Gender and Race in the Timing of Requests for Ethics Consultations: A Single-Center Study.

BACKGROUND: Clinical ethics consultants are expected to "reduce disparities, discrimination, and inequities when providing consultations," but few studies about inequities in ethics consultation exist.1 The objectives of this study were (1) to determine if there were racial or gender differences in the timing of requests for ethics consultations related to limiting treatment, and (2) if such differences were found, to identify factors associated with that difference and the role, if any, of ethics consultants in mitigating them. METHODS: The study was a mixed methods retrospective study of consultation summaries and hospital and ethics center data on 56 age-and gender-matched Caucasian and African American Medicare patients who received ethics consultations related to issues around limiting medical treatment in the period 2011 to 2014. The average age of patients was 70.9. RESULTS: Consultation requests for females were made significantly earlier in their stays in the hospital (6.57 days) than were consultation requests made for males (16.07 days). For African American patients, the differences in admission-to-request intervals for female patients (5.93 days) and male patients (18.64 days) were greater than for Caucasian male and female patients. Differences in the timing of a consultation were not significantly correlated with the presence of an advance directive, the specialty of the attending physician, or the reasons for the consult request. Ethics consultants may have mitigated problems that developed during the lag in request times for African American males by spending more time, on average, on those consultations (316 minutes), especially more time, on average, than on consultations with Caucasian females (195 minutes). Most consultations (40 of 56) did result in movement toward limiting treatment, but no statistically significant differences were found among the groups studied in the movement toward limiting treatment. The average number of days from consult to discharge or death were strongly correlated with the intervals between admission to the hospital and request for an ethics consultation. CONCLUSION: Our findings suggest race and gender disparities in the timing of ethics consultations that consultants may have partially mitigated.

Case Complexity and Quality Attestation for Clinical Ethics Consultants.

A proposal by the American Society for Bioethics and Humanities (ASBH) to identify individuals who are qualified to perform ethics consultations neglects case complexity in candidates' portfolios. To protect patients and healthcare organizations, and to be fair to candidates, a minimum case complexity level must be clearly and publicly articulated. This proof-of-concept study supports the feasibility of assessing case complexity. Using text analytics, we developed a complexity scoring system, and retrospectively analyzed more than 500 ethics summaries of consults performed at an academic medical center during 2013. We demonstrate its use with seven case summaries that range in complexity from uncomplicated to very complicated. We encourage the ASBH to require a minimum level of case complexity, and recommend that attestation portfolios include several cases of moderate complexity and at least one very complex case.

Growing an ethics consultation service: A longitudinal study examining two decades of practice.

BACKGROUND: Little is known about what factors may contribute to the growth of a consultation service or how a practice may change or evolve across time. METHODS: This study examines data collected from a busy ethics consultation service over a period of more than two decades. RESULTS: We report a number of longitudinal findings that represent significant growth in the volume of ethics consultation requests from 19 in 1990 to 551 in 2013, as well as important changes in the patient population for which ethics help is requested. The findings include (1) a steady growth in requests from primary care providers (e.g., physicians and nurses), as well as increases in ancillary services (e.g., social workers); (2) a decrease in length of stay (days) before ethics help is requested; (3) an increase in the reasons that individuals ask for help from ethics; (4) an upsurge in consults requests from areas outside the intensive care unit (ICU); (5) a decrease in patients that died during hospitalization (e.g., live discharges); and (6) growth in the numbers of patients lacking decision-making capacity. CONCLUSIONS: We believe the increases in consult requests reflect appropriate and necessary growth because recent consultations have also been associated with consultations requiring (7) additional interventions and (8) reasonably high time intensity scores.

A radiometric assay for glutamine:fructose-6-phosphate amidotransferase.

Glutamine:fructose-6-phosphate amidotransferase (GFAT) catalyzes the first step in the biosynthesis of amino sugars by transferring the amino group from l-glutamine to the acceptor substrate, fructose 6-phosphate, generating the products glucosamine 6-phosphate and glutamic acid. We describe a method for the synthesis and purification of the substrate, fructose 6-phosphate, and methods for a radiometric assay of human GFAT1 that can be performed in either of two formats: a small disposable-column format and a high-throughput 96-well-plate format. The method performed in the column format can detect 1 pmol of glucosamine 6-phosphate, much less than that required by previously published assays that measure GlcN 6-phosphate. The column assay demonstrates a broad linear range with low variability. In both formats, the assay is linear with time and enzyme concentration and is highly reproducible. This method greatly improves the sensitivity and speed with which GFAT1 activity can be measured and facilitates direct kinetic measurement of the transferase activity.

Kinetic characterization of human glutamine-fructose-6-phosphate amidotransferase I: potent feedback inhibition by glucosamine 6-phosphate.

Glutamine-fructose-6-phosphate amidotransferase (GFAT) catalyzes the first committed step in the pathway for biosynthesis of hexosamines in mammals. A member of the N-terminal nucleophile class of amidotransferases, GFAT transfers the amino group from the L-glutamine amide to D-fructose 6-phosphate, producing glutamic acid and glucosamine 6-phosphate. The kinetic constants reported previously for mammalian GFAT implicate a relatively low affinity for the acceptor substrate, fructose 6-phosphate (Fru-6-P, K(m) 0.2-1 mm). Utilizing a new sensitive assay that measures the production of glucosamine 6-phosphate (GlcN-6-P), purified recombinant human GFAT1 (hGFAT1) exhibited a K(m) for Fru-6-P of 7 microm, and was highly sensitive to product inhibition by GlcN-6-P. In a second assay method that measures the stimulation of glutaminase activity, a K(d) of 2 microm was measured for Fru-6-P binding to hGFAT1. Further, we report that the product, GlcN-6-P, is a potent competitive inhibitor for the Fru-6-P site, with a K(i) measured of 6 microm. Unlike other members of the amidotransferase family, where glutamate production is loosely coupled to amide transfer, we have demonstrated that hGFAT1 production of glutamate and GlcN-6-P are strictly coupled in the absence of inhibitors. Similar to other amidotransferases, competitive inhibitors that bind at the synthase site may inhibit the synthase activity without inhibiting the glutaminase activity at the hydrolase domain. GlcN-6-P, for example, inhibited the transfer reaction while fully activating the glutaminase activity at the hydrolase domain. Inhibition of hGFAT1 by the end product of the pathway, UDP-GlcNAc, was competitive with a K(i) of 4 microm. These data suggest that hGFAT1 is fully active at physiological levels of Fru-6-P and may be regulated by its product GlcN-6-P in addition to the pathway end product, UDP-GlcNAc.