Analysis of 20 Years of Ethics Consultations at a U.S. Children's Hospital.

AbstractEmpirical studies of pediatric clinical ethics cases are scant in the biomedical and bioethics literature. In this study, more than 100 detailed records of clinical ethics consultations spanning from 2000 to 2020 at a moderately sized U.S. Mid-Atlantic children's hospital were abstracted and analyzed. Findings of the analysis were generally consistent with other studies in pediatric clinical ethics, with additional insight into aspects of moral distress associated with cases, family engagement with consultations, and other characteristics of interest also documented. Over the 20-year time frame, ethics consults were completed on average twice a year, with a detectable upward trend. Consultations were requested across the spectrum of services and units within the hospital, with critical care environments represented most frequently and genetic and neurological conditions being the most common primary diagnoses. Ethical analysis most commonly related to questions around the principles of autonomy and beneficence.

What Factors Contribute to Ethical Problems in Patient Care? A Scoping Review and Case Series of Clinical Ethics Consultations.

AbstractBackground: Healthcare professionals (HCPs) are frequently exposed to ethical problems in patient care that can affect the quality of care. Understanding risk factors for ethical problems may help practitioners to address these problems at an early stage. This study aims to provide an overview of ethical risk factors in patient care. Risk factors known from the literature and those found in clinical ethics consultation (CEC) cases are reviewed. METHODS: A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland. RESULTS: Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty. CONCLUSIONS: There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.

Advocacy and Bioethics: Aspiration, Obligation, and Negotiation.

AbstractA long-standing tenet of healthcare clinical ethics consultation has involved the neutrality of the ethicist. However, recent pressing societal issues have challenged this viewpoint. Perhaps now more than ever before, ethicists are being called upon to take up roles in public health, policy, and other community-oriented endeavors. In this article, I first review the concept of professional advocacy and contrast this conceptualization with the role of patient advocate, utilizing the profession of nursing as an exemplar. Then, I explore the status of advocacy in clinical ethics and how this conversation intersects with the existing professional obligations of the bioethicist, arguing that the goals of ethics consultation and ethical obligations of the clinical ethicist are compatible with the role of professional advocate. Finally, I explore potential barriers to professional advocacy and offer suggestions for a path forward.

Intersectionality as a tool for clinical ethics consultation in mental healthcare.

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.

Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation.

BACKGROUND: Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. METHOD: Based on experiences and research into MCD facilitators' needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. RESULTS: The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. CONCLUSIONS: This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools.

Here for the people: The argument for making clinical ethics more patient-centred.

Healthcare organizations aim to provide excellent, patient-centred care. Many departments within a hospital excel in achieving this goal, but clinical ethics service providers would benefit from becoming more patient-centred. This article considers how ethics services can add a patient-facing component to their strategic direction and work portfolio. Through a case example, suggestions to guide ethics service providers in expanding their duties and responsibilities are provided, including consultation with families and education sessions. This reframing would include clarifying the role of ethics within a healthcare organization, making services more accessible to patients, families and the community, as well as engaging with other disciplines to provide well-rounded patient care. While the work currently being done by clinical ethics services is important and ought to be continued, ethics service providers should strive to achieve the goal of improving patient experiences and directly contribute to the excellent care being provided.

The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations.

BACKGROUND: Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice. METHODS: We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation. RESULTS: The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur. CONCLUSIONS: The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.

Frequency of Perceived Conflict between Families and Clinicians at Time of Clinical Ethics Consultation in Hospitalized Children.

BACKGROUND: Little is known about the frequency of conflict between clinicians and families at the time of pediatric clinical ethics consultation (CEC) and what factors are associated with the presence of conflict. METHODS: We conducted a retrospective cohort study at a single, tertiary urban US pediatric hospital that included all hospitalized patients between January 2008 and December 2019 who received CEC. Utilizing the hospital's CEC database that requires documentation of the presence of conflict by the consultant at the time of CEC, we determined the frequency and types of perceived conflict between families and clinicians. We also assessed the bivariable association between conflict and patient age, patient- or family-reported race/ethnicity, language for care, insurance status, clinical setting, and consultant involvement. RESULTS: Perceived conflict between clinicians and families was present in 44% (91/209) of CEC. We observed a higher occurrence of clinician-family conflict within certain consult topics than others, in particular, informed consent/parental permission (69%), cultural considerations (67%), benefit/harm assessment (58%), and limitation of life-sustaining treatment (58%). We found no other significant associations between the presence of perceived conflict and patient sociodemographic factors or CEC factors. CONCLUSIONS: Conflict between healthcare teams and families appears common in CEC, particularly with certain consult topics. Further study is needed to better understand conflict types, causes of conflicts, management and mediation strategies, and outcomes.

