An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

The Simulation Team Assessment Tool (STAT): development, reliability and validation.

INTRODUCTION: Simulation sessions prepare medical professionals for pediatric emergencies. No validated tools exist to evaluate overall team performance. Our objective was to develop and evaluate the inter-rater reliability and validity of a team performance assessment tool during simulated pediatric resuscitations. METHODS: We developed the Simulation Team Assessment Tool (STAT) which evaluated 4 domains: basic assessment skills, airway/breathing, circulation, and human factors. Scoring of each element was behaviorally anchored from 0 to 2 points. Two teams of resuscitation experts and two teams of pediatric residents performed the same simulated pediatric resuscitation. Each team was scored by six raters using the STAT. Intraclass correlation coefficients (ICC) were calculated to assess inter-rater reliability. Overall performance and domain scores between expert and resident teams were compared using repeated measures of analysis of variance to assess construct validity. RESULTS: ICCs for overall performance were 0.81. Domain ICCs were: basic skills 0.73, airway/breathing skills 0.30, circulation skills 0.76, human factors 0.68. Expert versus resident average scores were: overall performance 84% vs. 66% (p=0.02), basic skills 73% vs. 55% (p<0.01); airway 80% vs. 75% (p=0.25), circulation 90% vs. 69% (p=0.02), human factors 89% vs. 66% (p=0.02). CONCLUSIONS: The STAT's overall performance, basic skills, circulation, and human factors domains had good to excellent inter-rater reliability, discriminating well between expert and resident teams. Similar performance in the airway/breathing domain among all teams magnified the impact of a small number of rater disagreements on the ICC. Additional study is needed to better assess the airway/breathing domain.