Ethics Consultation Service Research Articles

Utilization and Evaluation of Ethics Consultation Services in Neonatal Intensive Care

Background: The opportunities of perinatal medicine have improved, but this has also been accompanied by increasing ethical challenges. Clinical ethics consultation services (CEC) could support medical teams facing these. However, nothing is currently known about the availability, utilization and evaluation of CEC in German neonatology units. Methods: This study was designed as a national, descriptive, mixed quantitative–qualitative questionnaire study. The head physicians of the pediatric departments and the heads (medical and nursing) of the corresponding neonatal intensive care units of the 213 German perinatal centers were asked to participate. Results: Ninety percent of the respondents (responding rate 24.4–38.0%) stated that CEC are established and available. However, utilization is rather low [rarely N = 40 (54.1%), never N = 12, (16.2%), occasionally N = 19 (25.7%)], although it was rated as very helpful. There was a significant correlation between utilization and perceived general usefulness (r = 0.224, p = 0.033) and support (r = 0.41, p < 0.001); whereas evaluations differed significantly between professional groups (t = −2.298, p = 0.23, Cohen’s d = 0.42). Conclusions: The contradiction between the low utilization despite positive evaluations could be related to perceived hurdles. These and the different perceptions within the professional groups give rise to the consideration of whether alternative approaches, e.g., liaison services, would be preferable in neonatology.

Two Approaches of ‘Proactive Consultation’: Towards Well-Functioning Clinical Ethics Consultation

AbstractIn recent years, the global need for clinical ethics consultation services (CECS) has increased to address ethical challenges, dilemmas, and moral distress in clinical environments. In Japan, many hospitals have introduced CECS over the past decade, but few such services work effectively because of the small number of consultations. To address this, we propose two proactive ethics consultation methods: inter-professional ethics rounds and patient note reviews. This paper provides a detailed explanation of these methods, complete with scenarios based on actual cases. These methods can make CECS ‘well-functioning’ by shifting the starting points of consultation from consultees to CECS providers. We then examine the impact and value of proactive ethics consultation as well as four critical factors for its success including attitude, positioning, and competency of proactive consultation teams. We believe our suggestions will provide valuable insights for future clinical ethics consultations and stimulate academic debate about what constitutes a ‘well-functioning’ CECS.

Clinical ethics consultation services: public-facing information on NCI-designated cancer center websites.

Clinical ethics consultation services (CECS) can be particularly complex in oncology, and widespread misconceptions exist about their nature. As a result, visibility and accessibility of information regarding CECS is critical. We investigated the availability and content of information regarding CECS on websites of NCI-designated comprehensive cancer centers and cancer centers (CCs). Each website was reviewed for information on CECS and reviewed for benchmarks partially derived from the American Society of Bioethics and Humanities recommendations for CECS. Our analysis revealed that of 70 NCI-designated center websites, 38 had information on CECS, and 17 were found directly on these sites. When CECS information was available, most websites provided a mission statement (71%) and an explanation of what constitutes an ethics consult (74%). Few provided a description of the consult process (45%) or service membership (39%). Our findings reveal a significant gap in CECS visibility on the websites of NCI-designated CCs.

Factors associated with Saudi physicians' utilization of clinical ethics consultation services.

Clinical Ethics Consultation (CEC) aims to resolve ethical dilemmas at the bedside. Through a structured process, CEC allows practitioners and patients to consult ethicists at times of moral conflict or uncertainty. Over the past few decades, CEC has become an invaluable part of healthcare practice. In Saudi Arabia, however, CEC services remain inexplicably underutilized. This study attempts to understand the factors associated with Saudi physicians' utilization of CEC to better meet the needs of practitioners and patients. Results indicate that although physicians routinely experience moral dilemmas, they seldom request a CEC. This is not due to unfamiliarity, lack of accessibility, or suspicion of ethical expertise. Rather, reluctance is likely due to an ingrained medical cultural stronghold that pressures practitioners to act heroically, and to resolve ethical dilemmas independently. Recommendations to improve the utilization of CEC services include wider availability, active collaborations with clinical practitioners, routine quality improvements, and managerial and national support.