Translational bioethics as a two-way street. Developing clinical ethics support instruments with and for healthcare practitioners.

This article discusses an approach to translational bioethics (TB) that is concerned with the adaptation-or 'translation'-of concepts, theories and methods from bioethics to practical contexts, in order to support 'non-bioethicists', such as researchers and healthcare practitioners, in dealing with their ethical issues themselves. Specifically, it goes into the participatory development of clinical ethics support (CES) instruments that respond to the needs and wishes of healthcare practitioners and that are tailored to the specific care contexts in which they are to be used. The theoretical underpinnings of this participatory approach to TB are found in hermeneutic ethics and pragmatism. As an example, the development of CURA, a low-threshold CES instrument for healthcare professionals in palliative care, is discussed. From this example, it becomes clear that TB is a two-way street. Practice may be improved by means of CES that is effectively tailored to specific end users and care contexts. The other way around, ethical theory may be enriched by means of the insights gained from engaging with practice in developing CES in a process of co-creation. TB is also a two-way street in the sense that it requires collaboration and commitment of both bioethicists and practitioners, who engage in a process of mutual learning. However, substantial challenges remain. For instance, is there a limit to the extent to which a method of moral reasoning can be adapted in order to meet the constraints of a given healthcare setting? Who is to decide, the bioethicist or the practitioners?

"Rectal Feeding"-Unethical Medical Officer Participation at CIA Secret Interrogation Facilities.

This Viewpoint discusses recently released information regarding the practice of "rectal feeding" among detainees at Guantanamo Bay and Central Intelligence Agency (CIA) secret prisons.

A semantic exploration: Nurse ethicist, medical ethicist, or clinical ethicist: Do distinctions matter?

Since the 1960s, it has been recognized that "medical ethics," the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one's prior profession's nomenclature as a prefix to "ethicist," under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good.

Fostering moral resilience through moral case deliberation.

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience.

Nursing ethics as a distinct entity within bioethics: Implications for clinical ethics practice.

The question of whether nursing ethics is a distinct entity within bioethics is an important and thought-provoking one. Though fundamental bioethical principles are appreciated and applied within the practice of nursing ethics, there exist distinct considerations which make nursing ethics a unique subfield of bioethics. In this article, we focus on the importance of relationships as a distinguishing feature of the foundation of nursing ethics, evidenced in its education, practice, and science. Next, we consider two objections to our claim of distinctiveness: first, that nursing ethics is merely an application of bioethical principles; second, that many bioethical subfields emphasize relationships. We respond by highlighting that throughout nursing education and generally in every career path that follows, the creation and nurturing of relationships is emphasized. Compassion and respect for the dignity of every patient is the framework upon which these therapeutic relationships are built. Much of the focus of nursing science rests on creating meaningful interpersonal experiences and human connection. After responding to each objection, we turn to the implications of this distinctiveness on clinical ethics practice, arguing that the strengths of our approach outweigh the limitations. The deep emphasis on creating meaningful interpersonal experiences and human connection supports a greater integration of relationships and social contexts into the evaluation of whether an action is ethically permissible, which is an important benefit in addressing the challenging human situations that patients face. Moreover, this perspective allows nurse ethicists to account for diverse and complex social structures and their influence in making ethical determinations. These strengths outweigh the limitations of potential inconsistencies between nurse and non-nurse clinical ethicists on the same service, a result we attribute to nursing ethics-and, in turn, the practice of the nurse ethicist-being framed by relationships to a larger extent than other bioethical subfields.

Perspectives on the role of the nurse ethicist.

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between 'nurse ethicist' and 'clinical ethicist' is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the 'tacit knowledge' and 'lived experience' they bring to clinical ethics consultation. However, the second author also warns that the 'nurse ethicist' must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as 'nurse ethicist' on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.

Nurse ethicists: Innovative resource or ideological aspiration?

In recent years, there have been growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts. Initially proposed in the cultural context of the USA where nurse ethicists have long been recognised, the idea is being advocated in other judications outside of the USA such as the UK, Australia and elsewhere. Such calls are not without controversy, however. Underpinning this controversy are ongoing debates about the theoretical, methodological and political dimensions of clinical ethics support services generally, and more recently where nurses might 'fit' within such a service. In considering whether nurse ethicists ought to have a place in clinical ethics support services, a number of questions arise such as: Is such a role warranted? If so, what credentials should nurses assuming the title of 'nurse ethicist' be required to have? What standards of practice ought nurse ethicists be required to uphold? What is the ultimate role and function of nurse ethicists in hospital contexts? And in what contexts might a nurse ethicist be most useful? In this essay, brief attention will be given to addressing these questions. It will be concluded that, as a minimum, nurses wishing to assume an advanced nursing practice role as a nurse ethicist must have substantive grounding in the foundational knowledge of the disciplines of both moral philosophy and nursing ethics. They must also not lose sight of the ultimate goal of nursing ethics, notably, to promote and advance ethical nursing practice and the provision of 'good' nursing care.

