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1.
J Clin Ethics ; 34(4): 296-306, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37991731

RESUMO

AbstractThere is a clear need for interventions that reduce moral distress among healthcare providers (HCPs), given the high prevalence of moral distress and the far-ranging negative consequences it has for them. Healthcare ethics consultants are frequently called upon to manage moral distress, especially among nursing staff. Recently, researchers have both broadened the definition of moral distress and demarcated subcategories of the phenomenon with the intent of creating more targeted and effective interventions. One of the most frequently occurring subcategories of moral distress in this new taxonomy has been labeled "moral-constraint distress," though scholars have argued that not all constraints on HCPs' moral agency are inappropriate given the often-competing healthcare values of patients, families, and clinical staff. To attempt to reduce the instances of moral distress in cases in which the constraints on HCPs' moral agency are justified, we propose an intervention that focuses on shifting the HCPs' "frame of reference" on moral-constraint distress, teaching HCPs how to distinguish unjustified and justified constraints on their moral agency. The anchors of this blueprint for reducing moral-constraint distress are the philosophical concepts of "values pluralism" and "values imposition." The rationale for this intervention is that, in situations where the constraint on moral agency is justified but the experience of moral distress could nevertheless be severe, the emphasis needs to be on helping the HCP to "think differently" rather than "act differently."


Assuntos
Bioética , Pessoal de Saúde , Humanos , Consultores , Diversidade Cultural , Princípios Morais
2.
MedEdPORTAL ; 19: 11324, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37456671

RESUMO

Introduction: Given the prevalence of conflict between physicians and patients and families, it is crucial that trainees build the skills to manage clinical conflict. Mediators employ an approach that can be applied to clinical encounters to prevent conflicts from escalating. This workshop introduced trainees to techniques commonly used by mediators to manage disputes. Methods: Medical students in a virtual workshop (cohort A) and clinical fellows in an in-person workshop (cohort B) were presented with a mediator's approach to interpreting patient and family behavior viewed as challenging. Trainees were introduced to two specific techniques designed to facilitate the resolution of clinical conflict. After an interactive large-group discussion of each method, small groups practiced applying the technique to a sample clinical case. Finally, participants completed an assessment of their perception of the workshop's effectiveness. Results: In early 2022, 15 medical students (cohort A) participated in a virtual workshop and 10 clinical fellows (cohort B) participated in an in-person workshop on clinical conflict management. Eight medical students from cohort A completed the postworkshop assessment (response rate: 53%); six clinical fellows from cohort B completed the assessment (response rate: 60%). Cohort A gave the workshop an overall evaluation of 4.6 out of 5.0; cohort B gave the workshop an overall score of 4.7 out of 5.0. Discussion: In both the virtual platform and the traditional in-person format, this workshop introduces a set of tools for navigating bedside conflicts with patients and their families that participants believed would better prepare them for such challenging interactions.


Assuntos
Relações Médico-Paciente , Médicos , Humanos , Comunicação , Aprendizagem
4.
Am J Bioeth ; 23(1): 50-60, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-34590938

RESUMO

Long used as a tool for medical compliance and adhering to treatment plans, behavior contracts have made their way into the in-patient healthcare setting as a way to manage the "difficult" patient and family. The use of this tool is even being adopted by healthcare ethics consultants (HECs) in US hospitals as part of their work in navigating conflict at the bedside. Anecdotal evidence of their increasing popularity among clinical ethicists, for example, can be found at professional bioethics meetings and conversations and idea-sharing among practitioners on HEC social media. While there are a handful of papers gesturing toward a bioethical critique of behavior contracts of various types, the use of behavior contracts in the context of interpersonal conflict has not been vetted by bioethicists to determine their ethical legitimacy or efficacy. In this paper, we highlight a set of ethical concerns that we believe must be addressed before continuing or widespread implementation of behavior contracts to manage the "difficult" patient or family.


