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Blackler L, Scharf AE, Matsoukas K, Colletti M, Voigt LP. 'If you build it, they will come…to the wrong door: evaluating patient and caregiver-initiated ethics consultations via a patient portal'. BMJ Health Care Inform 2024; 31:e100988. [PMID: 38677775 DOI: 10.1136/bmjhci-2023-100988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/17/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVES Memorial Sloan Kettering Cancer Center (MSK) sought to empower patients and caregivers to be more proactive in requesting ethics consultations. METHODS Functionality was developed on MSK's electronic patient portal that allowed patients and/or caregivers to request ethics consultations. The Ethics Consultation Service (ECS) responded to all requests, which were documented and analysed. RESULTS Of the 74 requests made through the portal, only one fell under the purview of the ECS. The others were primarily requests for assistance with coordinating clinical care, hospital resources or frustrations with the hospital or clinical team. DISCUSSION To better empower patients and caregivers to engage Ethics, healthcare organisations and ECSs must first provide them with accessible, understandable and iterative educational resources. CONCLUSION After 19.5 months, the 'Request Ethics Consultation' functionality on the patient portal was suspended. Developing resources on the role of Ethics for our patients and caregivers remains a priority.
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Affiliation(s)
- Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy E Scharf
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Konstantina Matsoukas
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Technology Division, Library Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michelle Colletti
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis P Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Mahadevan A, Azizi A, Dastur C, Stern-Nezer S, Nahmias J, Dayyani F. Characterization of patients requiring inpatient hospital ethics consults- A single center study. PLoS One 2024; 19:e0296763. [PMID: 38564582 PMCID: PMC10986956 DOI: 10.1371/journal.pone.0296763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 12/18/2023] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Ethics consultations are often needed at difficult junctures of medical care. However, data on the nature of how patient characteristics, including race/ethnicity, language, and diagnosis, affect ethics consult outcomes are lacking. METHODS We performed a retrospective cohort study of all patients who were seen by the Ethics Consult Service between 2017 and 2021 at a large tertiary academic center with the aim of determining whether patient demographic and clinical factors were associated with the timing of ethics consult requests and recommendations of the ethics team. RESULTS We found that patients admitted for COVID-19 had significantly longer median times to consult from admission compared with other primary diagnoses (19 vs 8 days respectively, p = 0.015). Spanish-speaking patients had longer median times to consult from admission compared to English speaking patients (20 vs 7 days respectively, p = 0.008), indicating that language barriers may play a role in the timing of ethics consultation. CONCLUSIONS This study demonstrates the need to consider clinical and demographic features when planning and prioritizing ethics consultations at large institutions to enhance consult efficiency, resource utilization, and patient experience and autonomy.
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Affiliation(s)
- Aditya Mahadevan
- University of California Irvine School of Medicine, Irvine, Irvine, CA, United States of America
| | - Armon Azizi
- University of California Irvine School of Medicine, Irvine, Irvine, CA, United States of America
| | - Cyrus Dastur
- Department of Neurology, Division of Neurocritical Care, University of California, Irvine, Irvine, CA, United States of America
| | - Sara Stern-Nezer
- Department of Neurology, Division of Neurocritical Care, University of California, Irvine, Irvine, CA, United States of America
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns, Critical Care & Acute Care Surgery, University of California, Irvine, Irvine, CA, United States of America
| | - Farshid Dayyani
- Department of Medicine, Division of Hematology and Oncology, University of California, Irvine, Irvine, CA, United States of America
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Siegel B, Taylor LS, Alizadeh F, Barreto JA, Daniel D, Alexander PMA, Lipsitz S, Moynihan K. Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital. Pediatr Crit Care Med 2024; 25:301-311. [PMID: 38193777 DOI: 10.1097/pcc.0000000000003422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN Retrospective cohort study using mixed methods. SETTING Single-center quaternary pediatric hospital. PATIENTS Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.
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Affiliation(s)
- Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Dennis Daniel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Peta M A Alexander
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Katie Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Fiester A. The "Ladder of Inference" as a Conflict Management Tool: Working with the "Difficult" Patient or Family in Healthcare Ethics Consultations. HEC Forum 2024; 36:31-44. [PMID: 35435533 DOI: 10.1007/s10730-022-09476-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/30/2022]
Abstract
Conflict resolution is a core component of healthcare ethics consultation (HEC) and proficiency in this skill set is recognized by the national bioethics organization and its HEC certification process. Difficult interpersonal interactions between the clinical team and patients or their families are often inexorably connected to the normative disputes that are the catalyst for the consult. Ethics consultants are often required to navigate challenging dynamics that have become entrenched and work with patient-provider or family-provider relationships that have already broken down. The first step in conflict resolution is diagnosing the source of the conflict. Because so many interpersonal and normative conflicts rest on misunderstanding and mischaracterization, the diagnosis of the problem requires untangling the actual positions and perspectives of the conflicting parties from the fallacious assumptions made about the parties' respective positions and views. Developed in management science, the Ladder of Inference (LOI) is a diagnostic tool for assisting stakeholders in re-examining the process they used to form beliefs about others involved in the conflict. The LOI is a device that detects errors in reasoning, including implicit racial bias, that lead to false judgments and counterproductive responses to those judgments. The LOI is an instrument that can be used by ethics consultants to help resolve contentious bedside conflicts, but the LOI can also be employed as a teaching tool used by healthcare ethics consultants in training the clinical staff in how to avoid such conflicts in the first place.
