COVID-19, Moral Conflict, Distress, and Dying Alone.

COVID-19 has truly affected most of the world over the past many months, perhaps more than any other event in recent history. In the wake of this pandemic are patients, family members, and various types of care providers, all of whom share different levels of moral distress. Moral conflict occurs in disputes when individuals or groups have differences over, or are unable to translate to each other, deeply held beliefs, knowledge, and values. Such conflicts can seriously affect healthcare providers and cause distress during disastrous situations such as pandemics when medical and human resources are stretched to the point of exhaustion. In the current pandemic, most hospitals and healthcare institutions in the United States have not allowed visitors to come to the hospitals to see their family or loved ones, even when the patient is dying. The moral conflict and moral distress (being constrained from doing what you think is right) among care providers when they see their patients dying alone can be unbearable and lead to ongoing grief and sadness. This paper will explore the concepts of moral distress and conflict among hospital staff and how a system-wide provider wellness programme can make a difference in healing and health.

Unwitting Accomplices: Endocrine Disruptors Confounding Clinical Care.

Burgeoning evidence over the last 25 years has identified myriad synthetic chemicals with the capacity to alter various aspects of hormone synthesis and action. These endocrine-disrupting chemicals (EDCs) have been linked to various diseases, including reproductive disorders, metabolic diseases, and developmental abnormalities, among others. Exposure to EDCs arises from industrial activity, use of personal and home care products, and consumption of contaminated food and water; however, the role of healthcare in exposing individuals to EDCs is grossly underappreciated. Indeed, through the use of medications as well as medical equipment and devices, healthcare providers are unknowing mediators of exposure to EDCs, chemicals that might not only promote disease but that may also antagonize the efficacy of treatments. The ethical implications of provider-dependent exposure are profound. A failure to disclose the endocrine-disrupting properties of medical interventions violates core principles of nonmaleficence, patient autonomy, and justice as well as the practice of informed consent. Furthermore, physicians' lack of knowledge regarding EDCs in medical practice artificially skews risk-benefit calculations that are fundamental to informed medical decision-making. To combat this underappreciated ethical challenge, urgent action is required. Healthcare providers must be educated about endocrine disruption. Known EDCs, defined by endocrinologists, should be clearly labeled on all medical products, and all medication components and devices should be screened for endocrine-disrupting properties. Finally, communication strategies must be devised to empower patients with knowledge about these risks. Providing ethically competent care requires an open acknowledgment of endocrine risks imposed by the medical community that have heretofore been ignored.

Regional Unrepresented Patient Advocacy Committee as an Alternative for Decision Making.

Acute care hospitals and extended care facilities across the United States care for patients who lack capacity to make medical decisions. When such patients are hospitalized and have no identifiable surrogate, their unrepresented status prompts questions about who should make decisions. This article explores using a regional state unrepresented patient advocacy committee as an alternative to appointment of a legal guardian or to using clinicians as decision makers.

Patient safety event reporting expectation: does it influence residents' attitudes and reporting behaviors?

BACKGROUND: Internal Medicine resident (IMR) physician reporting of patient safety events (PSEs) is suboptimal and may be related to poor attitudes toward reporting. PURPOSE: The objective was to evaluate the impact of a PSE reporting expectation on the rates of reporting among IMRs. METHODS: In this prospective cohort study, IMRs were informed of an expectation to submit 1 or more PSE report per month based on the ACGME core competencies. The PSE reports were collected over 9 months and compared with a 4-month baseline before the expectation. Report quality and IMRs' attitudes were also evaluated. RESULTS: There was a significant and initial increase in the total number of reports. However, the number of IMRs meeting the expectation of 1 or more report per month initially rose but was not sustained over the 9-month observational period. Report quality and IMRs attitudes toward reporting were positive but unchanged over time. CONCLUSIONS: Although a reporting expectation increased the total number of reports, the majority of IMRs did not maintain a 1 or more PSE report per month despite positive attitudes.

Accountability for medical error: moving beyond blame to advocacy.

