Introduction of a Novel Ethics Curriculum to the Third-Year Psychiatry Clerkship Experience

OBJECTIVE

The purpose of this study was to determine if a brief ethics curriculum embedded in a third-year required clerkship differentially impacted students' self-rated confidence versus competence (determined by a written examination) regarding ethical principles related to psychiatry.

METHODS

Using a naturalistic design, 270 medical students at the University of Washington were assigned to one of three groups during their third-year psychiatry clerkship: a control group with no additional ethics content, a group with access to a pre-recorded video ethics curriculum, or a group with live didactic sessions in addition to the video curriculum. All students took a pre- and post-test that assessed their confidence and competence in ethical theory and behavioral health ethics.

RESULTS

Confidence and competence were not statistically different across the three groups prior to completing the curriculum (p > 0.1). Post-test scores on confidence in behavioral health ethics were not significantly different between the three groups (p > 0.05). Post-test scores on confidence in ethical theory were significantly higher in the video-only and video + discussion group as compared to the control group (3.74 ± 0.55 and 4.00 ± 0.44 vs. 3.19 ± 0.59 respectively; p < 0.0001). Both the video-only and video + discussion group showed greater improvement in competence in ethical theory and application than the control group (0.68 ± 0.30 and 0.76 ± 0.23 vs. 0.31 ± 0.33, respectively; p < 0.0001) and behavioral health ethics (0.79 ± 0.14 and 0.85 ± 0.14 vs. 0.59 ± 0.15, respectively; p < 0.002).

CONCLUSIONS

With the addition of this ethics curriculum, students showed both increased confidence and competence in their ability to analyze ethical situations as well as increased competence regarding behavioral health ethics.

Rationale for integration of palliative care in the medical intensive care: A narrative literature review

Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.

Ethical and Professional Considerations in Integrated Behavioral Health

Integrated behavioral health models of care offer many benefits for patient experience and outcomes. However, multidisciplinary teams are comprised of professionals who each may have different professional norms and ethical obligations, which may at times be in conflict. This article offers a framework for negotiating potential conflicts between professional norms and expectations across disciplines involved in integrated behavioral health teams.

Disagreement Between Clinicians and Score in Decision-Making Capacity of Critically Ill Patients

OBJECTIVES

To compare the assessment of decision-making capacity of ICU patients by attending clinicians (physicians, nurses, and residents) with a capacity score measured by the Mini-Mental Status Examination, completed by Aid to Capacity Evaluation if necessary. The primary outcome was agreement between physicians' assessments and the score. Secondary outcomes were agreement between nurses' or residents' assessments and the score and identification of factors associated with disagreement.

DESIGN

A 1-day prevalence study.

SETTING

Nineteen ICUs in France.

SUBJECTS

All patients hospitalized in the ICU on the study day and the attending clinicians.

INTERVENTIONS

The decision-making capacity of patients was assessed by the attending clinicians and independently by an observer using the score.

MEASUREMENTS AND MAIN RESULTS

A total of 206 patients were assessed by 213 attending clinicians (57 physicians, 97 nurses, and 59 residents). Physicians designated more patients as having decision-making capacity (n = 92/206 [45%]) than score (n = 34/206 [17%]; absolute difference 28% [95% CI, 20-37%]; p = 0.001). There was a high disagreement between assessments of all clinicians and score (Kappa coefficient 0.39 [95% CI, 0.29-0.50] for physicians; 0.39 [95% CI, 0.27-0.52] for nurses; and 0.46 [95% CI, 0.35-0.58] for residents). The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15 (odds ratio, 2.92 [1.18-7.19], p = 0.02 for physicians; 4.97 [1.50-16.45], p = 0.01 for nurses; and 3.39 [1.12-10.29], p = 0.03 for residents) without differentiating between the Glasgow Coma Scale scores from 10 to 15.

CONCLUSIONS

The decision-making capacity of ICU patients was largely overestimated by all attending clinicians as compared with a score. The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15, suggesting that clinicians confused consciousness with decision-making capacity.

Assessment of Medical Decision-making Capacity in Patients With Dementia

Medical decision-making capacity, the patient's ability to exercise autonomy reasonably, is an essential component of both informed consent and informed refusal. The assessment of medical decision-making capacity is thus fundamental to the ethical practice of medicine. Medical decision-making capacity is not all or nothing but rather exists on a continuum and should be assessed on a decision-by-decision basis. Alzheimer disease and other neurocognitive disorders can affect a patient's medical decision-making capacity and may pose special challenges to capacity assessment. To illustrate some of these challenges, this article presents a case of a patient with Alzheimer disease who refused a recommended operation and discusses the components of capacity, a useful mnemonic and tools, the variability of state laws, and the roles neurologists and psychiatrists play in the assessment of capacity.