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Affiliation(s)
- Autumn Fiester
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, 423 Guardian Dr., Blockley Hall Floor 14, Philadelphia, PA, 19104, USA.
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Blackstone EC, Daly BJ. The Need for Specialized Oncology Training for Clinical Ethicists. HEC Forum 2024; 36:45-59. [PMID: 35426566 DOI: 10.1007/s10730-022-09477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/22/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.
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Affiliation(s)
- Eric C Blackstone
- Department of Bioethics, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA.
| | - Barbara J Daly
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA
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Olszewski AE, Zhou C, Ugale J, Ramos J, Patneaude A, Opel DJ. Frequency of Perceived Conflict between Families and Clinicians at Time of Clinical Ethics Consultation in Hospitalized Children. AJOB Empir Bioeth 2024; 15:60-65. [PMID: 37754199 DOI: 10.1080/23294515.2023.2262958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Little is known about the frequency of conflict between clinicians and families at the time of pediatric clinical ethics consultation (CEC) and what factors are associated with the presence of conflict. METHODS We conducted a retrospective cohort study at a single, tertiary urban US pediatric hospital that included all hospitalized patients between January 2008 and December 2019 who received CEC. Utilizing the hospital's CEC database that requires documentation of the presence of conflict by the consultant at the time of CEC, we determined the frequency and types of perceived conflict between families and clinicians. We also assessed the bivariable association between conflict and patient age, patient- or family-reported race/ethnicity, language for care, insurance status, clinical setting, and consultant involvement. RESULTS Perceived conflict between clinicians and families was present in 44% (91/209) of CEC. We observed a higher occurrence of clinician-family conflict within certain consult topics than others, in particular, informed consent/parental permission (69%), cultural considerations (67%), benefit/harm assessment (58%), and limitation of life-sustaining treatment (58%). We found no other significant associations between the presence of perceived conflict and patient sociodemographic factors or CEC factors. CONCLUSIONS Conflict between healthcare teams and families appears common in CEC, particularly with certain consult topics. Further study is needed to better understand conflict types, causes of conflicts, management and mediation strategies, and outcomes.
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Affiliation(s)
- Aleksandra E Olszewski
- Division of Critical Care Medicine, Department of Pediatrics, Lurie Children's Hospital and Northwestern University, Chicago, Illinois, USA
| | - Chuan Zhou
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jiana Ugale
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jessica Ramos
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, Washington, USA
| | - Arika Patneaude
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- School of Social Work, University of Washington, Seattle, Washington, USA
| | - Douglas J Opel
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Eisenberg L. Vulnerable Patients, Adult Protective Services Investigations, and Reticent Surrogates: What is the Role of Clinical Ethics? Am J Bioeth 2024; 24:140-141. [PMID: 38236851 DOI: 10.1080/15265161.2024.2279434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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8
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Tarzian A. Responding to a Nurse's Perceived Moral Distress Prompting an Ethics Consultation Request. Am J Bioeth 2024; 24:129-131. [PMID: 38236853 DOI: 10.1080/15265161.2024.2279441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Anita Tarzian
- University of Maryland Francis King Carey School of Law
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Erler KS, Robinson EM, Bandini JI, Regel EV, Zwirner M, Cremens C, McCoy TH, Romain F, Courtwright A. Clinical Ethics Consultation During the First COVID-19 Pandemic Surge at an Academic Medical Center: A Mixed Methods Analysis. HEC Forum 2023; 35:371-388. [PMID: 35290566 PMCID: PMC8922390 DOI: 10.1007/s10730-022-09474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 11/25/2022]
Abstract
While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters.