Assuntos
Bioética , Comitês de Ética Clínica , Humanos , Temas Bioéticos , Eticistas , Hospitais
5.
J Clin Ethics ; 33(3): 189-197, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36137200

RESUMO

In the article "An Argument for Standardized Ethical Directives for Secular Healthcare Services," Abram L. Brummett and Jamie C. Watson argue that, parallel to the directives of the Roman Catholic Church, secular healthcare ethics consultants (HECs) need substantive standardized ethical guidelines (what they call SEGs) that would constitute a best practice across all HECs in the U.S. Brummett and Watson believe that the absence of such directives constitutes an important deficit in clinical ethics consultation (CEC) that needs to be rectified in order for consultation to achieve the professionalism and universality necessary for legitimacy. This is a bold argument worthy of consideration, perhaps most because it challenges the field to engage in a self-assessment about its current and future directions against the backdrop of both the concerning data on national CEC and the current intense values polarization in the U.S. As part of assessment, I will argue in this essay that such a consensus document is not only impossible in our current national climate, but undesirable given the way that it would impose liberal clinical ethics values on an extremely values-pluralistic populace and exacerbate the deep divisions that many of us fear could be our national undoing.


Assuntos
Eticistas , Consultoria Ética , Códigos de Ética , Consultores , Diversidade Cultural , Atenção à Saúde , Humanos
6.
HEC Forum ; 2022 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-35435533

RESUMO

Conflict resolution is a core component of healthcare ethics consultation (HEC) and proficiency in this skill set is recognized by the national bioethics organization and its HEC certification process. Difficult interpersonal interactions between the clinical team and patients or their families are often inexorably connected to the normative disputes that are the catalyst for the consult. Ethics consultants are often required to navigate challenging dynamics that have become entrenched and work with patient-provider or family-provider relationships that have already broken down. The first step in conflict resolution is diagnosing the source of the conflict. Because so many interpersonal and normative conflicts rest on misunderstanding and mischaracterization, the diagnosis of the problem requires untangling the actual positions and perspectives of the conflicting parties from the fallacious assumptions made about the parties' respective positions and views. Developed in management science, the Ladder of Inference (LOI) is a diagnostic tool for assisting stakeholders in re-examining the process they used to form beliefs about others involved in the conflict. The LOI is a device that detects errors in reasoning, including implicit racial bias, that lead to false judgments and counterproductive responses to those judgments. The LOI is an instrument that can be used by ethics consultants to help resolve contentious bedside conflicts, but the LOI can also be employed as a teaching tool used by healthcare ethics consultants in training the clinical staff in how to avoid such conflicts in the first place.

8.
J Clin Ethics ; 33(1): 42-49, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35302518

RESUMO

Proficient listening has been viewed as a critical skill in HEC (healthcare ethics consultation) from the inception of the practice, and it is included in the field's set of core competencies that practitioners need to master to become a certified healthcare ethics consultant (HEC-C). Despite its centrality to the work of HEC, practitioners and trainees receive little or no formal training in the craft of listening, and there are few available resources that ethics consultants and trainees can access to enhance their listening skills. This dearth of training in the skill of listening belies the enormous challenge of listening proficiently. Although many clinical ethics researchers refer to the need for "active listening" in HEC, the term is employed without description or instruction. In this article, I argue that a more helpful depiction of the requisite skill is conveyed by the term "diagnostic listening." After describing the strategy of diagnostic listening, I introduce a novel technique for honing the listening skills needed for HEC: the ADEPT Model. The ADEPT Model is a tool that can begin to fill the training gap for this important skill.


Assuntos
Bioética , Eticistas , Comunicação , Eticistas/educação , Ética Clínica , Humanos , Encaminhamento e Consulta
9.
Am J Bioeth ; 19(11): 62-63, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31661413
10.
AJOB Empir Bioeth ; 9(3): 154-163, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29727598

RESUMO

BACKGROUND: It has been widely reported that medical trainees experience situations with profound ethical implications during their clinical rotations. To address this, most U.S. medical schools include ethics curricula in their undergraduate programs. However, the contents of these curricula vary substantially. Our pilot study aimed to discover, from the students' perspective, how ethics pedagogy prepares medical students for clerkship and what gaps might remain. METHODS: This qualitative study organized focus groups of third- and fourth-year medical students. Participants recounted ethical concerns encountered during clerkship rotations and reflected on how their medical school ethics curriculum informed their responses to these scenarios. Transcripts of the focus-group sessions were analyzed using a grounded theory approach to identify common themes that characterized the students' experiences. RESULTS: While students' accounts demonstrated a solid grasp of ethical theory and attunement to ethical concerns presented in the clinic, they also consistently evinced an inability to act on these issues given clerks' particular position in a complex learning hierarchy. Students felt they received too little training in the role-specific application of medical ethics as clinical trainees. We found a desire among trainees for enhanced practical ethics training in preparation for the clerkship phase of medical education. CONCLUSION: We recommend several strategies that can begin to address these findings. The use of roleplaying with standardized patients can enable students to practice engagement with ethical issues. Conventional ethics courses can focus more on action-based pedagogy and instruction in conflict management techniques. Finally, clear structures for reporting and seeking advice and support for addressing ethical issues can lessen students' apprehension about acting on ethical concerns.


