Infringement of the right to surgical informed consent: negligent disclosure and its impact on patient trust in surgeons at public general hospitals - the voice of the patient.

BACKGROUND: There is little dispute that the ideal moral standard for surgical informed consent calls for surgeons to carry out a disclosure dialogue with patients before they sign the informed consent form. This narrative study is the first to link patient experiences regarding the disclosure dialogue with patient-surgeon trust, central to effective recuperation and higher adherence. METHODS: Informants were 12 Israelis (6 men and 6 women), aged 29-81, who underwent life-saving surgeries. A snowball sampling was used to locate participants in their initial recovery process upon discharge. RESULTS: Our empirical evidence indicates an infringement of patients' right to receive an adequate disclosure dialogue that respects their autonomy. More than half of the participants signed the informed consent form with no disclosure dialogue, and thus felt anxious, deceived and lost their trust in surgeons. Surgeons nullified the meaning of informed consent rather than promoted participants' moral agency and dignity. DISCUSSION: Similarity among jarring experiences of participants led us to contend that the conduct of nullifying surgical informed consent does not stem solely from constraints of time and resources, but may reflect an underlying paradox preserving this conduct and leading to objectification of patients and persisting in paternalism. We propose a multi-phase data-driven model for informed consent that attends to patients needs and facilitates patient trust in surgeons. CONCLUSIONS: Patient experiences attest to the infringement of a patient's right to respect for autonomy. In order to meet the prima facie right of respect for autonomy, moral agency and dignity, physicians ought to respect patient's needs. It is now time to renew efforts to avoid negligent disclosure and implement a patient-centered model of informed consent.

Should Hospital Emergency Departments Be Used as Revenue Streams Despite Needs to Curb Overutilization?

This case asks how a hospital should balance patients' health needs with its financial bottom line regarding emergency department utilization. Should hospitals engage in proactive population health initiatives if they result in decreased revenue from their emergency departments? Which values should guide their thinking about this question? Drawing upon emerging legal and moral consensus about hospitals' obligations to their surrounding communities, this commentary argues that treating emergency departments purely as revenue streams violates both legal and moral standards.

In search of good care: the methodology of phenomenological, theory-oriented 'N=N case studies' in empirically grounded ethics of care.

This paper proposes a new perspective on the methodology of qualitative inquiry in (care) ethics, especially the interaction between empirical work and theory development, and introduces standards to evaluate the quality of this inquiry and its findings. The kind of qualitative inquiry the authors are proposing brings to light what participants in practices of care and welfare do and refrain from doing, and what they undergo, in order to offer 'stepping stones', political-ethical insights that originate in the practice studied and enable practitioners to deal with newly emerging moral issues. As the authors' aim is to study real-life complexity of inevitably morally imprinted care processes, their empirical material typically consists of extensive and comprehensive descriptions of exemplary cases. For their research aim the number of cases is not decisive, as long as the rigorous analysis of the cases studied provides innovative theoretical insights into the practice studied. Another quality criterion of what they propose that should be called 'N=N case studies' is the approval the findings receive from the participants in the practice studied.

A experiência do comitê de bioética de um hospital público / The experience of the Bioethics Committee from a public hospital / La experiencia del Comité de Bioética de un hospital público

Resumo O objetivo deste estudo foi analisar e sistematizar a experiência do comitê de bioética do Hospital Geral de São Mateus, hospital público estadual de São Paulo. Foi adotada metodologia qualitativa de pesquisa, com estratégia de estudo de caso. Duas técnicas de pesquisa foram utilizadas: análise documental e questionário com perguntas abertas aplicado aos participantes do comitê de bioética. Por meio da análise do material obtido foram constituídas quatro categorias: histórico e evolução do comitê; motivação para participar dele; casos marcantes ali discutidos; sugestões para aperfeiçoamento do comitê. Verificou-se que, além de discutir e deliberar, o comitê de bioética desenvolveu também papel educativo em relação aos profissionais e equipes envolvidos. Esse papel foi expandido para a instituição como um todo, por meio de simpósios com temas ligados à bioética. O estudo revela a importância de estimular a criação de instâncias desse tipo nas instituições de saúde do Brasil.

Abstract The objective of this study was to analyze and systematize the experience of the bioethics committee from the Hospital Geral de São Matheus (General Hospital of São Mateus), which is a public hospital in the State of São Paulo, Brazil. We adopted the qualitative research method, with the case study strategy. Two research techniques were applied: record analysis and an open ended questionnaire answered by the bioethics committee participants. Four categories were established after analyzing the material: history and evolution of the bioethics committee; motivation to participate in the bioethics committee; memorable cases discussed by the committee; suggestions for the improvement of the bioethics committee. It was noted that besides discussing and deliberating, the bioethics committee also developed an educational role for the involved professionals and teams. This role was also expanded to the institution as a whole, by means of symposia with topics related to bioethics. This study reveals the importance of stimulating the creations of such forums in Brazilian healthcare institutions.

