Palliative Care for Patients With Cancer: ASCO Guideline Update.

PURPOSE: To provide evidence-based guidance to oncology clinicians, patients, nonprofessional caregivers, and palliative care clinicians to update the 2016 ASCO guideline on the integration of palliative care into standard oncology for all patients diagnosed with cancer. METHODS: ASCO convened an Expert Panel of medical, radiation, hematology-oncology, oncology nursing, palliative care, social work, ethics, advocacy, and psycho-oncology experts. The Panel conducted a literature search, including systematic reviews, meta-analyses, and randomized controlled trials published from 2015-2023. Outcomes of interest included quality of life (QOL), patient satisfaction, physical and psychological symptoms, survival, and caregiver burden. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS: The literature search identified 52 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS: Evidence-based recommendations address the integration of palliative care in oncology. Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer. For patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services complementing existing or emerging supportive care interventions. Oncology clinicians from across the interdisciplinary cancer care team may refer the caregivers (eg, family, chosen family, and friends) of patients with cancer to palliative care teams for additional support. The Expert Panel suggests early palliative care involvement, especially for patients with uncontrolled symptoms and QOL concerns. Clinicians caring for patients with solid tumors on phase I cancer trials may also refer them to specialist palliative care.Additional information is available at www.asco.org/supportive-care-guidelines.

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.

Surgical Regret and Intraoperative Decision-Making: A Living Donor Kidney Case.

Surgical regret often experienced at times of a great loss may cause a surgeon to reflect on their practice and intraoperative decision-making. It is inevitable that in the surgical profession, both in training and practice, a surgeon's decisions will be questioned by themselves, peers, and possibly patients. Here, we explore a case of living donor kidney donation in which the surgeon chooses to discontinue the operation for an incidental finding. Ultimately, this is against the patient's wishes and a decision over which both the surgeon and patient experience moral hazard and regret. This article explores surgical regret from the lens of an altruistic donor case and a surgeon's inaction, discussing the ethics of the operative decision-making and surgeon's viewpoint intra- and post-operatively.

Consensus-based ethical best practices for performing educational point-of-care ultrasonography in the emergency department.

Objectives: There is no standardized protocol for performing educational point-of-care ultrasonography (POCUS) that addresses patient-centered ethical issues such as obtaining informed consent. This study sought to define principles for ethical application of educational POCUS and develop consensus-based best practice guidance. Methods: A questionnaire was developed by a trained ethicist after literature review with the help of a medical librarian. A diverse panel including experts in medical education, law, and bioethics; medical trainees; and individuals with no medical background was convened. The panel voted on their level of agreement with ethical principles and degree of appropriateness of behaviors in three rounds of a modified Delphi process. A high level of agreement was defined as 80% or greater consensus. Results: Panelists voted on 38 total items: 15 related to the patient consent and selection process, eight related to practices while performing educational POCUS, and 15 scenarios involving POCUS application. A high level of agreement was achieved for 13 items related to patient consent and selection, eight items related to performance practices, and 10 scenarios of POCUS application. Conclusions: Based on expert consensus, ethical best practices include obtaining informed consent before performing educational POCUS, allowing patients to decline educational POCUS, informing patients the examination is not intended to be a part of their medical evaluation and is not billed, using appropriate draping techniques, maintaining a professional environment, and disclosing incidental findings in coordination with the primary team caring for the patient. These practices could be implemented at institutions to encourage ethical use of educational POCUS when training physicians, fellows, residents, and medical students.

Inter-hospital Transfer Decision-making During the COVID-19 Pandemic: a Qualitative Study.

