Clinical Ethics Services Research Articles

Patient involvement in clinical ethics services: from access to participation and membership

Ethics consultation is a novel paradigm in European health-care institutions. In this paper, patient involvement in all clinical ethics activities is scrutinized. It is argued that patients should have access to case consultation services via clearly defined access paths. However, the right of both health-care professionals and patients indicates that patients should not always be notified of a consultation. Ethics education, another well-established function of an ethics committee, should equally be available for patients, lay people and hospital staff. Beyond access and utilization, lay membership on a clinical ethics service is a matter of transparency, equal participation, empowerment and democratization. Lay and patient perspectives will contribute to the quality of ethics services on all levels from case consultations to ethics education and policy development.

The role of patients in European clinical ethics consultation

As additional clinical ethics services become established, the role of patients and their relatives is attracting increased attention. In North America, patient involvement has been theoretically lauded and recommended by policy, but nevertheless is often neglected in practice.1 In Europe, this issue has not yet received a great deal of attention, although the importance of listening to the patient's voice has been recognized for some time.2 Despite this, patients have diverse involvement in European clinical ethics support. Patients or their relatives can, for example: be members of a clinical ethics committee; be notified when an ethics consultation is requested; or be involved in ethical deliberation to the same extent as clinicians.

Chapitre 1. Clinical Ethics as Practice

This paper discusses the importance of the practical turn represented by the development of clinical ethics for the field of bioethics. It discusses, first, the distinctive way that clinical ethics exhibits the practical turn in ethics. Second, it argues that primary purpose of clinical ethicists is to devise actionable approaches or "solutions" to ethical questions and issues arising in the course of patient care in addressing ethical conflicts, dilemmas, issues, and questions about cultural, personal, religious, and societal values. And, third, the paper explores the concerns about the qualifications of those who provide clinical ethics services, because the work of clinical ethics is done not only by academically trained bioethicists, but also by a broad range of health professionals on ethics consultation services and hospital ethics committees.

Empirical assessments of clinical ethics services: implications for clinical ethics committees

The need to evaluate the performance of clinical ethics services is widely acknowledged although work in this area is more developed in the United States. In the USA many studies that assess clinical ethics services have utilized empirical methods and assessment criteria. The value of these approaches is thought to rest on their ability to measure the value of services in a demonstrable fashion. However, empirical measures tend to lack ethical content, making their contribution to developments in ethical governance unclear. The steady increase of clinical ethics committees in the UK must be accompanied by efforts to evaluate their performance. As part of this evaluative work it is important to examine how the practice of clinical ethics committees can be informed by empirical measures.

Ethics Consultation in the Emergency Department

Clinical ethics teams exist in various forms and have assisted care providers for several decades. Our clinical ethics service at an urban, tertiary, teaching hospital provides ethics consultation to care providers, patients, and their family members. Scenarios prompting an ethics consultation may be complex, often involving social, cultural, and fiscal components. Because patients who receive an ethics consultation often require a lengthy hospital stay, our group searched for unique identifiers in a patient's presentation to facilitate earlier and, potentially, more effective interventions. Of particular interest to our group was the presentation of these patients to our institution from the emergency department (ED). Our group's subjective experience indicated that factors requiring ethics consultation were often present very early during hospitalization. A retrospective medical record review of a convenience sample of 50 records of patients who had received a formal clinical ethics consult within a 14-month timeframe was done. Those patients who were admitted to the hospital via the ED and subsequently received an ethics consultation were identified. The critical issues prompting the ethics consult were then evaluated. Eighteen (35%) of the study patients were originally admitted through the ED. Results showed that the ethical issue(s) that prompted the clinical ethics consult was regularly identifiable in the ED. Our study results indicate that issues prompting ethics consults may potentially be identified as patients present to the ED. Rapid and effective interventions proscribed through institutional policy guidelines could greatly assist nurses and other ED providers in identifying these at-risk patients upon entry of the ED. Such a policy would ultimately benefit both patient and provider.

Is there a future for clinical ethics services in Australia?

Clinical ethics refers to the consideration of ethical issues arising directly in the context of patient care. Health professionals are generally adept at effectively and sensitively managing ethical issues in clinical care. However, in some settings, multidisciplinary clinical ethics services may enhance clinical practice by assisting clinicians, patients and others to identify, understand and manage ethical issues. Clinical ethics services may be particularly valuable for situations in which moral perspectives diverge or communication has deteriorated. Such services may facilitate discussion and help the parties find mutually satisfactory solutions. Clinical ethics services may take various forms, including clinical ethics committees, ethics consultants, patient advocates or other mechanisms for responding to complaints and grievances. There is considerable disagreement about key aspects of clinical ethics services, including who should conduct them, how they should be run and what role they should play in decision-making.

Quality control for hospitals' clinical ethics services: proposed standards.

Hospital ethics committees have become widespread over the last 25 years, stimulated by the Quinlan decision of the New Jersey Supreme Court, the report of a President's Commission, and most recently by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which now man dates that each hospital seeking accreditation have a functioning process for the consideration of ethical issues in patient care. Laws and regulations in several states require that hospitals establish ethics committees, and some states stipulate that certain types of cases and disputes be taken to such committees. At least one state grants legal immunity to those who implement recommendations of an ethics committee.

An Account of the Usefulness of a Pilot Clinical Ethics Program at a Community Hospital

This article describes the development and implementation of a six-month pilot clinical ethics program at Saint Thomas Hospital (Nashville, Tenn). To assess the impact of this program, baseline data were gathered from a self-selected sample of critical and special care unit nurses and physicians about the "most troublesome" ethical dilemmas in their practices. Nurses and physicians reported facing similar dilemmas in practice. Nurses believed that chaplains and peers were most "beneficial" in resolving their "most troublesome" cases; physicians did not deem one particular individual or service to be of any greater benefit than any other in dilemma resolution. Nurses and physicians indicated that in many cases patients and families did not appear involved in the process. In a posttest survey following the pilot program, nurses rated the beneficial role of chaplains somewhat lower and agreed that the clinical ethics service was beneficial. As with the pretest sample, the posttest nurses evaluated the role of the attending physician as "detrimental" to resolving their ethical conflicts. In the posttest, physicians ranked the role of the clinical ethicist as comparable to that of chaplains and social workers.

Disability and the elderly.

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.