Clinical Ethics Consultation for Patients Impacted by Incarceration: A Single Center Retrospective Review.

Health care professionals and patients impacted by incarceration face unique medical, legal, and ethical issues. The frequency and nature of ethics consultations for these patients are underexplored. This study aimed to characterize the primary ethical issue and contextual features of ethics consultations involving patients impacted by incarceration. We conducted a qualitative concept content analysis of ethics consultations involving patients impacted by incarceration and calculated descriptive statistics of demographics to compare these patients with the broader population of patients impacted by incarceration at a single institution from January 1, 2015, through June 30, 2022. We identified 37,184 patients impacted by incarceration (people currently or formerly incarcerated or whose surrogate decision-maker is incarcerated) at our institution. Most were White (70%) and non-Hispanic (88%); 51% were male, 49% female. Individuals impacted by incarceration comprised 3% (n = 38) of ethics consults. Most were White (58%), male (79%), and hospitalized (92%). The primary ethical issues were surrogate decision-making (34%) and fiduciary duties (beneficence/nonmaleficence/best interest; 16%). The primary contextual feature was intra-family communication challenges (37%). Incarceration status impacts access to decision-makers and the provision of medically necessary care. Ethics consultation for women and individuals in outpatient and emergency settings could be underutilized. More education about ethics consultation services and coordination with correctional officials is recommended.

Receiving Clinical Ethics Consultation Services.

This symposium includes twelve personal narratives from those who have received clinical ethics consultation (CEC) services as a healthcare provider, patient, family member, or patient advocate. Three commentaries on these narratives are also included, authored by experts and scholars in bioethics, healthcare ethics consultation and certification, narrative medicine, and policy. The goal of this symposium is to call attention to the experiences of people who have received clinical ethics consultation (CEC) services as a healthcare provider, patient, family member, or patient advocate.

Educating and Training in Research Integrity (RI): A Study on the Perceptions and Experiences of Early Career Researchers Attending an Institutional RI Course

Research integrity (RI) is defined as adherence to ethical principles, deontological duties, and professional standards necessary for responsible conduct of scientific research. Early training on RI, especially for early-career researchers, could be useful to help develop good standards of conduct and prevent research misconduct (RM).The aim of this study is to assess the effectiveness of a training course on RI, by mapping the attitudes of early-career researchers on this topic through a questionnaire built upon the revised version of the Scientific Misconduct Questionnaire and administered to all participants at the beginning and at the end of the course.Results show that after the course, participants reporting a high understanding of the rules and procedures related to RM significantly increased (pre-course: 38.5%, post-course: 61.5%), together with the percentage of those reporting a lack of awareness on the extent of misconduct (pre-course: 46.2%, post-course: 69.2%), and of those who believe that the lack of research ethics consultation services strongly affects RM (pre-course: 15.4%, post-course: 61.5%). Early-career researchers agree on the importance to share with peers and superiors any ethical concern that may arise in research, and to create a work environment that fosters RI awareness.As a whole, results suggest the effectiveness of the course. Institutions should introduce RI training for early-career researchers, together with research methodology, integrity and ethics consultation services to support them. Senior scientists should promote RI into their research practices, and should stimulate engagement in peer-to-peer dialogue to develop good practices based on RI principles.