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Affiliation(s)
- Kimberly S Erler
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
- School of Health and Rehabilitation Science, MGH Institute of Health Professions, Boston, MA, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Patient Care Services Office of Quality, Safety and Practice, Boston, MA, USA
| | - Julia I Bandini
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- RAND Corporation, Boston, MA, USA
| | - Eva V Regel
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Mary Zwirner
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Fred Romain
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Respiratory Care, Mass General Hospital, Boston, MA, USA
| | - Andrew Courtwright
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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Perin M, De Panfilis L. Clinical Ethics Committee in an Oncological Research Hospital: two-years Report. Nurs Ethics 2023; 30:1217-1231. [PMID: 37326119 PMCID: PMC10710006 DOI: 10.1177/09697330231174529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
RESEARCH QUESTION AND AIM Clinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020, a CEC was established in an Oncology Research Hospital in the North of Italy. This paper describes the development process and the activities performed 20 months from the CEC's implementation, to increase knowledge about CEC's implementation strategy. RESEARCH DESIGN We collected quantitative data related to number and characteristics of CEC activities carried out from October 2020 to June 2022 using the CEC internal database. Data were reported descriptively and compared with data from the literature to provide a complete overview of the CEC's development and implementation process. PARTICIPANTS AND RESEARCH CONTEXT The study has been conducted at the local health authority (LHA) of Reggio Emilia. It is a report of the activities provided by the CEC, where no HPs or patients were involved. ETHICAL CONSIDERATIONS The report is part of a larger study named EVAluating a Clinical Ethics Committee implementation process (EvaCEC), which has been approved by the Local Ethics Committee (AUSLRE Protocollo n° 2022/0026554 of 24/02/2022). EvaCEC is also the first author's PhD project. FINDINGS In total, the CEC performed 7 ethics consultations (EC), published three policies related to particular ethical questions of clinical and organizational practice, provided one educational online course on ethics consultation targeting employed HPs, and promoted a specific dissemination process among the different departments of the LHA. According to our results, the CEC widely fulfilled the standard threefold set of clinical ethics support services tasks (namely, ethics consultation, ethics education, and policy development), but further investigations are needed to evaluate the CEC's impact on clinical practice. CONCLUSION Our findings may increase knowledge regarding the composition, role, and tasks of a CEC in an Italian setting, informing future strategies and efforts to regulate these institutions officially.
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Affiliation(s)
- Marta Perin
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ludovica De Panfilis
- Legal Medicine and Bioethics, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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11
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Metselaar S, Molewijk B. Fostering moral resilience through moral case deliberation. Nurs Ethics 2023; 30:730-745. [PMID: 37946387 DOI: 10.1177/09697330231183085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience.
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Affiliation(s)
- Suzanne Metselaar
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands
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12
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Moss AH. Should the Incapacitated Patient's Prior Refusal of Dialysis Be Honored? The Value of a Systematic Approach to Gathering Data in an Ethics Consultation. Am J Bioeth 2023; 23:90-91. [PMID: 37450530 DOI: 10.1080/15265161.2023.2218251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
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13
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Wolfe ID. Beyond the consult question: Nurse ethicists as architects of moral spaces. Nurs Ethics 2023; 30:710-719. [PMID: 37946395 DOI: 10.1177/09697330231151351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Nurse Ethicists bring a unique perspective to clinical ethics consultation. This perspective provides an appreciation of ethical tensions that will exist beyond the consult question into the moral space of patient care. These tensions exist even when an ethically preferable plan of action is identified. Ethically appropriate courses of action can still lead to moral dilemmas for others. The nurse ethicist provides a lens well suited to identify and respond to these dilemmas. The nurse-patient relationship is the ethical foundation of nursing practice and this relational ontology is well suited to addressing ethical dilemmas that exist prior to and beyond the initial consult question. This paper will describe one nurse ethicist's phronetic and pragmatic approach to a clinical ethics consult elucidated through feminist ethics and systems thinking. This paper will describe the theoretical basis for this method, present a case, and describe how this consultation approach provides a rich analysis based around relationships and responsibilities that also highlights the important ethical tensions within the social structure that exists around the patient and continue after the consult question is answered.
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Affiliation(s)
- Ian D Wolfe
- Children's Minnesota, Clinical Ethics Department, University of Minnesota Center for Bioethics, Minneapolis, MN, USA
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14
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Jones J, Ford PJ, Birchley G, Monteverde S. Perspectives on the role of the nurse ethicist. Nurs Ethics 2023; 30:652-658. [PMID: 37946393 DOI: 10.1177/09697330231189034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between 'nurse ethicist' and 'clinical ethicist' is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the 'tacit knowledge' and 'lived experience' they bring to clinical ethics consultation. However, the second author also warns that the 'nurse ethicist' must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as 'nurse ethicist' on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.
