What Factors Contribute to Ethical Problems in Patient Care? A Scoping Review and Case Series of Clinical Ethics Consultations.

AbstractBackground: Healthcare professionals (HCPs) are frequently exposed to ethical problems in patient care that can affect the quality of care. Understanding risk factors for ethical problems may help practitioners to address these problems at an early stage. This study aims to provide an overview of ethical risk factors in patient care. Risk factors known from the literature and those found in clinical ethics consultation (CEC) cases are reviewed. METHODS: A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland. RESULTS: Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty. CONCLUSIONS: There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.

[Kulturelle Kompetenz in der klinischen Ethik]. / Kulturelle Kompetenz in der klinischen Ethik.

INTRODUCTION: Language, cultural identity, values, or migration experiences of patients, relatives and medical professionals have a significant influence on health care. In individual cases, this can lead to the perceptions of moral problems and conflicts, and to requests for clinical ethics support service. What is the role of clinical ethicists in the face of such perceptions? How does a culturally competent clinical ethics support service look like? In the present contribution, this question will be examined on the basis of reflections on the relationship between culture and ethics as well as the discussion about culturally competent medical ethics. On that basis, recommendations for a culturally competent clinical ethics support are derived.

MALDI mass spectrometry imaging unravels organ and amyloid-type specific peptide signatures in pulmonary and gastrointestinal amyloidosis.

PURPOSE: Amyloidosis is a disease group caused by pathological aggregation and deposition of peptides in diverse tissue sites. Recently, matrix-assisted laser desorption/ionization mass spectrometry imaging coupled with ion mobility separation (MALDI-IMS MSI) was introduced as a novel tool to identify and classify amyloidosis using single sections from formalin-fixed and paraffin-embedded cardiac biopsies. Here, we tested the hypothesis that MALDI-IMS MSI can be applied to lung and gastrointestinal specimens. EXPERIMENTAL DESIGN: Forty six lung and 65 gastrointestinal biopsy and resection specimens with different types of amyloid were subjected to MALDI-IMS MSI. Ninety three specimens included tissue areas without amyloid as internal negative controls. Nine cases without amyloid served as additional negative controls. RESULTS: Utilizing a peptide filter method and 21 known amyloid specific tryptic peptides we confirmed the applicability of a universal peptide signature with a sensitivity of 100% and a specificity of 100% for the detection of amyloid deposits in the lung and gastrointestinal tract. Additionally, the frequencies of individual m/z-values of the 21 tryptic marker peptides showed organ- and tissue-type specific differences. CONCLUSIONS AND CLINICAL RELEVANCE: MALDI-IMS MSI adds a valuable analytical approach to diagnose and classify amyloid and the detection frequency of individual tryptic peptides is organ-/tissue-type specific.

Reflecting on the Reasons Pros and Cons Coercive Measures for Patients in Psychiatric and Somatic Care: The Role of Clinical Ethics Consultation. A Pilot Study.

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to "diagnose" and "solve" the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue-ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Age of anxiety and depression revisited: A meta-analysis of two European community samples (1964-2015).

Background/Objective: Based on studies using established psychometric scales, Twenge and coworkers have shown substantial increases in trait anxiety, depressive symptoms and neuroticism in North American population samples since the 1950s. Similar analyses for European samples have not yet been conducted. Our study therefore examined whether similar secular trends exist in German-speaking and British non-clinical samples together with possible connected societal factors. Method: A literature search identified 131 studies (N = 63,269) using the STAI, BDI or EPI in non-clinical samples between 1964 and 2015. Seven societal factors from national statistics were included. We conducted meta-analyses with displayed means and moderation analyses of publication year for all scales. Results: In contrast to North America results, anxiety, depression and neuroticism showed no increase in the two European populations. Publication year correlated negatively with and moderated trait anxiety (GER) and neuroticism (UK). Most societal factors were highly correlated with year of publication. Trait anxiety and neuroticism were significantly predicted by age at marriage and unemployment rate in German-speaking countries. Conclusion: The difference in secular trends between European and North American samples may indicate society specific developments connected to different societal factors.