Accountability in medicine, once assigned primarily to individual doctors, is today increasingly shared by groups of health-care providers. Because patient safety experts emphasize that most errors are caused not by individual providers, but rather by system breakdowns in complex health-care teams, individual doctors are left to wonder where their accountability lies. Increasingly, teams deliver care. But patients and doctors alike still think of accountability in individual terms, and the law often measures it that way. Drawing on an example of delayed lung cancer diagnosis, we describe the mismatch between how we view errors (systems) and how we apportion blame (individuals). We discuss "collective accountability," suggesting that this construct may offer a way to balance a "just culture" and a doctor's specific responsibilities within the framework of team delivery of care. The concept of collective accountability requires doctors to adopt transparent behaviors, learn new skills for improving team performance, and participate in institutional safety initiatives to evaluate errors and implement plans for preventing recurrences. It also means that institutions need to prioritize team training, develop robust, nonpunitive reporting systems, support clinicians after adverse events and medical error, and develop ways to compensate patients who are harmed by errors. A conceptual leap to collective accountability may help overcome longstanding professional and societal norms that not only reinforce individual blame and impede patient safety but may also leave the patient and family without a true advocate.

Online ethics discussion forum facilitates medical center clinical ethics case reviews.

Clinical ethics consultants are increasingly called upon to give counsel in the clinical arena on issues including but not limited to withdrawal or withholding of specific medical treatments, assisting minors and mentally impaired patients with care decisions, working with difficult patients and families, identifying appropriate surrogate decision makers, and executing advance directives and end-of-life decisions. Often, the consultant may need to convene the ethics committee members to review and provide feedback for a given case. This process may be difficult to schedule in a timely way because of member's clinical and other work-related obligations. To this end, the University of Illinois Medical Center in Chicago has set up a unique Web board to facilitate ongoing case discussions via a secured, password-protected ethics committee online forum. This allows for real-time review by all ethics committee members. We will explain our online process as well as discuss our clinical case experiences.

Brain Neoplasm and the Potential Impact on Self-Identity.

Cancers of the brain can cause alterations in a person's neurocognitive abilities, and in some patients can even challenge their concept of self and self-identity. Cancer treatment may offer some hope for longer survival, but residual neurocognitive alterations generally remain. Individualized care for these patients should include information related to anticipated effects of their disease or treatments affecting their perception or expression of self. At present, the concepts of self and self-identity are largely unexplored in neuro-oncology, but we will discuss this clinical population in order to highlight the need for further clinical evaluation of these phenomena among patients with brain neoplasm. Finally, we will briefly note the need for a clinical tool to assess self and self-identity changes in brain tumor patients.

Rationing of resources: ethical issues in disasters and epidemic situations.

In an epidemic situation or large-scale disaster, medical and human resources may be stretched to the point of exhaustion. Appropriate planning must incorporate plans of action that minimize public health morbidity and mortality while maximizing the appropriate use of medical and human healthcare resources. While the current novel H1N1 influenza has spread throughout the world, the severity of this strain of influenza appears to be relatively less virulent and lethal compared to the 1918 influenza pandemic. However, the presence of this new influenza strain has reignited interest in pandemic planning. Amongst other necessary resources needed to combat pandemic influenza, a major medical resource concern is the limited number of mechanical ventilators that would be available to be used to treat ill patients. Recent reported cases of avian influenza suggest that mechanical ventilation will be required for the successful recovery of many individuals ill with this strain of virus. However, should the need for ventilators exceed the number of available machines, how will care providers make the difficult ethical decisions as to who should be placed or who should remain on these machines as more influenza patients arrive in need of care? This paper presents a decision-making model for clinicians that is based upon the bioethical principles of beneficence and justice. The model begins with the basic assumptions of triage and progresses into a useful algorithm based upon utilitarian principles. The model is intended to be used as a guide for clinicians in making decisions about the allocation of scarce resources in a just manner and to serve as an impetus for institutions to create or adapt plans to address resource allocation issues should the need arise.

Aggression in a patient with primary brain tumor: ethical implications for best management.

We present a case of a 55-year-old male diagnosed with glioblastoma (GB) involving the left frontal, parietal, and temporal lobes that developed aggression and committed a violent act against his wife. Aggression and violence have rarely been presented in the neuro-oncology literature, but have been well documented in stroke and dementia literature. We discuss the case along with the ethical principles as well as best management practices that may have been employed. As our therapies improve overall survival in brain tumors, aggression is an important behavior that the field must acknowledge.