Changes in the routine work and moral distress in psychiatric care during the COVID-19 pandemic : A survey among physicians active in inpatient care in Germany

During the COVID-19 pandemic anumber of ethical challenges have arisen in the healthcare system. Apsychological response to moral challenges is termed moral distress (MD). Identification of causes of MD in inpatient psychiatric care in the context of the COVID-19 pandemic in Germany. Asurvey was conducted using aself-administered non-validated online questionnaire as part of across-sectional study, in which 26items about the experience of MD were examined and open questions about the handling of the pandemic and its effects on everyday work were posed. Physicians who worked in inpatient psychiatric care during the COVID-19 pandemic in Germany were surveyed anonymously with aconvenience sample. The data acquisition took place between 17 November 2020 and 6 May 2021. A total of 141participants were included. They indicated multiple pandemic-related changes in their daily work partly resulting in MD. MD is aneglected potential burden of inpatient psychiatric care under pandemic conditions (and beyond), which requires further research and an adequate handling. These results include implications for decision makers in crisis teams as well as aneed for support services such as clinical ethics consultation services.

Discussion Guide for the Rushton Article

Discussion Guide for the Rushton Article

480 Integrating a Research Ethics Program within an Academic Health Science Center

OBJECTIVES/GOALS: Research ethics services are critical to the clinical, research, and educational missions of an academic health science center. Our ethics program aims to develop a culture where investigators are as intellectually engaged in ethical issues of scientific integrity as they are in study design, data collection, and implementation. METHODS/STUDY POPULATION: This descriptive analysis depicts the historical development, from 2010 to 2022, of our research ethics program as an exemplar of ethics integration into the research enterprise of an academic health science center that engages in translational research. In this culture, clinicians, translational researchers and their scientific peers, research participants, and community members become involved in ethics investigation, deliberation, and innovation. RESULTS/ANTICIPATED RESULTS: There are four pillars to our research ethics program: 1) research ethics consultation service, which fosters the development of ethical best practices and standards for the practice of translational research; 2) education, which provides customized training and educational opportunities in research ethics to diverse stakeholders; 3) leadership, through collaboration and partnerships; 4) scholarly engagement, in the pursuit of innovative ethics research and professional development. Through these initiatives we can engage a broad constituency of stakeholders, become an integral component of research oversight, engage as active participants in the research enterprise, and have a critical role in guiding institutional culture. DISCUSSION/SIGNIFICANCE: The integration of our ethics program mirrors the translational science continuum which promotes the multidirectional flow of ideas among ethics consultants, laboratory/clinical scientists, implementation researchers and the community.

491 Outcomes of an Integrated Research Ethics Consultation Service

OBJECTIVES/GOALS: The need for mechanisms of ethical discourse and guidance has increased as translational research collaborations become more complex. The goal of this project is to analyze the stakeholder engagement and ethical issues our research ethics consultation service (RECS) conducted over a two year period. METHODS/STUDY POPULATION: We conducted a retrospective review of our RECS database from 2020 to 2022. We examined the nature of the research and ethical issues of concern from consult requestors, including whether or not consults were preventative. In addition, we assessed the educational outreach conducted during that timeframe as a measure of service awareness. RESULTS/ANTICIPATED RESULTS: There was a total of 42 consults conducted over the previous year. There were a wide variety of issues related to informed IRB-related processes (31%), consent (24%), QA/QI determination (12%), authorship (10%), confidentiality (7%), diversity/inclusion (7%), grant preparation (7%). Many of the consults (n=28, 67%) included secondary issues. A few consults (n=4, 10%) were preventative, meaning that the consult was requested in anticipation or consideration of a potential ethical issue. Outreach efforts extended to a diverse array of institutional stakeholders and trainees. DISCUSSION/SIGNIFICANCE: The RECS serves numerous constituencies throughout our institution on ethical issues spanning nearly all aspects of research design, conduct, and analysis. These data highlight initiatives to increase study efficiency (in collaboration with institutional research oversight) and helps to direct educational efforts and outreach.