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Affiliation(s)
- Jenny Jones
- Retired, Metro South Health, Brisbane, QLD, Australia
| | - Paul J Ford
- Neuroethics Program, Cleveland Clinic, Cleveland, OH, USA
| | - Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Settimio Monteverde
- School of Health Professions, Bern University of Applied Sciences, Bern, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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15
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Olszewski AE, Zhou C, Ugale J, Ramos J, Patneaude A, Opel DJ. Disparities in Clinical Ethics Consultation among Hospitalized Children: A Case-Control Study. J Pediatr 2023; 258:113415. [PMID: 37028752 DOI: 10.1016/j.jpeds.2023.113415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/26/2023] [Accepted: 03/21/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To identify sociodemographic factors associated with pediatric clinical ethics consultation (CEC). STUDY DESIGN Matched, case-control study at a single center, tertiary pediatric hospital in the Pacific Northwest. Cases (patients hospitalized January 2008-December 2019 with CEC) were compared with controls (those without CEC). We determined the association of the outcome (CEC receipt) with exposures (race/ethnicity, insurance status, and language for care) using univariate and multivariable conditional logistic regression. RESULTS Of 209 cases and 836 matched controls, most cases identified as white (42%), had public/no insurance (66%), and were English-speaking (81%); most controls identified as white (53%), had private insurance (54%), and were English-speaking (90%). In univariate analysis, patients identifying as Black (OR: 2.79, 95% CI: 1.57, 4.95; P < .001), Hispanic (OR: 1.92, 95% CI: 1.24, 2.97; P = .003), with public/no insurance (OR: 2.21, 95% CI: 1.58, 3.10; P < .001), and using Spanish language for care (OR: 2.52, 95% CI: 1.47, 4.32; P < .001) had significantly increased odds of CEC, compared with patients identifying as white, using private insurance, and using English for care, respectively. In multivariable regression, Black race (adjusted OR: 2.12, 95% CI: 1.16, 3.87; P = .014) and public/no insurance (adjusted OR: 1.81, 95% CI: 1.22, 2.68; P = .003) remained significantly associated with receipt of CEC. CONCLUSIONS We found disparities in receipt of CEC by race and insurance status. Further study is needed to determine the causes of these disparities.
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Affiliation(s)
- Aleksandra E Olszewski
- Division of Critical Care Medicine, Department of Pediatrics, Lurie Children's Hospital and Northwestern University, Chicago, IL.
| | - Chuan Zhou
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Jiana Ugale
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA
| | - Jessica Ramos
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, WA
| | - Arika Patneaude
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA; Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; University of Washington School of Social Work, Seattle, WA
| | - Douglas J Opel
- Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA; Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Blackler L, Scharf AE, Matsoukas K, Colletti M, Voigt LP. Call to action: empowering patients and families to initiate clinical ethics consultations. J Med Ethics 2023; 49:240-243. [PMID: 34732393 DOI: 10.1136/medethics-2021-107426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
Clinical ethics consultations exist to support patients, families and clinicians who are facing ethical or moral challenges related to patient care. They provide a forum for open communication, where all stakeholders are encouraged to express their concerns and articulate their viewpoints. Ethics consultations can be requested by patients, caregivers or members of a patient's clinical or supportive team. Although patients and by extension their families (especially in cases of decisional incapacity) are the common denominators in most ethics consultations, these constituents are the least likely to request them. At many healthcare organisations in the USA, ethics consultations are overwhelmingly requested by physicians and other clinicians. We believe it is vital that healthcare institutions bridge the knowledge gaps and power imbalances over access to ethics consultation services through augmented policies, procedures and infrastructure. With enhanced education and support, patients and families may use ethics consultation to elevate their voices and prioritise their unique characteristics and preferences in the delivery of their healthcare. Empowering patients and families to request ethics consultation can only strengthen the patient/family-clinician relationship, enhance the shared decision-making model of care and ultimately lead to improved patient-centred care.
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Affiliation(s)
- Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy E Scharf
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Konstantina Matsoukas
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Technology Division, Library Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michelle Colletti
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis P Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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17
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Weaver MS, Shostrom VK, Sharma S, Keegan A, Walter JK. Pediatric Ethics Consultation Services. Pediatrics 2023; 151:e2022058947. [PMID: 36720707 PMCID: PMC9979273 DOI: 10.1542/peds.2022-058947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Although guidelines call for the presence of pediatric ethics consultation services (PECS), their existence in children's hospitals remains unquantified. This study determined the prevalence of PECS in children's hospitals and compared the practice environments of those with versus without PECS. METHOD The Children's Hospital Association Annual Benchmark Report survey from 2020 and PECS data were analyzed for the association of PECS with domains of care. RESULTS Two hundred thirty-one hospitals received survey requests, with 148 submitted and 144 reachable to determine PECS (62% response rate), inclusive of 50 states. Ninety-nine (69%) reported having ethics consultation services. Freestanding children's hospitals (28% of all hospitals) were more likely to report the presence of PECS (P <.001), making up 41% of hospitals with a PECS. The median number of staffed beds was 203 (25th quartile 119, 75th quartile 326) for those with PECS compared with 80 for those without (25th quartile 40, 75th quartile 121). Facilities with palliative care, higher trauma ratio, intensive care, and comprehensive programs were more likely to have PECS. Academic affiliation was associated with PECS presence (P <.001). Settings associated with skilled nursing facilities or long-term care programs were not more likely to have PECS. Hospitals designated as federally qualified health centers (P = .04) and accountable care organizations (P = .001) were more likely to have PECS. CONCLUSION Although PECS function as formal means to clarify values and mitigate conflict, one-third of children's hospitals lack PECS. Future research is needed to understand barriers to PECS and improve its presence.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Valerie K. Shostrom
