Hospital Clinical Ethics Committees Research Articles

Rural health dialogue for the sustainability of help-seeking behaviors among older patients: grounded theory approach

BackgroundHelp-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs.MethodsAll procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20,220,002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants’ perceptions and behaviors regarding HSBs.ResultsTwenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs.ConclusionsMitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.

Encountering uncertainty and complexity in decision-making: an observational study of clinical reasoning among medical and interprofessional groups of health care students

ABSTRACT Poor teamwork and clinical decisions have a major impact on patient outcomes and safety. Clinical decision-making rarely occurs under ideal conditions, but complex health care environments make this particularly challenging for new graduate health professionals as beginner practitioners. Recent evidence indicates that effective collaboration also enhances quality of clinical decisions for patients with complex needs. However, collaborative decision-making is not standard in educational curricula, where clinical decision-making is usually taught in profession-specific courses emphasizing individual rationality and cognition. The aim of this study was to gain detailed insights into the practice of clinical decision-making by small groups of medical and other health care students. A qualitative observational study design was used. Students (n = 45) took part in a short role-play of a hospital clinical ethics committee meeting discussing three complex patient cases, considering clinical and ethical aspects of care, and made a group decision about priorities for treatment. Audio-recorded data were transcribed verbatim and inductively analyzed based on Strauss’s “Theoretical Coding” approach. Coding and interpretation of transcripts resulted in three key themes: a) values/beliefs as a basis for negotiation; b) encountering obstacles; c) overcoming obstacles. All groups benefited from shared knowledge, assisting each other in dealing with uncertainty and perceived emotional burden. In small groups, they were able to overcome challenges and fulfil a goal potentially beyond many of them as individuals. Provision of learning opportunities where students learn to share expertise and decision-making responsibilities has the potential to optimize their learning in preparation for challenges in future practice.

Feasibility, effectiveness, and satisfaction achieved by the transdisciplinary intervention of a clinical-hospital ethics committee. A qualitative and quantitative study.

A clinical ethics committee (CEC) has educational, regulatory, advisory, mediation, and reflexive functions. As any health care service, the consults with the CEC should be subjected to review and quality improvement. The study objectives were to assess the feasibility, effectiveness, and satisfaction with the bioethical recommendations made by the CEC and assess their impact on the treating team and the patient's family. Descriptive, retrospective, qualitative, and quantitative study of clinical cases submitted to the hospital's CEC between January 1st, 2013 and December 31st, 2017 using data from the CEC minute book, medical records, registries from the Office for Remote Communication, and semi-structured interviews with health care team members. A total of 108 cases (106 patients) were analyzed: 73 cases with survey and registries and 35 with registries only. The main most frequent reasons for consultation were adequacy of therapeutic effort (46/42.6%), severe neurological involvement (15/13.9%), patient's quality of life (11/10.2%), patient-family-health system conflict (7/6.5%), and family's refusal of treatment (6/5.6%). High levels of satisfaction (> 95%) and moderate levels of feasibility (> 74%) and effectiveness (> 85%) were observed. In only 50/108 cases (46.3%), the consultation with the CEC was registered in the medical record, 44% of health care providers stated that the consultation had a positive impact on the patient and their family. Results helped to establish improvement opportunities, especially in terms of documentation and communication in the consultation process.

Kidney transplantation and patients who decline SARS-CoV-2 vaccination: an ethical framework.

SummaryAs SARS‐CoV‐2 vaccines have started to be rolled out, a key question facing transplant units has been whether listing for transplantation should be contingent on recipients having received a vaccine. We aimed to provide an ethical framework when considering potential transplant candidates who decline vaccination. We convened a working group comprising transplant professionals, lay members and patients and undertook a literature review and consensus process. This group's work was also informed by discussions in two hospital clinical ethics committees. We have reviewed arguments for and against mandating vaccination prior to listing for kidney transplantation and considered some practical difficulties which may be associated with a policy of mandated vaccination. Rather than requiring that all patients must receive the SARS‐CoV‐2 vaccine prior to transplant listing, we recommend considering vaccination status as one of a number of SARS‐CoV‐2‐related risk factors in relation to transplant listing. Transplant units should engage in individualised risk–benefit discussions with patients, avoid the language of mandated treatments and strongly encourage uptake of the vaccine in all patient groups, using tailor‐made educational initiatives.

