RESUMO
For those with advanced life-limiting illness, the optimization of quality of life and avoidance of nonbeneficial treatments at the end of life are key ethical concerns. This article evaluates the efficacy of an Interdisciplinary Ethics Panel (IEP) approach to decision making at the end of life for unbefriended nursing home residents who lack decisional capacity and have advanced life-limiting illness, through the use of a nine-step algorithm developed for this purpose. We reviewed the outcomes of three quality-of-care phased initiatives conducted in our facility, a large public nursing home in New York City, between June 2016 and February 2020, which indicated that this IEP approach promoted advance-care planning, as palliative measures were endorsed to optimize quality of life for this vulnerable population at the end of life. We also examined another quality-of-care initiative when this IEP approach was applied to end-of-life decision making for nursing home residents who had a surrogate during the COVID-19 pandemic. This application appeared to be beneficial in adding more residents to our Palliative Care Program while it improved rates of advance-care planning. When all of the above findings are considered, we believe this novel IEP approach and algorithm have the potential to be applied elsewhere after appropriate assessment.
Assuntos
Planejamento Antecipado de Cuidados , COVID-19 , Assistência Terminal , Morte , Tomada de Decisões , Humanos , Casas de Saúde , Pandemias , Qualidade de VidaRESUMO
Evolving practice requires peer review of clinical ethics (CE) consultation for quality assessment and improvement. Many institutions have identified the chart note as the basis for this process, but to our knowledge, electronic health record (EHR) systems are not necessarily designed to easily include CE consultation notes. This article provides a framework for the inclusion of CE consultation notes into the formal EHR, describing a developed system in the Epic EHR that allows for the elaborated electronic notation of the CE chart note. The implementation of the "meaningful use" criteria for EHR, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, requires that health professionals meet certain standards for quality, efficiency, and safety, all of which overlap with the goals of standardization, peer review, and quality improvement within CE consultation.
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Registros Eletrônicos de Saúde , Consultoria Ética , Uso Significativo , Garantia da Qualidade dos Cuidados de Saúde , Humanos , Melhoria de Qualidade , Estados UnidosRESUMO
Despite the critical importance of patient-physician trust, it may be compromised among vulnerable patients, such as (1) incarcerated patients and (2) those patients who have been victims of trauma. The purpose of this study was to examine patient-physician trust among forensic and civilian psychiatric inpatient populations and to explore whether it varied based on a patient's history of incarceration and/or victimization. A trust survey (WFPTS) and a trauma instrument (LEC-5) were administered to 93 patients hospitalized on forensic and civilian psychiatric hospital units in a large, urban public hospital. Results showed no difference in patient-physician trust between incarcerated and civilian patients. Similarly, there was no effect of a history of physical assault or sexual assault on ratings of patient-physician trust. However, the hospitalized civilian and forensic patients who reported being the victim of weapons assault had significantly lower patient-physician trust scores than their counterparts.
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Vítimas de Crime/psicologia , Pacientes Internados/psicologia , Relações Médico-Paciente , Prisioneiros/psicologia , Trauma Psicológico/psicologia , Confiança/psicologia , Violência/psicologia , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.
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Certificação , Eticistas/normas , Consultoria Ética/normas , Competência Profissional/normas , Qualidade da Assistência à Saúde , Certificação/normas , Certificação/tendências , Ética Médica , Humanos , Projetos Piloto , Qualidade da Assistência à Saúde/normas , Estados UnidosRESUMO
Unlike bioethics mediators who are employed by healthcare organizations as outside consultants, mediators who are embedded in an institution must be authorized to chronicle a clinical ethics consultation (CEC) or a mediation in a patient's medical chart. This is an important privilege, as the chart is a legal document. In this article I discuss this important part of a bioethics mediator's tool kit in my presentation of a case illustrating how bioethics mediation may proceed, and what this approach using both bioethics and mediation may add.