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Keegan
- Children’s Hospital Association, Lenexa, Kansas
| | - Jennifer K. Walter
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics and Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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18
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Weaver MS, Sharma S, Walter JK. Pediatric Ethics Consultation Services, Scope, and Staffing. Pediatrics 2023; 151:e2022058999. [PMID: 36720710 PMCID: PMC9979255 DOI: 10.1542/peds.2022-058999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES National standards and guidelines call for a mechanism to address ethical concerns and conflicts in children's hospitals. The roles, responsibilities, and reach of pediatric ethics consultation services (PECS) remain unmeasured. The purpose of this study is to quantify staffing, structure, function, scope, training, and funding of PECS. METHODS Cross-sectional online survey was shared with an ethics informant at 181 children's hospitals in the United States from March to June 2022. Data were summarized descriptively and with semantic content analyses. RESULTS One hundred seventeen surveys were received from individual children's hospitals in 45 states and Washington DC (response rate 65%), with 104 qualifying for survey completion. Almost one-quarter of settings received 50 or more pediatric ethics consults in the past 12 months. On average, 7.4 people at each institution have responsibility for completing ethics consults. Estimated full-time equivalent salary support for ethics is on average 0.5 (range 0-3, median 0.25). One-third (33%) of facilities do not offer any salary support for ethics and three-quarters do not have an institutional budget for the ethics program. Clinical staff primarily initiate consults. End-of-life, benefits versus burdens of treatments, and staff moral distress were the most frequently consulted themes. Almost one-quarter (21%) of children's hospitals do not receive any consults from patients or families. CONLUSIONS The findings from this study reveal wide variation in PECS practices and raise concern about the lack of financial support provided for PECS despite substantial workloads.
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Affiliation(s)
- Meaghann S. Weaver
- Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, Nebraska
- National Center for Ethics in Healthcare, Washington, District of Columbia
| | - Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jennifer K. Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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19
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Lanphier E, Anani UE. Whose Trauma? Who's Trauma Informed? Am J Bioeth 2023; 23:98-100. [PMID: 36594996 DOI: 10.1080/15265161.2022.2146787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Elizabeth Lanphier
- Cincinnati Children's Hospital Medical Center
- University of Cincinnati College of Medicine
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20
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Sankary LR, Morley G, Ford PJ. Trusting the Ethics Consultant: Adopting a Trauma-Informed Approach to Ethics Consultation. Am J Bioeth 2023; 23:101-103. [PMID: 36594998 DOI: 10.1080/15265161.2022.2146789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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21
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Rudolph KA. "What Does a Life Worth Living Mean to You?" Narrative Approaches to Ethics Consultation in the Context of Trauma, Treatment Refractory Depression, and Life-Sustaining Care Refusals. Am J Bioeth 2023; 23:103-106. [PMID: 36595007 DOI: 10.1080/15265161.2022.2146790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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22
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Tarzian AJ. Trauma-Informed Ethics Consultation in the ICU: Exploring Best Practices in a Case Involving a Self-Inflicted Gunshot Wound. Am J Bioeth 2023; 23:96-97. [PMID: 36594994 DOI: 10.1080/15265161.2023.2146409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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23
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Nicoli F, Grossi AA, Testa J, Picozzi M. The Circle Method: A Novel Approach to Clinical Ethics Consultation. J Clin Ethics 2023; 34:79-91. [PMID: 36940352 DOI: 10.1086/723428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractDifferent methods are available in clinical ethics consultation. In our experience as ethics consultants, certain individual methods have proven insufficient, and so we use a combination of methods. Based on these considerations, we first critically analyze the pros and cons of two well-known methods in the working field of clinical ethics, namely Beauchamp and Childress's four-principle approach and Jonsen, Siegler, and Winslade's four-box method. We then present the circle method, which we have used and refined during several clinical ethics consultations in the hospital setting.
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24
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Audu A, Hartsock J, Wocial L. Choosing a Side: Clinician Perspective Taking in Ethics Consultations. J Clin Ethics 2023; 34:40-50. [PMID: 36940353 DOI: 10.1086/723318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractEthics consultation is a service provided to patients, families, and clinicians to support decisions during ethical dilemmas. This study is a secondary qualitative analysis of 48 interviews from clinicians involved in an ethics consultation at a large academic health center. An inductive secondary analysis of this data set led to the emergence of one key theme, the apparent perspective the clinicians adopted as they recalled a specific ethics case. This article presents a qualitative analysis of the propensity of clinicians involved in an ethics consultation to adopt the subjective viewpoints of their team, their patient, or both simultaneously. Clinicians demonstrated an ability to take the patient perspective (42%), the clinician perspective (31%), or the clinician-patient perspective (25%). Our analysis suggests the potential for narrative medicine to build the empathy and moral imagination necessary to bridge the gap in perspectives between key stakeholders.
