Examining ethical issues that arise in providing ED/hospital care for patients experiencing elder mistreatment and approaches to address them.

Clinicians in the emergency department and hospital who treat patients experiencing elder mistreatment (EM) can expect to encounter challenging ethical dilemmas. Collaboration with ethics and EM consultation services offers teams an important opportunity to improve patient-centered outcomes and address value-based concerns when treating these patients. This article describes the role of a hospital clinical ethics consultation service and best practices for collaboration between ethics and EM consultation services. Illuminated via four case studies, the article presents several core ethical frameworks, including allowing patients the dignity of risk, considerations around a harm reduced discharge, involving abusers in surrogate decision making, and providers' experience of moral distress when dealing with patients experiencing EM. Increasing collaboration with ethics and elder mistreatment services can help teams more effectively respond to EM.

Centering equity in a longitudinal health systems science curricula.

What was the educational challenge?Health inequity impedes care at every level of the health care system. Despite this, health equity is not the foundation for most health systems science (HSS) curricula.What was the solution?We reframed our HSS curricula to focus on health equity.How was the solution implemented?We integrated equity concepts into all HSS content areas. First-year content emphasizes structural competency and is delivered through didactics, discussions, interprofessional education, panels, and service-learning requirements. Second-year content applies HSS principles in the clinical space through direct patient care and assignments. Third- and fourth-year content focuses on HSS advocacy and leadership.What lessons were learned that are relevant to a wider global audience?It is crucial to center health equity in medical curricula to improve patient outcomes. Proper faculty development, non-judgmental discussions, and integration with clinical and medical sciences are critical to successful implementation.What are the next steps?We will address feedback, emphasize relevance to patients and populations, and refine outcome measures.

Medical Decision Making for Unrepresented Patients: A Reflection on Colorado's Approach with Implications for Elsewhere.

Unrepresented patients are some of the most vulnerable patients encountered in the healthcare system today. One of the challenges associated with healthcare for unrepresented patients is the lack of a standardized legal approach to decision making for this highly vulnerable population. Current statutory approaches vary widely without best practices or consensus guidelines. In 2016, Colorado passed a medical proxy law that established a process for the appointment of an independent physician to serve as a temporary proxy decision maker for an unrepresented patient. Although this approach helps to identify a decision maker when no proxy is available, the appropriate standards for decision making remain uncertain. A peer-to-peer session at the Clinical Ethics Unconference in 2022 approached this conundrum with a focus on the best interests standard and the appropriate use of patients' context in decision making.

Appetite-guided approach to pediatric enteral tube weaning in the home setting: A pilot study.

BACKGROUND: Infants and children, who temporarily use feeding tubes to maintain body composition and growth, often have difficulty resuming oral feeds once medically stable. We report survey results from Growing Independent Eaters (GIE), an interdisciplinary approach providing home-based virtual support during a child-led appetite-guided enteral wean. METHOD: Surveys addressing participant wean success, weight, and feeding practices were sent to 76 families who participated in a GIE-led wean; 31 surveys were completed and returned. RESULTS: All participants who were not eating or drinking orally prewean were fully or partially weaned off enteral support. Infants weaned faster (37.7 days) than children (80.1 days). Mean weight loss during the intervention was 6.6% for infants and 5.9% for children. Six months postwean, 93% of participants surpassed their prewean weight. CONCLUSION: The GIE method was successful for weaning infants and children off enteral support.

The Ethics Ambassador Program: A Grassroots Approach.

The Ethics Ambassador program at the University of Colorado Hospital was born from a desire to encourage earlier ethics consultation, with the goal of providing timely, effective, and patient-centered ethics support. The selected Ethics Ambassadors are individuals from multiple roles across the hospital who receive regular education to serve as an ethics resource for their respective units or specialties. As embedded individuals, they are better able to recognize the unique needs and challenges of their units and provide relevant ethics education to staff and faculty. Outcomes of the first year of the program illustrated the diverse ethics needs across the hospital and the benefits of utilizing embedded individuals, able to straddle both the domains of ethics and the needs of their individual units.

Comprehensive Quality Assessment in Clinical Ethics.

Scholars and professional organizations in bioethics describe various approaches to "quality assessment" in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes "quality" in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, iin this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction.