Identification of core ethical topics for interprofessional education in the intensive care unit: a thematic analysis

Medical educators have not identified effective approaches for interprofessional ethics education of clinicians who work in intensive care units (ICUs), in spite of the fact that ICUs have a high incidence of ethical conflicts. As a first step in designing an interprofessional ethics education initiative tailored to the needs of ICU team members, we interviewed 12 professionals from the medical and surgical ICUs of a tertiary care academic medical center to understand what they know about medical ethics. Respondents were interviewed between November 2016 and February 2017. We used the 'think aloud' approach and realist thematic analysis of the sessions to evaluate the extent and content of interprofessional team members' knowledge of medical ethics. We found wide variation in their knowledge of and facility in applying the principles and concepts of biomedical ethics and ways of resolving ethical conflicts. Ethics education tailored to these areas will help equip critical care professionals with the necessary knowledge and skills to discuss and address ethical conflicts encountered in the ICU. Preventive ethics rounds are one approach for providing real-time, embedded interprofessional ethics education in the clinical setting.

Ten Best Practices for the Older Patient in the Emergency Department

This article reviews 10 best practices that integrate geriatric principles into emergency department processes of care. These best practices are grouped around ten words: complexity; clinician education; geriatric-specific; atypical; medication; variability; cognitive impairment; psychosocial issues; end-of-life care; and interdisciplinary.

[Palliative care : Challenges in the intensive care unit]

Intensive care unit (ICU) stays often result due to an acute, potentially life-threatening illness or aggravation of a chronic life-threatening illness. In many cases, ICU patients die after life-sustaining treatments are withdrawn or withheld. When patients are asked, they prefer to die at home, although logistic and medical problems often prevent this. Therefore, attention focuses on care at the end of life in the ICU. Despite many efforts to improve the quality of care, evidence suggests that the quality in hospitals varies significantly and that palliative care in the ICU has not significantly improved over time. In this review, aspects of palliative care that are specific to ICU patients are discussed.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Ethics skills laboratory experience for surgery interns

INTRODUCTION AND PURPOSE

Ethics curricula are nearly universal in residency training programs, but the content and delivery methods are not well described, and there is still a relative paucity of literature evaluating the effect of ethics curricula. Several commentators have called for more ethics curriculum development at the postgraduate level, and specifically in surgery training. We detail our development and implementation of a clinical ethics curriculum for surgery interns.

METHODS

We developed curricula and simulated patient cases for 2 core clinical ethics skills--breaking bad news and obtaining informed consent. Educational sessions for each topic included (1) framework development (discussion of interns' current experience, development of a consensus framework for ethical practice, and comparison with established frameworks) and (2) practice with simulated patient followed by peer and faculty feedback. At the beginning and end of each session, we administered a test of confidence and knowledge about the topics to assess the effect of the sessions.

RESULTS

A total of 98 surgical interns participated in the ethics skills laboratory from Spring 2008 to Spring 2011. We identified significant improvement in confidence regarding the appropriate content of informed consent (<0.001) and capacity to break bad news (<0.001). We also identified significant improvement in overall knowledge regarding informed consent (<0.01), capacity assessment (<0.05), and breaking bad news (0.001). Regarding specific components of informed consent, capacity assessment, and breaking bad news, significant improvement was shown in some areas, while we failed to improve knowledge in others.

CONCLUSIONS

Through faculty-facilitated small group discussion, surgery interns were able to develop frameworks for ethical practice that paralleled established frameworks. Skills-based training in clinical ethics resulted in an increase in knowledge scores and self-reported confidence. Evaluation of 4 annual cohorts of surgery interns demonstrates significant successes and some areas for improvement in this educational intervention.

Conflicts and communication gaps in the intensive care unit

PURPOSE OF REVIEW

Conflicts occur frequently in the ICU. Research on ICU conflicts is an emerging field, with only few recent studies being available on intrateam and team-family conflicts. Research on communication in the ICU is developing at a faster pace.