Resumen El objetivo de este estudio fue analizar y sistematizar la experiencia del Comité de Bioética del Hospital Geral de São Matheus (Hospital General de San Mateo), hospital público del estado de São Paulo, Brasil. Se adoptó la metodología de investigación cualitativa, con la estrategia de estudio de caso. Se utilizaron dos técnicas de investigación: análisis de documentos y cuestionarios con preguntas abiertas aplicadas a los participantes del Comité de Bioética. A través del análisis del material obtenido se constituyeron cuatro categorías: historia y evolución del Comité; motivación para participar de éste; casos importantes discutidos en el Comité de Bioética; sugerencias para la mejora del mismo. Se encontró que, además de discutir y decidir, el Comité de Bioética también ha desempeñado un papel educativo en relación a los profesionales y a los equipos involucrados. Esta función también se amplió a la institución en su conjunto por medio de simposios sobre temas relacionados con la bioética. El estudio pone de manifiesto la importancia de estimular la creación de tales organismos en las instituciones de salud en Brasil.

Rethinking critical reflection on care: late modern uncertainty and the implications for care ethics.

Care ethics as initiated by Gilligan, Held, Tronto and others (in the nineteen eighties and nineties) has from its onset been critical towards ethical concepts established in modernity, like 'autonomy', alternatively proposing to think from within relationships and to pay attention to power. In this article the question is raised whether renewal in this same critical vein is necessary and possible as late modern circumstances require rethinking the care ethical inquiry. Two late modern realities that invite to rethink care ethics are complexity and precariousness. Late modern organizations, like the general hospital, codetermined by various (control-, information-, safety-, accountability-) systems are characterized by complexity and the need for complexity reduction, both permeating care practices. By means of a heuristic use of the concept of precariousness, taken as the installment of uncertainty, it is shown that relations and power in late modern care organizations have changed, precluding the use of a straightforward domination idea of power. In the final section a proposition is made how to rethink the care ethical inquiry in order to take late modern circumstances into account: inquiry should always be related to the concerns of people and practitioners from within care practices.

The meaning of smoking for patients with mental disorder.

When patients smoke cigarettes in psychiatric services, it brings to the forefront current ethical and political dilemmas. This study aims to explore the meaning attributed to smoking by mental health patients who smoke and who are hospitalized in a psychiatric ward of a general hospital. This qualitative descriptive study was conducted with 96 smokers who were hospitalized in a psychiatric ward in Brazil. Semi-structured interviews, test of nicotine dependence, and content thematic analysis were carried out. The results show that tobacco has an important role in the lives of psychiatric patients. The meanings they attribute to tobacco use are related to overcoming difficulties that are consequential of mental disorders and of side effects caused by their treatments.

Evaluation of the work of hospital districts' research ethics committees in Finland.

The main task of research ethics committees (RECs) is to assess research studies before their start. In this study, 24 RECs that evaluate medical research were sent questionnaires about their structure and functions. The RECs were divided into two separate groups: those working in university hospital districts (uRECs) and those in central hospital districts (non-uRECs). The two groups were different in many respects: the uRECs were bigger in size, covered a wider range of disciplines (both medical and non-medical), had better resources and more frequent and regular meetings. After the survey was performed and analysed, the Medical Research Act was amended so that only hospital districts with a medical faculty in their region had a duty to establish ethics committees. After the amendment, the number of RECs evaluating medical research in Finland decreased from 25 to 9. The ethics committees that remained had wider expertise and were better equipped already by the time of this survey. Only one non-uREC was continuing its work, and this was being done under the governance of a university hospital district. Simple measures were used for qualitative analysis of the work of RECs that evaluate medical research. These showed differences between RECs. This may be helpful in establishing an ethics committee network in a research field or administrational area.

The changing composition of a hospital ethics committee: a tertiary care center's experience.

A growing body of research has demonstrated significant heterogeneity of hospital ethics committee (HEC) size, membership and training requirements, length of appointment, institutional support, clinical and policy roles, and predictors of self identified success. Because these studies have focused on HECs at a single point in time, however, little is known about how the composition of HECs changes over time and what impact these changes have on committee utilization. The current study presents 20 years of data on the evolution of the Massachusetts General Hospital HEC. Between 1993 and 2012, the average number of committee members per year was 38±3 and the average length of membership was 4.8±0.4 years. During that time, the committee performed 934 consults, averaging 47±3 per year. Attendance rates fell from 61.5 to 23.8% over the study period and were inversely correlated with the total number of members. Between 1993 and 2012, the committee saw substantial growth in the diversity of the professional backgrounds of its members. Multivariate analysis, however, suggests that substantial changes in committee composition did not impact its utilization and that other factors are more likely to explain fluctuations in consultation volume.

Lewd, crude, and rude behavior: the impact of manners and etiquette in the general hospital.