BACKGROUND: Inter-hospital patient transfers to hospitals with greater resource availability and expertise may improve clinical outcomes. However, there is little guidance regarding how patient transfer requests should be prioritized when hospital resources become scarce. OBJECTIVE: To understand the experiences of healthcare workers involved in the process of accepting inter-hospital patient transfers during a pandemic surge and determine factors impacting inter-hospital patient transfer decision-making. DESIGN: We conducted a qualitative study consisting of semi-structured interviews between October 2021 and February 2022. PARTICIPANTS: Eligible participants were physicians, nurses, and non-clinician administrators involved in the process of accepting inter-hospital patient transfers. Participants were recruited using maximum variation sampling. APPROACH: Semi-structured interviews were conducted with healthcare workers across Michigan. KEY RESULTS: Twenty-one participants from 15 hospitals were interviewed (45.5% of eligible hospitals). About half (52.4%) of participants were physicians, 38.1% were nurses, and 9.5% were non-clinician administrators. Three domains of themes impacting patient transfer decision-making emerged: decision-maker, patient, and environmental factors. Decision-makers described a lack of guidance for transfer decision-making. Patient factors included severity of illness, predicted chance of survival, need for specialized care, and patient preferences for medical care. Decision-making occurred within the context of environmental factors including scarce resources at accepting and requesting hospitals, organizational changes to transfer processes, and alternatives to patient transfer including use of virtual care. Participants described substantial moral distress related to transfer triaging. CONCLUSIONS: A lack of guidance in transfer processes may result in considerable variation in the patients who are accepted for inter-hospital transfer and in substantial moral distress among decision-makers involved in the transfer process. Our findings identify potential organizational changes to improve the inter-hospital transfer process and alleviate the moral distress experienced by decision-makers.

Promoting Antiracist Mental Health Crisis Responses.

Clinicians cannot always directly or effectively engage patients experiencing mental health crises. This article considers the common practice of relying upon law enforcement personnel to facilitate mental health checks and considers its implications for Black patients. An antiracist approach to decriminalizing acute exacerbations of mental illness requires clinicians' engagement in educating, training, and policymaking. This article recommends strategies for effective real-time communication before, during, and after a 911 call involving a person experiencing a mental health crisis.

Taking the burden off: a study of the quality of ethics consultation in the time of COVID-19.

BACKGROUND: The quality of ethics consults is notoriously difficult to measure. Survey-based assessments cannot capture nuances of consultations. To address this gap, we conducted interviews with health professionals who requested ethics consults during the initial phase of the COVID-19 pandemic. METHOD: Healthcare professionals requesting ethics consultation between March 2020 and May 2020 at a tertiary academic medical centre were eligible to participate. We asked participants to comment on the consults they called and thematically analysed responses to identify features associated with optimal quality consultations. RESULTS: Of 14 healthcare providers, 8 (57%) were women and professions were as follows: 11 (79%) medical doctors, 1 (7%) social worker, 1 (7%) physician assistant and 1 (7%) nurse practitioner. Two aspects of quality emerged: satisfaction and value. Themes within the domain of satisfaction included: responsiveness of the ethics consultant, willingness to consult, institutional role of the ethics service and identifying areas for improvement. When describing value, respondents spoke of the intrapersonal and interpersonal worth of consultation. CONCLUSION: Participants were generally satisfied with ethics consultation services, similar to opinions of those found in pre-COVID-19 survey studies. Our qualitative approach allowed for a richer exploration of the value of ethics consultation during the pandemic and has implications for ethics consultation services more broadly. Ethics consultation-emphasising both the process and outcome-created valuable moral spaces, promoting thoughtful and ethical responses to dilemmas in patient care. Future assessments should incorporate patient and family/surrogate perspectives and explore the domain of education as an additional quality measure.

Interprofessional geriatric and palliative care intervention associated with fewer hospital days.