High Cytokine Levels in O Blood Group Determine Protection Against Mechanical Ventilation or Mortality Risk in COVID-19

Background: ABO blood groups are associated with different risk of viral infections. In vitro studies demonstrated how anti-A and anti-B antibodies neutralized the infectious capacity of SARS-CoV-2. Therefore, here we describe the inflammatory response of COVID-19 patients in the context of the blood group aiming to assess the lower severity status found in group O patients.Methods: Prospective and consecutive study including blood samples from 108 adult patients diagnosed with COVID-19 and admitted to the “Hospital Clínico Universitario” Valladolid, Spain between March 24 and April 11 2020. Patients were divided according to their ABO blood group. Plasma aliquots were analyzed, in duplicate, for the quantification of 45 mediators by MAGPIX system (Luminex). Statistical analysis was performed using the R statistical package version 4.0.2 Findings: We found a lower risk (2.16 times) of mechanical ventilation or death in patients with blood group O [Log Rank: p=0.042, Hazard Ratio: 0.463, CI 95% (0.213-1.004), p=0.050]. Moreover, 15 cytokines were significantly over-expressed (and only one under-expressed) in blood group O. Last, a multivariate model found BDNF, IL-13 and IL-27 as the best cytokines able to differentiate the immune profile based on blood group. Interpretation: Our cohort showed how blood group O was associated with both lower rates of hospital admission and a lower risk of intubation or death. Indeed, these patients produced higher amounts of cytokines in response to SARS-CoV-2, hence mounting an effective immune response which allowed them to control the viral infection and therefore decrease the risk of further complications.Funding Statement: This research was funded by Instituto de Salud Carlos III, grant number COV20/00491.Declaration of Interests: Alvaro Tamayo-Velasco declares no conflict of interest. - María Jesús Peñarrubia-Ponce declares no conflict of interest. - Francisco Javier Álvarez declares no conflict of interest. - Hugo Gonzalo-Benito declares no conflict of interest. - Ignacio de la Fuente declares no conflict of interest. - Sonia Pérez González declares no conflict of interest. - Lucía Rico declares no conflict of interest. - María Teresa Jiménez-García declares no conflict of interest. - Alba Sánchez-Rodríguez declares no conflict of interest. - Milagros Hijas-Villaizan declares no conflict of interest. - Marta Martín Fernández declares no conflict of interest. - Carlos Dueñas declares no conflict of interest. - Esther Gómez-Sánchez declares no conflict of interest. - María Heredia-Rodríguez declares no conflict of interest. - Óscar Gorgojo-Galindo declares no conflict of interest. - Itziar Fernández declares no conflict of interest. - Lourdes del Río declares no conflict of interest. - Irene Carnicero-Frutos declares no conflict of interest. - María Fe Muñoz-Moreno declares no conflict of interest. - Eduardo Tamayo declares no conflict of interest. - David Bernardo declares no conflict of interest. - Pedro Martínez-Paz declares no conflict of interest.Ethics Approval Statement: The study was approved by the Hospital's Clinical Ethics Committee (CEIm) and approval was obtained from all study participants (cod: PI 20-1717).

Medical Innovation in a Children's Hospital: 'Diseases desperate grown by desperate appliance are relieved, or not at all'.

A balance needs to be struck between facilitating compassionate access to innovative treatments for those in desperate need, and the duty to protect such vulnerable individuals from the harms of untested/unlicensed treatments. We introduced a principle-based framework (2009) to evaluate such requests and describe its application in the context of recently evolved UK, US and European regulatory processes. 24 referrals (20 individual; four group) were received by our quaternary children's hospital Clinical Ethics Committee (CEC) over the 5-year period (2011-16). The CEC-rapid response group evaluated individual cases within 48-hours; the main referrers being haematology/oncology, immunology or transplant services (14). Most requests were for drug/vaccine/pre-trial access (13) or biological/cellular therapies (8). The majority of individual requests were approved (19/20); neutral or negative opinions were given in 5, including 3 group requests. Recently evolved regulatory processes share common criteria and conditions to our framework including: demonstration of clinical need; sound scientific basis with lack of viable alternative; risks-benefit/best interests evaluation; arrangements for fully informed consent; no compromise of arrangements to test treatment for licensing purposes; consideration of resource implications. There are differences between individual processes and with our framework, with respect to procedures, scope, application format, costs and obligation to make available all outcome data. Our experience has emphasized the need for an independent, principled, consistent, fair and transparent response to the increasing demand for innovative treatment on a compassionate basis. We believe that there is a need for harmonization of the recent proliferation of regulation and legislation in this area.

