Coaching doctors to improve ethical decision-making in adult hospitalised patients potentially receiving excessive treatment: Study protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Fast medical progress poses a significant challenge to doctors, who are asked to find the right balance between life-prolonging and palliative care. Literature indicates room for enhancing openness to discuss ethical sensitive issues within and between teams, and improving decision-making for benefit of the patient at end-of-life. METHODS: Stepped wedge cluster randomized trial design, run across 10 different departments of the Ghent University Hospital between January 2022 and January 2023. Dutch speaking adult patients and one of their relatives will be included for data collection. All 10 departments were randomly assigned to start a 4-month coaching period. Junior and senior doctors will be coached through observation and debrief by a first coach of the interdisciplinary meetings and individual coaching by the second coach to enhance self-reflection and empowering leadership and managing group dynamics with regard to ethical decision-making. Nurses, junior doctors and senior doctors anonymously report perceptions of excessive treatment via the electronic patient file. Once a patient is identified by two or more different clinicians, an email is sent to the second coach and the doctor in charge of the patient. All nurses, junior and senior doctors will be invited to fill out the ethical decision making climate questionnaire at the start and end of the 12-months study period. Primary endpoints are (1) incidence of written do-not-intubate and resuscitate orders in patients potentially receiving excessive treatment and (2) quality of ethical decision-making climate. Secondary endpoints are patient and family well-being and reports on quality of care and communication; and clinician well-being. Tertiairy endpoints are quantitative and qualitative data of doctor leadership quality. DISCUSSION: This is the first randomized control trial exploring the effects of coaching doctors in self-reflection and empowering leadership, and in the management of team dynamics, with regard to ethical decision-making about patients potentially receiving excessive treatment.

Interprofessional perspectives on care for patients with low anterior resection syndrome: A qualitative study.

AIM: Many patients are confronted with low anterior resection syndrome after rectal surgery. The perspectives of both healthcare professionals and patients on the impact of bowel problems may differ. This study aimed to explore experiences of healthcare professionals on how to provide, organise and optimise care for patients with low anterior resection syndrome from an interprofessional perspective. METHODS: An explorative qualitative design was used. Healthcare professionals were recruited in October 2018 in one general teaching hospital and one university hospital. Twenty one healthcare professionals from different professions caring for patients with low anterior resection syndrome were included in three focus group interviews. RESULTS: Healthcare professionals confirmed a lack of focus on patients who are confronted with low anterior resection syndrome and stated a need for a standardised approach of care. Additionally, three levels for care optimization emerged from the data: information before surgery with strong emphasis on the timing of informing, counselling of patients when confronted with low anterior resection syndrome and organisation of care. CONCLUSIONS: Healthcare professionals find it important to adopt the moment and amount of information to the coping mechanism and timing of the trajectory. Counselling and follow-up of patients with LARS should be organised proactively and should not remain restricted to pharmacological and nutritional advice. A possible strategy is to develop and implement late effects nurse-led clinics coordinated by the clinical nurse specialist.

Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies.

PURPOSE/OBJECTIVES: To explore variations in coping with moral distress among physicians and nurses in a university hospital oncology setting.
. RESEARCH APPROACH: Qualitative interview study.
. SETTING: Internal medicine (gastroenterology and medical oncology), gastrointestinal surgery, and day clinic chemotherapy at Ghent University Hospital in Belgium.
. PARTICIPANTS: 17 doctors and 18 nurses with varying experience levels, working in three different oncology hospital settings. 
. METHODOLOGIC APPROACH: Patients with cancer were interviewed based on the critical incident technique. Analyses were performed using thematic analysis.
. FINDINGS: Moral distress lingered if it was accompanied by emotional distress. Four dominant ways of coping (thoroughness, autonomy, compromise, and intuition) emerged, which could be mapped on two perpendicular continuous axes. CONCLUSIONS: Moral distress is a challenging phenomenon in oncology. However, when managed well, it can lead to more introspection and team reflection, resulting in a better interpersonal understanding.
. INTERPRETATION: Team leaders should recognize their own and their team members' preferred method of coping and tailored support should be offered to ease emotional distress.