Ethics consultation in patients with behavioral and psychological symptoms of dementia

The increasing age of the patient population around the globe and in the United States has resulted in a growing number of patients with dementia. In this manuscript, we examined the role of the ethics consultation service in patients who have dementia and associated cognitive and neuropsychiatric sequelae. We addressed a particularly challenging case presenting with behavioral and psychological symptoms of dementia. We discussed the ethical questions and challenges considered by the ethics consultation service and compared these with current suggestions and expectations from the research literature regarding the role of ethics consultation service in dementia management. We demonstrated two potentially useful approaches of clinical ethical analysis, the principalist theorem and Jonsen's four quadrants approach. While the number of consults in patients with behavioral and psychological symptoms of dementia is likely to increase in clinical ethics, the role of the ethics consultation service in this cohort of patients still remains to be determined. There are significant gaps in understanding of the ethics consultation service role in dementia management, and much work remains to be undertaken on the part of regulatory and healthcare systems in clarifying their roles, expectations, and competencies.

Emerging Experiences with Virtual Clinical Ethics Consultation: Case Studies from the United States and Malaysia.

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.

I Had Never Heard Someone Use That Word Before

I Had Never Heard Someone Use That Word Before Adrienne Feller Novick The patient was dying. As the social worker, I had arranged the meeting and sat shoulder to shoulder with the family and the attending physician in the small nondescript room. The family was grief-stricken and asked intelligent questions as they made difficult decisions about end-of-life care for their loved one. The doctor spoke with gentle kindness, acknowledging their difficult decision as he completed the neon pink Medical Orders for Life Sustaining Treatment (MOLST) form and left the room. I was tangled up with emotions; I felt relieved that the meeting had gone smoothly, sad for the patient and family, and in awe of the doctor for his ability to lead the difficult conversation. I stayed behind to ask the family if there was anything I could do to help them. [End Page E4] Before I could speak, the patient's wife turned to me and said, "I am so glad that k--- left the room." (Using a derogatory word for a person of the Jewish faith). My brain began processing the statement. I am a Jewish woman. Did I hear that right? Did she say what I think she said? Should I say something? I froze, and time seemed to stop. She was looking at me expectantly, waiting for a response. Her face reminded me of someone waiting for the other person to return a "high five." I was flooded with emotion. A succession of thoughts ran through my head, everything from being rude in response or getting physical. I did neither. I said nothing. I smiled and left the room feeling like I had been gut-punched. I was in denial. I made excuses for the wife; she was stressed. I kept thinking I must not have heard her correctly and that I was overreacting. I continued to work with the family as though nothing had happened until the patient died five days later. I felt ashamed and never told anyone about what happened. I regretted not saying anything. I replayed the conversation in my mind and felt depressed and angry. Inside I felt complicit for not speaking up, but I had no words. I assumed bias in healthcare was rare. I did nothing. Years later, after I completed a patient visit in the Intensive Care Unit (ICU), I observed a group of surgical residents doing rounds. The attending welcomed me to join this valuable clinical learning experience. As the group approached the next bed, the patient pointed to one resident and loudly said, "I don't want a doctor who looks like that to come near me." I gasped aloud and froze, waiting to see what would happen next. The attending looked directly at the patient and said calmly, "We are all here to help you. That is not an appropriate thing for you to say." Then, he turned to the resident and nodded, directing them to resume their bedside assessment. The patient mumbled something inaudibly and said nothing. To my astonishment, the doctor acknowledged the microaggression (a microaggression is a statement, action, or incident regarded as discrimination), addressed the issue, respectfully supported the resident, created a safe space for everyone on the healthcare team and resumed quality patient care without missing a beat. He modeled a strategy to address patient bias and taught a valuable skill. This was a learning moment for me. It helped me refocus my past experience and provided me with a useful strategy to address bias in the future. As a member of the medical ethics consultation service, I listen, provide support, and aid in challenging communications. I had the opportunity to model the communication strategy I acquired in the ICU. The medical ethics team was consulted for a patient refusing treatment. The patient was disrespectful to healthcare team members, cursing at nurses and residents, using ethnic slurs, and saying he "would rather die than let one of them touch him. I entered the patient's room with the healthcare team, introduced myself, and explained the reason for my visit. The patient defiantly agreed he had used slurs, saying he wanted to go home. I continued, everyone here...