A Mental Capacity Act 2005 Questionnaire

The hospital's clinical ethics committee sought to gauge health-care professionals’ level of knowledge and usage of the Mental Capacity Act 2005 within the hospital trust. The hospital's personnel were asked to complete a 10 part questionnaire relating to the basic contents of the Act. Four hundred questionnaires were distributed and 249 (62%) were returned completed and valid for analysis. A ‘pass-mark’ of 70% (7/10) was assumed; the results showed that 48% of respondents scored ≤ 50% (≤5/10), 74% of respondents scored <70% (<7/10) and only 24% of respondents scored ≥70% (≥7/10). It was concluded that the Mental Capacity Act 2005 was not being effectively implemented within the Trust. Measures to increase the awareness and usage of the Act have subsequently been instigated. We believe that these measures will improve the awareness and knowledge of the Mental Capacity Act 2005 within the hospital Trust lead to its better utilization.

A description of an effective process for dealing with complex ethical dilemmas in a tertiary children's hospital

Background ‘A’ was referred to the hospital clinical ethics committee; with a rare, genetic, severely life-limiting condition with learning difficulties, endocrine, metabolic and skeletal problems; leading to multi-systemic complications. The key issues were: –To determine the limits of medical treatment in complex cases, involving several professionals. –Dealing with conflict when there was a discrepancy between parental and clinician views –How to determine the best interests of the child. Aims To discuss analytically, the ethical issues identified in the case of a child presenting with a rare and complex syndrome, with repeated admissions. To disseminate learning around the process used in a tertiary Children9s Hospital, of dealing with complex ethical dilemmas. Methods An analysis of the issues was undertaken, using principles and concepts of medical ethics and law. The process involved detailed, critical and reflective discussions between the referring team and the members of the clinical ethics committee over a continuous period. Parental views as well as ‘A9s wishes were ascertained using specialist input. Results The process was felt to be very helpful for all involved with the following benefits and learning points: –It was a good experience to learn to “hear the voice of the mute child” and make ‘A’ central to decision-making, rather than professional or parental views. –A consensus was achieved on a management plan which felt quite enabling and supportive to the clinical team –It optimised use of clinical and legal resources in the Trust. –It contributed to embed the ethics committee more firmly within the clinical governance arrangements of the hospital contributing towards good quality care. –It helped sustain a fragile therapeutic relationship with the family at a difficult juncture –It potentially helped change practice in a positive way. –Important to involve all the clinical team members rather than the referrer alone. –Flexibility needed in arranging meetings repeatedly and at short notice. Conclusions There is experiential evidence that referring complex clinical dilemmas to an ethics committee improves clinical effectiveness and patient experience. This needs to be formally evaluated.

Barriers and facilitators to consulting hospital clinical ethics committees

Hospitals in many countries have had clinical ethics committees for over 20 years. Despite this, there has been little research to evaluate these committees and growing evidence that they are underutilized. To address this gap, we investigated the question 'What are the barriers and facilitators nurses and physicians perceive in consulting their hospital ethics committee?' Thirty-four nurses, 10 nurse managers and 31 physicians working at four Canadian hospitals were interviewed using a semi-structured interview guide as part of a larger investigation. We used content analysis of the interview data related to barriers and facilitators to use of hospital ethics committees to identify nine categories of barriers and nine categories of facilitators. These categories as well as their subcategories are discussed and those specific to nurses or physicians are identified. The need to increase health professionals' use of clinical ethics committees through reducing barriers and maximizing facilitators is discussed.

Evolution of hospital clinical ethics committees in Canada

To investigate the current status of hospital clinical ethics committees (CEC) and how they have evolved in Canada over the past 20 years, this paper presents an overview of the...

Hospital Clinical Ethics Committees The Geneva Experience - Switzerland

Hospital ethics committees were created in the United States of America in the 1970s. Their aims were the education of the hospital personnel in the field of ethics, the development of policies and the publication of guidelines concerning ethical issues, as well as consultations and case reviews of hospitalized patients when an ethical concern was present. During the last thirty years, these committees disseminated, particularly in Western Europe. In this manuscript, we describe the benefit, but also some difficulties with these committees, and we propose some solutions. The characteristics of these committees are discussed (i.e. typology of members, functioning and legitimacy). Finally, we carefully describe our local hospital clinical ethics committee in Geneva (Switzerland), which was founded in 1994 and it still very active. After fifteen years of experience, we remain strongly in favour of the implementation of such committees in any modern hospital.

The Ashley treatment: a step too far, or not far enough?

This “current controversies” contribution describes the recent case of a severely disabled six year old girl who has been subjected to a range of medical interventions at the request of...