RECENT FINDINGS

Recent findings come from one multinational epidemiological survey on intrateam conflicts and one qualitative study on the causes and consequences of conflicts. Advances in research on communication with families in the ICU have improved our understanding of team-family and intrateam conflicts, thus suggesting targets for improvement.

SUMMARY

Data about ICU conflicts depend on conflict definition, study designs (qualitative versus quantitative), patient case-mix, and detection bias. Conflicts perceived by caregivers are frequent and consist mainly in intrateam conflicts. The two main sources of conflicts in the ICU are end-of-life decisions and communication issues. Conflicts negatively impact patient safety, patient/family-centered care, and team welfare and cohesion. They generate staff burnout and increase healthcare costs. Further qualitative studies rooted in social-science theories about workplace conflicts are needed to better understand the typology of ICU conflicts (sources and consequences) and to address complex ICU conflicts that involve systems as opposed to people. Conflict prevention and resolution are complex issues requiring multimodal interventions. Clinical research in this field is insufficiently developed, and no guidelines are available so far. Prevention strategies need to be developed along two axes: improved understanding of family experience, preferences, and values, as well as evidence-based communication may reduce team-family conflicts and organizational measures including restoring leadership, multidisciplinary teamwork, and improved communication within the team may prevent intrateam conflicts in the ICU.

Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment

This integrative review aims to provide a synthesis of research findings of health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to or refuse treatment within the general hospital setting. Search strategies included relevant health databases, hand searching of key journals, ‘snowballing’ and expert recommendations. The review identified various knowledge gaps and attitudinal dispositions of health-care professionals, which influence their behaviours and decision-making in relation to capacity to consent processes. The findings suggest that there is tension between legal, ethical and professional standards relating to the assessment of capacity and consent within health care. Legislation and policy guidance concerning capacity assessment processes are lacking, and this may contribute to inconsistencies in practice.

Family involvement in the end-of-life decisions of competent intensive care patients

In this article, we report the findings from a qualitative study that explored how relatives of terminally ill, alert and competent intensive care patients perceived their involvement in the end-of-life decision-making process. Eleven family members of six deceased patients were interviewed. Our findings reveal that relatives narrate about a strong intertwinement with the patient. They experienced the patients' personal individuality as a fragile achievement. Therefore, they viewed their presence as crucial with their primary role to support and protect the patient, thereby safeguarding his values and interests. However, their inclusion in decision making varied from active participation in the decision-making process to acceptance of the physicians' decision or just receiving information. We conclude that models of informed shared decision making should be utilised and optimised in intensive care, where nurses and physicians work with both the patient and his or her family and regard the family as partners in the process.

Everyday ethics in internal medicine resident clinic: an opportunity to teach

OBJECTIVES

Being a good doctor requires competency in ethics. Accordingly, ethics education during residency training is important. We studied the everyday ethics-related issues (i.e. ordinary ethics issues commonly faced) that internal medical residents encounter in their out-patient clinic and determined whether teaching about these issues occurred during faculty preceptor-resident interactions.

METHODS

This study involved a multi-method qualitative research design combining observation of preceptor-resident discussions with preceptor interviews. The study was conducted in two different internal medicine training programme clinics over a 2-week period in June 2007. Fifty-three residents and 19 preceptors were observed, and 10 preceptors were interviewed. Transcripts of observer field notes and faculty interviews were carefully analysed. The analysis identified several themes of everyday ethics issues and determined whether preceptors identified and taught about these issues.

RESULTS

Everyday ethics content was considered present in 109 (81%) of the 135 observed case presentations. Three major thematic domains and associated sub-themes related to everyday ethics issues were identified, concerning: (i) the Doctor-Patient Interaction (relationships; communication; shared decision making); (ii) the Resident as Learner (developmental issues; challenges and conflicts associated with training; relationships with colleagues and mentors; interactions with the preceptor), and; (iii) the Doctor-System Interaction (financial issues; doctor-system issues; external influences; doctor frustration related to system issues). Everyday ethics issues were explicitly identified by preceptors (without teaching) in 18 of 109 cases (17%); explicit identification and teaching occurred in only 13 cases (12%).

CONCLUSIONS

In this study a variety of everyday ethics issues were frequently encountered as residents cared for patients. Yet, faculty preceptors infrequently explicitly identified or taught these issues during their interactions with residents. Ethics education is important and residents may regard teaching about the ethics-related issues they actually encounter to be highly relevant. A better understanding of the barriers to teaching is needed in order to promote education about everyday ethics in the out-patient setting.