Doctors' stories, patients' stories: a narrative approach to teaching medical ethics

Patient values in patient-provider communication about participation in early phase clinical cancer trials: a qualitative analysis before and after implementation of an online value clarification tool intervention

BACKGROUND

Patients with advanced cancer who no longer have standard treatment options available may decide to participate in early phase clinical trials (i.e. experimental treatments with uncertain outcomes). Shared decision-making (SDM) models help to understand considerations that influence patients' decision. Discussion of patient values is essential to SDM, but such communication is often limited in this context and may require new interventions. The OnVaCT intervention, consisting of a preparatory online value clarification tool (OnVaCT) for patients and communication training for oncologists, was previously developed to support SDM. This study aimed to qualitatively explore associations between patient values that are discussed between patients and oncologists during consultations about potential participation in early phase clinical trials before and after implementation of the OnVaCT intervention.

METHODS

This study is part of a prospective multicentre nonrandomized controlled clinical trial and had a between-subjects design: pre-intervention patients received usual care, while post-intervention patients additionally received the OnVaCT. Oncologists participated in the communication training between study phases. Patients' initial consultation on potential early phase clinical trial participation was recorded and transcribed verbatim. Applying a directed approach, two independent coders analysed the transcripts using an initial codebook based on previous studies. Steps of continuous evaluation and revision were repeated until data saturation was reached.

RESULTS

Data saturation was reached after 32 patient-oncologist consultations (i.e. 17 pre-intervention and 15 post-intervention). The analysis revealed the values: hope, perseverance, quality or quantity of life, risk tolerance, trust in the healthcare system/professionals, autonomy, social adherence, altruism, corporeality, acceptance of one's fate, and humanity. Patients in the pre-intervention phase tended to express values briefly and spontaneously. Oncologists acknowledged the importance of patients' values, but generally only gave 'contrasting' examples of why some accept and others refuse to participate in trials. In the post-intervention phase, many oncologists referred to the OnVaCT and/or asked follow-up questions, while patients used longer phrases that combined multiple values, sometimes clearly indicating their weighing.

CONCLUSIONS

While all values were recognized in both study phases, our results have highlighted the different communication patterns around patient values in SDM for potential early phase clinical trial participation before and after implementation of the OnVaCT intervention. This study therefore provides a first (qualitative) indication that the OnVaCT intervention may support patients and oncologists in discussing their values.

TRIAL REGISTRATION

Netherlands Trial Registry: NL7335, registered on July 17, 2018.

Writing the worlds of genomic medicine: experiences of using participatory-writing to understand life with rare conditions

The diagnostic and treatment possibilities made possible by the development and subsequent mainstreaming of clinical genomics services have the potential to profoundly change the experiences of families affected by rare genetic conditions. Understanding the potentials of genomic medicine requires that we consider the perspectives of those who engage with such services; there are substantial social implications involved. There are increasing calls to think more creatively, and draw on more participatory approaches, in evoking rich accounts of lived experience. In this article, we discuss our rationale for, and experiences of, using 'participatory-writing' to understand the diverse, variable and multilayered everyday lives of families and how these correspond with the emerging, rapidly changing and complex field of genomic medicine. Participatory-writing has many benefits as a method for social inquiry. Writing can be expressive and self-revelatory, providing insight into personal and sensitive topics. Writing together produces new conversations and relationships. Pieces written by participants have the potential to affect readers, evoking and enlivening research and prompting professional change. Working with a writing tutor, we organised a participatory-writing programme for families touched by genetic conditions. This involved a series of workshops with an emphasis on building confidence in expressing lived experience through experimenting with different writing techniques. Afterwards we arranged reflective interviews with participants. We drew on dialogical narrative analysis to engage with participants' written pieces, and highlight what everyday life is like for the people who live with, and care for, those with genetic conditions. The stories produced through our writing-groups unfold the implications of new genomic technologies, illuminating how genomics acts to (and likewise, fails to) reconfigure aspects of people's lives outside of the clinic, while simultaneously existing as a sociotechnical frame that can eclipse the wider contexts, challenges and liveliness of life with rare genetic conditions.