Doctors and clinical ethics committees: friends or foes?

German and French abstracts see p. 49 & 50 Background: Whose interests should a hospital clinical ethics committee (CEC) serve? This is a particularly important question in conflicts regarding life and death decisions. This question has been raised in Norway by clinicians, politicians and lay people. Method: A retrospective evaluation of six high conflict cases discussed in CECs, all dealing with forgoing life prolonging treatment to children. The information about the cases is taken from media coverage. The focus is on reasons for conflict and on the role of the CECs. The author was involved in the CEC discus- sion of four of the six cases. Findings: Parents' distrust in the medical judgments seemed to be an important reason why conflicts developed. In addition value conflicts were obvious, but value aspects sometimes could be covered by clinicians in medical facts. When advice was given in the CEC, they all supported the doctors' decision. The child's best interest was the focus of the CEC. In only one of these cases did the CEC's discussion seem to have had practical consequences. Conclusion: The most important function for a CEC is to secure that value issues are recognized and dealt with in a competent way. Neutrality issues cannot be ignored in the work of the CECs. Lay CEC members, open and systematic working procedures, transparency of arguments and early involvement of all involved parties including the patients and / or next of kin in the discussion seem to be important in order to address neutrality issues.

Physician attitudes towards ventilatory support for spinal muscular atrophy type 1 in Australasia

Without ventilatory support, premature death from respiratory insufficiency is virtually universal in infants with spinal muscular atrophy type 1 (SMA1). With mechanical ventilation, however, long-term survival has been reported from numerous international centres. We aimed to characterize physician attitudes to the various forms of ventilatory support for children with SMA1. We surveyed neurologists, respiratory physicians, clinical geneticists and intensivists from all major paediatric hospitals in Australia and New Zealand regarding their views on ventilatory management of SMA1. Ninety-two of the 157 (59%) physicians surveyed replied. Respondents included 16 clinical geneticists, 19 intensive care physicians, 28 neurologists and 29 respiratory physicians. Almost half (47%) opposed invasive ventilation of children with SMA1 and respiratory failure precipitated by intercurrent illness. The majority (76%) opposed invasive ventilatory support for chronic respiratory failure in SMA1. In contrast, non-invasive ventilation was felt by 85% to be appropriate for acute respiratory deteriorations, with 49% supporting long-term non-invasive ventilatory support. Most physicians felt that decisions regarding ventilation should be made jointly by parents and doctors, and that hospital Clinical Ethics Committees should be involved in the event of discordant opinion regarding further management. A majority felt that a defined hospital policy would be valuable in guiding management of SMA1. Respiratory support in SMA1 is an important issue with significant ethical, financial and resource management implications. Most physicians in Australian and New Zealand oppose invasive ventilatory support for chronic respiratory failure in SMA1. Non-invasive ventilation is an accepted intervention for acute respiratory decompensation and may have a role in the long-term management of SMA1. Clinical Ethics Committees and institutional policies have a place in guiding physicians and parents in the management of children with SMA1.

Implementation of guidelines for No-CPR orders by a general medicine unit in a teaching hospital.

No-cardiopulmonary resuscitation (CPR) orders are frequently used to limit the use of cardiopulmonary resuscitation in patients who die in hospital. International research has consistently highlighted major deficiencies in the formulation, documentation and communication of such orders. There has been little Australian research into No-CPR orders and the impact of clinical guidelines. This audit aimed to examine compliance with published guidelines for No-CPR orders previously developed by the hospital Clinical Ethics Committee. The notes of all patients who died while under the care of the General Medicine Unit during June-December 1994 were reviewed to evaluate the use of No-CPR orders. Adherence to hospital No-CPR guidelines was evaluated as well as the principal diagnosis, age, level of care and competence of patients to state their wishes. A No-CPR order was documented in 61% (n = 40) of the 66 patients who died during this period. Of these patients 80% were judged to be incompetent and were unable to be involved in decisions not to resuscitate. There was substantial compliance with the guidelines, with the exception of documenting involvement of nursing staff. No-CPR orders are frequently implemented as a result of failure to respond to curative therapy and do not represent abandonment of the patient. Although this study demonstrates the value of No-CPR guidelines and the audit process, the findings raise fundamental issues regarding the involvement of nursing staff, and of patients, that need to be further addressed.

Paediatrics at the cutting edge: do we need clinical ethics committees?

OBJECTIVES: To investigate the need for hospital clinical ethics committees by studying the frequency with which ethical dilemmas arose, the perceived adequacy of the process of their resolution, and the...