Assuntos
Estágio Clínico , Currículo , Ética Médica/educação , Estudantes de Medicina , Adulto , Atitude do Pessoal de Saúde , Educação de Graduação em Medicina , Feminino , Grupos Focais , Humanos , Masculino , Pesquisa Qualitativa , Estudantes de Medicina/estatística & dados numéricos , Adulto Jovem
12.
Am J Bioeth ; 18(1): 3-11, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29313768

RESUMO

Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from "longshot" to "fantasy" is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.


Assuntos
Comunicação , Cuidados Críticos , Cuidados para Prolongar a Vida , Relações Profissional-Família/ética , Falha de Tratamento , Feminino , Humanos , Lactente , Masculino
13.
Paediatr Int Child Health ; 36(1): 4-6, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26750779

RESUMO

Human milk banks are vital for providing donor milk to infants for whom there are maternal or postnatal barriers to the mother's own milk. Although more than 35 countries have active milk banks, not one of those is a Muslim country.(1) Despite widespread support for breastfeeding across the Muslim world, religious constraints surrounding milk-sharing have created challenging barriers to the creation of milk banks. The religious objection centres around the Islamic tenet that consuming human milk builds a kinship bond between individuals who have consumed the same woman's milk which prohibits future marriage between the 'milk-brothers and sisters.' While a small-scale, experimental 'milk exchange' programme has been attempted in two Muslim countries (Kuwait and Malaysia), the only proposed milk bank in the Muslim world was a pilot programme in Turkey that was halted because of religious concerns. The problem with milk banking is the step in the process during which the milk from individual donors is pooled and de-identified, making it impossible to trace its origins and acknowledge the newly formed kinship relationship. To meet the need for Muslim children to be able to access human milk while remaining compliant with the prevalent understanding of Islamic doctrine on milk-sharing, we propose a new approach to milk banking that we term the Conditional Identified Milk Banking System (CIMBS). In this new system, both the donor's and recipient's identities are accessible to all parties through a voluntary registry, and the milk-pooling is limited to three milk donors. Based on recent survey data, we believe that there would be receptivity among practicing Muslims and religious leaders to this alternative approach.


Assuntos
Fidelidade a Diretrizes , Cuidado do Lactente/métodos , Islamismo , Bancos de Leite Humano/organização & administração , Leite Humano , Religião e Medicina , Aleitamento Materno , Humanos , Lactente , Bancos de Leite Humano/ética , Doadores não Relacionados
15.
Am J Bioeth ; 15(8): 3-9, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26225503

RESUMO

Given the widening gap between the number of individuals on transplant waiting lists and the availability of donated organs, as well as the recent plateau in donations based on neurological criteria (i.e., brain death), there has been a growing interest in expanding donation after circulatory determination of death. While the prevalence of this form of organ donation continues to increase, many thorny ethical issues remain, often creating moral distress in both clinicians and families. In this article, we address one of these issues, namely, the challenges surrounding patient and surrogate informed consent for donation after circulatory determination of death. First we discuss several general concerns regarding consent related to this form of organ donation, and then we address additional issues that are unique to three different patient categories: adult patients with medical decision-making capacity or potential capacity, adult patients who lack capacity, and pediatric patients.


Assuntos
Sistema Cardiovascular , Morte , Consentimento Livre e Esclarecido/ética , Competência Mental , Valores Sociais , Doadores de Tecidos , Sobrevivência de Tecidos , Coleta de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/ética , Adulto , Circulação Sanguínea , Morte Encefálica , Criança , Tomada de Decisões , Humanos , Consentimento dos Pais/ética , Opinião Pública , Consentimento do Representante Legal/ética , Confiança
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