Clinical ethics consultation documentation in the era of open notes

BACKGROUND

In 2021, federal rules from the 21st Century Cures Act mandated most clinical notes be made available in real-time, online, and free of charge to patients, a practice often referred to as "open notes." This legislation was passed to support medical information transparency and reinforce trust in the clinician-patient relationship; however, it created additional complexities in that relationship and raises questions of what should be included in notes intended to be read by both clinicians and patients.

MAIN BODY

Even prior to open notes, how an ethics consultant should document a clinical ethics consultation was widely debated as there can be competing interests, differing moral values, and disagreement about pertinent medical information in any given encounter. Patients can now access documentation of these discussions through online portals which broach sensitive topics related to end-of-life care, autonomy, religious/cultural conflict, veracity, confidentiality, and many others. Clinical ethics consultation notes must be ethically robust, accurate, and helpful for healthcare workers and ethics committee members, but now also sensitive to the needs of patients and family members who can read them in real-time.

CONCLUSION

We explore implications of open notes for ethics consultation, review clinical ethics consultation documentation styles, and offer recommendations for documentation in this new era.

American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care

This report presents the American Society of Clinical Oncology's (ASCO's) evaluation of the adaptations in care delivery, research operations, and regulatory oversight made in response to the coronavirus pandemic and presents recommendations for moving forward as the pandemic recedes. ASCO organized its recommendations for clinical research around five goals to ensure lessons learned from the COVID-19 experience are used to craft a more equitable, accessible, and efficient clinical research system that protects patient safety, ensures scientific integrity, and maintains data quality. The specific goals are: (1) ensure that clinical research is accessible, affordable, and equitable; (2) design more pragmatic and efficient clinical trials; (3) minimize administrative and regulatory burdens on research sites; (4) recruit, retain, and support a well-trained clinical research workforce; and (5) promote appropriate oversight and review of clinical trial conduct and results. Similarly, ASCO also organized its recommendations regarding cancer care delivery around five goals: (1) promote and protect equitable access to high-quality cancer care; (2) support safe delivery of high-quality cancer care; (3) advance policies to ensure oncology providers have sufficient resources to provide high-quality patient care; (4) recognize and address threats to clinician, provider, and patient well-being; and (5) improve patient access to high-quality cancer care via telemedicine. ASCO will work at all levels to advance the recommendations made in this report.

[Breast, cervical and colo-rectal simultaneous mass screening program for women 50 to 69 years old in Isere]

A cervical screening campaign is implemented in the Isere department since 1990 for women aged 50 to 69, together with breast cancer and colo-rectal cancer screening. The attendance rate is about 30% but a survey performed among this population shows that 68.6% of these women did presented for screening during the year following their invitation. One and a half per cent of all smears were abnormal or ASCUS smears. Cancer detection rate for invasive cancer and CIN III was 1.3/1000. General practitioners and gynaecologists took the same part in the programme. During a postal survey conducted among them, they declared that they felt concerned with cancer screening, even if they met some difficulties. This results suggest that nominative invitations and a good cooperation of GPs may improve the coverage of eligible women. For the future success of the National Programme, which is to be implemented in France, organisational arrangements have to be set up. The review of positive points and difficulties met by Isere's local programme may help to discuss it.

[Campaign for cervical cancer screening with vaginal smears in women aged 50-69 years in Isère (France). Results of the first round (January 1991-June 1993)]

The department of Isère, which is involved since 1990 in a breast cancer screening campaign concerning women aged 50 to 69, has managed to associate a cervical and colorectal cancers screening program. The target sample size is 98,000 individuals. Women are asked to refer their general practitioner or gynaecologist for cervicovaginal smears. Each woman is invited at a screening interval of 30 months. The results of the first invitation (November 1990-December 1992) are reported. Thus 29,570 women did referred, so that the screening uptake is 30% and 20,083 women (68%) had Pap smears inside the screening program. 1.1% of the smears were unsatisfactory and 1.2% of the tests showed abnormalities. Ninety-six percent of the women who had been referred for further examinations have been followed up. Thirty-eight women (representing 17% of smears with abnormalities) had surgery (conisation, hysterectomy, Wertheim). Among them, 5 cases of invasive cervical carcinoma and 25 in situ carcinoma were detected. The detected cancer prevalence per 1,000 women screened is 1.5/1000. An organised screening program for cervical cancer in association with breast cancer screening, seems to be an effective way of increasing smears realisation in women aged 50 to 69, and of involving general practitioners in cervical cancer screening.