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25
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Vo H, Campelia GD, Olszewski AE. Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method. J Clin Ethics 2023; 34:11-26. [PMID: 36940357 DOI: 10.1086/723322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractRacism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it (a) creates a more just approach, (b) supports individual consultants and services, and (c) facilitates communication in contexts where racism impinges on effecting good patient care.
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26
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Mubarak E, Kaur S, Min MTK, Hughes MT, Rushton CH, Ali J. Emerging Experiences with Virtual Clinical Ethics Consultation: Case Studies from the United States and Malaysia. J Clin Ethics 2023; 34:51-57. [PMID: 36940355 PMCID: PMC10184515 DOI: 10.1086/723317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractThe COVID-19 pandemic has inspired numerous opportunities for telehealth implementation to meet diverse healthcare needs, including the use of virtual communication platforms to facilitate the growth of and access to clinical ethics consultation (CEC) services across the globe. Here we discuss the conceptualization and implementation of two different virtual CEC services that arose during the COVID-19 pandemic: the Clinical Ethics Malaysia COVID-19 Consultation Service and the Johns Hopkins Hospital Ethics Committee and Consultation Service. A common strength experienced by both platforms during virtual delivery included improved ability for local practitioners to address consultation needs for patient populations otherwise unable to access CEC services in their respective locations. Additionally, virtual platforms allowed for enhanced collaboration and sharing of expertise among ethics consultants. Both contexts encountered numerous challenges related to patient care delivery during the pandemic. The use of virtual technologies resulted in decreased personalization of patient-provider communication. We discuss these challenges with respect to contextual differences specific to each service and setting, including differences in CEC needs, sociocultural norms, resource availability, populations served, consultation service visibility, healthcare infrastructure, and funding disparities. Through lessons learned from a health system in the United States and a national service in Malaysia, we provide key recommendations for health practitioners and clinical ethics consultants to leverage virtual communication platforms to mitigate existing inequities in patient care delivery and increase capacity for CEC globally.
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27
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Wallner J. Healthcare Ethics Consultation in Austria: Joining the International Path of Professionalization. J Clin Ethics 2023; 34:69-78. [PMID: 36940354 DOI: 10.1086/723427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractHealthcare ethics consultation has been developed, practiced, and analyzed internationally. However, only a few professional standards have evolved globally in this field that would be comparable to standards in other areas of healthcare. This article cannot compensate for this situation. It contributes to the ongoing debate on professionalization by presenting experiences with ethics consultation in Austria, though. After exploring its contexts and providing an overview of one of its primary ethics programs, the article analyzes the underlying assumptions of "ethics consultation" as an essential effort on the path to professionalize ethics consultation.
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Weaver MS, Wichman C, Sharma S, Walter JK. Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work. AJOB Empir Bioeth 2022; 14:135-142. [PMID: 36574230 DOI: 10.1080/23294515.2022.2160512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged. METHODS Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children's hospitals and five programmatic domains. RESULTS 104 children's hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of consultants. Academically-affiliated children's hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5. CONCLUSIONS While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults.
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Affiliation(s)
- Meaghann S Weaver
- Department of Pediatrics, Pediatric Palliative Care, University of Nebraska Medical Center, Omaha, NE, USA
- Veterans Health Affairs, National Center for Ethics in Healthcare, Washington, DC, USA
| | - Christopher Wichman
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shiven Sharma
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer K Walter
- Department of Medical Ethics and Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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29
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Schmitz D, Duewell M. Ethics Consultation-A Blind Spot of Philosophy in Bioethics? Am J Bioeth 2022; 22:47-48. [PMID: 36416432 DOI: 10.1080/15265161.2022.2134486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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30
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Sanchini V, Crico C, Casali PG, Pravettoni G. Measuring the impact of clinical ethics support services: further points for consideration. J Med Ethics 2022; 48:877-878. [PMID: 36316032 DOI: 10.1136/jme-2022-108671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Virginia Sanchini
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | - Chiara Crico
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Paolo G Casali
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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31
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Scofield G. On Certification's Real Role. Am J Bioeth 2022; 22:W5-W6. [PMID: 35723591 DOI: 10.1080/15265161.2022.2089277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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32
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Sharma S, Weaver MS, Walter JK. The Accessibility of Inpatient Pediatric Ethics Consultation Services to Patient Caregivers. Hosp Pediatr 2022; 12:e291-e294. [PMID: 35934755 PMCID: PMC9486872 DOI: 10.1542/hpeds.2022-006662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ethics consultation services (ECS) support clinical decision-making when there are values conflicts. Accessibility to ECS by patients and families is required to benefit from the service. Multiple national guidelines encourage ready availability of ECS to all stakeholders including patients and families. METHODS All facilities registered with the Children's Hospital Association (n = 190) were contacted using a protocol modeled after an adult ethics consultation practice study. After an online search to identify an ethics contact, calls were made to hospital operators, and each transfer was documented as well as time to ECS contact. If no contact was identified on progression through the call protocol or on completion of the call pathway on 3 occasions each spaced by 1 week, the ECS was labeled "unreached." RESULTS Only 36 (19%) ECS contacts were identified via online search with the remainder 154 (81%) requiring phone calls. Fewer than one-quarter of operators (n = 34/154, 22%) could identify a contact name or number for ECS. Thirty ECS (16%) remained unreachable after completion of the call pathway or 3 separate attempts. Successful ECS contact required an average of 2.9 attempts. Maximum call hold duration was 25 minutes. Callback times averaged 5.8 business days after voicemail. CONCLUSIONS This study revealed limited reachability of ECS. ECS should make their contact information available online and improve information available to operators.
