Beyond the Hospital Walls: The Role of the Ethicist in Community Healthcare Settings.

AbstractCommunity-based "free" clinics can be a key site of primary and preventive care, especially for underserved members of the community. Ethical issues arise in community clinics. Despite this-and the fact that ethics consultation is a well-established practice within hospitals-ethics support is rarely integrated within community clinics, and the clinical ethicist's role in community care settings remains unexplored. In this article I explore what community-engaged practice might look like for the clinical ethicist. I share my experience of being invited into a local community clinic where a team of volunteers, in partnership with a local church, provide care to persons experiencing housing and food security in our county. First, I outline some of the key ethical issues we encounter in our clinic, including how to promote the agency of community members, develop shared standards for clinic volunteers, and balance different values and priorities within the partnership. Second, I explore how the ethicist's knowledge and skills translate into this setting. I argue that, given the range of ethical issues that arise in community clinics and the need for ongoing dialogue, education, and critical reflection within such partnerships, there is a role for the clinical ethicist in this space. I discuss how clinical ethicists might begin to develop community-based partnerships and practices.

Using a virtue ethics lens to develop a socially accountable community placement programme for medical students.

BACKGROUND: Community-based education (CBE) involves educating the head (cognitive), heart (affective), and the hand (practical) by utilizing tools that enable us to broaden and interrogate our value systems. This article reports on the use of virtue ethics (VE) theory for understanding the principles that create, maintain and sustain a socially accountable community placement programme for undergraduate medical students. Our research questions driving this secondary analysis were; what are the goods which are internal to the successful practice of CBE in medicine, and what are the virtues that are likely to promote and sustain them? METHODS: We conducted a secondary theoretically informed thematic analysis of the primary data based on MacIntyre's virtue ethics theory as the conceptual framework. RESULTS: Virtue ethics is an ethical approach that emphasizes the role of character and virtue in shaping moral behavior; when individuals engage in practices (such as CBE), goods internal to those practices (such as a collaborative attitude) strengthen the practices themselves, but also augment those individuals' virtues, and that of their community (such as empathy). We identified several goods that are internal to the practice of CBE and accompanying virtues as important for the development, implementation and sustainability of a socially accountable community placement programme. A service-oriented mind-set, a deep understanding of community needs, a transformed mind, and a collaborative approach emerged as goods internal to the practice of a socially accountable CBE. The virtues needed to sustain the identified internal goods included empathy and compassion, connectedness, accountability, engagement [sustained relationship], cooperation, perseverance, and willingness to be an agent of change. CONCLUSION: This study found that MacIntyre's virtue ethics theory provided a useful theoretical lens for understanding the principles that create, maintain and sustain CBE practice.

Role of community health service programs in navigating the medical ethical slippery slope-a 10-year retrospective study among medical students from southern China.

BACKGROUND: For promoting autonomous learning motivation, the learning effect of community-oriented service is beneficial, because through community participation and service, students can transfer their implicit cognition of ethics into explicit cognition, leading to the cultivation of a sympathetic partnership between the community and medical students. Despite the proven benefits of medical students' community health service (CHS) in Western countries, CHS programs designed for medical students are not well established in mainland China, and their effects on medical students' ethical cognition are largely unknown. This study evaluated the effects of CHS programs on the ethical cognition of medical students. METHODS: A cross-sectional study was conducted on third- and fourth-year medical students and graduates working at Shantou University Medical College by using a self-administered anonymous questionnaire. Through interviews, we applied a thematic approach to analyze the responses of the participating students. The questionnaire adopted in this study was revised based on a review of the literature on medical ethics in medical students and on the CHS environment in China. The reviewed questionnaires included an evaluation questionnaire on cultivating medical ethics in a CHS context, and questionnaires used to explore the cultivation and transformation of medical ethics in medical students during the preclinical period. RESULTS: A total of 361 (54.4%) undergraduate medical students and 302 (45.6%) graduates participated in this survey. Significant differences were observed in self-evaluation of the cognitive development of ethics between those who had participated in CHS programs 1-5 times and those who had participated > 6 times. The successful identification of accepting money from the patients under the table as unethical behavior significantly differed (p = .031) among the graduates but not (p = .567) among the undergraduate students. The participants expressed the positive impact of CHS programs on their self-development. CONCLUSION: CHS programs can be widely applied in medical education in China. This educational strategy, which supports medical professionalism and incorporates humanitarian behavior as a complement to learning, should be encouraged and promoted nationally.