BACKGROUND: With increasing complexity of our aging inpatient population, we implemented an interprofessional geriatric and palliative care intervention on a hospitalist service. This study aimed to measure the intervention's impact on length of stay (LOS), 30-day readmission, and the daily intensity of inpatient services utilization. METHODS: Using a nonrandomized controlled intervention at a 1000-bed U.S. academic quaternary medical center, we studied 13,941 individuals admitted to a general medicine hospitalist service (of which 5644 were age > =65 years); 1483 were on intervention teams (576 age > =65 years), 5413 concurrent controls, and 7045 historical controls. On 2 of 11 hospitalist teams, a geriatrician, palliative care physician and social worker attended multidisciplinary discharge rounds twice weekly, to recommend inpatient geriatric or palliative care consult (GPCC), postacute nursing or home care, versus postdischarge outpatient consultation. We measured the difference in improvement over time between intervention and control team patients for the following: (1) LOS adjusted for case-mix index, (2) 30-day readmissions, and (3) intensity of hospital service utilization (mean services provided per patient per day). RESULTS: Adjusted LOS (in hospital days) was decreased by 0.36 days (p = 0.039) for the 1483 patients in the intervention teams, with greater LOS reduction of 0.55 days per admission (p = 0.022) on average among the subset of 576 older patient admissions. Readmissions were unchanged (-1.17%, p = 0.48 for all patients; 1.91%, p = 0.46 for older patients). However, the daily relative value unit (RVU) utilization was modestly increased for both the overall and older subgroup, 0.35 RVUs (p = 0.041) and 0.74 RVUs (p < 0.001) per patient-day on average across the intervention teams, respectively. CONCLUSION: An interprofessional intervention of geriatric and palliative care consultation in collaboration with a hospitalist service may reduce LOS, especially for geriatric patients, without an increase in readmissions. This model may have broader implications for hospital care and should be further studied.

A Pre-Doctoral Clinical Ethics Fellowship for Medical Students.

INTRODUCTION: Despite the need for trained physician ethicists, fellowships in clinical ethics are limited and primarily offered to those who have completed a graduate degree. The standardization of credentialing for clinical ethics consultants (CECs) and the restructuring of undergraduate medical education allow innovative models to train CECs that can provide an expanded opportunity for formal ethics training at an earlier stage. METHODS: At the University of Michigan Medical School we developed, implemented, and evaluated a pre-doctoral clinical ethics fellowship program from 2017 to 2019 for senior medical students, designed to meet established competencies for CECs. Consultation notes from the beginning and end of the fellowship program were randomly selected for each fellow and independently rated by two faculty ethicists who used the validated Ethics Consultation Quality Assessment Tool (ECQAT). Inter rater reliability and trends in scores over time were calculated. RESULTS: Three students successfully completed the fellowship at the University of Michigan Medical School, conducted at least 50 formal ethics consultations, and spent approximately 40 hours a week on service for a minimum of six months. All students finished the fellowship with teaching and policy development experience, first-authored peer-reviewed manuscripts, and national presentations. The fellows demonstrated improvement in their ECQAT overall holistic rating score; all ended their fellowship with a holistic score of adequate or above. There was 92 percent agreement between raters with respect to the acceptability of the fellows' ethics consult notes. Two fellows have taken and passed the Healthcare Ethics Consultant-Certification (HEC-C) exam offered by the American Society for Bioethics and Humanities (ASBH). CONCLUSIONS: Integration of a pre-doctoral fellowship model that meets professional certification standards for clinical ethics consultation creates an opportunity for medical students to become trained CECs early in their career.

Should One Kind of Freedom Be Restricted to Promote Another?

Due to restraints' consequences for personal liberty and dignity, the threshold to apply restraints is understandably high and heavily regulated. However, there can be clinical scenarios in which restraint use can facilitate a patient's freedom. This article considers such a case and examines conditions under which using restraints offers therapeutic benefit for patients with traumatic brain injuries.

Pediatric Interprofessional ICU Ethics Rounds: A Single-Center Study.

OBJECTIVES: We sought to examine whether sociodemographic differences, such as race and socioeconomic status, existed between patients in the PICU, pediatric cardiothoracic ICU (PCTU), and NICU who were identified as having ethical issues during interprofessional ethics rounds and all other patients admitted to these units and to characterize the primary ethical issues identified in this context. METHODS: We compared sociodemographic factors among patients admitted to a quaternary academic children's hospital between January 2017 and December 2018 who were identified as having ethical issues during PICU, PCTU, and NICU interprofessional ethics rounds (n = 122) with those of all other patients admitted to these units (n = 4971). χ2 tests or Fisher's exact tests, Mann-Whitney U tests, and a multivariable logistic regression analysis were performed. RESULTS: With bivariate analyses, we detected significant differences by race, insurance type, and ventilator dependence, but no significant differences between the 2 groups existed on the basis of sex, ethnicity, religion, primary language, age, or a socioeconomic status metric. After we adjusted for confounders using a multivariable logistic regression analysis, only patients who were ventilator dependent were at significantly higher odds (odds ratio = 5.78; confidence interval = 3.69-9.04; P < .001) of being identified as having ethical issues. Goals of care was the most frequent ethical issue (44%). CONCLUSIONS: Except for ventilator dependence, patients with ethical issues during PICU, PCTU, and NICU interprofessional ethics rounds are demographically similar to overall patients admitted in these units. Future research should be used to assess whether proactive rounds impact the timing of ethics consultation requests as well as to determine if interprofessional ethics rounds influence volume and acuity in formal ethics consultation practices.