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Affiliation(s)
- Shiven Sharma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meaghann S Weaver
- Department of Pediatrics, University of Nebraska, Omaha, Nebraska
- National Center for Ethics in Healthcare, Washington, DC
| | - Jennifer K Walter
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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33
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Lanphier E, Anani UE. Enriching the Theory and Practice of Trauma Informed Ethics Consultation. Am J Bioeth 2022; 22:W7-W9. [PMID: 35972312 DOI: 10.1080/15265161.2022.2110991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Elizabeth Lanphier
- Cincinnati Children's Hospital Medical Center
- University of Cincinnati College of Medicine
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34
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Marron JM, Hantel A, Abel GA, Peppercorn JM. Ethics Consultation in Oncology: The Search for Quality in Quantity. JCO Oncol Pract 2022; 18:610-613. [PMID: 35947815 PMCID: PMC9509056 DOI: 10.1200/op.22.00440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 09/03/2023] Open
Affiliation(s)
- Jonathan M. Marron
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Office of Ethics, Boston Children's Hospital, Boston, MA
| | - Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jeffrey M. Peppercorn
- Center for Bioethics, Harvard Medical School, Boston, MA
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
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35
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Marathe PH, Zhang H, Blackler L, Stetson PD, Voigt LP, Friedman DN. Ethics Consultation Requests After Implementation of an Electronic Health Record Order. JCO Oncol Pract 2022; 18:e1505-e1512. [PMID: 35749678 PMCID: PMC9509102 DOI: 10.1200/op.22.00174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/22/2022] [Accepted: 05/19/2022] [Indexed: 09/03/2023] Open
Abstract
PURPOSE As the role of clinical ethics consultation in health care advances, there are calls to standardize the process of consultation. The Ethics Committee at Memorial Sloan Kettering Cancer Center (MSK) hypothesized that the process of requesting an ethics consultation could be improved by instituting an electronic health record (EHR) order for consultation requests. This report summarizes the impact of adopting an EHR order for ethics consultation requests at MSK. METHODS This retrospective review of all clinical ethics consultations requested at a tertiary cancer center from May 2017 to February 2020 spans 17 months before and after implementation of an electronic order for consultation requests. Summary statistics are presented using Pearson chi-square analyses with a significance level of 0.05. RESULTS There was a significant increase in the total number of consultation requests placed after implementation of the EHR order (n = 165, 0.08% of total patients) compared with before (n = 108, 0.05% of total patients; P = .007). The number of consults requested by providers from inpatient (P = .02) and outpatient (P = .04) settings significantly increased. The proportion of consults placed by medical versus nonmedical providers remained unchanged (P = .32). CONCLUSION In this large single-institution retrospective study, implementation of an EHR order for ethics consultation requests was associated with a significant increase in the number of consultation requests. Implementation of an electronic order may decrease barriers to ethics consultation in diverse practice settings. Further longitudinal, multicenter studies are needed to assess strategies to improve access to clinical ethics consultation for oncology patients.
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Affiliation(s)
- Priya H. Marathe
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hao Zhang
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Liz Blackler
- Office of the Physician-In-Chief, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter D. Stetson
- Office of the Physician-In-Chief, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louis P. Voigt
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology, Weill Cornell Medical College,New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
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Jones-Schenk J. Can Ethics Consultation Services Evolve to Support the Moral Distress of Caregivers? J Contin Educ Nurs 2022; 53:297-298. [PMID: 35858144 DOI: 10.3928/00220124-20220603-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Ethics consultation services were first implemented in the 1970s to provide physicians, other care providers, and family members with expert advice to address difficult ethical dilemmas in care. As nurses are increasingly confronted with moral dilemmas related to patient preferences, needs, and choices that conflict with their personal beliefs, the need for professional support has never been greater. This need may signal a new role for ethics consultation services. [J Contin Educ Nurs. 2022;53(7):297-298.].