[Open-door psychiatry and community mental health work]. / Offene Psychiatrie und gemeindepsychiatrische Arbeit.

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

Moral Economy and Moral Capital in the Community of Clinical Practice.

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Conflicting rationales: leader's experienced ethical challenges in community health care for older people.

BACKGROUND: Ethical challenges arise in all types of care, and leaders need to be aware of how to resolve these challenges. Healthcare systems tend to be organised around medical conditions, and the patient is often faced with a series of uncoordinated visits to multiple specialties. Ideally, care should be organised around the patient's needs. AIM: The purpose of this article was to highlight some ethical challenges perceived by leaders with responsibility for management and service distribution, finance and ensuring quality of community health services for older people. METHOD: This study had a qualitative design with a qualitative content analysis of one focus group with six leaders that met four times in total. Leaders from the community healthcare sector in one Norwegian municipality were included, representing both nursing homes and home-based health care. The study followed the intentions of the Declaration of Helsinki and standard ethical principles. The Norwegian Social Science Data Services approved the study. All participants voluntarily gave written informed consent. FINDINGS: The main theme that emerged from this study was the ethical challenge leaders felt in the form of an inherent conflict between a caring rationale versus economic or technological rationales. Four categories emerged: (i) Management: quality versus economy; (ii) Prioritisation: fair distribution of healthcare services; (iii) Responsibility: considering individuals' needs versus the needs of the whole community; and (iv) Welfare technology: possibilities and challenges. CONCLUSION: Leaders' responsibilities in community health care for older people need to strike a balance between ethical principles in the management of limited resources.

Action Guide for Addressing Ethical Challenges of Resource Allocation Within Community-Based Healthcare Organizations.

This article proposes an action guide to making decisions regarding the ethical allocation of resources that affect access to healthcare services offered by community-based healthcare organizations. Using the filter of empirical data from a study of decision making in two community-based healthcare organizations, we identify potentially relevant conceptual guidance from a review of frameworks and action guides in the public health, health policy, and organizational ethics literature. We describe the development of this action guide. We used data from a prior empirical study of the values that influence decision making about the allocation of resources in particular types of community-based healthcare organizations. We evaluated, organized, and specified the conceptual guidance we found in 14 frameworks for ethical decision making. The result is an action guide that includes four domains that are relevant to the context of the decision to be made, eight domains that are relevant to the process of the decision to be made, and 15 domains that are relevant to the criteria of the decision to be made. We demonstrate the potential use of this action guide by walking through an illustrative resource allocation decision. The action guide provides community-based healthcare organizations with a conceptually grounded, empirically informed framework for ethical decision making.

Ethics support in community care makes a difference for practice.

BACKGROUND: Through the Norwegian ethics project, ethics activities have been implemented in the health and care sector in more than 200 municipalities. OBJECTIVES: To study outcomes of the ethics activities and examine which factors promote and inhibit significance and sustainability of the activities. RESEARCH DESIGN: Two online questionnaires about the municipal ethics activities. Participants and research context: A total of 137 municipal contact persons for the ethics project answered the first survey (55% response rate), whereas 217 ethics facilitators responded to the second survey (33% response rate). Ethical considerations: Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services. FINDINGS: Around half of the respondents found the ethics project to have been highly significant for daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations to patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision. DISCUSSION: This study shows that ethics initiatives can be both sustainable and significant for practice. There is a need to create regional or national structures for follow-up and develop more comprehensive ethics training for ethics facilitators. CONCLUSION: It is both possible and potentially important to implement clinical ethics support activities in community health and care services systematically on a large scale. Future ethics initiatives in the community sector should be designed in light of documented promoting and inhibiting factors.

The Norwegian national project for ethics support in community health and care services.