Domains of quality for clinical ethics case consultation: a mixed-method systematic review.

BACKGROUND: "Clinical ethics consultation" (CEC) is the provision of consultative services by an individual or team with the aim of helping health professionals, patients, and their families grapple with difficult ethical issues arising during health care. There are almost 25,000 articles in the worldwide literature on CEC, but very few explicitly address measuring the quality of CEC. Many more address quality implicitly, however. This article describes a rigorous protocol for compiling the diverse literature on CEC, analyzing it with a quality measurement lens, and seeking a set of potential quality domains for CEC based on areas of existing, but hitherto unrecognized, consensus in the literature. METHODS/DESIGN: This mixed-method systematic review will follow a sequential pattern: scoping review, qualitative synthesis, and then a quantitative synthesis. The scoping review will include categorizing all quality measures for CEC discussed in the literature, both quantitative and qualitative. The qualitative synthesis will generate a comprehensive analytic framework for understanding the quality of CEC and is expected to inform the quantitative synthesis, which will be a meta-analysis of studies reporting the effects of CEC on pre-specified clinical outcomes. DISCUSSION: The literature on CEC is broad and diverse and has never been examined with specific regard to quality measurement. We propose a novel mixed-methods approach to compile and synthesize this literature and to derive a framework for assessing quality in CEC. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015023282.

A Case of Attempted Suicide in Huntington's Disease: Ethical and Moral Considerations.

A 62-year-old female with Huntington's disease presented after a suicide attempt. Her advance directive stated that she did not want intubation or resuscitation, which her family acknowledged and supported. Despite these directives, she was resuscitated in the emergency department and continued to state that she would attempt suicide again. Her suicidality in the face of a chronic and advancing illness, and her prolonged consistency in her desire to take her own life, left careproviders wondering how to provide ethical, respectful care to this patient. Tension between the ethical principles of autonomy and beneficence is central in this case. The patient's narrative demonstrated that her suicide was an autonomous decision, free from coercion or disordered thinking from mental illness. Beneficence then would seem to necessitate care aligned with the patient's desire to end her life, which created ethical uneasiness for her family and careproviders. The case highlights several end-of-life ethical considerations that have received much recent attention. With ongoing discussions about the legalization of aid in dying across the country, caregivers are challenged to understand what beneficence means in people with terminal illnesses who want a say in their death. This case also highlights the profound moral distress of families and careproviders that arises in such ethically challenging scenarios.

Failure to fail: the institutional perspective.

PURPOSE: To determine institutional barriers to placing failing students on probation, dismissing students. METHODS: An online survey study was distributed to Student Affairs Deans or the equivalent at allopathic (MD) and osteopathic (DO) medical schools, and physician assistant (PA) and nurse practitioner (NP) schools across the United States. Nineteen (40%) of the 48 schools responded: six MD, four DO, five PA and four NP. The survey contained demographic questions and questions regarding probation and dismissal. Themes were independently coded and combined via consensus based on grounded theory. The survey was distributed until saturation of qualitative responses were achieved. RESULTS: Respondents identified variations in the use of probation and dismissal and a wide range of barriers, with the greatest emphasis on legal concerns. Respondents felt that students were graduating who should not be allowed to graduate, and that the likelihood of a student being placed on probation or being terminated was highly variable. DISCUSSION: Our results suggest that institution culture at heath professions schools across the United States may represent an obstacle in placing failing learners on probation and dismissing learners who should not graduate. Additional studies are needed to prove if these concerns are founded or merely fears.

Creutzfeldt-Jacob disease presenting as severe depression: a case report.

BACKGROUND: An 81 year old female presented with altered mental status after new onset of severe depression and suicidal ideation with recent psychiatric hospitalization. CASE PRESENTATION: Key clinical features included muscle rigidity, prominent startle reflex, and rapidly progressing cognitive decline. Initial working hypothesis was serotonin syndrome or neuroleptic malignant syndrome but continued deterioration after medication removal prompted evaluation for alternative etiology. Work-up revealed elevated 14-3-3 CSF protein which suggested the prion disorder which was confirmed on post-mortem examination of brain tissue. CONCLUSION: While the degree of depression was unusually severe, the case highlights the behavioral and psychiatric manifestations which frequently accompany Creutzfeldt-Jacob disease.