Patient perceptions of trust formation in the surgeon-patient relationship: A thematic analysis.

OBJECTIVE: Trust is crucial to the success of any personal or professional relationship. Literature on trust in the surgeon-patient relationship has been largely explored through quantitative methodologies, primarily examining why trust may or may not exist. We aimed to qualitatively elucidate the mechanisms of how trust develops between otolaryngologists and their patients. METHODS: Patients were recruited by surgery scheduling staff following an outpatient visit where a decision had been made to proceed with surgery at a tertiary academic medical center. We used qualitative realist thematic analysis of phone interviews to explore participants' (n = 17) perceptions and conceptualization of trust formation within the surgeon-patient relationship. RESULTS: Thematic analysis revealed three themes regarding trust formation in the surgeon-patient relationship: 1) Trust Across Various Contexts; 2) Impact of Prior Knowledge; and 3) Interpersonal Connection during the Clinical Encounter. CONCLUSION: An interpersonal surgeon-patient connection is crucial to the formation of trust. Trust is also influenced by surgeon and institutional reputation and witnessed surgeon interactions with the healthcare team. PRACTICE IMPLICATIONS: Patients perceive trust in a surgeon as carrying unique importance. To optimize conditions for trust development in this context, surgical care paradigms should promote meaningful preoperative interpersonal surgeon-patient relationships and positive surgeon and institutional reputations.

Patient Perceptions of Trust in Trainees During Delivery of Surgical Care: A Thematic Analysis.

OBJECTIVE: Trust is an essential element of an effective physician-patient relationship. There is limited literature examining trust between trainees and patients in the surgical setting. The goal of this study was to investigate how otolaryngology patients perceive trust in trainees during delivery of surgical care. DESIGN: We extracted trainee-specific data from a larger, qualitative interview study examining trust in the surgeon-patient relationship. We then used realist thematic analysis to explore preoperative otolaryngology patients' perceptions of trust in trainees during delivery of surgical care. SETTING: Department of Otolaryngology-Head and Neck Surgery at Michigan Medicine in Ann Arbor, MI, a tertiary academic medical center. PARTICIPANTS: Using convenience sampling, adults 18 years or older scheduled to undergo elective otolaryngologic surgery between February and June 2019 were invited, and 12 agreed to participate in the study. RESULTS: All participants (n = 12) self-identified as White/Caucasian with a mean age of 60 years (range, 28-82). Participants were 50% (n = 6) female and 50% (n = 6) male. Thematic analysis of participants' perspectives about trust in trainees during delivery of surgical care revealed 3 themes. Trust in trainees is conditional based on (i) level of trainee involvement; (ii) trust in the attending surgeon; and, (iii) trust in the institution. CONCLUSION: Trust in trainees during delivery of surgical care is conditional on types of tasks trainees perform, bounded by trust in their attending surgeon, and positively influenced by institutional trust. Trainees and surgical educators must look to innovative methods to engender trust more efficiently in the clinic and immediate pre-operative setting. Such approaches can have a positive impact on patient outcomes, facilitate stronger trainee-attending interpersonal relationships, and empower surgeons to practice the professional values integral to surgical care.

Hospital Visitation Policies During the SARS-CoV-2 Pandemic.

A significant change for patients and families during SARs-CoV-2 has been the restriction of visitors for hospitalized patients. We analyzed SARs-CoV-2 hospital visitation policies and found widespread variation in both development and content. This variation has the potential to engender inequity in access. We propose guidance for hospital visitation policies for this pandemic to protect, respect, and support patients, visitors, clinicians, and communities.