BACKGROUND: Internationally, clinical ethics support has yet to be implemented systematically in community health and care services. A large-scale Norwegian project (2007-2015) attempted to increase ethical competence in community services through facilitating the implementation of ethics support activities in 241 Norwegian municipalities. The article describes the ethics project and the ethics activities that ensued. METHODS: The article first gives an account of the Norwegian ethics project. Then the results of two online questionnaires are reported, characterizing the scope, activities and organization of the ethics activities in the Norwegian municipalities and the ethical topics addressed. RESULTS: One hundred and thirty-seven municipal contact persons answered the first survey (55 % response rate), whereas 217 ethics facilitators from 48 municipalities responded to the second (33 % response rate). The Norwegian ethics project is vast in scope, yet has focused on some institutions and professions (e.g., nursing homes, home-based care; nurses, nurses' aides, unskilled workers) whilst seldom reaching others (e.g., child and adolescent health care; physicians). Patients and next of kin were very seldom involved. Through the ethics project employees discussed many important ethical challenges, in particular related to patient autonomy, competence to consent, and cooperation with next of kin. The "ethics reflection group" was the most common venue for ethics deliberation. CONCLUSIONS: The Norwegian project is the first of its kind and scope, and other countries may learn from the Norwegian experiences. Professionals have discussed central ethical dilemmas, the handling of which arguably makes a difference for patients/users and service quality. The study indicates that large (national) scale implementation of CES structures for the municipal health and care services is complex, yet feasible.

[Organisational challenges of community information offices for the elderly in Switzerland : A qualitative study with ethical reflections]. / Strukturelle Herausforderungen kommunaler Altersstellen in der Schweiz : Eine qualitative Studie mit ethischer Reflexion.

BACKGROUND: Current Swiss politics concerning age and ageing are orientated towards the principle "out-patient before in-patient". As part of new regulations, in 2011 all communities were required to set up information offices to answer questions about out-patient and in-patient care. OBJECTIVES: The aim of this qualitative study was to analyse in which form and under which conditions such information offices are run. METHODS: A qualitative study was conducted which consisted of semistructured interviews with managers of information offices. They were analysed using qualitative content analysis. RESULTS: The analysis shows that on the one hand the information offices have the potential to serve an important role in the communities and that they have a highly complex, demanding and responsible function. On the other hand the results illustrate that in organisational respects the situation is highly heterogeneous and unregulated. CONCLUSION: For the running of the information offices, there is need for action such as the definition of general framework, quality standards, qualifications and values profiles, objectives, mission, responsibility and legitimation, instruments for networking and cooperations.

Electronic Medical Records and the Technological Imperative: The Retrieval of Dialogue in Community-Based Primary Care.

Electronic medical records are regarded as an important tool in primary health-care settings. Because these records are thought to standardize medical information, facilitate provider communication, and improve office efficiency, many practices are transitioning to these systems. However, much of the concern with improving the practice of record keeping has related to technological innovations and human-computer interaction. Drawing on the philosophical reflection raised in Jacques Ellul's work, this article questions the technological imperative that may be supporting medical record keeping. Furthermore, given the growing emphasis on community-based care, this article discusses important non-technological aspects of electronic medical records that might bring the use of these records in line with participatory primary-care medicine.

Ethics reflection groups in community health services: an evaluation study.

BACKGROUND: Systematic ethics support in community health services in Norway is in the initial phase. There are few evaluation studies about the significance of ethics reflection on care. The aim of this study was to evaluate systematic ethics reflection in groups in community health (including nursing homes and residency), - from the perspectives of employees participating in the groups, the group facilitators and the service managers. The reflection groups were implemented as part of a research and development project. METHODS: A mixed-methods design with qualitative focus group interviews, observations and written reports were used to evaluate. The study was conducted at two nursing homes, two home care districts and a residence for people with learning disabilities. Participants were employees, facilitators and service managers. The study was guided by ethical standard principles and was approved by the Norwegian Social Science Data Services. RESULTS: We found support for ethics reflection as a valuable measure to strengthen clinical practice. New and improved solutions, more cooperation between employees, and improved collaboration with patients and their families are some of the results. No negative experiences were found. Instead, the ethics reflection based on experiences and challenges in the workplace, was described as a win-win situation. The evaluation also revealed what is needed to succeed and useful tips for further development of ethics support in community health services. CONCLUSIONS: Ethics reflection groups focusing on ethical challenges from the participants' daily work were found to be significant for improved practice, collegial support and cooperation, personal and professional development among staff, facilitators and managers. Resources needed to succeed were managerial support, and anchoring ethics sessions in the routine of daily work.

Approach to caring for developmentally disabled adults in the community: medical, ethical, and legal considerations.