Antecedentes/Objetivo: En base a estudios que usan escalas psicométricas establecidas, Twenge y colegas han mostrado aumentos sustanciales en la ansiedad rasgo, los síntomas depresivos y el neuroticismo en muestras de población norteamericana desde los años 1950. Análisis similares no se han realizado para muestras europeas. Este estudio examina si tendencias seculares existen en muestras no clínicas de habla alemana y británica, junto con posibles factores sociales conexos. Método: Una búsqueda de literatura identificó 131 estudios (N = 63.269) utilizando el STAI, BDI o EPI en muestras no clínicas, 1964-2015. Se incluyeron siete factores sociales de las estadísticas nacionales. Realizamos meta-análisis con medias y análisis de moderación del año de publicación para las escalas. Resultados: En contraste con los resultados norteamericanos, ansiedad, depresión y neuroticismo no han mostrado un aumento en las dos poblaciones europeas. El año de publicación se correlacionó negativa y moderadamente con la ansiedad (GER) y neuroticismo (UK). Ansiedad y neuroticismo fueron predichas significativamente por la edad en el matrimonio y la tasa de desempleo en los países de habla alemana. Conclusión: La diferencia en las tendencias seculares entre las muestras europeas y norteamericanas puede indicar desarrollos específicos de la sociedad relacionados con diferentes factores sociales.

[Clinical ethics in psychiatry: state of the art]. / Klinische Ethik in der Psychiatrie: State of the Art.

AIM: Overview on Clinical Ethics Consultation in Psychiatry. METHOD: Systematic literature search in data bases (PubMed, Web of Knowledge, SpringerLink, PubPsych, PsychSpider und PsycINFO) against the background of practical experiences with pilot model of implementation of Ethics Consultation in one psychiatric university hospital. RESULTS: Reports on Ethics Consultation in Psychiatry were published only sporadically. This is contrasted by recent experiences showing considerable needs for ethics support in Child and Adolescent Psychiatry, Adult as well as Forensic Psychiatry. DISCUSSION: This somewhat "late" development of Ethics Consultation in Psychiatry (compared with somatic medicine) might have structural reasons (lacking resources), be related to strong compensatory competencies of psychiatric staff, esp. regarding communication or legal knowledge, but could also relate to an under-estimation ("under-diagnostic") of ethical problems in psychiatric patient care - both, in the eyes of psychiatric insiders, as well as seen from the outside. CONCLUSIONS: Needs for model projects and accompanying research on Ethics Consultation in Psychiatry. Proved in practice: patient- as well as team-oriented ethics support.

Evidence - competence - discourse: the theoretical framework of the multi-centre clinical ethics support project METAP.

In this paper we assume that 'theory' is important for Clinical Ethics Support Services (CESS). We will argue that the underlying implicit theory should be reflected. Moreover, we suggest that the theoretical components on which any clinical ethics support (CES) relies should be explicitly articulated in order to enhance the quality of CES. A theoretical framework appropriate for CES will be necessarily complex and should include ethical (both descriptive and normative), metaethical and organizational components. The various forms of CES that exist in North-America and in Europe show their underlying theory more or less explicitly, with most of them referring to some kind of theoretical components including 'how-to' questions (methodology), organizational issues (implementation), problem analysis (phenomenology or typology of problems), and related ethical issues such as end-of-life decisions (major ethical topics). In order to illustrate and explain the theoretical framework that we are suggesting for our own CES project METAP, we will outline this project which has been established in a multi-centre context in several healthcare institutions. We conceptualize three 'pillars' as the major components of our theoretical framework: (1) evidence, (2) competence, and (3) discourse. As a whole, the framework is aimed at developing a foundation of our CES project METAP. We conclude that this specific integration of theoretical components is a promising model for the fruitful further development of CES.