BACKGROUND: Lewd, crude, and rude behaviors of patients and staff members have the potential to complicate care; unfortunately, the medical literature on manners and etiquette is sparse. OBJECTIVE: We sought to understand the impact of lewd, crude, and rude behaviors in the general hospital and to provide a context in which to educate clinicians about the management of troublesome behaviors of patients and staff members. METHOD: We reviewed the history of etiquette in the general hospital, and discuss the ethical ramifications and clinical management of inappropriate behaviors. RESULTS: Lewd, crude, and rude language and behaviors are often heard and seen in the general hospital; such behaviors can be understood in a biopsychosocial context. CONCLUSIONS: Teaching trainees about manners and etiquette can help them identify and manage offensive behaviors and can facilitate the provision of effective and ethical care.

How do hospitals deal with euthanasia requests in Flanders (Belgium)? A content analysis of policy documents.

OBJECTIVE: To describe the form and content of ethics policies on euthanasia in Flemish hospitals and the possible influence of religious affiliation on policy content. METHODS: Content analysis of policy documents. RESULTS: Forty-two documents were analyzed. All policies contained procedures; 57% included the position paper on which the hospital's stance on euthanasia was based. All policies described their hospital's stance on euthanasia in competent terminally ill patients (n=42); 10 and 4 policies, respectively, did not describe their stance in incompetent terminally and non-terminally ill patients. Catholic hospitals restrictively applied the euthanasia law with palliative procedures and interdisciplinary deliberations. The policies described several phases of the euthanasia care process--confrontation with euthanasia request (93%), decision-making process (95%), care process in cases of no-euthanasia decision (38%), preparation and performance of euthanasia (79%), and aftercare (81%)--as well as involvement of caregivers, patients, and relatives; ethical issues; support for caregivers; reporting; and practical examples of professional attitudes and communication skills. CONCLUSION: Euthanasia policies go beyond summarizing the euthanasia law by addressing the importance of the euthanasia care process, in which palliative care and interdisciplinary cooperation are important factors. PRACTICE IMPLICATIONS: Euthanasia policies provide tangible guidance for physicians and nurses on handling euthanasia requests.

Constant Observation in the general hospital: a review.

The role of Constant Observation (COb) in the general hospital is addressed. The difficulties of managing acute psychological disturbance in the general hospital are described. Concerns about confused behavior and suicidal risk appear to be the most common reasons for ordering COb. Organic brain syndrome is the most common diagnosis made in patients receiving COb. Medico-legal, ethical and therapeutic aspects of COb are noted. To our knowledge there is no research evidence that COb significantly decreases the rate of suicide in the general hospital. It appears that the role of COb is enshrined in the general hospital as a result of medico-legal process in addition to its therapeutic role. Further research in this area is needed.

An eight-year follow-up national study of medical school and general hospital ethics committees in Japan.

BACKGROUND: Ethics committees and their system of research protocol peer-review are currently used worldwide. To ensure an international standard for research ethics and safety, however, data is needed on the quality and function of each nation's ethics committees. The purpose of this study was to describe the characteristics and developments of ethics committees established at medical schools and general hospitals in Japan. METHODS: This study consisted of four national surveys sent twice over a period of eight years to two separate samples. The first target was the ethics committees of all 80 medical schools and the second target was all general hospitals with over 300 beds in Japan (n = 1457 in 1996 and n = 1491 in 2002). Instruments contained four sections: (1) committee structure, (2) frequency of annual meetings, (3) committee function, and (4) existence of a set of guidelines for the refusal of blood transfusion by Jehovah's Witnesses. RESULTS: Committee structure was overall interdisciplinary. Frequency of annual meetings increased significantly for both medical school and hospital ethics committees over the eight years. The primary activities for medical school and hospital ethics committees were research protocol reviews and policy making. Results also showed a significant increase in the use of ethical guidelines, particularly those related to the refusal of blood transfusion by Jehovah's Witnesses, among both medical school and hospital ethics committees. CONCLUSION: Overall findings indicated a greater recognized degree of responsibilities and an increase in workload for Japanese ethics committees.

Relations between ethnic Croats and ethnic Serbs at Vukovar General Hospital in wartime and peacetime.

This article examines war and peacetime ethnic relations at Vukovar General Hospital in Croatia's Eastern Slavonia region. A negotiated peace agreement paved the way for a multi-sectored approach to the reintegration of Eastern Slavonia back into the state and rapprochement between ethnic groups under the supervision of a United Nations transitional administration. This case study provides a glimpse into the realities of those peace-building processes on an institutional level in Eastern Slavonia's healthcare system. The reintegration of Vukovar hospital, the transition of Eastern Slavonia's health sector and peace-building in the region in general received much deserved accolades despite some flaws and minor setbacks. These experiences can still serve as a model for the rest of Croatia and for other countries emerging from civil conflicts.