.9 million people) have established at least one committee. Center for Medical Ethics (SME), University of Oslo, receives an annual amount of US$335,000 from the Ministry of Health and Care Services to coordinate the committees and to facilitate competency building for committee members.
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Gaudine A, Lamb M, LeFort SM, Thorne L. Barriers and facilitators to consulting hospital clinical ethics committees. Nurs Ethics 2011; 18:767-80. [PMID: 21646320 DOI: 10.1177/0969733011403808] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hospitals in many countries have had clinical ethics committees for over 20 years. Despite this, there has been little research to evaluate these committees and growing evidence that they are underutilized. To address this gap, we investigated the question 'What are the barriers and facilitators nurses and physicians perceive in consulting their hospital ethics committee?' Thirty-four nurses, 10 nurse managers and 31 physicians working at four Canadian hospitals were interviewed using a semi-structured interview guide as part of a larger investigation. We used content analysis of the interview data related to barriers and facilitators to use of hospital ethics committees to identify nine categories of barriers and nine categories of facilitators. These categories as well as their subcategories are discussed and those specific to nurses or physicians are identified. The need to increase health professionals' use of clinical ethics committees through reducing barriers and maximizing facilitators is discussed.
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Affiliation(s)
- Alice Gaudine
- School of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada.
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The functioning of hospital ethics committees: a multiple-case study of four Canadian committees. HEC Forum 2011; 23:225-38. [PMID: 21544679 DOI: 10.1007/s10730-011-9151-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A multiple-case study of four hospital ethics committees in Canada was conducted and data collected included interviews with key informants, observation of committee meetings and ethics-related hospital documents, such as policies and committee minutes. We compared the hospital committees in terms of their structure, functioning and perceptions of key informants and found variation in the dimensions of empowerment, organizational culture of ethics, breadth of ethics mandate, achievements, dynamism, and expertise.
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Kalager G, Førde R, Pedersen R. Is the discussion of patient cases in clinical ethics-committees useful? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:118-21. [PMID: 21267026 DOI: 10.4045/tidsskr.10.0183] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND All health enterprises in Norway today have at least one clinical ethics committee (CEC). One of the aims is to give advice and to counsel the hospital staff on ethical issues. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from these committees in individual cases. MATERIAL AND METHODOLOGY The local committees were requested to distribute a questionnaire to all clinicians who had submitted a case to the committee during the previous 18 months. The survey was anonymous. Out of the 86 questionnaires that were distributed, 43 (50%) were returned to the Centre for Medical Ethics. RESULTS The majority of clinicians had a number of reasons for contacting the committee. The most usual reason was the desire to have a broad consultation on a case (70%), which was regarded as useful. The most common issue discussed was limiting the treatment of a seriously ill patient (56%), the will/wishes of the next-of-kin (40%) and patient autonomy (37%). The committee gave advice in 50% of the cases. Thirty-eight percent of the consultations resulted in practical consequences, including the discontinuation of treatment in six cases. INTERPRETATION Because of the low response percentage, the results must be interpreted with caution. The work of the committees is generally evaluated as useful, and the consultations can have practical consequences. However, it is challenging to make this work better known among clinicians and to conduct quality assurance.
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Affiliation(s)
- Guro Kalager
- Centre for Medical Ethics, University of Oslo, Postbox 1130 Blindern, 0318 Oslo, Norway
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