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Karlawish J, Peterson A, Clapp JT, Largent EA. A Case of Patient Abandonment, or an Abandonment of Patients? Am J Bioeth 2022; 22:86-87. [PMID: 35737506 PMCID: PMC9809500 DOI: 10.1080/15265161.2022.2075961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Maradiaga GR, Hendley N, Moskop JC. Patient Abandonment in the Emergency Department? Am J Bioeth 2022; 22:90-92. [PMID: 35737498 DOI: 10.1080/15265161.2022.2075963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Char D. Important Design Questions for Algorithmic Ethics Consultation. Am J Bioeth 2022; 22:38-40. [PMID: 35737487 DOI: 10.1080/15265161.2022.2075054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Tarzian AJ. Who's Abandoning Whom? The Role of Ethics Consultation for Unaccompanied Emergency Department Patients with Dementia. Am J Bioeth 2022; 22:84-85. [PMID: 35737479 DOI: 10.1080/15265161.2022.2076406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Haltaufderheide J, Nadolny S, Vollmann J, Schildmann J. Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants. J Med Ethics 2022; 48:401-406. [PMID: 34006601 PMCID: PMC9132864 DOI: 10.1136/medethics-2020-107129] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/09/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints-and for what reasons-should be considered when evaluating the quality of a service. In this paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research.
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Affiliation(s)
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
- Nursing Science Staff Unit, Franziskus Hospital Harderberg, Niels-Stensen-Kliniken, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University, Bochum, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University, Halle-Wittenberg, Germany
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Forcier MBL, Joyner BL, Davis AM. One Goal, Two Roles: Clinicians and Clinical Ethicists Should Approach Patients' Ambivalence Differently. Am J Bioeth 2022; 22:50-52. [PMID: 35616969 DOI: 10.1080/15265161.2022.2063443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Duffee J. Trauma-Informed Ethics and Relational Health. Am J Bioeth 2022; 22:62-65. [PMID: 35475954 DOI: 10.1080/15265161.2022.2055217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- James Duffee
- Wright State University Boonshoft School of Medicine
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Lanphier E, Anani UE. Trauma Informed Ethics Consultation. Am J Bioeth 2022; 22:45-57. [PMID: 33684027 DOI: 10.1080/15265161.2021.1887963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like TIC) is systematically sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners.
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Affiliation(s)
- Elizabeth Lanphier
- Cincinnati Children's Hospital Medical Center
- University of Cincinnati College of Medicine
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Ford PJ, Morley G, Sankary LR. When Obligations Conflict: Necessary Violations of Trauma Informed Care in Ethics Consultation? Am J Bioeth 2022; 22:60-62. [PMID: 35475964 DOI: 10.1080/15265161.2022.2055220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Healy M, Tuohy B. Trauma and Community: Trauma-Informed Ethics Consultation Grounded in Community-Engaged Principles. Am J Bioeth 2022; 22:71-73. [PMID: 35475966 DOI: 10.1080/15265161.2022.2055211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Megan Healy
- Lewis Katz School of Medicine at Temple University
| | - Brian Tuohy
- Lewis Katz School of Medicine at Temple University
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Guta A, Buchman DZ, Schmidt RA, Perri M, Strike C. Trauma-Informed Approaches in Healthcare Ethics Consultation: A Missing Element in Healthcare for People Who Use Drugs during the Overdose Crisis? Am J Bioeth 2022; 22:68-70. [PMID: 35475957 DOI: 10.1080/15265161.2022.2055208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Adrian Guta
- School of Social Work, University of Windsor
| | - Daniel Z Buchman
- Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, University of Toronto
- Joint Centre for Bioethics, University of Toronto
| | - Rose A Schmidt
- Centre for Addiction and Mental Health
- Dalla Lana School of Public Health, University of Toronto
| | - Melissa Perri
- Dalla Lana School of Public Health, University of Toronto
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto
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Carter BS. My Story is Traumatic, You Probably Would Not Understand. Am J Bioeth 2022; 22:58-60. [PMID: 35475962 DOI: 10.1080/15265161.2022.2055215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Bruce L, Herbst JL. Extending Trauma-Informed Principles to Hospital System Policy Development. Am J Bioeth 2022; 22:65-68. [PMID: 35475965 DOI: 10.1080/15265161.2022.2055210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Lori Bruce
- Interdisciplinary Center for Bioethics, Yale University
| | - Jennifer L Herbst
- Quinnipac College School of Law
- Frank H. Netter MD School of Medicine, Quinnipiac University
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Affiliation(s)
| | - Dalia M Feltman
- NorthShore University HealthSystem
- University of Chicago Pritzker School of Medicine
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