OBJECTIVE: To review the medical, ethical, and legal obligations in caring for adults with developmental disabilities (DDs) living in the community. SOURCES OF INFORMATION: Google and MEDLINE searches were conducted using the terms disabled, disability, vulnerable, and community. The pertinent legislation was reviewed. MAIN MESSAGE: The treatment of a patient with DDs varies with factors such as the pathogenesis of the patient's current problem, comorbid conditions, the severity of his or her disabilities, and his or her current social supports. While the shift from institutional to community care for patients with DDs is widely accepted as being beneficial, providing high-quality community care has proven to be challenging. However, there is little research on how to effectively provide community support to adults with DDs. As primary care providers, family physicians are often the first point of contact for patients, and are responsible for both the coordination and the continuity of care. With the movement toward preventive care and early disease detection, the patient's active participation is also vital. The patient's values and goals are an essential consideration, even when they are contrary to the patient's good health or the clinician's own values. The legislation for vulnerable persons varies among the provinces. Thus, the obligation to report suspected abuse might depend on whether the vulnerable person is living in a care facility or the community; whether the person with the suspicion is a service provider or health care professional; and whether the specific circumstances fall within the legislative definition of abuse or neglect. CONCLUSION: Primary care providers must give adults with DDs compassionate care that respects the patients' wishes.

Evaluation of ethical reflections in community healthcare: a mixed-methods study.

BACKGROUND: Ethical reflections over care practices are important. In order to be able to perform such reflections, healthcare professionals must learn to think critically about their care practice. AIM: The aim of this study was to evaluate whether an introduction to and practice in ethical reflections in community healthcare have consequences for the healthcare personnel's practice. RESEARCH DESIGN: A mixed-methods design was adopted with five focus group interviews and an electronic questionnaire based on results from the interviews. PARTICIPANTS AND RESEARCH CONTEXT: A total of 29 community healthcare personnel with experience in ethical reflections participated in the interviews. The electronic questionnaire was sent via email to 2382 employees in community healthcare services in 13 municipalities in southern part of Norway. ETHICAL CONSIDERATIONS: The study was guided by the intentions of the Declaration of Helsinki and ethical standard principles and approved by the Norwegian Social Science Data Services. RESULTS: An introduction to and practice in performing ethical reflections brought about an ethical awareness with understanding and respect for both colleagues and patients. The leader had a key role. Lack of time was a hindrance for ethical reflections. Three factors could predict meaningful ethical reflections: higher age of personnel, higher percentage of employment and longer experience with ethical reflections. DISCUSSION: According to other studies, ethical reflections may enhance moral development of colleagues and their actions as advocates for the patients. A deepened ethical awareness, professional competency and sufficient time resources will guarantee proper caregiving. CONCLUSION: A supportive environment that prioritizes participation in reflection meetings is decisive. To practice ethical reflections will provide better care for patients. A challenge for the community healthcare system is to offer adequate positions that provide the personnel an opportunity to be involved as caregivers and to participate in ethical reflections.

Experiences and challenges of an interprofessional community of practice in HIV and AIDS in Tshwane district, South Africa.

Collaboration amongst stakeholders remains a central tenet to achieving goals in planning, implementation, monitoring and evaluation of HIV and AIDS prevention and care strategies. This paper describes the experiences of members of a health care team who joined efforts to collaborate and form a community of practice (CoP) in HIV and AIDS. Qualitative, exploratory case study methods were used. Twenty-six participants were interviewed. Transcripts from the interviews were subjected to the thematic framework of data analysis. Based on the analysis, three themes emerged as impacting on collaboration and these were: the understanding and expectations of being a CoP member; professionalism and ethics within the CoP and collaboration in HIV and AIDS care. The key findings were that the understanding and expectations from the CoP varied. Ethical principles including respect, trust and confidentiality were identified as key tenets of collaboration and were expressed in various ways. The expectations of being a CoP member, the ethical principles within the CoP all impacted in differing ways on how they collaborated. The implication of this study suggests that consultation during inception and throughout the process, clarification of roles, transparency and respect are cardinal points in professional relationships.

A road map to building ethics capacity in the home and community care and support services sector.

There are unique ethical issues that arise in home and community care because of its locus and range of service. However, the academic literature on ethical issues in the sector of home and community care and support remains minimal. Opportunities for education, collaboration and exchange among professionals and care providers are also severely limited. Although the proposed solution of developing ethics capacity in the home care setting is over 20 years old, only modest progress had been made until recently. This article introduces the Community Ethics Network (CEN), a replicable network of home and community care agencies in the Greater Toronto Area. Its achievements can be attributed to a commitment to work toward a common approach to ethical decision-making and to a focus on education, case reviews and policy development. CEN has produced numerous positive outcomes; key among these is the development and delivery of standardized training on ethics to more than 2,000 front-line staff of diverse backgrounds/professions and representing over 40 different organizations.