Credentialing Character: A Virtue Ethics Approach to Professionalizing Healthcare Ethics Consultation Services.

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates.Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one's role as a moral agent and reflection on one's progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project.

Pediatric Ethics Consultation Services.

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. 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. 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. 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.

Pediatric Ethics Consultation Services, Scope, and Staffing.

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. 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. 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. 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.

Ethical Issues faced by Home Care Physicians and Nurses in Japan and their Ethics Support Needs: a Nationwide Survey.

This study aimed to identify the ethical issues faced by home care physicians and nurses, and the support they require. It was conducted in collaboration with the Japanese Association for Home Care Medicine from November to December 2020. An e-mail was sent to 2785 physicians and 582 nurses who are members of the society, requesting their participation in a web-based survey targeting physicians and nurses with practical experience in home care; 152 physicians and 53 nurses responded. Home care physicians and nurses face ethical issues, some of which are that "the patient's wishes cannot be reliably understood owing to their impaired decision-making capacity" and "there is disagreement between the patient and their family members over the necessary healthcare." The respondents sought "experience with, and insight into, healthcare ethics" and "home care" from people with whom they would consult on ethical issues, but at the time of the actual consultation, those individuals were the main healthcare professionals involved with the patient. In addition, the respondents desired to have "multidisciplinary discussions in the community," "participation of healthcare ethics experts at meetings," and "meetings held by healthcare ethics experts" to discuss specific cases. Given these results and the history of healthcare ethics education in Japan-which has been implemented mostly for healthcare providers-we conclude that it is important for academic societies that offer healthcare ethics education to healthcare providers and regional core hospitals with ethics support resources to collaborate to provide ethics consultation services in the community.

Clinical Ethics Concerns of Rural Healthcare Providers

Purpose: This project aimed to identify ethical concerns in rural hospitals and elicit ideas for establishing clinical ethics services to meet needs. Methods: Two-hundred-fifty-six rural physicians were sent an email requesting participation in an electronic survey. Data were entered into Microsoft excel. Findings: Seventy-four (29%) physicians responded; 59% have an ethics committee available to them. Of these ethics committees, 43% are available 24/7. Ethical dilemmas were categorized into themes, with end-of-life care and vulnerable adult concerns identified most commonly. Online group-learning is the preferred training method for ethics education. Thirty-eight percent would likely use a tele-ethics service if available. Conclusions: Providers in rural health systems face unique and complex ethical dilemmas and would likely utilize remote support for complex bioethical situations. Given these findings, the next step is to develop and pilot an ethics service that would include the three traditional roles for a clinical ethics service: policy development, education, and clinical ethics consultation services.

Healthcare workers’ perception of the usefulness of a healthcare ethics consultation service

Background and objectiveClinical ethics consultation services (CEC) have arisen from Healthcare Ethics Committees (HEC) to address ethical conflicts in real-time. Our aim was to determine the perception of usefulness of a CEC service among healthcare workers one year after its creation as well as to assess changes in trends in the use of the CEC and HEC between 2015 and 2021. Materials and methodsThis observational, cross-sectional study was based on a standardized survey of healthcare workers at an urban tertiary care hospital. The results were also compared to those from an identical survey conducted in the same population in 2015. ResultsA total of 213 professionals participated (mean age 44 ± 11 years, 69% women). The professionals were more familiar with the HEC than the CEC service (94% vs 61%; p < 0.001). Forty-five individuals (21%) had consulted the CEC since its implementation; 95% of them found the consultation useful. Physicians knew about and used the CEC more than other groups of professionals. The degree of knowledge of the HEC increased significantly by 2021 compared to 2015 (94% v. 76%; p < 0.001). Some areas for improvement identified were the need for greater dissemination of the service, guaranteeing institutional resources to maintain the service, and encouraging greater participation from different professional groups. ConclusionsKnowledge of the institutional HEC and CEC services has increased in recent years among healthcare workers, who considered the CEC service to be useful for addressing ethical conflicts in daily practice.