[Simultaneous screening of cancers of the breast, cervix, colon and rectum. The Isère experience]

The mass screening program for cancer in the Isere department offers women between 50 and 69 years a medical consultation and three tests: mammography for breast cancer screening, Pap smear for cervical cancer screening, and hemoccult for colorectal cancer. During the first round, 29,570 women took part in the program, 21% had a mammography, 20% Pap smears and 25% a hemoccult. In breast cancer screening, the rate for further examination was 11.9%, the breast cancer detection rate was 5.4 per 1,000 women screened and the detection rate of invasive tumor < or = 10 mm: 2.0 per 1,000. In cervical cancer screening, the rate of abnormal examinations was 1.2%. The cervical cancer detection rate was 1.5 per 1,000. The rate of positive hemoccult was 2.7% and the rate of colorectal cancers and polyps 10 mm or larger was 2.7 per 1000. Results of screening are satisfying, but compliance rate is too low. Acceptance rate must be examined in following rounds.

Prognostic value of epidermal growth factor receptor in a series of 303 breast cancers

125I-EGF (epidermal growth factor) binding assay was used in tumoral specimens concerning 303 clinical T1-T2, N0-N1 breast carcinoma diagnosed between May 1987 and October 1989. Binding assay for epidermal growth factor receptor (EGFR) was performed using single saturating concentration of 125I-EGF incubated with membrane preparations in the presence or absence of unlabelled EGF. A median value of 3 fmol EGF binding capacity per mg of membrane was obtained and then selected as the threshold value to define positive and negative EGFR tumour samples. According to this definition, 50.8% of the samples were EGFR positive. We noted an inverse relationship between the expression of EGFR and that of oestrogen receptor, and a decreased EGFR expression with tumour differentiation. With a rather short median follow-up (16 months), the multivariate analysis shows that progesterone receptor appears as the only powerful predictor of disease-free survival (P = 0.002), taking into account that 70% of the patients received an adjuvant medical treatment.

The antihypertensive efficacy of ketanserin in the elderly evaluated by ambulatory blood pressure measurement

To assess the role of the serotonin antagonist ketanserin in the management of hypertension in the elderly, 12 patients with a mean age of 68 years (range 60-79 years) were treated with ketanserin in a randomised double-blind placebo-controlled cross-over trial. Clinic BP, ambulatory BP, renal function, and pharmacokinetics were assessed. The doses of ketanserin used were 40 mg (ten patients) and 20 mg (two patients) twice daily for 8 weeks. Mean clinic sitting BP was reduced from 169 +/- 5/98 +/- 2 on placebo to 155 +/- 5/88 +/- 3 mmHg (NS/P less than 0.05/P less than 0.05) and standing pressure from 168 +/- 6/100 +/- 3 to 157 +/- 5/91 +/- 3 mmHg (NS/P less than 0.01). Mean ambulatory systolic BP was unaffected by active treatment (167 +/- 7 vs 164 +/- 5) while diastolic pressure was lowered from 99 +/- 2 to 94 +/- 2 mmHg (P less than 0.05). This effect appeared to be mainly confined to the first two hours after drug administration. Renal blood flow was unaltered by treatment. The mean plasma half-life of ketanserin was 20.9 +/- 5.5 hours. Side effects were minimal. In conclusion, while ketanserin may be effective as assessed in the clinic, its efficacy on ambulatory monitoring is substantially less impressive.

Estimation of epidermal growth factor receptor in 177 breast cancers: correlation with prognostic factors

Steroid receptors (ER, PR) and EGF-receptor were determined on 177 loco-regional primary breast cancers. Binding assay for EGF receptor was performed using a single saturating concentration of 125I-EGF incubated with membranes in the presence or absence of unlabeled EGF. With threshold values of 5 fmol/mg and 10 fmol/mg for EGF-R and steroid receptors respectively, we noted an inverse relationship between the expression of EGF-R, and ER and PR. EGF-R expression is decreased with tumor differentiation.

Correlation measurements using clipped laser speckle

Clipped laser speckle is used to measure the correlation of time-varying laser speckle. As with standard intensity correlation, clipped speckle is correlated to determine the magnitude of the correlation coefficient. The simple nature of clipped speckle permits high-speed measurements of correlation and velocity. A closed form approximation to the clipped correlation function valid for arbitrary clipping thresholds is presented. The approximation is used to make correlation measurements on speckle from a rotating diffuser using a 2-D random access detector array.