When the bells toll: engaging healthcare providers in catastrophic disaster response planning.

Catastrophic disaster planning and response have been impeded by the inability to better coordinate the many components of the emergency response system. Healthcare providers in particular have remained on the periphery of such planning because of a variety of real or perceived barriers. Although hospitals and healthcare systems have worked successfully to develop surge capacity and capability, less successful have been the attempts to inculcate such planning in the private practice medical community. Implementation of a systems approach to catastrophic disaster planning that incorporates healthcare provider participation and engagement as one of the first steps toward such efforts will be of significant importance in ensuring that a comprehensive and successful emergency response will ensue.

Family solidarity and informal care: the case of care for people with dementia.

According to Bayertz the core meaning of solidarity is the perception of mutual obligations between the members of a community. This definition leaves open the various ways solidarity is perceived by individuals in different communities and how it manifests itself in a particular community. This paper explores solidarity as manifested in the context of families in respect of caregiving for a family member who has become dependent because of disease or illness. Though family caregiving is based on the same perception of mutual obligation as the solidarity that supports welfare arrangements in society, the manifestation of solidarity in families is different. Solidarity that underpins welfare arrangements is based on a perception of mutual obligation towards an anonymous dependent other and is enforced by the government. Solidarity in families is directed towards a concrete other and is based on free choice, albeit often accompanied by a strong sense of personal duty. In this paper we try to distinguish between solidarity as a sociological concept and as a moral concept. An important moral element of solidarity, as expressed in families, is the need for recognition of family caregivers, not only of their concrete practical efforts, but also of their own identity as caregivers and as individuals. We illustrate this argument by referring to examples in the Nuffield Council on Bioethics report Dementia: ethical issues, about the experiences of family caregivers in dementia care and the importance for them of recognition of their role.

Pro-active monitoring and social interventions at community level mitigate the impact of coronavirus (COVID-19) epidemic on older adults' mortality in Italy: A retrospective cohort analysis.

BACKGROUND: The COVID-19 epidemic in Italy has severely affected people aged more than 80, especially socially isolated. Aim of this paper is to assess whether a social and health program reduced mortality associated to the epidemic. METHODS: An observational retrospective cohort analysis of deaths recorded among >80 years in three Italian cities has been carried out to compare death rate of the general population and "Long Live the Elderly!" (LLE) program. Parametric and non-parametric tests have been performed to assess differences of means between the two populations. A multivariable analysis to assess the impact of covariates on weekly mortality has been carried out by setting up a linear mixed model. RESULTS: The total number of services delivered to the LLE population (including phone calls and home visits) was 34,528, 1 every 20 day per person on average, one every 15 days during March and April. From January to April 2019, the same population received one service every 41 days on average, without differences between January-February and March-April. The January-April 2020 cumulative crude death rate was 34.8‰ (9,718 deaths out of 279,249 individuals; CI95%: 34.1-35.5) and 28.9‰ (166 deaths out of 5,727 individuals; CI95%:24.7-33.7) for the general population and the LLE sample respectively. The general population weekly death rate increased after the 11th calendar week that was not the case among the LLE program participants (p<0.001). The Standardized Mortality Ratio was 0.83; (CI95%: 0.71-0.97). Mortality adjusted for age, gender, COVID-19 weekly incidence and prevalence of people living in nursing homes was lower in the LLE program than in the general population (p<0.001). CONCLUSIONS: LLE program is likely to limit mortality associated with COVID-19. Further studies are needed to establish whether it is due to the impact of social care that allows a better clients' adherence to the recommendations of physical distancing or to an improved surveillance of older adults that prevents negative outcomes associated with COVID-19.

Authoritarian versus responsive communitarian bioethics.

A communitarian approach to bioethics adds a core value to a field that is often more concerned with considerations of individual autonomy. Some interpretations of liberalism put the needs of the patient over those of the community; authoritarian communitarianism privileges the needs of society over those of the patient. Responsive communitarianism's main starting point is that we face two conflicting core values, autonomy and the common good, and that neither should be a priori privileged and that we have principles and procedure that can be used to work out this conflict but not to eliminate it. Additionally, it favours changing behaviour mainly through the creation of norms and by drawing on informal social control rather than by coercion.