Beyond the consult question: Nurse ethicists as architects of moral spaces.

Nurse Ethicists bring a unique perspective to clinical ethics consultation. This perspective provides an appreciation of ethical tensions that will exist beyond the consult question into the moral space of patient care. These tensions exist even when an ethically preferable plan of action is identified. Ethically appropriate courses of action can still lead to moral dilemmas for others. The nurse ethicist provides a lens well suited to identify and respond to these dilemmas. The nurse-patient relationship is the ethical foundation of nursing practice and this relational ontology is well suited to addressing ethical dilemmas that exist prior to and beyond the initial consult question. This paper will describe one nurse ethicist's phronetic and pragmatic approach to a clinical ethics consult elucidated through feminist ethics and systems thinking. This paper will describe the theoretical basis for this method, present a case, and describe how this consultation approach provides a rich analysis based around relationships and responsibilities that also highlights the important ethical tensions within the social structure that exists around the patient and continue after the consult question is answered.

Using Patient Quotations in Chart Notes: A Clinical Ethics Perspective.

AbstractPer the OpenNotes directive of the 21st Century Cures Act implemented in 2021, patients and their legally recognized representatives must be able to access the electronic medical record in real time. This is an opportunity for clinical ethicists and other providers to reflect on their charting practices, particularly how and when they quote patients. Although using direct quotations is common because it seems to avoid misinterpretation, it may not always be appropriate. In this article, we discuss some of the risks and benefits of quoting in the context of OpenNotes and provide suggestions for how clinical ethicists can leverage their unique position to help mitigate some of these risks and promote more reflective charting practices among the teams they work with.

Conflictos éticos en los cuidados de Enfermería durante la pandemia por COVID-19 / Ethical conflicts in Nursing care during the COVID-19 pandemic

Objetivos: el objetivo principal fue identificar los conflictos éticos con los que se encontraron las/os enfermeras/os durante la pandemia por COVID-19 en España en el ámbito profesional.Método: se realizó un estudio cualitativo mediante etnografía para acercarse a la experiencia vivida por las/os enfermeras/os trabajando en España durante la primera ola de la pandemia COVID-19. Se empleó un muestreo intencional para seleccionar a 33 participantes, a quienes se contactó para llevar a cabo entrevistas no estructuradas por vía telemática. El análisis de los datos se efectuó mediante un enfoque temático que involucró la identificación de unidades de significado y la generación de códigos.Resultados: participaron 29 enfermeras/os, mayoritariamente mujeres trabajadoras en un hospital. Se identificaron tres conflictos éticos principales. El primero se relacionó con la “Priorización por edad: conflicto en el tratamiento equitativo”, que surgió debido a la limitación de recursos y la toma de decisiones difíciles. El segundo conflicto se denominó “Morir en soledad: conflicto con el trato humano del paciente”, ya que los familiares no podían acompañar a sus allegados al final de sus vidas por las restricciones de visita. El tercer conflicto fue “Cuidar con (in)seguridad: conflicto de poner al paciente, la enfermera y la familia en riesgo”, relacionado con la escasez de material de protección, lo que generó temor a posibles contagios tanto en el ámbito profesional como familiar.Conclusiones: la identificación de estos conflictos éticos subraya la necesidad de reorientar la ética del cuidado en salud para futuras pandemias por parte de los gestores de centros sanitarios. (AU)

Objective: the main objective was to identify the ethical conflicts faced by Nursing professionals during the COVID-19 pandemic in Spain in their professional setting.Method: a qualitative study was conducted through ethnography in order to approach the experience lived by Nursing professionals working in Spain during the first wave of the COVID-19 pandemic. Intentional sampling was used to select 33 participants, who were contacted to participate in non-structured online interviews. Data analysis was conducted with a thematic approach which involved the identification of units of meaning and the generation of codes.Results: the study included 29 Nursing professionals, mostly women, working at a hospital. Three main ethical conflicts were identified. The first was related to “Prioritization by age: conflict in equitable treatment”, which came up due to limited resources and difficult decision making. The second conflict was called “Dying alone: a conflict with the humane treatment of patients”, because relatives could not accompany patients at the end of their lives due to visiting restrictions. The third conflict was: “Care with (in)security: the conflict of putting patients, nurses and relatives at risk”, associated with the lack of protection materials, which generated fear of potential contagion both in the professional and the family setting.Conclusion: the identification of these ethical conflicts underlines the need to redirect the ethics of healthcare for future pandemics by health center managers. (AU)