Applications of Narrative Medicine to Surgical Education

Narrative medicine describes the application of story to medical education and practice. Although it has been implemented successfully in many medical schools as a part of undergraduate medical education, applications to the residency environment have been relatively limited. There are virtually no data concerning the adoption of narrative medicine within surgical residencies. This paper provides a brief introduction to the formal discipline of narrative medicine. We further discuss how storytelling is already used in surgical education and summarize the literature on applications of narrative medicine to residents in other specialties. The relevance of narrative medicine to the ACGME core competencies is explored. We conclude with specific suggestions for implementation of narrative medicine within surgical residency programs.

Ethics and gender issues in palliative care in nursing homes: an Austrian participatory research project

BACKGROUND

The development of palliative care in nursing homes in German-speaking countries has gained in importance within the past 15-20 years. Ethical and gender issues are core aspects of a palliative care culture and should therefore be better understood.

AIMS AND OBJECTIVES

The aim of this study was to highlight insights regarding ethical and gender issues, based on the experiences of professionals in nursing homes.

DESIGN

A 2-year participatory action research study was performed in collaboration with three nursing homes in Austria.

METHODS

The article focusses on 10 group discussions with interdisciplinary professional teams that were conducted to generate ethical narratives. Thematic and narrative analysis was undertaken both individually and within the interdisciplinary research team. Findings and interpretations were validated with practitioners and researchers.

FINDINGS

A total of 36 narratives were collected and summarised within eight themes concerning the theoretical journey of a nursing home resident with relatives from entry into the house until death. The most burdensome ethical dilemmas are not the ones around death and dying but rather those relating to small-scale everyday work/life issues. Sharing experiences and feelings in ethical discussions provides relief. Emotions are important facilitators of insight into ethical dilemmas. Gender issues can be observed in care situations as well as in the organisational structure of nursing homes.

CONCLUSIONS

Opportunities to share experiences and perspectives around ethical questions in interdisciplinary group discussions help professionals to better understand difficult issues and find appropriate ways of managing them.

IMPLICATIONS FOR PRACTICE

There is a need for communication structures such as facilitated ethical discussions that enable nursing home staff to reflect their everyday decisions. Expression of emotions should be encouraged in ethical decision-making processes in nursing homes. Gender-sensitive reflection supports the development of palliative care as organisational culture.

Textual practices in crafting bioethics cases

Bioethics case reports generally treat aspects of moral fathomability, characterised and addressed in different ways. This paper reads the case as a textual model of scenarios and draws attention to its structure, narrative shape, linguistic register, and the effects of tone and temporality on reader expectation and responsiveness. Such textual elements of case composition reflect authorial purpose and influence the interpretation, including moral and ethical interpretation, of bioethics cases.

A faculty development workshop in narrative-based reflective writing

Narrative approaches are used increasingly in the health professions with a range of objectives. We must acquaint educators with this burgeoning field and prepare them for the incorporation of story-telling in their pedagogical practices. The authors describe a template for a faculty development workshop designed to foster self-reflection through the use of narrative techniques and prepare clinical teachers to deploy such approaches. The design is based on a six-year experience in delivering introductory workshops in narrative approaches to medical teachers. The workshops, which served as a model for the template, have been offered to a total of 92 clinicians being trained to mentor medical students. A generic template is described. It includes a table of core concepts from narrative theory, a set of probing questions useful in a basic technical analysis of texts and a list of initiating prompts for exercises in reflective writing. A workshop organized and deployed using this template is deliverable over a half-day. The model has proven to be feasible and highly valued by participants. It can be adapted for other contexts by educators across the continuum of health professional education.

Critically ill patients and end-of-life decision-making: the senior medical resident experience

In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either English or French, and the transcripts then underwent a hermeneutic phenomenological analysis. The resident was the central figure in the narrated incident, along with the patients' relatives and other attending physicians. The vast majority of interviews recounted negative experiences that involved delivering bad news to patients' families and managing difficult communications with them and with physician colleagues. Emotional distress and suffering were often part of their decision-making process. Narrating their experiences was viewed as a positive event. Data analysis uncovered 6 general themes that were organized into 2 categories, the first one grouping together themes related to interactions with the patients' families and the second comprising themes related to interactions with physician coworkers. The findings suggest that physician trainees' narratives are a rich source of data regarding what constitutes meaningful training experiences and what they learn from them. Educational approaches that incorporate the telling of stories would allow students to express their feelings, doubts, and opinions about their work experiences and could thus foster personal and emotional learning in critical care.