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Consultores , Eticistas , Consultoria Ética , Prontuários Médicos/normas , Negociação , Ética Médica , Humanos , Estados UnidosRESUMO
In "Surmounting Elusive Barriers: The Case for Bioethics Mediation," Bergman argues that professionals trained in bioethics, reluctant to acquire the skills of mediation, would better be replaced by a cadre of mediators with some bioethics knowledge, to which I respond, "yes ... but."
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Bioética/tendências , Conflito de Interesses , Conflito Psicológico , Eticistas/normas , Negociação , Relações Médico-Paciente/ética , Poder Psicológico , HumanosRESUMO
Autumn Fiester identifies an important element in clinical ethics consultation (CEC) that she labels, from the Greek, aporia, "state of perplexity," evidenced in CEC as ethical ambiguity. Fiester argues that the inherent difficulties of cases so characterized render them inappropriate for voting and more amenable to mediation and the search for consensus. This commentary supports Fiester's analysis and adds additional reasons for rejecting voting as a process for resolving disputes in CEC including: it distorts the analysis by empowering individual voters preferences and biases rather than focusing on the interests and wishes of the patient and family; it offers an insufficiently sensitive model for resolving the awesome, nuanced, conflicted, and ethically complex issues surrounding life and death; it marginalizes minority opinions that may have moral validity.
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Conflito Psicológico , Democracia , Consultoria Ética/ética , Obrigações Morais , Negociação , Política , Valores Sociais , Humanos , MasculinoRESUMO
Clinical ethics consultation has become an important resource, but unlike other health care disciplines, it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project was launched to pilot-test approaches to train, credential, privilege, and evaluate consultants.
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Credenciamento , Eticistas/normas , Consultoria Ética/normas , Autonomia Profissional , Competência Profissional , Qualidade da Assistência à Saúde , Comitês Consultivos , Credenciamento/normas , Eticistas/educação , Consultoria Ética/organização & administração , Consultoria Ética/tendências , Ética Clínica , Ética Médica , Ética Profissional , Humanos , Prontuários Médicos , Responsabilidade SocialRESUMO
Quality improvement (QI) activities can improve health care but must be conducted ethically. The Hastings Center convened leaders and scholars to address ethical requirements for QI and their relationship to regulations protecting human subjects of research. The group defined QI as systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings and concluded that QI is an intrinsic part of normal health care operations. Both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board; rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice. The group formulated a framework that would use key characteristics of a project and its context to categorize it as QI, human subjects research, or both, with the potential of a customized institutional review board process for the overlap category. The group recommended a period of innovation and evaluation to refine the framework for ethical conduct of QI and to integrate that framework into clinical practice.
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Atenção à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/ética , Atenção à Saúde/organização & administração , Comitês de Ética em Pesquisa , Experimentação Humana/ética , Experimentação Humana/legislação & jurisprudência , Humanos , Estados UnidosAssuntos
Filhos Adultos , Terapia Antirretroviral de Alta Atividade , Dissidências e Disputas , Consultoria Ética , Negociação , Assistência Terminal/ética , Recusa do Paciente ao Tratamento , Complexo AIDS Demência/diagnóstico , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Cuidados Paliativos na Terminalidade da Vida , Humanos , Narração , Estado Vegetativo Persistente , Suspensão de TratamentoRESUMO
PURPOSE: The aim of this article was to identify major research needs related to quality of life at the end of life and quality of the dying process for vulnerable older people at home, in assisted living facilities, in skilled nursing facilities, and in prisons. DESIGN AND METHODS: Review and analysis of the literature was used. RESULTS: The science is generally weak in relationship to what is known about quality of life at the end of life and quality of dying for vulnerable older adults in different settings. Few studies address actively dying patients and the reasons for transfers between home and other settings. Existing studies are primarily anecdotal, descriptive, have small samples, and involve a single setting. Participant decisional capacity is a barrier to conducting research in these settings. IMPLICATIONS: Research recommendations for each setting and across settings are provided. The National Institutes of Health should clarify criteria for enrollment of persons with diminished, fluctuating, and absent decisional capacity in research.