Experienced speech-language pathologists' responses to ethical dilemmas: an integrated approach to ethical reasoning

PURPOSE

To investigate the approaches of experienced speech-language pathologists (SLPs) to ethical reasoning and the processes they use to resolve ethical dilemmas.

METHOD

Ten experienced SLPs participated in in-depth interviews. A narrative approach was used to guide participants' descriptions of how they resolved ethical dilemmas. Individual narrative transcriptions were analyzed by using the participant's words to develop an ethical story that described and interpreted their responses to dilemmas. Key concepts from individual stories were then coded into group themes to reflect participants' reasoning processes.

RESULTS

Five major themes reflected participants' approaches to ethical reasoning: (a) focusing on the well-being of the client, (b) fulfilling professional roles and responsibilities, (c) attending to professional relationships, (d) managing resources, and (e) integrating personal and professional values. SLPs demonstrated a range of ethical reasoning processes: applying bioethical principles, casuistry, and narrative reasoning when managing ethical dilemmas in the workplace.

CONCLUSIONS

The results indicate that experienced SLPs adopted an integrated approach to ethical reasoning. They supported clients' rights to make health care choices. Bioethical principles, casuistry, and narrative reasoning provided useful frameworks for facilitating health professionals' application of codes of ethics to complex professional practice issues.

Ethics-in-oncology forums

BACKGROUND

We developed an ethics curriculum for hematology/oncology fellows who had already learned medical ethics from medical school and residency programs. The goal of the ethics program was to train fellows in ethics issues specific to hematology/oncology; to raise awareness of ethical issues; and to teach fellows to write, edit, and publish reviews in specific ethical issues.

METHODS

Fellows learned to summarize expert opinions, to understand diversity in cultural concepts relating to ethics, and to crystallize their approaches to ethical dilemmas to selected oncology patients. Fellows were also trained to write ethics discussions in manuscript format, edit the manuscripts, and submit them for publication.

RESULTS

We hypothesized that fellows would learn ethics in oncology by recognizing and choosing an ethical dilemma from among patient population; reviewing the literature for a discussion of relevant ethical issues; presenting the case and facilitating discussion to an ethics-in-oncology committee; hearing faculty and peer input into their cases; and finally writing, editing, and publishing the deliberation. It also increased understanding of health systems management, a new competency required by the Accreditation Council for Graduate Medical Education for board certification.

CONCLUSIONS

Fellows' perceptions about the experience were positive. We recommend that other subspecialty programs consider this format for teaching ethics in their subspecialties.

Ethics education after licensing: ideas for increasing diversity in content and process

Continuing professional education in ethics for psychologists is becoming more common, as psychology licensing boards in 14 states now require continuing education in ethics as a condition of licensure renewal. This article suggests ways to improve the quality of ethics continuing education by diversifying the content and teaching methods.

Teaching medical ethics to experienced staff: participants, teachers and method

Almost all articles on education in medical ethics present proposals for or describe experiences of teaching students in different health professions. Since experienced staff also need such education, the purpose of this paper is to exemplify and discuss educational approaches that may be used after graduation. As an example we describe the experiences with a five-day European residential course on ethics for neonatal intensive care personnel. In this multidisciplinary course, using a case-based approach, the aim was to enhance the participants' understanding of ethical principles and their relevance to clinical and research activities. Our conclusion is that working with realistic cases encourages practising nurses and physicians to apply their previous knowledge and new concepts learnt in the course, thus helping them to bridge the gap between theory and practice.

Neonatal ethical decision making: where does the NNP fit in?

Neonatal nurse practitioners are frequently confronted with ethical dilemmas in the NICU. This article reflects on the historical basis of ethical decision making and the issues some novice NNPs face today regarding their participation in the decision-making process. It examines various educational strategies that can be used to help NNPs to develop the skills they need to participate collaboratively in ethical decision making in the NICU. It concludes with recommendations for further research.

Do case studies mislead about the nature of reality?

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis.